Associations of Internal Medicine Residency Milestone Ratings and Certification Examination Scores With Patient Outcomes.

Importance: Despite its importance to medical education and competency assessment for internal medicine trainees, evidence about the relationship between physicians' milestone residency ratings or the American Board of Internal Medicine's initial certification examination and their hospitalized patients' outcomes is sparse. Objective: To examine the association between physicians' milestone ratings and certification examination scores and hospital outcomes for their patients. Design, Setting, and Participants: Retrospective cohort analyses of 6898 hospitalists completing training in 2016 to 2018 and caring for Medicare fee-for-service beneficiaries during hospitalizations in 2017 to 2019 at US hospitals. Main Outcomes and Measures: Primary outcome measures included 7-day mortality and readmission rates. Thirty-day mortality and readmission rates, length of stay, and subspecialist consultation frequency were also assessed. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year. Exposures: Certification examination score quartile and milestone ratings, including an overall core competency rating measure equaling the mean of the end of residency milestone subcompetency ratings categorized as low, medium, or high, and a knowledge core competency measure categorized similarly. Results: Among 455 120 hospitalizations, median patient age was 79 years (IQR, 73-86 years), 56.5% of patients were female, 1.9% were Asian, 9.8% were Black, 4.6% were Hispanic, and 81.9% were White. The 7-day mortality and readmission rates were 3.5% (95% CI, 3.4%-3.6%) and 5.6% (95% CI, 5.5%-5.6%), respectively, and were 8.8% (95% CI, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%) for mortality and readmission at 30 days. Mean length of stay and number of specialty consultations were 3.6 days (95% CI, 3.6-3.6 days) and 1.01 (95% CI, 1.00-1.03), respectively. A high vs low overall or knowledge milestone core competency rating was associated with none of the outcome measures assessed. For example, a high vs low overall core competency rating was associated with a nonsignificant 2.7% increase in 7-day mortality rates (95% CI, -5.2% to 10.6%; P = .51). In contrast, top vs bottom examination score quartile was associated with a significant 8.0% reduction in 7-day mortality rates (95% CI, -13.0% to -3.1%; P = .002) and a 9.3% reduction in 7-day readmission rates (95% CI, -13.0% to -5.7%; P < .001). For 30-day mortality, this association was -3.5% (95% CI, -6.7% to -0.4%; P = .03). Top vs bottom examination score quartile was associated with 2.4% more consultations (95% CI, 0.8%-3.9%; P < .003) but was not associated with length of stay or 30-day readmission rates. Conclusions and Relevance: Among newly trained hospitalists, certification examination score, but not residency milestone ratings, was associated with improved outcomes among hospitalized Medicare beneficiaries.

Geriatricians, general internists, and potentially inappropriate medications for a national sample of older adults.

BACKGROUND: Older adults are often prescribed medications that are potentially dangerous and geriatricians have specialized training in treating polypharmacy that may benefit these patients. To examine this, we compared potentially inappropriate medication (PIM) prescribing rates between geriatricians and similar general internists in the United States. METHODS: Using national cross-sectional data from 2013 to 2019, we compared annual PIM prescribing rates between 2815 outpatient geriatricians certified by the American Board of Internal Medicine in 1994-2018 and general internists matched 1:1 on IM certification exam score and year, residency exam pass rate, gender, and US birth and/or US medical school. PIM prescribing was based on the Healthcare Effectiveness Data and Information Set (HEDIS) PIM physician annual prescribing measures which consider medications flagged as potentially inappropriate in the American Geriatric Society Beers Criteria® guideline. We also examined prescribing of appropriate alternative medications. Prescribing rates were calculated as the percentage a physician's patients with Medicare fee-for-service part D enrollment seen in the outpatient setting in a given year (mean: 150 patients per physician) with a PIM prescription they prescribed. RESULTS: Across 30,677 physician-year observations, geriatricians were 16.7% less likely (95% confidence interval (CI): -19.8 to -13.7, p < 0.001) to prescribe a PIM (7.2% versus 8.7% of patients respectively) and 2.7% more likely (95% CI: 0.8 to 4.5, p = 0.004) to prescribe an appropriate alternative medication (52.0% versus 50.7% of patients respectively). Lower PIM prescribing was observed for most medication sub-types including central nervous system, anticholinergic, pain, and endocrine medications. In sensitivity analyses, differences in prescribing were similar when comparing recently trained physicians with more experienced physicians. CONCLUSION: Findings suggest geriatricians in the United States prescribe PIMs at lower rates than general internists. This highlights the value geriatricians provide as well as opportunities to embed key principles of geriatric care into internal medicine training and health care delivery systems.

