Board Certification, MOC, and the Rise of Physician Independence: Why More Doctors Are Rethinking the Recertification Monopoly

Yoon Hang Kim, MD, MPH

Board Certified in Preventive Medicine

Residential Fellowship Trained Integrative Medicine Physician

Institute of Functional Medicine Scholarship Recipient

www.directintegrativecare.com

Something is shifting in American medicine, and it goes well beyond the usual complaints about paperwork and burnout. A growing number of physicians—especially those in direct primary care (DPC), cash-pay models, and independent integrative practices—are asking a question that would have been unthinkable a generation ago: Do I still need ABMS board certification?

I’ve been practicing integrative and functional medicine for over two decades. I hold triple board certification, completed my fellowship under Dr. Andrew Weil at the University of Arizona, and have built integrative medicine programs at institutions including Miami Cancer Institute, the University of Kansas Medical Center, and WellMed/Optum. I say all of that not to list credentials, but to make a point: even physicians with deep institutional experience are recognizing that the current Maintenance of Certification (MOC) system has become disconnected from clinical reality.

This isn’t an anti-certification screed. It’s a clear-eyed look at the data, the economics, the emerging alternatives, and the convergence of physician autonomy movements—from DPC to the National Board of Physicians and Surgeons (NBPAS)—that are collectively reshaping how we think about competency, accountability, and lifelong learning in medicine.

The MOC Problem: Burden Without Evidence

The American Board of Medical Specialties (ABMS) launched its MOC requirements in 2000, and the backlash has been building ever since. The numbers tell a striking story.

A landmark 2016 cross-specialty national survey published in the Mayo Clinic Proceedings found that 81% of physicians considered MOC a burden, only 24% agreed that MOC activities were relevant to their patients, and just 15% felt the process was worth the time and effort. Perhaps most telling, only 9% believed their patients cared about their MOC status. The study found no association between negative attitudes toward MOC and burnout—this wasn’t disgruntled physicians lashing out. It was a broad, cross-specialty consensus that the system lacks value.

The American Medical Association has identified MOC as one of twelve external factors driving physician burnout, noting that MOC activities are “typically handled after work,” adding to an already overwhelming administrative load. A 2023 American Society of Clinical Oncology survey reinforced these findings: 82% of oncologists considered MOC unnecessary beyond typical CME requirements, and 74% reported it did not improve their clinically relevant knowledge or patient care quality.

The Infectious Diseases Society of America has estimated that its members spend 25 to 62 hours per year on recertification and licensure activities, at costs of $3,400 to $4,100 over a typical ten-year cycle. For physicians among the lowest paid specialties, these represent significant burdens that compound existing burnout pressures.

As Karen Schatten of NBPAS wrote in Medical Economics: “ABMS Maintenance of Certification is a proprietary continuing education product that to date has no high-quality evidence that it improves patient care. The cost and burden associated with MOC remains a significant factor driving physicians out of medicine.” This observation gains weight when you consider that ABMS’s own 2019 survey found only 12% of physicians found value in MOC—a figure that ABMS itself published.

The Monopoly Question: When Certification Becomes Coercion

Understanding why MOC persists despite overwhelming physician dissatisfaction requires understanding the economic architecture behind it. ABMS recently announced a record 988,737 certified physicians—effectively the entire active physician workforce. This isn’t because nearly a million doctors love MOC. It’s because the system has been structured to make opting out professionally devastating.

Here’s how it works: ABMS operates a for-profit subsidiary, ABMS Solutions LLC, which reported $8 million in revenue for 2022 with another $28 million in assets. Hospitals, health systems, residency programs, insurers, and state boards purchase credential verification data from ABMS Solutions. If a physician chooses not to participate in MOC, ABMS Solutions reports them as “not certified”—effectively stripping their credential. The physician is then at risk of losing hospital privileges, insurance panel participation, and even academic appointments.

This has not gone unnoticed by federal regulators. In April 2024, the Federal Trade Commission (FTC), the Department of Justice (DOJ), and the Department of Health and Human Services (HHS) jointly launched a public portal for reporting anti-competitive practices in healthcare—and specifically cited “unnecessary physician recertification requirements” as an example of potentially anti-competitive conduct. NBPAS had formally requested FTC relief in September 2023, arguing that ABMS and its constituent boards were using monopoly power to exclude competitors from the continuing certification market.

