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Examining the Burden of Licensure, Certification, and Related Credentialing Costs in Young Physicians

      To the Editor:
      The financial burden of the overall licensure and certification process borne by physicians-in-training, and those who have recently completed their training and are beginning to enter clinical practice, has become excessive.
      • Nora L.M.
      • Wynia M.K.
      • Granatir T.
      Of the profession, by the profession, and for patients, families, and communities: ABMS board certification and medicine’s professional self-regulation.
      • Teirstein P.S.
      • Topol E.J.
      The role of maintenance of certification programs in governance and professionalism.
      • Frake P.C.
      • Cheng A.Y.
      • Howell R.J.
      • Patel N.J.
      Resident physicians’ perspectives on health care reform.
      • Frintner M.P.
      • Mulvey H.J.
      • Pletcher B.A.
      • Olson L.M.
      Pediatric resident debt and career intentions.
      It is worth reminding ourselves that for most new physicians these costs must be managed while concurrently beginning to repay large education debts and incurring the general expenses of becoming established in early family and professional life.
      Based on our review and analysis, total estimated expenses and opportunity costs associated with licensure and certification occurring through completion of the first board recertification cycle for physicians is between $10,000 and $20,000, depending on specialty, geographic location, and utilization of preparatory courses and materials. When compared with a sample population of advanced nurse practitioners or physician assistants, the difference is staggering. For the same time period, non–physician-practitioner organizations charge less than $3000 for their licensing and certification (see the Table). Beyond the fiscal strain imposed on physicians by the mandated expenses, there are associated travel expenses and lost work time associated with examinations and recertification. Furthermore, preparatory expenses (eg, attending preparatory courses, purchasing self-help materials, and additional travel expenses), while not mandatory, are a significant expense shouldered by most young physicians, and these have widely variable (but oftentimes immense) associated costs.
      TableComparison of Physicians and Provider Expenses Associated With Medical Licensing, Board Certifications, Continued Certifications, and Other Expenses
      Elective preparatory expenses, lost wages, and travel expenses are not included. All examination and licensing costs as of September 13, 2015.
      ,
      All attempts were made to be accurate and up-to-date with fees and licensure requirements. However, given the complex nature of the different medical professions and the variation in requirements based on practitioner type, society, specialty, and geographic location, our calculations are approximations of the true costs.
      ExpenseInternal medicine physicianPediatric anesthesiologistNurse practitionerCertified registered nurse anesthetistPhysician assistant
      Medical education training exam(s)$3305

      USMLE examination fees. USMLE Exam Fees web site. http://www.nbme.org/students/examfees.html and http://www.fsmb.org/licensure/usmle-step-3/cost-and-fees. Accessed September 13, 2015.

      $3305

      USMLE examination fees. USMLE Exam Fees web site. http://www.nbme.org/students/examfees.html and http://www.fsmb.org/licensure/usmle-step-3/cost-and-fees. Accessed September 13, 2015.

      $200

      Fees & payment. National Council of State Boards of Nursing web site. https://www.ncsbn.org/1203.htm. Accessed September 13, 2015.

      $200

      Fees & payment. National Council of State Boards of Nursing web site. https://www.ncsbn.org/1203.htm. Accessed September 13, 2015.

      $475

      PANCE Registration information. National Commission on Certification of Physician Assistants web site. http://www.nccpa.net/pance-registration. Accessed September 13, 2015.

      State license
      • Teirstein P.S.
      • Topol E.J.
      The role of maintenance of certification programs in governance and professionalism.
      $1000

      Licensing physicians. Arizona Medical Board web site. https://www.azmd.gov/FAQ/LicensingPhysicians.aspx. Accessed September 13, 2015.

      $1000

      Licensing physicians. Arizona Medical Board web site. https://www.azmd.gov/FAQ/LicensingPhysicians.aspx. Accessed September 13, 2015.

      $200

      Applications & forms. Arizona State Board of Nursing web site. https://www.azbn.gov/licensure-certification/applications-forms. Accessed September 13, 2015.