Adoption of Internal Medicine Milestone Ratings and Changes in Bias Against Black, Latino, and Asian Internal Medicine Residents.

BACKGROUND: The 2014 adoption of the Milestone ratings system may have affected evaluation bias against minoritized groups. OBJECTIVE: To assess bias in internal medicine (IM) residency knowledge ratings against Black or Latino residents-who are underrepresented in medicine (URiM)-and Asian residents before versus after Milestone adoption in 2014. DESIGN: Cross-sectional and interrupted time-series comparisons. SETTING: U.S. IM residencies. PARTICIPANTS: 59 835 IM residents completing residencies during 2008 to 2013 and 2015 to 2020. INTERVENTION: Adoption of the Milestone ratings system. MEASUREMENTS: Pre-Milestone (2008 to 2013) and post-Milestone (2015 to 2020) bias was estimated as differences in standardized knowledge ratings between U.S.-born and non-U.S.-born minoritized groups versus non-Latino U.S.-born White (NLW) residents, with adjustment for performance on the American Board of Internal Medicine IM certification examination and other physician characteristics. Interrupted time-series analysis measured deviations from pre-Milestone linear bias trends. RESULTS: During the pre-Milestone period, ratings biases against minoritized groups were large (-0.40 SDs [95% CI, -0.48 to -0.31 SDs; P < 0.001] for URiM residents, -0.24 SDs [CI, -0.30 to -0.18 SDs; P < 0.001] for U.S.-born Asian residents, and -0.36 SDs [CI, -0.45 to -0.27 SDs; P < 0.001] for non-U.S.-born Asian residents). These estimates decreased to less than -0.15 SDs after adoption of Milestone ratings for all groups except U.S.-born Black residents, among whom substantial (though lower) bias persisted (-0.26 SDs [CI, -0.36 to -0.17 SDs; P < 0.001]). Substantial deviations from pre-Milestone linear bias trends coincident with adoption of Milestone ratings were also observed. LIMITATIONS: Unobserved variables correlated with ratings bias and Milestone ratings adoption, changes in identification of race/ethnicity, and generalizability to Milestones 2.0. CONCLUSION: Knowledge ratings bias against URiM and Asian residents was ameliorated with the adoption of the Milestone ratings system. However, substantial ratings bias against U.S.-born Black residents persisted. PRIMARY FUNDING SOURCE: None.

Evolving Practice Choices by Newly Certified and More Senior General Internists : A Cross-Sectional and Panel Comparison.

