Research
Original Investigation
Association Between Imposition of a Maintenance of Certification Requirement and Ambulatory Care–Sensitive Hospitalizations and Health Care Costs Bradley M. Gray, PhD; Jonathan L. Vandergrift, MS; Mary M. Johnston, MS; James D. Reschovsky, PhD; Lorna A. Lynn, MD; Eric S. Holmboe, MD; Jeffrey S. McCullough, PhD; Rebecca S. Lipner, PhD Editorial page 2340 IMPORTANCE In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. OBJECTIVE To measure associations between the original ABIM MOC requirement and
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outcomes of care. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. MAIN OUTCOMES AND MEASURES Quality measures were ambulatory care–sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). RESULTS Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, −1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of −$167 (95% CI, −$270.5 to −$63.5; P = .002; 2.5% of overall mean cost). CONCLUSION AND RELEVANCE Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.
JAMA. 2014;312(22):2348-2357. doi:10.1001/jama.2014.12716 2348
Author Affiliations: American Board of Internal Medicine, Philadelphia, Pennsylvania (Gray, Vandergrift, Lynn, Lipner); James Madison University, Harrisonburg, Virginia (Johnston); Mathematica Policy Research, Washington, DC (Reschovsky); Accreditation Council for Graduate Medical Education, Chicago, Illinois (Holmboe); University of Minnesota, Minneapolis (McCullough). Corresponding Author: Bradley M. Gray, PhD, 510 Walnut St, Ste 1700, Philadelphia, PA 19106-3699 (
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Imposition of a MOC Requirement and Outcomes of Care
O
ne of the largest changes in physician accreditation policy was the initiation of a 10-year Maintenance of Certification (MOC) requirement in 1990 by the American Board of Internal Medicine (ABIM). This change was also adopted by 24 certifying boards of the American Board of Medical Specialties (ABMS), affecting 85% of all US physicians.1 Despite the breadth of this policy change and considerable efforts by certifying boards to apply these requirements and by physicians to complete the requirements, to our knowledge, no studies have examined the association between this policy change and either the quality or efficiency of care.2 Previous studies showed positive relationships between initial certification and better health outcomes3,4 and between certification examination performance and quality 5 and efficiency 6 of care measures. Although these studies validated certification as a marker of competence, none have examined the consequences of the MOC requirement itself. We addressed this gap by using a natural experiment in which 1 group of general internal medicine physicians (general internists) had to fulfill the 10-year MOC requirement and another group did not because they had originally certified 2 years earlier. Using outcomes for 2 cohorts of Medicare beneficiaries treated by these 2 groups 10 years after their original certification, we measured the association between the original MOC requirement and changes in ambulatory care– sensitive hospitalizations (ACSHs) and health care costs. In doing so, we tested the hypotheses that the MOC requirement was associated with higher-quality and more efficient care.
Methods Physician and Patient Sample The study protocol was approved by the Essex Institutional Review Board. The physician sample consisted of nonsubspecializing general internists originally certified in 1989 or 1991. The 1989 general internists were grandfathered out of the requirement (MOC-grandfathered) and the 1991 general internists were required to complete MOC by 2001 (MOCrequired). We chose general internists who originally certified in 1991 rather than 1990 (when the requirement was first instituted) because the 1990 group—the first to be required to complete MOC—was less likely to enroll and complete MOC and, among those completing MOC, more likely to substantially delay their enrollment and completion. These problems were rectified in the 1991 group. We assumed that the 2-year difference in the initial certification year between the MOC-required and MOC-grandfathered general internists would not cause their delivery of health care services and types of beneficiaries treated to be different 10 years later. Using Medicare claims, we drew the beneficiary sample from beneficiaries who had any billing contact with the general internist sample in 2001. To follow this cohort over time, we then obtained Medicare claims for these beneficiaries from 1999 to 2005 (the study period). We subsequently excluded beneficiaries who were younger than 65 years on January 1,
