Friday, April 13, 2018

What the ABIM, ACC, and Facebook Have in Common

Mr. Mark Zuckerberg, uncomfortably stuttering and stammering before Senator Cantwell about a little-known company named Palantir (aka "Stanford Analytica"), reminded me of a similar moment when Christine Cassel, MD from the American Board of Internal Medicine (ABIM) had to answer questions about her affiliations with Premier, Inc., and Kaiser Foundation Health Plans and Hospitals upon taking the helm at the National Quality Forum. Dr. Cassel brushed off those concerns as "distractions" by resigning from the boards of those corporations, in large part to avoid questions of why those relationships were an issue.

Nowhere did Ms. Cassel explain that her former non-profit corporation, the American Board of Internal Medicine, had changed its bylaws in 1997 to allow virtually unlimited conflicts of interests to benefit their organization. I remember the ABIM's website claiming their organization gets 97% of its money from its physician-diplomates. Now we see nothing could be farther from the truth. Funds are flowing back from the ABIM Foundation as a "Funding Initiative." And ABIM executives have always enjoyed a wonderfully lucrative relationship with CECity, the $400M data-gathering subsidiary of the hospital group purchase organization, Premier, Inc.:
Through Premier, client organizations are able to quickly and cost-effectively launch their own sophisticated online initiatives directly to their target audience (e.g. members, employees, associates, applicants/diplomates, etc.) by leveraging Premier’s multi-million dollar investment in world-class applications and enterprise-level infrastructure (SAS 70 Type II).

At its core, Premier’s products link performance management (data acquisition via web forms, IVR, external and internal registries, data feeds, etc), assessment, benchmarking, peer comparison, and identification of gaps (financial, knowledge and patient care) with interventions that drive performance improvement.

Our platforms align this cycle of performance management and improvement with various incentive programs to drive healthcare provider participation.

As a CMS-qualified registry for the Physician Quality Reporting System (MIPS, ePrescribing, MOC-MIPS) and as the service provider for many physician certifying boards (e.g. ABIM, ABO, AOA) Premier is uniquely positioned to align professional and financial incentives with CQI to deliver ‘game-changing’ quality initiatives that have proven and measurable results.
This CECity/Premier relationship is firmly embedded in the ABIM's HIPAA Business Associate Addendum agreement every practicing physician must agree to as a condition of enrolling in "Maintenance of Certification (MOC)" (also known as "continuous certification").  With the lack of disclosure of this relationship by the ABIM, is clear that patients and doctors alike aren't supposed to know their personal data are being sold.

The American College of Cardiology

The same data-gathering strategy appears to be true for the American College of Cardiology (ACC). The ACC has always had the ability to side-step the ABIM and re-certification but has chosen not to do so.  Physician and patient data are too important to them, too. I was naive to think that was because of the use of physician data for their NCDR "registries" used by the nation's hospitals. Instead, it seems there may much bigger play in mind, as reported by CNBC:
Facebook provided a quote from Cathleen Gates, the interim CEO of the American College of Cardiology, explaining the possible benefits of the plan:

"For the first time in history, people are sharing information about themselves online in ways that may help determine how to improve their health. As part of its mission to transform cardiovascular care and improve heart health, the American College of Cardiology has been engaged in discussions with Facebook around the use of anonymized Facebook data, coupled with anonymized ACC data, to further scientific research on the ways social media can aid in the prevention and treatment of heart disease—the #1 cause of death in the world. This partnership is in the very early phases as we work on both sides to ensure privacy, transparency and scientific rigor. No data has been shared between any parties."

Health systems are notoriously careful about sharing patient health information, in part because of state and federal patient privacy laws that are designed to ensure that people's sensitive medical information doesn't end up in the wrong hands.

To address these privacy laws and concerns, Facebook proposed to obscure personally identifiable information, such as names, in the data being shared by both sides.

However, the company proposed using a common cryptographic technique called hashing to match individuals who were in both data sets. That way, both parties would be able to tell when a specific set of Facebook data matched up with a specific set of patient data.
While I appreciate the flowery take of this breach by ACC's spokesperson, I'm afraid the ACC's hand is stuck firmly in the financial data mine cookie jar. After all, as we've seen with Facebook and our recent election, not all uses of data are always in our patients' best health care or financial interest.

It's amazing, isn't it? These databases once thought to be a product of ingenuity by for-profit and non-profit organizations, are looking more and more like a product born of little more than opportunity and necessity.

But others much smarter than I have known this long ago. To the ABIM, the ACC, and Facebook: it's all just about guns, germs, and steel.