BACKGROUND: Hospital medicine has grown as a field. However, no study has examined trends in career choices by internists over the past decade. OBJECTIVE: To measure changes in practice setting for general internists. DESIGN: Using Medicare fee-for-service claims (2008 to 2018) and data from the American Board of Internal Medicine, practice setting types were measured annually for general internists initially certifying between 1990 and 2017. SETTING: General internists (non-subspecializing) treating Medicare fee-for-service beneficiaries. PATIENTS: Medicare fee-for-service beneficiaries aged 65 years and older with at least 20 evaluation and management (E&M) visits annually. MEASUREMENTS: Practice setting types were defined as hospitalist (>95% inpatient E&M), outpatient only (100% outpatient E&M), or mixed. RESULTS: 67 902 general internists, comprising 80% of all general internists initially certified from 1990 to 2017 (n = 84 581), were studied. From 2008 to 2018, both hospitalists and outpatient-only physicians increased as percentages of general internists (25% to 40% and 23% to 38%, respectively). This was accompanied by a 56% decline in the percentage of mixed-practice physicians (52% to 23%) as these physicians largely migrated to outpatient-only practice. By 2018, 71% of newly certified general internists practiced as hospitalists compared with only 8% practicing as outpatient-only physicians. Most (86% of hospitalists in 2013) had the same practice type 5 years later. This retention rate was similar across early career and more senior physicians (86% and 85% for the 1999 and 2012 initial certification cohorts, respectively) and for the outpatient-only practice type (95%) but was only 57% for the mixed practice type. LIMITATION: Practice setting measurement relied only on Medicare fee-for-service claims. CONCLUSION: Newly certified general internists are largely choosing hospital medicine as their career choice whereas more senior physicians increasingly see patients only in the outpatient setting. PRIMARY FUNDING SOURCE: This study did not receive direct funding.

The association between physician knowledge and inappropriate medications for older populations.

BACKGROUND: Older patients are often prescribed potentially inappropriate medications (PIMs) given their age. We measured the association between a physician's general knowledge and their PIM prescribing. METHODS: Using a 2013-2017 cross-sectional design, we related a general internist's knowledge (n = 8196) to their prescribing of PIMs to fee-for-service Medicare beneficiaries, age ≥ 66 years with part D coverage, which they saw in the outpatient setting the year after their exam (n = 875,132). Physician knowledge was based on the American Board of Internal Medicine's (ABIM) Internal Medicine Maintenance of Certification (IM-MOC) exam scores. Medications included 72 PIMs from the American Geriatric Society's Beers Criteria and appropriate alternatives to these medications. Logistic regressions controlled for physicians practice/training characteristics and patient-risk factors. RESULTS: Annually, 11.0% of patients received a PIM and 57.2% received an appropriate alternative medication. Patients seen by physicians scoring in the top versus bottom quartile were 8.6% less likely (95% confidence interval [CI]: -12.7 to -4.5, p < 0.001) to be prescribed a PIM and 4.7% more likely (95% CI: 1.7 to 7.6, p = 0.001) to be prescribed an appropriate alternative medication. The difference in PIM prescribing grew to 12.1% fewer (95% CI: -15.1 to -9.1) patients when limiting the sample to the 58.9% of patients being prescribed a PIM or appropriate alternative medication. Among patients receiving any medication, this was similar to the percent difference in PIM prescribing between solo and large practices (≥50 physicians, -10.2%, 95% CI: 13.6-6.5, p < 0.001) or between group and academic practices (-11.7%, 95% CI: -15.3 to -7.9, p < 0.001). PIM prescribing was more positively associated with patient characteristics including age, gender, and total number of medications prescribed. CONCLUSIONS: Better physician general knowledge, as measured by an ABIM exam, was associated with fewer PIM prescriptions. Future research should examine whether general educational interventions, such as MOC, effect PIM prescribing.

Clinical Knowledge and Trends in Physicians' Prescribing of Opioids for New Onset Back Pain, 2009-2017.

