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Does increased malpractice risk lead to increased rates of certification in internal medicine?


Park J, Lipner RS. — American Board of Internal Medicine

Presented: AcademyHealth Annual Research Meeting, June 2011

Research Objective: With much attention focused on medical errors and patient safety issues, as well as spiraling health care costs, Maintenance of Certification (MOC) is recognized as one professional response to the need for public accountability and transparency. The MOC program assures that the physician is committed to continuous professional development, lifelong learning and quality improvement. However, participating in the MOC process is voluntary, and there has been relatively little research on understanding factors that affect physicians’ inclination to maintain their certification. In this study, we examined whether and to what extent increased malpractice threat in the practice region was associated with physicians' decision to maintain their certification.

Study Design: The analyses were conducted using the American Board of Internal Medicine (ABIM) certification files linked to data from the National Practitioner Data Bank and the Medical Liability Monitor from 2000 through 2008. Using physician-level linear probability models with a state-level fixed effects adjustment, we estimated the effect of time-lagged state-level malpractice risk on the likelihood of an internist enrolling in and completing the MOC program. A vector of malpractice risk was measured by up to three years' lagged average number of malpractice claims, damage amounts awarded, number of adverse action reports, and malpractice premiums in each state to allow internists to respond to the risk from the prior years. To avoid a possible source of endogeneity bias, we used changes in state tort laws as instruments for malpractice risk and conducted additional analyses to test the robustness of our results.

Population Studied: 38,656 internists certified between 1990 and 1998.

Principal Findings: The results showed that increases in state-level malpractice risk significantly improve rates of enrolling in and completing the MOC program in Internal Medicine. In particular, there was a dramatic increase in the likelihood of an internist enrolling in the MOC program in states where professional liability insurance premiums are rising. A one percent increase in lagged three-year average premium in state was associated with a 2.7 percentage-point increase in the likelihood of an internist enrolling in the MOC program (p<.01). While higher medical liability premium was a significant determinant of enrollment decision, the frequency and severity of liability claims were positively associated with completing the MOC program. A one percent increase in lagged three-year average number of malpractice claims and payment amounts in state was associated with about a five percentage-point increase in the likelihood of an internist completing the MOC program (p<.01). The results from the instrumental variables approach also supported the positive relationship between malpractice risk and internists’ current MOC status.

Conclusions: Malpractice prevalence in a region is associated with greater likelihood of an internist enrolling in and completing the MOC program.

Implications for Policy, Delivery or Practice: Legal and financial risks inherent in the practice of medicine are a matter of vital importance for all physicians. Understanding determinants to maintain certification is important, as the specialty boards try to meet their obligations to the public to promote quality of care through MOC for all physicians.

For more information about this presentation, please contact Research@abim.org.