Original Investigation Research
1999, enrolled in Medicare Advantage, or resided outside the United States during the study period to provide continuous claims data from 1999 through 2005. We then limited the sample to beneficiaries whose primary physician was either an MOC-required general internist (MOC-required beneficiary) or an MOC-grandfathered general internist (MOCgrandfathered beneficiary). Determination of a potential primary physician was based on specialty types that typically render primary care services or manage chronic conditions (eMethods 2 in the Supplement). Beneficiaries were attributed to general internists who provided the plurality of the patient’s evaluation and management visits occurring in ambulatory care settings (ie, general internist with the most eligible visits). Because we were trying to identify changes in practice due to MOC, our attribution methodology was designed to identify beneficiaries who had an ongoing relationship with an ABIM general internist before and after 2001. For a beneficiary to be attributed to a general internist, the general internist needed to be their plurality general internist for at least 2 individual years in both the 1999-2001 period and the 2001-2003 period and be the plurality provider across each of these 3-year periods (eMethods 6 in the Supplement). We balanced the characteristics of the attributed treatment (MOC-required) and control (MOC-grandfathered) beneficiary cohorts by matching propensity scores, which were constructed from estimating a logistic regression of the likelihood of being in the treatment cohort on baseline demographic characteristics, chronic conditions, and the characteristics of attributed general internists (eMethods 13 in the Supplement). We used nearest-neighbor matching within a 0.2 caliper without replacement.7,8 We retained all beneficiaries in the MOC-required cohort who matched at least 1 beneficiary in the MOC-grandfathered cohort to maintain the generalizability of our treated sample.
Outcome Measures We used annual incidence of an ACSH as the primary quality measure, reported as the number per 1000 beneficiaries. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care.9 For example, patients with diabetes are more likely to be hospitalized for diabetic complications if they are not adequately monitored or fail to receive patient education needed for selfmanagement. Our ACSH measures were developed by the Agency for Healthcare Research and Quality and are also known as prevention quality indicators.9 We used 3 annual incidence measures of ACSHs: any ACSH, any chronic condition ACSH, and any acute condition ACSH. A list of conditions and procedures used to construct ACSH measures are included in the Supplement (eMethods 3 in the Supplement). Other service utilization measures included any hospitalization and any emergency department visit during a year. The main cost measure was per-beneficiary annual health care costs, excluding post-acute health care costs (eMethods 8 in the Supplement; for sensitivity test including post-acute costs). Costs were also delineated by ambulatory and inpa-
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2349
Imposition of a MOC Requirement and Outcomes of Care
Original Investigation Research
Table 3. Regression−Based Estimates of Associations Between the Maintenance of Certification (MOC) Requirement and Differences in Outcome Growth Across Beneficiary Cohorts and MOC Periods Mean (SD) Unadjusted Study Period (1999-2005)
Unadjusted Pre-MOC Period, (1999-2000) MOC-Required Beneficiaries
Unadjusted Post-MOC Period (2002-2005)
MOC-Grandfathered Beneficiaries
MOC-Required Beneficiaries
MOC-Grandfathered Beneficiaries
Regression-Adjusted Difference Across Beneficiary Cohorts and MOC Periods Differential Change (95% CI)
P Value
.92
Annual Incidence Measures ACSH by condition typea Any
53.2 (224.5)
37.9 (190.9)
37.0 (188.8)
61.8 (240.8)
61.4 (240.1)
0.1 (−1.7 to 1.9)
Acute
27.6 (163.9)
18.1 (133.2)
17.9 (132.6)
32.9 (178.3)
32.7 (177.8)
0.3 (−1.1 to 1.6)
.70
Chronic
29.4 (168.8)
21.8 (146.0)
21.0 (143.5)
33.7 (180.5)
33.5 (179.8)
−0.2 (−1.5 to 1.2)
.80
Hospitalization
214.3 (410.3)
174.7 (379.7)
175.2 (380.1)
234.6 (423.7)
236.4 (424.9)
−0.5 (−3.8 to 2.8)
.78
Emergency department visit
284.9 (451.4)
239.4 (426.7)
234.3 (423.5)
311.1 (462.9)
309.9 (462.5)
−3.2 (−6.8 to 0.3)
.07
5156.7 (10 065.0)
5132.6 (9858.4)
7632.8 (13 988.7)
Ambulatory 3676.6 (5024.7)
2838.3 (3441.8)
2847.1 (3409.0)
4078.1 (5573.3)
4176.9 (5736.0)
−84.1 (−121.6 to −46.6)