Importance: Opioid musculoskeletal pain overprescribing was widespread in the mid-2000s. The degree to which prescribing changed as awareness of the danger grew among physicians with different levels of clinical knowledge remains unstudied. Objective: To compare the association of clinical knowledge with opioid prescribing from 2009 to 2011 when prescribing peaked nationally with 2015 to 2017 when guidelines shifted away from opioid prescribing. Design, Setting, and Participants: This cross-sectional study included 10 246 midcareer general internal medicine physicians in the United States who saw patients who were Medicare beneficiaries with Part D enrollment from 2009 to 2017. Main Outcomes and Measures: Any opioid prescription and high dosage or long duration (HDLD) (>7 days or >50 daily morphine milligram equivalents) opioid prescriptions filled within 7 days of applicable visits for new low back pain concerns. Associations between opioid prescribing for new low back pain concerns during outpatient visits and clinical knowledge measured by prior year American Board of Internal Medicine (ABIM) Maintenance of Certification examination performance were estimated using serial cross-sectional logit regressions. Regression covariates included yearly examination quartile (ie, knowledge quartile) interacted with 3-year group dummies (ie, early: 2009-2011; middle: 2012-2014; late: 2015-2017), state and year dummies, physician, practice, patient characteristics, and state opioid regulations. Results: Of the 55 387 low back pain visits included in this study, 37 185 (67.1%) were visits with female patients, 41 978 (75.8%) were with White patients, and the mean (SE) age of patients was 76.2 (<0.01) years. The rate of opioid prescribing was 21.6% (11 978) for any opioid prescription and 17.6% (9759) for HDLD prescriptions. From 2009 to 2011, visits with physicians in the highest and lowest knowledge quartiles had similar adjusted opioid prescribing rates with a 0.5 (95% CI, -1.9 to 3.0) percentage point difference. By 2015 to 2017, visits with physicians in the highest knowledge quartile prescribed opioids less frequently that physicians in the lowest knowledge quartile (4.6 percentage point difference; 95% CI, -7.5 to -1.8 percentage points). Visits in which HDLD opioids were prescribed showed no difference in the early period but showed a difference in the late period when comparing physicians in the highest and lowest knowledge quartiles (early period: difference -0.1; 95% CI, -2.4 to 2.2 percentage points; late period difference: 4.8; 95% CI, -7.4 to -2.1 percentage points). Conclusions and Relevance: In this cross-sectional study, when the standard of care shifted away from routine opioid prescribing, physicians who performed well on an ABIM examination were less likely to prescribe opioids for back pain than physicians who performed less well on the examination.

Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims.

OBJECTIVE: Diagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors. SETTING/PARTICIPANTS: 1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 'index' outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke). OUTCOME MEASURES: 90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations. DESIGN: Using retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics. RESULTS: Rates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI -5.0 to -0.7, p=0.008), 4.1 fewer hospitalisations (95% CI -6.9 to -1.2, p=0.006) and 4.9 fewer ED visits (95% CI -8.1% to -1.6%, p=0.003) per 1000 visits. CONCLUSION: Higher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

Changes in Stress and Workplace Shortages Reported by U.S. Critical Care Physicians Treating Coronavirus Disease 2019 Patients.

OBJECTIVES: Eleven months into the coronavirus disease 2019 pandemic, the country faces accelerating rates of infections, hospitalizations, and deaths. Little is known about the experiences of critical care physicians caring for the sickest coronavirus disease 2019 patients. Our goal is to understand how high stress levels and shortages faced by these physicians during Spring 2020 have evolved. DESIGN: We surveyed (October 23, 2020 to November 16, 2020) U.S. critical care physicians treating coronavirus disease 2019 patients who participated in a National survey earlier in the pandemic (April 23, 2020 to May 3, 2020) regarding their stress and shortages they faced. SETTING: ICU. PATIENTS: Coronavirus disease 2019 patients. INTERVENTION: Irrelevant. MEASUREMENT: Physician emotional distress/physical exhaustion: low (not at all/not much), moderate, or high (a lot/extreme). Shortage indicators: insufficient ICU-trained staff and shortages in medication, equipment, or personal protective equipment requiring protocol changes. MAIN RESULTS: Of 2,375 U.S. critical care attending physicians who responded to the initial survey, we received responses from 1,356 (57.1% response rate), 97% of whom (1,278) recently treated coronavirus disease 2019 patients. Two thirds of physicians (67.6% [864]) reported moderate or high levels of emotional distress in the Spring versus 50.7% (763) in the Fall. Reports of staffing shortages persisted with 46.5% of Fall respondents (594) reporting a staff shortage versus 48.3% (617) in the Spring. Meaningful shortages of medication and equipment reported in the Spring were largely alleviated. Although personal protective equipment shortages declined by half, they remained substantial. CONCLUSIONS: Stress, staffing, and, to a lesser degree, personal protective equipment shortages faced by U.S. critical care physicians remain high. Stress levels were higher among women. Considering the persistence of these findings, rising levels of infection nationally raise concerns about the capacity of the U.S. critical care system to meet ongoing and future demands.