In May 2025, NBPAS submitted a statement to the House Judiciary Antitrust Subcommittee describing ABMS and the ACGME as having “created a vertically integrated, self-reinforcing system that blocks competition, limits physician autonomy, and misuses taxpayer-funded resources.” The statement highlighted that physician board certification is largely funded by over $15 billion in annual federal Graduate Medical Education (GME) funding—public investment that is then leveraged by private organizations to enforce compliance with their proprietary products.

NBPAS: The Alternative That Physicians Built

The National Board of Physicians and Surgeons was founded in 2015 by renowned cardiologist Paul Teirstein, MD, along with twenty other physician leaders, after more than 22,000 physicians signed a petition opposing MOC requirements. Today, NBPAS certifies over 15,000 physicians across all 50 states and is accepted at over 200 hospitals, health systems, academic institutions, telemedicine companies, major payers, and the Veterans Health Administration.

The contrast with ABMS could not be sharper. NBPAS requires initial certification from ABMS or AOA, an active medical license, and 50 hours of specialty-specific AMA PRA Category 1 CME over 24 months. The cost is $189 for two years. The application takes less than five minutes. There are no high-stakes examinations, no mandatory modules, no late fees. Physicians choose the CME most relevant to their individual practices and patient populations.

A critical milestone came in July 2022, when The Joint Commission designated NBPAS as a “Designated Equivalent Source Agency,” enabling hospitals and health systems to use NBPAS certification for credentialing and privileging requirements. This was a watershed moment. As NBPAS Associate Director Karen Schatten noted, NBPAS recertification is 72% less costly on average than other pathways, which supports physician recruitment and retention.

Voices from the Movement

The NBPAS testimonial page reads like a manifesto of physician liberation. Physicians across specialties are sharing their experiences of switching—and the relief is palpable.

One physician wrote: “Dropped my original certification this year. I am now solely boarded through the NBPAS. I am so incredibly proud of what this grassroots effort has accomplished and I continue to encourage more physicians to join our ranks.”

Another stated: “There is not much that gives me hope in our physician world these days, but NBPAS is a bright shining light of hope of the integrity and autonomy of our profession.”

A solo practitioner captured the frustration of many: “I own a very specialized solo medical practice and haven’t performed traditional family medicine in years. However, to see some of the patients that want to see me, it requires me to get certified for some insurances which require board certification. Not only am I being forced to be tested on medical conditions that I will never see, I also have to spend money and time away from my practice.”

Dr. Michelle Cooke, a family physician who founded Sol Direct Primary Care in southwest Atlanta, encapsulated the DPC perspective in a 2024 DPC News article. After letting her ABFM certification lapse, she wrote: “As a DPC physician, I’m much more discerning about which boxes I check and why. Increasingly, I saw little value in maintaining my ABFM certification.” She now certifies through NBPAS at a fraction of the cost, with her malpractice insurer recognizing the certification for premium discounts.

Judith Bateman, MD, a practicing rheumatologist in Michigan, cited MOC as a direct cause for early retirement among her colleagues. In NBPAS’s February 2024 press release, she noted: “Three colleagues in my area have just retired at relatively young ages, each pointing to MOC as one of the factors which weighed in their decision.” In an era of critical physician shortages, every premature retirement represents patients who will struggle to find care.

The DPC Revolution and the Certification Question

Direct Primary Care has grown from approximately 500 practices in 2015 to thousands of clinics nationwide, with surveys indicating around 9% of family physicians now practice in some form of DPC model. Market reports project continued growth through the 2020s, driven by physicians seeking reduced administrative burden, professional autonomy, and meaningful patient relationships unencumbered by insurance bureaucracy.

A 2021 study published in the Journal of the American Board of Family Medicine and conducted through the University of Kansas Medical Center found that DPC physicians consistently reported more favorable views of their practice model compared to fee-for-service peers, emphasizing benefits like lower administrative burden, improved doctor-patient relationships, and better access for patients. These aren’t physicians running from medicine. They’re running toward it—toward the version of practice they trained for.

Here’s where board certification intersects with practice model. In traditional employment settings—hospitals, large health systems, insurance panels—ABMS board certification and active MOC participation are de facto mandatory for credentialing, privileging, and payer contracts. In a pure DPC or cash-pay setting, physicians who hold an active medical license can see patients without maintaining ABMS certification, removing the key external enforcement mechanism for ongoing MOC participation.

The available data present a nuanced picture. A national survey of DPC physicians found that the majority remain board certified, primarily in family medicine, with minorities in internal medicine and pediatrics. A 2025 cross-sectional survey of pediatric DPC practices reported 85% board certification rates. Board certification clearly remains the norm in DPC—but these are snapshots, not longitudinal tracking. What they don’t capture is how many physicians, once established in DPC and no longer tethered to hospital and payer requirements, choose not to recertify when their ten-year ABMS cycle comes due.