-Wes

Monday, April 09, 2018

An Internet Quiz: ABIM's Website Moves the Goalposts Again

The Internet loves mystery...

and cover-up.

There are very bright minds out there, and nothing gets those juices flowing for the dedicated Internet sleuths than when someone is trying to hide a carefully crafted change that benefits the Big Guy and screws the Little Man.

Lately, I've been watching the myriad of changes to the ABIM website.

It's got a whole new look and feel, full of big flashy graphics, but little on content. They will argue, no doubt, that it's all made to improve the navigation on their website and to introduce the bold new ideas they have concocted to be sure the fine print is missed.

So here's the challenge.

Take a minute and go the the ABIM website. (Warning, you'll need more than just a minute for this contest, but if you've got the time, this might satisfy criteria for some MOC points/CME credit).

Click on the Maintenance of Certification banner.

Look over to the left and find the "Policies" button. Here's what the screen looks like today:

(Click to enlarge)

Scroll down to look at what you've missed below the fold, as shown here: 

(Click to enlarge)

Now, this is where things get fun. It will be like The Price Is Right, where Bob Barker asks the contestant to look behind Door Number 1, Door Number 2, or Door Number 3. Go ahead, and click on one of those drop-down arrows of your choosing. What you don't realize, it that behind every one of those arrows, is the hidden surprise that has changed - your MOC® contract with ABIM in all its (hidden) glory.

So here's the challenge...

... which part(s) has(have) changed in the last six months?

Good luck!

-Wes




Wednesday, April 04, 2018

Feldman: MOC is Good For You

It was helpful for me to read this take on maintenance of certification from Wake Forest dermatologist Steve R Feldman, MD, PhD in The-Dermatologist.com. There are so many straw dogs here it boggles the mind, but the piece exposes a level of naïveté by academic supporters that really don't seem to understand the myriad of problems with MOC. Take this quote, for instance:
The provision of medical care is highly regulated. Not all the regulations are to physicians’ liking. Along with our monopoly power, comes controls that are designed to assure the quality of the care we provide. Our education has been regulated, getting licensed has been regulated, and getting certified has been regulated. Now, maintaining that certification has been regulated, too.
Dr. Feldman justified MOC because, well, we need more regulation! He seems to imply we should just get over it folks: the unaccountable member boards of the ABMS can do as they please with your money. Buy a condo in the name of "Choosing Wisely?" Sure. Send some funds off-shore to the Cayman Islands for their retirement fund while you do the dirty work of seeing patients? Sure. Buy a nice pond or purchase a nice car collection with your colleagues testing fees? Heck yeah! And why not run a for-profit real estate management firm with certification funds, too? Why of course! Then you can perform research on your colleagues without informed consent! And best of all, you can make sure your pals on the Dermatology board force working physicians into becoming HIPAA Business Associates to CECity (A subsidiary of the $4 billion hospital Group Purchase Organization, Premier, Inc.) when they sign up for their recertification tests? Man, the digital data party never stops giving!

Poor guy. Maybe Dr. Feldman didn't know about all this. Or maybe he still needs to threaten working doctors to scratch his social justice itch. (Let's hope not.)

But if that was not enough, Dr. Feldman made this suggestion as an alternative to our current re-certification mess:
If the argument that MOC has not been shown to improve quality, claiming a CME requirement assures quality seems suspect at best. What would a serious solution look like? It would have quantitative, representative measures. Perhaps, it could include random independent evaluation of videotaped patient encounters, supplemented by review of treatment decisions made of lesions and rashes based on photographs or on “secret shoppers.” All the really serious means to document and assure quality would be far more heinous than anything being considered now.
Threats of physicians won't dispel the truth about MOC: it is corrupt to the core. It has harmed physicians. It threatens their right to work on the basis of metric that does nothing to improve the quality or safety of patient care.

Dr. Feldman asks for a viable alternative to MOC. Really, the answer is very simple.

End it.

Completely...

... just as the AMA House of Delegates voted to do so almost three years ago.

-Wes

Saturday, March 31, 2018

AOA Agrees to Settle Antitrust Claims

According to the court docket, the American Osteopathic Association (AOA) is in talks to settle the anti-trust claim (Case 1:2016cv04644) made against it on August 1, 2016, by four osteopathic physicians. The terms of the settlement are still being negotiated, but the case has been dismissed on an administrative basis without prejudice. Perhaps the evidence of the AOA President's address in July 2017 that attempted to spin the benefits of decoupling AOA membership to certification and the evidence that the AOA stood to lose over $1M in revenue each year as a result of the decoupling made it clear to all that the AOA was caught with their hand in the regulatory capture cookie jar.

