A researcher who examined the certification fees and finances at the nation’s medical specialty boards suggests it's time to take a fresh look at the board certification process.
Brian C. Drolet, MD, the co-author of a JAMA study examining the certification fees and finances at the nation’s medical specialty boards, believes the non-profit boards under the American Board of Medical Specialties charge too much money, and test clinicians on a broad range of procedures that they likely will never encounter.
Drolet spoke with HealthLeaders Media recently. The following is a lightly edited transcript.
HLM: What prompted this study?
Drolet: I happen to be in the middle of my board certification process. I took my written exam last year and I am taking the oral exam in the fall. I am preparing and paying for all of the steps and as I was doing that I couldn’t help but ask what are the objectives of this process and where are these charges going?
HLM: What is the cost of your certification?
Drolet: In total it’ll be about $5,000 between the three exams. It’s about $1,500 roughly for each exam, written, oral and hand specialty.
HLM: Had you asked your specialty board about the fees?
Drolet: No. It’s really just a final common pathway for most of us. We finish residency and the assumption is we are going to become board certified. For my particular job, I have to be board certified in order to be employed in my position. So, it is not a question so much as it is something that I just have to do.
HLM: Do alternative sources for certification exist?
Drolet: There are some alternative boards that have started in the last few years. The ABMS is the primary place for board certification and for years they really did have a monopoly on certification.
HLM: You also raise questions about the clinical relevance of these exams. Please elaborate.
Drolet: From my own experience, I am trained as a plastic surgeon but I do primarily hand surgery. My board certification exams include questions about cranial/facial surgery, breast reconstruction, procedures and areas of the specialty that I don’t practice and that I won’t ever practice.
That is probably a similar circumstance for many physicians. If you’re a nephrologist and you’re taking the internal medicine boards then maybe you’re answering questions about infectious disease and cardiology, things that are not as clinically relevant as something you will be doing on a day-to-day basis.
HLM: What can be done to resolve the issues you raise?
Drolet: The process of residency training and board certification might be better integrated. Residency training accredited programs have a lot of oversight from the ACGME to say that they are training good plastic surgeons or nurses or whatever particular specialty they are.
They should integrate the residency programs with board certification whereby when I complete my residency in plastic surgery at an accredited program, there is a streamlined process for me to become board certified. Is it possible to have a final certification exam at the end of residency training?
If you’ve done a good job in your residency and they certify that this person has completed all the necessary components to be a plastic surgeon, what is the purpose of the additional step?
That additional step adds a lot of studying and cost and a whole different experience that has to be completed that hasn’t necessarily been shown to make a significant difference in clinical outcomes.
HLM: The ABMS net balance has more than doubled in a decade. What is driving that?
Drolet: The primary income source for the boards are fees from examinations, so about 90% of revenues for the boards comes from examination fees charged to candidates and diplomats of the board, and only 20% of expenditures are towards those examination fees.
If you look at the finances, it costs them much less to administer the exams than they charge for the exams. They have a margin year-over-year where they increase their assets by whatever they don’t spend on the administration of exams, and whatever compensation they have for employees and officers.
HLM: What would be a reasonable net balance?
Drolet: They are nonprofit organizations and they need to maintain a certain amount of assets for times when they have financial troubles. There are different recommendations from different consulting groups.
Some say from six months to two years. It would depend upon the boards. Some boards have more expenses so they would need more assets.
But, it’s hard to nail down a specific number. You would want to look at what other nonprofits do and what they have to do to maintain their assets through any financial hardships.
And, then you’d have to ask what is the mission of the boards and what do their expenditures go to. If their mission is for certifying physicians in the specialty of that board, how much does that cost and based whatever assets are necessary on that expense.
HLM: You came up with a net balance of $635 million. That’s a lot of money!
Drolet: That is their net balance. That is their assets minus liabilities. Some of the boards have started using deferred revenue accounting, where they apply the examination revenue as a liability, saying they haven’t administered the exams for the people who’ve paid for it, and so that makes it a little trickier to interpret the finances. But all in all you are looking at a huge generation of assets.
We examined their Form 990s. They are pretty standard after you’ve read a few hundred. For example, I’m looking at neuro surgery certification of exam fees, business code 900099, $29,616,384 in total revenue. So, for most of the boards it’s pretty darn specific. They say this is what it costs and this is what we bring in for the exams and this is what we pay.
JAMA did a good job of scrutinizing our data abstraction. It’s not like a line-item budget.
I am sure the accountants who take care of the boards finances have a line-item that says this is what we bring in for this, this is what it costs us for that.
Until they are willing to share that, we can’t verify that the tax records are exactly what the specific finances are. But, based on reading many, many of these there seems to validate that this is their revenue and this is their expenses based on their reporting to the federal government.
HLM: Any idea what they are doing with this net balance?
Drolet: I don’t actually no, truthfully. From the tax forms it looks like most of it is sitting in various investments. Some of their revenue is on their investment income, but I’m not sure how much.
HLM: Was your study peer reviewed?
Drolet: Yes. They were rigorous. We did this a few times to make sure we were fully checked.
HLM: How did these certification boards get so bloated?
Drolet: That’s a great question. I don’t really know the history. When I was a medical student, if you’d asked me if I was going to be board certified, I’d have said absolutely. It’s the final common pathway.
This is the next step in what you do, and all along you pay for licensing exams and it is one test after another. It seems like we have reached the point where people are questioning it and asking if this is what we need to be doing, is this the right thing to do?
HLM: Are you hearing complaints from your colleagues?
Drolet: In my peer class there is definitely discussion that this is an extremely labor intensive process. In the past three weeks, getting my cases together for boards,
I probably spent 30 hours preparing documents and photographs, getting them ready for the tests. That’s time not spent with patients or family. That’s time just spent preparing documents for a test.
HLM: What’s next?
Drolet: The next step is to look at outcomes comparisons between board-certified and non-certified physicians. The problem is most physicians are board certified, about 80%. For my job I can’t have a job without board certification, so it’s what you do.
John Commins is a senior editor at HealthLeaders.