      $200

      Applications & forms. Arizona State Board of Nursing web site. https://www.azbn.gov/licensure-certification/applications-forms. Accessed September 13, 2015.

      $125

      Schedule of fees. Arizona Regulatory Board of Physician Assistants web site. http://www.azpa.gov/PA%20Center/Fee_Schedule.aspx. Accessed September 13, 2015.

      Renewal fees (10-y total, eg, AZ)
      • Teirstein P.S.
      • Topol E.J.
      The role of maintenance of certification programs in governance and professionalism.
      $4000

      Licensing physicians. Arizona Medical Board web site. https://www.azmd.gov/FAQ/LicensingPhysicians.aspx. Accessed September 13, 2015.

      $4000

      Licensing physicians. Arizona Medical Board web site. https://www.azmd.gov/FAQ/LicensingPhysicians.aspx. Accessed September 13, 2015.

      $320

      License renewal FAQs. Arizona State Board of Nursing web site. https://www.azbn.gov/faqs/licensure-certification/registered-nurse-practical-nurse/license-renewal-faqs. Accessed September 13, 2015.

      $320

      License renewal FAQs. Arizona State Board of Nursing web site. https://www.azbn.gov/faqs/licensure-certification/registered-nurse-practical-nurse/license-renewal-faqs. Accessed September 13, 2015.

      $1665

      Schedule of fees. Arizona Regulatory Board of Physician Assistants web site. http://www.azpa.gov/PA%20Center/Fee_Schedule.aspx. Accessed September 13, 2015.

      Drug Enforcement Agency license (3-y license)
      • Frake P.C.
      • Cheng A.Y.
      • Howell R.J.
      • Patel N.J.
      Resident physicians’ perspectives on health care reform.
      $731

      Application for registration under Controlled Substances Act of 1970 (new applicants only). Drug Enforcement Administration, Office of Diversion Control web site. https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/newAppLogin.jsp. Accessed September 13, 2015.

      $731

      Application for registration under Controlled Substances Act of 1970 (new applicants only). Drug Enforcement Administration, Office of Diversion Control web site. https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/newAppLogin.jsp. Accessed September 13, 2015.

      $731

      Application for registration under Controlled Substances Act of 1970 (new applicants only). Drug Enforcement Administration, Office of Diversion Control web site. https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/newAppLogin.jsp. Accessed September 13, 2015.

      $731

      Application for registration under Controlled Substances Act of 1970 (new applicants only). Drug Enforcement Administration, Office of Diversion Control web site. https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/newAppLogin.jsp. Accessed September 13, 2015.

      $0

      Application for registration under Controlled Substances Act of 1970 (new applicants only). Drug Enforcement Administration, Office of Diversion Control web site. https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/newAppLogin.jsp. Accessed September 13, 2015.

      Board certification
      • Frintner M.P.
      • Mulvey H.J.
      • Pletcher B.A.
      • Olson L.M.
      Pediatric resident debt and career intentions.
      $1365

      ABIM Certification Exam. American Board of Internal Medicine web site. http://www.abim.org/exam/cert-cost.aspx. Accessed September 13, 2015.

      $1550

      Dates, fees, & registration. American Board of Anesthesiologists web site. http://www.theaba.org/Exams/Traditional-Part-1/Dates,-Fees-and-Registration. Accessed September 13, 2015.

      $270

      Family Nurse Practitioner Certification fee. American Nurses Credentialing Center web site. http://www.nursecredentialing.org/familynp. Accessed September 13, 2015.

      $725

      National Certification Examination (NCE) Handbook. National Board of Certification and Recertification for Nurse Anesthetists web site. http://www.nbcrna.com/certification/SiteAssets/Pages/Program-Administration/NCE_Handbook.pdf. Accessed September 13, 2015.

      $350

      Specialty certificates of added qualifications (CAQS). National Commission on Certification of Physician Assistants web site. http://www.nccpa.net/Specialty-CAQs. Accessed September 13, 2015.

