Transitioning from Medical Licensure to Certification: Architects Show a Way

A good place for reform‐​minded public health policymakers to start is to consider how licensure works in the architecture profession. Based on a hybrid of licensing and certification, it enables architects to practice in 54 states and territories plus the District of Columbia. The certification even lets them practice in Canada, Mexico, New Zealand, and Australia. Architects, who often work on multiple projects in different regions of the country or the world, would be stymied if there was no way around licensing obstacles. The solution they developed points a way for other professions.

The way the architecture industry handles the matter is through the National Council of Architectural Registration Boards, a private non‐​profit organization that credentials and certifies training, competency, and work quality of architects. The NCARB was founded in 1919 to encourage state architecture licensing boards to establish uniform standards across the country. Today, licensing boards in all 55 U.S. jurisdictions grant a license to any applicant who is NCARB‐​certified.

An architect needs only to pay state licensing fees as well as a certificate transmittal fee to the NCARB. Canada, Mexico, New Zealand, and Australia recognize NCARB certification as well. NCARB is working to seek recognition by other Asian‐​Pacific countries. The NCARB also offers two “alternative paths” to certification for applicants who have substantial work experience in architecture but have not graduated from accredited architectural programs. Architects may apply directly to state licensing boards and jump through all the hoops necessary to obtain a state license. But once an architect is NCARB‐​certified, the obstacles get removed from the road.

While the architecture model is markedly better than that used for health professionals, it could be better. Architects must still go through the hassle of getting a state architecture license when an NCARB certificate is all they really need. The licensing boards are redundant. They only add bureaucracy and cost to the process. The certification process should completely replace licensure. States should end licensing boards and allow architects maintaining NCARB certification to automatically set up practice. They should also permit architects who are certified by other accredited organizations that may arise to compete with NCARB.

Still, when state lawmakers take a critical look at how health care licensing laws stand in the way of getting health care to their constituents, they can learn much from the architecture example. A move toward certification as an alternative to licensure would allow more individuals to enter the pool of health care providers based upon skill and experience. Nurse practitioners and physician assistants, for example, would be able to offer more services to patients by demonstrating proficiency to the certification organization. This would increase patients’ access and broaden their choices.

And as policymakers work toward these reforms, they must keep in mind that a license to practice medicine does not necessarily ensure quality care. Private credentialing and certification organizations, such as the American Board of Surgery and the American Board of Internal Medicine, provide the sort of vetting of practitioners’ training and competency that health‐​care consumers need when seeking medical advice. Insurance plans and health care facilities also carefully screen providers before adding them to their panels. Licensing boards only confirm that practitioners meet basic requirements, and do not provide the more detailed information consumers often require.

The fact is that licensing doesn’t protect people in the ways many people assume it does. Once doctors have a license, they may practice any specialty they choose. Many hospitals or insurance companies, on the other hand, may require their panels of providers to be specialty‐​board certified. For example, a physician with no formal training or certification in psychiatry can post “psychiatrist” on the office door but would not be able to practice psychiatry in a hospital. Credentialing protects people by carefully examining and verifying physicians’ depth of training and experience in the area in which they claim to have expertise.

Certifying entities and credentialing by health care organizations provide a more accurate assessment of training and competence. And it is important for certifying entities to be open to competition. Several of the medical specialties, including plastic surgery, spine surgery, pain management, and sleep medicine, have more than one organization from which to seek certification of training and competence. And most certification organizations are private. They compete based on the quality of their credentialing. There are also organizations that certify the certifiers. Practitioners compete based on the reputation of their certifications as well.

Ultimately, when pursuing any reforms, policymakers must remember that artificial shortages develop wherever there are barriers to entry by new providers. Clinician‐​licensing laws artificially reduce the availability of health care practitioners and the availability of care. Replacing licensing with certification will help to rectify the situation and increase the availability of critical health care services nationwide.