Association of Use of the NEJM Knowledge+ Product and Performance on the ABIM IM-MOC Exam.

Phenomenon: Internal medicine physicians in the United States must pass the American Board of Internal Medicine Internal Medicine Maintenance of Certification (ABIM IM-MOC) examination as part of their ABIM IM-MOC requirements. Many of these physicians use an examination product to help them prepare, such as e-Learning products, including the ACP's MKSAP, UpToDate, and NEJM Knowledge+, yet their effectiveness remains largely unstudied. Approach: We compared ABIM IM-MOC examination performance among 177 physicians who attempted an ABIM IM-MOC examination between 2014-2017 and completed at least 75% of the NEJM Knowledge+ product prior to the ABIM IM-MOC examination and 177 very similar matched control physicians who did not use NEJM Knowledge+. Our measures of ABIM IM-MOC exam performance for NEJM Knowledge+ users were based on the results of the first attempt immediately following the NEJM Knowledge+ use and for non-users were based on the applicable matched examination performance. The three dichotomous examination performance outcomes measured on the first attempt at the ABIM IM-MOC examination included pass rate, scoring in the upper quartile, and scoring in the lower quartile. Findings: Use of NEJM Knowledge+ was associated with a regression adjusted 10.6% (5.37% to 15.8%) greater likelihood of passing the MOC examination (p < .001), 10.7% (2.61% to 18.7%) greater likelihood of having an examination score in the top quartile (p = .009), and -10.8% (-16.8% to -4.86%) lower likelihood of being in the bottom quartile of the MOC examination (p < .001) as compared to similar physicians who did not use NEJM Knowledge+. Insight: Physicians who used NEJM Knowledge+ had better ABIM IM-MOC exam performance. Further research is needed to determine what aspects of e-Learning products best prepare physicians for MOC examinations.

Opportunities for Maintenance of Certification to Better Reflect Scope of Practice Among Medical Oncologists.

PURPOSE: Critics argue that the American Board of Internal Medicine's medical oncology Maintenance of Certification examination requires medical oncologists with a narrow scope of practice to spend time studying material that is no longer relevant to their practice. However, no data are available describing the scope of practice for medical oncologists. METHODS: Using Medicare claims, we examined the scope of practice for 9,985 medical oncologists who saw 8.6 million oncology conditions in 2016, each of which was assigned to 1 of 23 different condition groups. Scope of practice was then measured as the percentage of oncology conditions within each of the 23 groups. We grouped physicians with similar scopes of practice by applying K-means clustering to the percentage of conditions seen. The scope of practice for each physician cluster was determined from the cancers that encompassed the majority of average oncology conditions seen among physicians composing the cluster. RESULTS: We found 20 distinct scope-of-practice clusters. The largest (n = 6,479 [65.5%]) had a general oncology scope of practice. The remaining physicians focused on a narrow scope of cancers, including 22.6% focused on ≥ 1 solid tumors and 11.9% focused on hematologic malignancies. The largest focused cluster accounted for 7.7% of physicians focused on breast cancer. CONCLUSION: A single American Board of Internal Medicine Maintenance of Certification assessment in medical oncology is most appropriate for approximately 65% of certified medical oncologists' practices. However, the addition of assessments focused on breast cancer and hematologic malignancies could increase this figure to upwards of 85% of certified medical oncologists.