      Oral board examination
      • Cascardo D.
      Overcoming the physician shortage: steps to successful physician recruitment and retention.
      $0$2100

      Dates, fees, & registration. American Board of Anesthesiologists web site. http://www.theaba.org/Exams/Traditional-Part-2/Dates,-Fees-and-Registration. Accessed September 13, 2015.

      $0$0$0
      Subspecialty board certification
      • Cascardo D.
      Overcoming the physician shortage: steps to successful physician recruitment and retention.
      $0$1600

      Dates, fees, and registration. American Board of Anesthesiologists web site. http://www.theaba.org/Exams/Pediatric-Anesthesiology/Dates,-Fees-and-Registration. Accessed September 13, 2015.

      $0$0$0
      Maintenance of certification (per 10 y)

      USMLE examination fees. USMLE Exam Fees web site. http://www.nbme.org/students/examfees.html and http://www.fsmb.org/licensure/usmle-step-3/cost-and-fees. Accessed September 13, 2015.

      $1940

      Enroll, cost & policies. American Board of Internal Medicine web site. http://www.abim.org/maintenance-of-certification/policies.aspx#program-fees. Accessed September 13, 2015.

      $2100

      About MOCA. American Board of Anesthesiologists web site. http://www.theaba.org/MOCA/About-MOCA. Accessed September 13, 2015.

      $200

      Family Nurse Practitioner Certification Maintain Certification. American Nurses Credentialing Center web site. http://www.nursecredentialing.org/familynp#maintain. Accessed September 13, 2015.

      $440

      Recertification application frequently asked questions (FAQs). National Board of Certification and Recertification for Nurse Anesthetists web site. http://www.nbcrna.com/recertification/Documents/Recertification%20FAQs%20January%202015.pdf. Accessed September 13, 2015.

      $0
      Total$12,341$16,386$1921$2616$2615
      a Elective preparatory expenses, lost wages, and travel expenses are not included. All examination and licensing costs as of September 13, 2015.
      b All attempts were made to be accurate and up-to-date with fees and licensure requirements. However, given the complex nature of the different medical professions and the variation in requirements based on practitioner type, society, specialty, and geographic location, our calculations are approximations of the true costs.
      As financial pressures continue to mount for practicing physicians, we must recognize that in this era of ever-changing health care reform and downstream changes in physicians’ roles and responsibilities, being a physician in the 21st century is arguably more demanding and stressful than at any time in history. It is our firm belief that contemporary accreditation bodies should not unduly add to the stress and financial burdens physicians encounter. Instead, medicine’s credentialing and certification monopolies should transparently assess and report the value of ongoing and new programs (eg, maintenance of certification activities), work toward reducing the overall costs of credentialing and recredentialing physicians, and seek novel opportunities to support our profession’s newest members. Doing so would reduce the overall trend of increasing bureaucracy and costs and allow young physicians to better focus on delivering patient care and becoming health care’s future leaders.
      Physician shortages are real, and we must minimize ill-constructed financial barriers to a career in medicine or limitations on specialty choice.

      USMLE examination fees. USMLE Exam Fees web site. http://www.nbme.org/students/examfees.html and http://www.fsmb.org/licensure/usmle-step-3/cost-and-fees. Accessed September 13, 2015.

      Unless credentialing/recredentialing and other financial and nonfinancial burdens on physicians are remediated in the current period of increasing government-dictated equalization of scopes of practice and payments to physicians versus nonphysician providers, young trainees will increasingly ask, “Why sacrifice to become a physician?”

      References

        • Nora L.M.
        • Wynia M.K.
        • Granatir T.
        Of the profession, by the profession, and for patients, families, and communities: ABMS board certification and medicine’s professional self-regulation.
        JAMA. 2015; 313: 1805-1806
        • Teirstein P.S.
        • Topol E.J.
        The role of maintenance of certification programs in governance and professionalism.
        JAMA. 2015; 313: 1809-1810
        • Frake P.C.
        • Cheng A.Y.
        • Howell R.J.
        • Patel N.J.
        Resident physicians’ perspectives on health care reform.
        Otolaryngol Head Neck Surg. 2011; 145: 30-34
        • Frintner M.P.
        • Mulvey H.J.
        • Pletcher B.A.
        • Olson L.M.
        Pediatric resident debt and career intentions.
        Pediatrics. 2013; 131: 312-318
      1. USMLE examination fees. USMLE Exam Fees web site. http://www.nbme.org/students/examfees.html and http://www.fsmb.org/licensure/usmle-step-3/cost-and-fees. Accessed September 13, 2015.

