There’s a lot of talk about creating a better health care delivery system based on value, not volume.  Much of the focus is on insurers rewarding doctors financially for improving patients’ health in a cost-effective way.  But there’s more to creating a sustainable model for health care that improves quality and lowers costs, and it’s something we can start right now to see results within the next decade: reform the recertification process for doctors.

Currently, doctors are recertified based exclusively on their book knowledge.  Wouldn’t it be better to base medical certification at least in part on how doctors actually practice medicine?  If doctors knew their clinical practices would influence their recertification chances, the resultant accountability would help to improve quality and reduce costs within the 10-year cycle that medical specialty boards generally require for recertification.

As an analogy, would you drive differently if your actual driving habits were retrospectively reviewed as part of a license renewal process?  Probably.  How many fewer accidents and deaths from speeding might there be, and how much more affordable might insurance be as a result? And wouldn’t you rather drive with someone you actually knew followed speed limits rather than someone who just passed a written test demonstrating knowledge of those limits?

The impact of incorporating physician practice into recertification.  How doctors practice medicine would be affected if they knew it mattered for recertification.  Today, medical specialty board recertification procedures require continuing medical education and the demonstration of this knowledge through test modules.  However, no medical specialty board certification process reviews how a physician actually practices in the office.  In other words, a physician may be required to take continuous medical education courses, pass learning modules that assess their medical knowledge, and even self-assess their practice using specific patients — but there is no independent oversight of medical records and medical claims submissions to assess whether a physician employed this learning in their actual practice.

Consider antibiotics.  Specialty societies endorse and publish clinical practice guidelines regarding when specific antibiotics should or should not be used, but medical certification boards do not review whether or not the doctor adhered to these guidelines. If such adherence were incorporated into the certification process, the medical profession itself could create a level of accountability that would likely improve the quality and reduce the cost of health care.

Measuring what physicians actually do at the point of care is important because the variability of how physicians practice medicine is a major component of why our health care system doesn’t always deliver optimal quality and why medical costs are higher on average than they should be.  The over- and under-utilization of health care resources causes some patients to get care that is too little, too late, and others to get care that is too much, too often.

How our proposal would work.  How could we incorporate assessments of a physician’s actual practice patterns into the recertification process?  Here’s a start:  All health plans and the Centers for Medicare and Medicaid (CMS) would submit their physician claim data to an independent third party data analytics company.  Based on this data, along with a physician’s electronic medical record data, the third party would score a physician’s practice patterns according to medical board definitions of quality reflecting the clinical practice guidelines endorsed by the physician’s specialty.

This new requirement of incorporating actual practice patterns into part of the recertification process would be implemented in a reasonable time frame defined by the medical certification boards. The boards could use many of the practice improvement pathways that already exist to support those physicians identified by this independent analysis as needing practice improvement, reducing clinical variability with the ultimate goal of improving quality.

Physicians, particularly those not using electronic medical records, would have the opportunity to review the output of the independent third-party results and augment them with information from their medical records.   The medical certification boards would then use information from the independent third party as a required module to become certified in their specialty of practice.

All physicians also would be given some leeway to reflect the individuality of their patients along with the ambiguities and imperfections in the measures and the relevant guidelines. And prior to the medical board’s target date for full implementation, the data submitted to the independent third party, along with any augmented data, would be available as a preliminary practice analysis that would highlight specific areas for quality improvement. Physicians would  have time before their next required certification to learn from the practice results and implement changes to their practice habits to improve how they treat patients.   Over time, physicians that continued to score very poorly would be at higher risk of losing their certification.

This recertification reform would support the journey from our current “fee-for-service” system that pays for volume to a “pay-for-value” system. Most important, including practice pattern assessments as a required module in the recertification process would provide a sustainable method for a continuous infusion of quality and affordability into our health care system.

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