Over the last several years there has been a marked increase in the anti-testing movement. Citing concerns about fairness, stress among examinees, overkill and “teaching to the test,” among other issues, parents, educators and students have pushed back. For example, just a few years ago some 60,000 New York schoolchildren refused to take federally mandated state tests.
The anti-testing movement is evident in the healthcare arena as well, with widespread provider pushback against Maintenance of Certification (MOC) exams. Many providers believe that maintaining current knowledge and skills using Continuing Medical Education (CME) is sufficient and that periodic retesting is too onerous and expensive, and not proof of improved patient outcomes. As a result, we’ve seen a recent rise in state legislation introduced to eliminate the requirement for MOC.
Some of these concerns may be well founded. But there are reasons why many medical providers are required to test throughout their careers. Certifying bodies such as the National Commission on Certification of Physician Assistants (NCCPA)—where I’m the president and CEO—can draw on what we know about how providers and adult learners acquire knowledge and skills to improve our current assessment strategies.
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The link between certification and quality care
Physicians, physician assistants (PAs) and nurse practitioners (NPs) all must pass an initial certification exam. Most physicians and all PAs also need to pass exams throughout their careers to maintain certification, as well.
A 2008 study in the Archives of Internal Medicine showed an association between the MOC exam scores and quality of care for Medicare beneficiaries. Over the past few years, a plethora of research has examined this issue. Writing for the Journal of Pediatrics, David Nichols, M.D., took a sweeping look at some of the more recent studies conducted over the last few years and concluded that by and large, MOC is correlated to improved clinical outcomes. In June 2018, new research shared in the Annals of Internal Medicine found that maintaining certification was positively associated with physician performance scores on a set of HEDIS process measures.
There is a correlation between MOC and delivering the right care, and conversely, there may also be an association between the absence of MOC and delivery of the wrong care. A 2017 American Board of Internal Medicine (ABIM) study showed a correlation between medical knowledge as demonstrated on the MOC exam and lower risk of disciplinary actions. That study’s findings suggested that physicians who do not pass the exam are two times more likely to have such action against them.
Is certification a guarantee of quality? No. Is it a proxy measure we can use to help establish a quality baseline? In an industry where establishing widespread quality measures often proves elusive, absolutely.
MOC establishes trust for patients and payers
Patients report differences in providers, from bedside manner and communication skills to their use of technology and referral rates. For patients, certification indicates that providers have taken the steps necessary to maintain a current fund of medical knowledge, a professional facet that engenders trust and greater engagement.
In the past, patients did not have access to the wealth of information that is currently available to them and they usually did not question their provider’s judgment or decisions. But in today’s world, patients are empowered to ask questions, and research shows the public is more skeptical of their providers. Today’s patients also have access to a wealth of medical and provider information, thanks to the internet. Online guides, such as Consumer Reports’ “Finding Doctor Right,” implore patients to “ask if your doctor is board certified!” Many healthcare consumers also have access to online physician selection tools available from their health plan or employer; tools that help them learn more about their providers. The clear majority of these provider selection tools rely on certification as a baseline data point. We want patients to be engaged, to ask questions and to care about quality. Information about certification is one of a handful of meaningful indicators we can give patients while we continue the uphill climb to develop other quality measures that matter to consumers.
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Certification is a huge help to other healthcare stakeholders. For healthcare payers, certification provides an objective assessment of clinical credentials. While payers may not require certification, often they will ask for an explanation if the provider is not certified.
Making positive changes to the existing system of certification
The MOC discussion over the past five years has created a meaningful dialogue and ongoing analysis, aimed at finding ways to make it less of a mandate and more about flexibility and options.
While it is essential that certifying bodies remain independent, physician certification boards that direct the MOC are now implementing a wide range of reforms.
Organizations such as NCCPA are also listening and have heard the concerns of our constituents.
For PAs, NCCPA has been evaluating the recertification exam process for over three years. We have benefited from current and emerging literature on adult learning, learning-styles principles and enhanced knowledge on how individuals learn and retain new and complex information.
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Specifically, rather than sit for a half-day exam at a secure test center, longitudinal assessments of PAs—which measure knowledge over time—will be piloted over the next two years.
In addition, technology now enables examinees to answer questions from any device, anywhere. We no longer need to tether an examinee to a desktop computer.
MOC is how providers keep up
It is estimated that by 2020, medical knowledge will double every 73 days. Neither medical schools nor any other education program or CME can make up for this. It is an ongoing process of lifelong learning. Although no one likes testing, it is one way to ensure our healthcare providers take the time to learn and digest the most current knowledge in healthcare.
The goal in the ongoing debate over provider testing is not to choose sides on who or what is right. The goal is to find assessment methods that are relevant to providers in an increasingly complex healthcare system, and that are meaningful and beneficial to those who are the recipients of their care. In the long run, if we do this right, we can bolster both care quality and patient trust.
Dawn Morton-Rias, Ed.D., PA-C, is the president and CEO of the National Commission on Certification of Physician Assistants (NCCPA), the nation's only certifying body for PAs. She has been certified as a PA for over 30 years and has worked in family medicine, addictive medicine, gynecology and providing acute care for the homeless.