US Doctors of Osteopathy deserve to have the terms of the settlement disclosed publicly.

-Wes

Sunday, March 25, 2018

ABMS/ACP "Vision:" Specialty Societies To Do MOC® Dirty Work

With the ABIM still holding out on filing its FY 2017 Form 990's for the ABIM and the ABIM Foundation, the newly-formed ABMS "Vision Commission" is serving as a distractor to what's really happening behind the scenes. Instead of ending the corrupt Maintenance of Certification (MOC®) program, the ABMS and its colluding specialty societies are working feverishly to recruit willing doctors to build content so they can take the lucrative MOC® baton from the ABIM. It is abundantly clear to everyone that the ABIM is in a world of financial and legal hurt, and the ripple effects of their corruption are being felt across the ACGME and the US medical subspecialty society infrastructure. Here's a copy of the letter the American College of Cardiology (ACC) and Heart Rhythm Society (HRS) are circulating to carefully-selected individuals:
As you may know, The American Board of Internal Medicine (ABIM) has announced plans to offer new options for Maintenance of Certification (MOC) assessment beginning in January 2018. ABIM’s current 10-year exam will remain available as an assessment option for those seeking to maintain one or more Board certifications. In addition to the two MOC options offered directly, the ABIM has committed to working with three medical specialty societies – the ACC, the American Society of Clinical Oncology (ASCO) and the American College of Physicians (ACP) – to explore development of additional collaborative maintenance pathways (CMPs) through which physicians can maintain board certification. The goal of this effort is to offer board certified physicians additional flexibility in how they can demonstrate to their peers and the public that they meet standards and are keeping their medical knowledge current.

The ACC has proposed an MOC option for cardiovascular medicine that uses enhanced versions of its Self-Assessment Program (SAP) collection (with a formal knowledge assessment function built into the products) as an alternative to taking the ABIM 10-year examination or the 2-year Knowledge Check-In series. The enhanced SAP collection would comprise ACCSAP (general cardiology), CathSAP (interventional cardiology), EP SAP (electrophysiology), Heart Failure SAP (heart failure) and ACHD SAP (adult congenital heart disease). Developing this comprehensive collection of enhanced SAPs that covers all cardiovascular topics with ABIM board certification exams supports the tacit position that the College is the professional home of all cardiovascular specialists.

Dr. Patrick O’Gara has accepted the invitation to serve as the Self-Assessment Program Editor-in-Chief for the SAP Collection. Dr. Joe Marine and Dr. Ken Ellenbogen have accepted the invitation to serve as Co-Editors of EP SAP and Dr. Edward Gerstenfeld as your Topic Editor. On behalf of Drs. O’Gara, Marine, Ellenbogen, Gerstenfeld and the ACC, we are pleased to extend an invitation to be an author on the topic of Pathophysiology in the chapter entitled Clinical Arrhythmias: Atrial and sub-topic Atrial Fibrillation in ACC’s newest offering in line with the EP SAP product. Please review the attached letter and position description. We look forward to your response by Monday, March 26, 2018.

Regards,


Liara

Liara Fredericks-Brown
Digital Content Specialist
American College of Cardiology
This is not about "quality" health care. This is not for "patient safety." This is about one simple thing: the money.

It is also about manipulating their colleagues with rent-seeking for their own political avarice and greed.

-Wes

Friday, March 16, 2018

One Final Push

This weekend, the national multi-specialty survey of US physicians sponsored by Practicing Physicians of America will be closing to allow time for analysis. To date, the response to the survey has been remarkable: physicians from all 50 states and nearly every US territory have participated with 47 subspecialties (both medical and surgical) represented. In case I should forget, I should also like to add a special word of thanks to those who helped spread the word about this survey, especially members of the Pennsylvania Medical Society, the Association of Independent Doctors, and Doximity. The power of social media to reach working physicians has been amazing.

Currently, I estimate the error of the survey will be as low as ± 1 or 2%, depending on the question asked. Obviously, the more (credible) responses we receive, the more powerful the survey since non-responder bias is present with surveys.

So talk it up one last time, share it like crazy, and encourage your colleagues who have not competed the survey to do so. I have no doubt the results of this survey will be eye-opening to all.

-Wes


P.S.: Goodness: Just realized I published this without the link to the survey!  Here it is: https://www.surveymonkey.com/r/PPA_MOCSurvey





Friday, March 09, 2018

ABIM and the ABIM Foundation: Consumer Fraud?

