For more than a decade, consumers and purchasers have been convinced that financial incentives, such as pay-for-performance, are a key to improving our healthcare system. Results of this concept—a form of extrinsic motivation—have been mixed. For example, a study published this year by BMJ (the online British Medical Journal) determined that a highly incentivized physician pay-for-performance program in the United Kingdom ultimately did not improve outcomes in patients with high blood pressure.
Not by money alone
Physicians will respond better to intrinsic incentives to improve than to P4P
We are confident that a powerful and complimentary pathway to healthcare quality lies in tapping into the physician's intrinsic motivation for improvement and professional growth. It is this internally directed motivation that forms the foundation of professionalism and serves as the foundation for the American Board of Medical Specialties Maintenance of Certification program.
Board certification, unlike licensure, is a voluntary process and demonstrates to the public a physician's expertise in a particular specialty or subspecialty of medicine. Approximately 85% of U.S. physicians are board certified by one or more of the 24 ABMS member boards. Studies have shown that, compared to those who are not board certified, physicians who are board certified by an ABMS member board deliver higher quality care and their patients have better outcomes. Further, surveys show the public values the assurance that board certification provides.
But research also tells us that physicians' skills can decline over time. This informed the development and implementation of the ABMS certification maintenance program. It is a system of professional lifelong education and assessment tools that support continued professional development and public accountability to keep pace with rapidly accelerating scientific knowledge, medical technology and professional standards as they apply to their specialties. We believe quality physicians inherently understand this to be true and are motivated to strive toward this quality of patient care.
The maintenance program is designed to promote lifelong learning by continually measuring physicians on six core competencies: professionalism; patient care and procedural skills; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; and systems-based practice. Physicians continually refresh and expand their knowledge in these competencies through a four-part process: licensure and professional standing; lifelong learning and self-assessment; cognitive expertise; and practice performance assessment. Depending on the specialty, a combination of tools are used to measure lifelong learning and self-assessment and practice performance assessment, such as patient and peer surveys, self-assessment tests, patient chart reviews, outcomes comparisons, exams and treatment scenario simulations, among others.
Although implementation of the maintenance program is relatively recent, early research by ABMS member boards is demonstrating its value. For instance, a study in the Archives of Internal Medicine concluded that physician cognitive skills, as measured by an American Board of Internal Medicine maintenance exam, are associated with higher rates of quality of care for Medicare patients.
Recently, another study, published in Circulation, demonstrated evidence that more intensive educational efforts could help to improve the quality of care physicians deliver to patients with diabetes. The ABMS is committed to continuing to build a body of evidence to assess, improve and demonstrate the value of the certification maintenance program.
It is clear that the extrinsic motivation pathway will continue to be a major force in the effort of healthcare payers to improve the quality of care. To be effective, however, healthcare quality improvement efforts will most likely require approaches designed to appeal to intrinsic motivation, such as those employed through the certification maintenance program.
To this end, ABMS and its member boards are committed to educating external audiences regarding the benefits of the program, as well as raising awareness among physicians of the importance of participation in the program. Extrinsic and intrinsic accountability activities can and should align in order to achieve results that will benefit all of us. We, therefore, are engaging in dialogue with healthcare purchasers, health organizations, consumers and patients to explore a new, shared accountability framework that takes advantage of potential synergies.
As an example, in 2010, ABMS reached out to Congress as it worked on healthcare reform to inform them of the value of board certification. This resulted in the Patient Protection and Affordable Care Act linking the ABMS certification maintenance program with the CMS' Physician Quality Reporting program.
Physicians have an intrinsic desire to deliver quality care, and that intrinsic motivation is at the heart of the professional and helps build a critical connection between physicians and patients. As the ABMS board certification and certification maintenance programs evolve, we invite you to visit CertificationMatters.org to learn more about the process and our quest to improve our nation's healthcare. We are confident that the certification maintenance program, which speaks to doctors' pride and professionalism, will be a major driving force as we work together to build a quality healthcare enterprise.
Dr. Kevin Weiss is president and CEO of the American Board of Medical Specialties.
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