Physician clinical knowledge, practice infrastructure, and quality of care.

OBJECTIVES: To understand if and how one dimension of physician skill, clinical knowledge, moderates the relationship between practice infrastructure and care quality. STUDY DESIGN: We included 1301 physicians who certified in internal medicine between 1991 and 1993 or 2001 and 2003 and took the American Board of Internal Medicine (ABIM)'s Maintenance of Certification (MOC) exam and completed ABIM's diabetes or hypertension registry during their 10-year recertification period between 2011 and 2014. Composite quality scores (overall, process, and intermediate outcome) were based on chart abstractions. Practice infrastructure scores were based on a web-based version of the Physician Practice Connections Readiness Survey. Our measure of clinical knowledge was drawn from MOC exam performance. METHODS: We regressed a physician's composite care quality scores against the interaction between their practice infrastructure and MOC exam scores with controls for physician, practice, and patient panel characteristics. RESULTS: We found that a physician's exam performance significantly moderated the association between practice infrastructure and care quality (P for interaction = .007). For example, having a top quintile practice infrastructure score was associated with a quality care score that was 7.7 (95% CI, 4.3-11.1) percentage points (P <.001) higher among physicians scoring in the top quintile of their MOC exam, but it was unrelated (0.7 [95% CI, -3.8 to 5.3] percentage points; P = .75) to quality among physicians scoring in the bottom quintile on the exam. CONCLUSIONS: Physician skill, such as clinical knowledge, is important to translating patient-centered practice infrastructure into better care quality, and so it may become more consequential as practice infrastructure improves across the United States.

How Physicians Prepare for Maintenance of Certification Exams: A Qualitative Study.

PURPOSE: Little is known about how board-certified physicians prepare for their periodic maintenance of certification (MOC) examinations. This qualitative study explores how physicians experience MOC exam preparation: how they prepare for the exams and decide what to study and how exam preparation compares with what they normally do to keep their medical knowledge current. METHOD: Between September 2016 and March 2017, the authors interviewed 80 primary care physicians who had recently taken either the American Board of Family Medicine or American Board of Internal Medicine MOC exam. They analyzed transcripts and notes from these interviews looking for patterns and emergent themes, using the constant comparative method and a social practice theory perspective. RESULTS: Most interviewees studied for their MOC exams by varying from their routines for staying current with medical knowledge, both by engaging with a different scope of information and by adopting different study methods. Physicians described exam preparation as returning to a student/testing mindset, which some welcomed and others experienced negatively or with ambivalence. CONCLUSIONS: What physicians choose to study bounds what they can learn from the MOC exam process and, therefore, also bounds potential improvements to their patient care. Knowing how physicians actually prepare, and how these activities compare with what they do when not preparing for an exam, can inform debates over the value of requiring such exams, as well as conversations about how certification boards and other key stakeholders in physicians' continuing professional development could improve the MOC process.

Do State Continuing Medical Education Requirements for Physicians Improve Clinical Knowledge?

OBJECTIVE: To evaluate the effect of state continuing medical education (CME) requirements on physician clinical knowledge. DATA SOURCES: Secondary data for 19,563 general internists who took the Internal Medicine Maintenance of Certification (MOC) examination between 2006 and 2013. STUDY DESIGN: We took advantage of a natural experiment resulting from variations in CME requirements across states over time and applied a difference-in-differences methodology to measure associations between changes in CME requirements and physician clinical knowledge. We measured changes in clinical knowledge by comparing initial and MOC examination performance 10 years apart. We constructed difference-in-differences estimates by regressing examination performance changes against physician demographics, county and year fixed effects, trend-state indicators, and state CME change indicators. DATA COLLECTION: Physician data were compiled by the American Board of Internal Medicine. State CME policies were compiled from American Medical Association reports. PRINCIPAL FINDINGS: More rigorous CME credit-hour requirements (mostly implementing a new requirement) were associated with an increase in examination performance equivalent to a shift in examination score from the 50th to 54th percentile. CONCLUSIONS: Among physicians required to engage in a summative assessment of their clinical knowledge, CME requirements were associated with an improvement in physician clinical knowledge.