Early Tuesday morning I attended an excellent continuing educational video-conference hosted by Paul Friedman, MD at the Mayo Clinic at our institution. Anyone who knows Paul knows what an excellent educator and mentor he has become for electrophysiologists around the world. The case involved patient that was a CRT failure, the workup of that condition, the decisions made, and how they handled the case using His bundle pacing, with some pearls about that physiology. I attended the conference voluntarily and without coercion because of the excellent educational value it provides me yet I received no continuing medical education credit (CME) or ABMS Maintenance of Certification (MOC®) credit for doing so.

Because I wasn't scheduled to start a case after that, I then attended a lecture on pulmonary hypertension and its management delivered by one of our cardiology fellows. That lecture was  sanctioned by the University of Chicago as qualifying for CME credit, but not MOC. It, too, was excellent, and refreshed my understanding of the various oral and intravenous therapies available to treat this disorder. I then traveled to another hospital to perform three procedures.

ABIM Website - Click to enlarge
Later that day between cases, I had a colleague who has been forced to re-certify in April of this year and perform MOC® modules lest he lose his credentials to practice at our hospital, look up my publicly available information on the ABIM website for me, and there I was: certified in Internal Medicine, Cardiology, and Cardiac Electrophysiology, but not participating in MOC®.

I know most of the long-time readers of this blog are probably thinking that I should wear that "Not Participating in MOC" designation as a badge of honor, but I look at this very differently.

This designation on their website does not include my CME credits (which the ABIM co-brands with their MOC product) and suggests to the public that I "don't keep up" in my field. By co-branding MOC® with CME, they suggest they are equivalent, but they clearly are not. Not participating in certain CME offerings can't remove me or my partner from my job, but not participating in MOC® can. And if MOC is so important to the ABIM and its corporate cronies in the ACGME heirarchy (inlcuding the powerful hospital and ABMS lobbyists), how am I advertised as "certified" yet not participating in MOC®? This is confusing to the public and makes no sense, particularly when we see the fighting going on at the state legislative level over the "need" for forced "continuous education" of physicians.

Yesterday, I was also tipped to this (seen at the right): an event hosted by the Jewish
Health Activist Network Announcement
(Click to enlarge)
Healthcare Foundation entitled "Spreading and Sustaining the Choosing Wisely Campaign" to be held on Thursday, April 12, 2018 from 5:30PM to 7:30PM in Pittsburgh, PA. The ABIM Foundation's Executive Vice President and Chief Operating Officer, Mr. Daniel Wolfson is the keynote speaker. "Following his comments, Mr. Mark DeRubeis, CEO of the Premier Medical Associates, and Mr. Jim Coslow, Director of Value Based Care, will share how - and why now - Premier has embraced Choosing Wisely."

We must recall that the ABIM has no money on paper, and all of their remaining assets reside with the ABIM Foundation who is speaking and promoting their marketing campaign at our expense at this program. All of their funds come from working physicians' certification and re-certification fees (with the exception of a few grants from the Robert Wood Johnson Foundation). The ABIM Foundation has nothing to do with physician certification, as evidenced by this notice. They have a different mission than assuring physician competence - rather, to promote the next physician payment model of value-based care for themselves.

The ABIM does not place our continuing education credits on their website, yet lists us as not participating in MOC. They call me "certified" publicly on their website, yet the ABIM and my hospital consider my colleague somehow less qualified because he didn't participate in MOC® and pay his money, but are more than happy to continue billing on his behalf in the meantime. Through regulatory capture, the ABIM forces my colleague to take the ABIM MOC® test in April, while not forcing me to do the same and promoting me as "certified" on their website. If my colleague should fail (he won't, just speculating), then me and my colleagues would have to manage his patients and take call more frequently when he is removed from our staff. In effect, there is a multiplier effect if one doctor doesn't recertify on other physicians.

I know this is a strong statement, but given these realities and given what I know about the ABIM Foundation (especially how it received its funds) and its financial shenannigans that include the purchase of a multi-million dollar personal condominium, off-shoring of funds to the Cayman Islands, its many public tax filing discrepancies, I believe the ABIM and ABIM Foundation are engaging in consumer fraud when they post my MOC® status as they do and claim recertification is about physicians "keeping up." As others are noticing, their monopoly on this lucrative product  should not allow them to be qualified tax-exempt organization either.

I believe MOC® is a shell game that deceives the public about the quality of their physicians on a massive scale. It's time to just say no.

-Wes