Correspondence

HMOs and Physicians without Board Certification

N Engl J Med 1993; 328:1501-1502May 20, 1993

Article

To the Editor:

The practice by health maintenance organizations (HMOs) of demanding board certification of participating physicians has become an important factor influencing access to health care in Massachusetts and the rest of the United States.

When managed care first appeared, HMOs enlisted physicians and then used these rosters to market their plans. Concurrently, they developed credentialing criteria, which typically included information on training and licensure, board certification, and malpractice experience. Then HMOs began to emphasize in their marketing that they had only board-certified physicians on their panels, implying that this restriction defined a better plan.

As managed care has grown in the United States and has begun to exclude physicians who are not board certified, some of these physicians have had to leave practice. The number of primary care physicians in the United States who may be affected is unfortunately large, totaling 93,566 (47,596 in internal medicine, 13,093 in pediatrics, and 32,877 in family and general practice)1.

In Massachusetts, managed care plays an important part in the delivery of health care. A physician in private practice cannot survive without participating in several HMOs. So far, only small HMOs have excluded physicians who are not board certified, but lately larger, stronger plans have entered the field. Their policies are expected to cause major problems with the public's access to care. The data in Table 1Table 1Rates of Board Certification among Members of the Massachusetts Medical Society Practicing in Massachusetts, 1992. indicate the magnitude of the problem in Massachusetts2.

Most of these 1196 physicians without certification are men over the age of 50, women, and international medical graduates. The demography is clearly a reflection of the era in which these physicians graduated, gained their licenses, and started practice. There were no family practice boards and no family practice residency programs. There were pediatric and internal medicine boards, but even so, many physicians did not become certified, because doing so was not considered important for private practice. Some women could not complete their residencies because of pregnancy and family considerations.

The exclusion of more than 1000 physicians now providing primary care in Massachusetts will exacerbate current problems of access for patients and at the same time deprive many competent, experienced physicians of their livelihoods. What is needed is a change in credentialing criteria that reflects the value of the same or similar training followed by multiple years of practice experience and recognized competency in clinical practice.

Asha P. Wallace, M.D.
60 Dedham Ave., Needham, MA 02192

2 References

1. 1

   Physician characteristics and distribution in the U.S. Chicago: American Medical Association, 1992.
   

2. 2

   Rates of board certification among members of the Massachusetts Medical Society practicing in Massachusetts. Waltham: Massachusetts Medical Society, August 1992.