The Illustrative Pattern

An increasingly common trajectory looks something like this: A physician completes residency and obtains initial board certification. After years of fee-for-service or employed practice, they transition to DPC or a cash-pay model. Once established, they gradually disengage from hospital credentialing committees and insurance panels. When the MOC cycle comes due—the ten-year exam, the escalating fees, the modules on conditions they haven’t treated in a decade—they make a calculation. They either let ABMS certification lapse in favor of state licensure and CME alone, or they transition to NBPAS for a streamlined alternative that honors their commitment to lifelong learning without the institutional overhead.

This pattern is visible in physician-authored accounts across platforms from Medical Economics to KevinMD to personal physician blogs. One family physician who switched from ABMS to NBPAS wrote candidly about the experience: the NBPAS application took minutes, cost under $200, and allowed him to choose CME relevant to his actual practice. He reported no difficulty finding employment a year later and described the switch as “one of the best things I did for my wallet and sanity.”

The Integrative Medicine Perspective: Why This Matters Beyond Primary Care

I operate a direct-pay telemedicine practice—Direct Integrative Care—capped intentionally at 99 patients to preserve the quality of attention each person deserves. My clinical focus includes complex chronic conditions: autoimmune disorders, mast cell activation syndrome, fibromyalgia, chronic pain, Long COVID, and integrative oncology support. Much of my work centers on Low-Dose Naltrexone therapy, which I’ve been prescribing and studying for over two decades.

The MOC apparatus was never designed for physicians like me—or, frankly, for the thousands of us who have carved out specialized clinical niches that don’t map neatly onto the broad-spectrum examinations that ABMS member boards administer. When you’ve spent twenty years developing expertise in a specific therapeutic area, being required to study and test on conditions you haven’t encountered clinically in a decade is not lifelong learning. It’s bureaucratic theater.

The direct-pay model gives me clinical freedom that insurance-based practice never could. I set my own documentation standards, spend the time each patient requires, choose treatment protocols based on clinical judgment rather than formulary restrictions, and direct my continuing education toward the areas that actually serve my patients. This is not a retreat from accountability. If anything, it’s a more honest form of it—accountability to the patient sitting in front of me, not to a credentialing committee that has never reviewed my charts, met my patients, or evaluated my outcomes.

Where We Go from Here

The convergence of several forces is creating a genuine inflection point in physician certification:

Federal antitrust scrutiny is intensifying. The FTC/DOJ/HHS joint portal, NBPAS’s formal FTC complaint, and congressional testimony are subjecting the ABMS certification monopoly to a level of regulatory attention it has never faced. The framing of MOC as a potentially anti-competitive practice—rather than a quality assurance measure—represents a fundamental shift in the conversation.

Alternative certification pathways are gaining institutional legitimacy. The Joint Commission’s 2022 recognition of NBPAS as a Designated Equivalent Source Agency was not symbolic. It gave hospitals a credentialing pathway that does not require ABMS MOC—and over 200 institutions have acted on it. The Veterans Health Administration’s acceptance adds further weight.

DPC and cash-pay practice models continue to grow. As more physicians exit insurance-based practice, the external enforcement mechanism for MOC participation weakens. Each physician who builds a sustainable practice outside the hospital-insurance complex demonstrates that clinical competence does not require ongoing tribute to ABMS.

The physician shortage makes the status quo untenable. When experienced physicians cite MOC as a factor in early retirement—as Dr. Bateman’s Michigan colleagues did—we are not dealing with an abstract policy debate. We are dealing with patient access to care. Every physician driven out of practice by administrative burden represents a community that loses a healer.

A Call for Honest Medicine

I believe in lifelong learning. I believe in accountability. I believe physicians should be current in their clinical knowledge and transparent about both their capabilities and their limitations. What I do not believe is that any single private organization should hold monopoly power over a physician’s ability to practice medicine—particularly when its own surveys show that the vast majority of physicians find its product burdensome and clinically irrelevant.

The rise of NBPAS, the growth of DPC, and the entry of federal antitrust regulators into this space all point in the same direction: toward a system where physicians choose their own continuing education, where certification reflects clinical competence rather than compliance with a proprietary product, and where the goal of lifelong learning serves patients rather than the revenue models of credentialing organizations.

