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Most Health Plans Do Not Require Pediatricians To Be Board Certified

Armen Hareyan's picture

Health Plans and Pediatricians

Health plans conduct a credentialing process to select and retain qualified clinicians who will provide care to their subscribers. The credentialing process is designed to aid health plans in choosing competent clinicians from among all physicians who apply to care for their patients, according to background information in the article. Plans typically establish a set of minimum criteria that must be met by a physician to be granted privileges. One of the tools available to health plans to help ensure physician competence is assessment of board certification status.

Freed and colleagues conducted a telephone survey of credentialing personnel from 244 U.S. health plans, from February through July 2005. The plans were stratified by enrollment size, Medicaid proportion, and for-profit or not-for-profit status. The response rate was 79 percent (193 health plans).

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Overall, 174 (90 percent) of the 193 health plans do not require general pediatricians to be board certified at the time of initial credentialing. Of the 161 health plans that require a pediatric residency, 98 (61 percent) have no time frame in which board certification must be achieved. A total of 80 (41 percent) of the 193 health plans require a general pediatrician to be certified at some point in their association with the health plan. Similarly, only 40 percent ever require subspecialists to become board certified in their subspecialty. Although 41 percent of plans report requiring recertification of general pediatricians, almost half do not have a time frame in which recertification must occur. Seventy-seven percent of plans allow physicians to bill as subspecialists with expired certificates.

"The finding that so few health plans require board certification for a pediatrician to bill as a subspecialist raises questions as to the ability of the plans to ensure the initial or continued competence of these physicians. Such actions also may be self-defeating to plans' quality improvement efforts, as they negate an incentive for these physicians to become certified," the authors write.

"These findings, although specific to pediatrics, very likely apply to the credentialing processes for other primary care disciplines if not more widely to all who undergo plan credentialing. Although there has been variation among specialties in the initiation of time-limited certificates, the ABP has required recertification for almost 20 years. We believe it unlikely that our finding represents a time lag by health plans in incorporating pediatric recertification into their credentialing processes. Many health plans currently do not use board certification in their credentialing processes. Likely, increasing pressure from the public regarding preferences for demonstrable efforts in patient safety will result in a greater emphasis on quality assessments in physician credentialing. As such, the new Maintenance of Certification program will provide health plans with a useful tool in this process," the researchers conclude. (JAMA. 2006;295:913-918)