Association between the American Board of Internal Medicine's General Internist's Maintenance of Certification Requirement and Mammography Screening for Medicare Beneficiaries.

BACKGROUND: Breast cancer is a leading cause of death in the United States. Continuing medical education programs such as the American Board of Internal Medicine's Maintenance of Certification (MOC) program can increase early detection of cancers by educating physicians about the benefits of screening. Did the imposition of American Board of Internal Medicine's MOC requirement affect guideline-compliant mammography screening? METHOD: To address this question, we took advantage of a natural experiment that occurred when one group of general internists was required to complete MOC by 2001 because they initially certified in 1991 (MOC required) and another group was grandfathered out of this requirement because they initially certified in 1989 (MOC grandfathers). To measure associations with the MOC requirement, we compared mammography screening in the 2 years before and the 3 years after the 2001 MOC requirement among beneficiaries treated by the MOC-required physicians and compared this difference with the same difference in mammography screening among a control group of beneficiaries treated by the MOC-grandfathered physicians. RESULTS: We found that the MOC requirement was associated with a regression adjusted 2.8% increase (p < .001) in annual screening and 1.7% increase (p < .001) in biennial screening. When we limited the sample to beneficiaries with no screening at baseline (1999 and 2000), these figures increased to 8.5% (p = .02) and 6.4% (p = .01), respectively. CONCLUSIONS: The MOC requirement was associated with an improvement in guideline-compliant mammography screening with the most pronounced improvements among women who were the least adherent at baseline and therefore might have benefited the most from screening.

The role of internal medicine subspecialists in patient care management.

OBJECTIVES: To understand the clinical roles in which internal medicine (IM) subspecialists engage, especially those involving ongoing patient management. STUDY DESIGN: Measures of physician clinical roles were based on survey responses collected from 8020 mid-career IM subspecialists who registered for the American Board of Internal Medicine maintenance of certification program (86% registration/response rate) between 2009 and 2013. METHODS: Each subspecialist reported their percentage of clinical time in 5 clinical roles: primary, principal, longitudinal consultative, medical consultative, and procedural care. We characterized an IM subspecialist's clinical role focus as those roles that composed a majority of their clinical time. RESULTS: Most IM subspecialists reported spending a majority of their time performing 1 (65%) or 2 (31%) clinical roles. Most (54%) reported a clinical role focused on ongoing patient care management roles, including principal care (eg, total responsibility for a specific condition, 23%), longitudinal consultative care (eg, shared care, 21%); or a mixed clinical role focus composed of both principal and longitudinal consultative care (8%). We also found that physicians focused on ongoing patient care management roles represent a significant percentage of physicians within most IM subspecialties (ranging from 19% to 88% across subspecialties). CONCLUSIONS: A subspecialist's clinical role focus is an important practice characteristic, and many subspecialists perceive themselves as playing a significant role in care management. These findings suggest there are opportunities to incorporate subspecialists into newer payment and care delivery reforms; they also bring to light reasons that training and certification programs should consider the different clinical role foci subspecialists adopt.

Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.

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 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.

Tax subsidies for employment-related health insurance: estimates for 2006.

Employment-related health insurance is subsidized through exemptions from federal and state income taxes, as well as from taxes for Social Security and Medicare. Proposals to modify this subsidy are a perennial subject of policy debate. We present tax-subsidy projections from a new data resource constructed using a statistical linkage between the establishment and household components of the Medical Expenditure Panel Survey (MEPS). We project that the total federal and state tax subsidy in 2006 for employment-related coverage of active workers will exceed 200 billion dollars. We present per worker tax-subsidy estimates and an analysis of insurance incidence by establishment characteristics.