As NBPAS founder Dr. Paul Teirstein has said: “Our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice.” The physicians who are choosing DPC, choosing NBPAS, or choosing to direct their own learning pathways are not abandoning professionalism. They are reclaiming it.

This is honest medicine. And it is long overdue.

References

Cook DA, Blachman MJ, West CP, Wittich CM. Physician attitudes about maintenance of certification: a cross-specialty national survey. Mayo Clin Proc. 2016;91(9):1336-1345. doi:10.1016/j.mayocp.2016.07.004

American Medical Association. The 12 factors that drive up physician burnout. AMA Practice Management. 2020. https://www.ama-assn.org/practice-management/physician-health/12-factors-drive-physician-burnout

Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020. Mayo Clin Proc. 2022;97(3):491-506.

Schatten K. Prescribing insanity: Monopoly in continuous board certification drives costs up and physicians out. Medical Economics. November 2025. https://www.medicaleconomics.com/view/monopoly-in-continuous-board-certification-drives-physicians-out-of-medicine

National Board of Physicians and Surgeons. About NBPAS: Physician-led, non-profit, continuous certification. https://nbpas.org/pages/about-us

National Board of Physicians and Surgeons. Testimonials. https://nbpas.org/pages/testimonials

National Board of Physicians and Surgeons. Press release: NBPAS leads groundswell of support to address continuous board certification monopoly. February 28, 2024. https://nbpas.org/blogs/featured-news/press-release-february-2024

National Board of Physicians and Surgeons. Statement to House Judiciary Antitrust Subcommittee. May 2025. https://www.congress.gov/119/meeting/house/118236/documents/HHRG-119-JU05-20250514-SD004-U4.pdf

National Board of Physicians and Surgeons. Press release: NBPAS requested relief from the Federal Trade Commission. April 25, 2024. https://nbpas.org/blogs/featured-news/press-release-april-2024

Medscape. Docs gain accrediting option as NBPAS gets credentialing authority. August 2022. https://www.medscape.com/viewarticle/978166

Walton-Shirley M. ABIM or NBPAS recredentialing: Do we really have a choice? Medscape. October 31, 2022. https://www.medscape.com/viewarticle/983128

Cooke M. I’m DPC certified now! Why I let go of my ABFM board certification. DPC News. December 5, 2024. https://dpcnews.com/practice-tip/im-dpc-certified-now-why-i-let-go-of-my-abfm-board-certification/

Etz RS, Gonzalez MM, Brooks EM, et al. Direct primary care: Family physician perceptions of a growing model. J Am Board Fam Med. 2021;34(5):907-914. doi:10.3122/jabfm.2021.05.210052

Healio Primary Care. ‘That criticism was justified’: ABIM MOC program adapts, faces new challenges. September 2024. https://www.healio.com/news/primary-care/20240919/that-criticism-was-justified-abim-moc-program-adapts-faces-new-challenges-and-success

Healio Primary Care. ‘We’re listening’: ABIM axes ‘confusing’ MOC program requirement. December 2024. https://www.healio.com/news/primary-care/20241204/were-listening-abim-axes-confusing-moc-program-requirement

Physicians Practice. The unnecessary burden of maintenance of certification. November 2020. https://www.physicianspractice.com/view/unnecessary-burden-maintenance-certification

Medical Economics. The MOC revolt: NBPAS fights for relevancy. November 2020. https://www.medicaleconomics.com/view/moc-revolt-nbpas-fights-relevancy

About the Author

Yoon Hang Kim, MD, MPH is a board-certified physician specializing in integrative and functional medicine. A graduate of Dr. Andrew Weil’s Integrative Medicine Fellowship at the University of Arizona, Dr. Kim has been practicing integrative medicine since 1999. He is recognized internationally as an expert in Low-Dose Naltrexone (LDN) therapy, having authored two books on LDN and published peer-reviewed research on chronic pain management. Dr. Kim has presented at multiple LDN Research Trust conferences and provides guest podcast appearances on integrative medicine topics.

Dr. Kim practices virtual telemedicine through Direct Integrative Care, serving patients in Iowa, Illinois, Missouri, Georgia, Florida, and Texas.

Clinical Services: www.directintegrativecare.com

Educational Services: www.yoonhangkim.com

YouTube: youtube.com/@YoonHangKimMD

LDN Support Group: ldnsupportgroup.org

Disclaimer: This publication is for educational and informational purposes only and does not constitute medical or legal advice. The views expressed represent the author’s clinical perspective informed by over two decades of practice. Physicians considering changes to their certification status should consult relevant state licensing requirements and institutional policies.