      2. Fees & payment. National Council of State Boards of Nursing web site. https://www.ncsbn.org/1203.htm. Accessed September 13, 2015.

      3. PANCE Registration information. National Commission on Certification of Physician Assistants web site. http://www.nccpa.net/pance-registration. Accessed September 13, 2015.

      4. Licensing physicians. Arizona Medical Board web site. https://www.azmd.gov/FAQ/LicensingPhysicians.aspx. Accessed September 13, 2015.

      5. Applications & forms. Arizona State Board of Nursing web site. https://www.azbn.gov/licensure-certification/applications-forms. Accessed September 13, 2015.

      6. Schedule of fees. Arizona Regulatory Board of Physician Assistants web site. http://www.azpa.gov/PA%20Center/Fee_Schedule.aspx. Accessed September 13, 2015.

      7. License renewal FAQs. Arizona State Board of Nursing web site. https://www.azbn.gov/faqs/licensure-certification/registered-nurse-practical-nurse/license-renewal-faqs. Accessed September 13, 2015.

      8. Application for registration under Controlled Substances Act of 1970 (new applicants only). Drug Enforcement Administration, Office of Diversion Control web site. https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/newAppLogin.jsp. Accessed September 13, 2015.

      9. ABIM Certification Exam. American Board of Internal Medicine web site. http://www.abim.org/exam/cert-cost.aspx. Accessed September 13, 2015.

      10. Dates, fees, & registration. American Board of Anesthesiologists web site. http://www.theaba.org/Exams/Traditional-Part-1/Dates,-Fees-and-Registration. Accessed September 13, 2015.

      11. Family Nurse Practitioner Certification fee. American Nurses Credentialing Center web site. http://www.nursecredentialing.org/familynp. Accessed September 13, 2015.

      12. National Certification Examination (NCE) Handbook. National Board of Certification and Recertification for Nurse Anesthetists web site. http://www.nbcrna.com/certification/SiteAssets/Pages/Program-Administration/NCE_Handbook.pdf. Accessed September 13, 2015.

      13. Specialty certificates of added qualifications (CAQS). National Commission on Certification of Physician Assistants web site. http://www.nccpa.net/Specialty-CAQs. Accessed September 13, 2015.

        • Cascardo D.
        Overcoming the physician shortage: steps to successful physician recruitment and retention.
        J Med Pract Manage. 2014; 29: 223-226
      14. Dates, fees, & registration. American Board of Anesthesiologists web site. http://www.theaba.org/Exams/Traditional-Part-2/Dates,-Fees-and-Registration. Accessed September 13, 2015.

      15. Dates, fees, and registration. American Board of Anesthesiologists web site. http://www.theaba.org/Exams/Pediatric-Anesthesiology/Dates,-Fees-and-Registration. Accessed September 13, 2015.

      16. Enroll, cost & policies. American Board of Internal Medicine web site. http://www.abim.org/maintenance-of-certification/policies.aspx#program-fees. Accessed September 13, 2015.

      17. About MOCA. American Board of Anesthesiologists web site. http://www.theaba.org/MOCA/About-MOCA. Accessed September 13, 2015.

      18. Family Nurse Practitioner Certification Maintain Certification. American Nurses Credentialing Center web site. http://www.nursecredentialing.org/familynp#maintain. Accessed September 13, 2015.

      19. Recertification application frequently asked questions (FAQs). National Board of Certification and Recertification for Nurse Anesthetists web site. http://www.nbcrna.com/recertification/Documents/Recertification%20FAQs%20January%202015.pdf. Accessed September 13, 2015.