Saturday, July 05, 2014

The Effects of Maintenance of Certification and Crony Capitalism

This note was recently posted on Sermo (login required) Friday:
"I just got results from recent ABIM 10 yr recert and I failed. I over prepared for this exam, studied daily for months, Harvard review course, analyzed over 1000 board type questions the week before, teach medical students daily. I have never come close to failing any previous board exams."
After a panicked e-mail was sent to the American Board of Internal Medicine (ABIM) inquiring if there might be an error in the scoring of the examination, this email was received:
Dear Dr. B:

Thank you for your recent e-mail to the American Board of Internal Medicine (ABIM).

ABIM is entirely satisfied that there was no error in scoring your examination. The scoring process is a meticulous one. A rigorous set of quality control steps are carried out on every examination. Before final scores are approved, the reliability, validity, and fairness of the examinations are verified by the ABIM. ABIM will not release results until it is satisfied that a reliable instrument has been administered and data are accurate. Additional information about the way ABIM develops and scores its examinations is at ABIM's website at www.abim.org/about/examInfo/developed.aspx.

If you would like to have your examination rescored, please put your request in writing. All requests must be received within six months of the results' mailing date. Include your name, candidate identification number, the examination to be rescored, and a check for $250.00 payable to the American Board of Internal Medicine. Send to:

Rescore Request
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106-3699

Results of the rescore will be mailed to you within eight weeks of receiving your request.

If you need further assistance, you may reply to this e-mail or call us at 1-(800)-441-ABIM (2246) Monday through Friday, 8:30 a.m. to 8:00 p.m., and Saturday, 9:00 a.m. to 12:00 p.m. EST.

Respectfully,

Ethan Lambert
Customer Service Representative
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106
Phone: 1-800-441-ABIM
215-446-3500
Fax: 215-446-3590
www.abim.org
This scenario could happen to any US physician undergoing the American Board of Medical Specialties (ABMS) proprietary Maintenance of Certification program today. The hundreds of hours of preparation, survey collection, and timed test, all wasted. And since hospital credentials, legal credibility, and inclusion on insurance panels are increasingly requiring a favorable certification "status," the potential consequences to U.S. physicians are very serious indeed.

This threat to U.S. physicians' ability to practice medicine comes at a time when insured patient populations have swollen. So why would such a "Maintenance of Certification" program be beneficial for American's? Is such a program really about assuring some definition of quality physician? Or might it be about something very different?

While the realities of this situation are sure to raise physician emotions (and maybe the concerns of patients, too), there are several important facts that all physicians and interested patients should understand regarding the American board of Medical Specialties' (ABMS) Maintenance of Certification process that is administered by the American Board of Internal Medicine (ABIM):
  1. The Patient Protection and Affordable Care Act (Affordable Care Act)1 modified sections of Social Security Law2 to require Maintenance of Certification of physicians as a condition of receiving payments from Centers for Medicare and Medicaid Services (CMS).3
  2. While other organizations may create a "qualified Maintenance of Certification program," the only program specifically authorized  in the Affordable Care Act is the Maintenance of Certification program from the American Board of Medical Specialties (ABMS).3
  3. "Qualified Maintenance of Certification" programs must contain surveys as part of their criteria4 despite their lack of scientific rigor.
  4. According to law, the Maintenance of Certification program will be operated by a "specialty body" of the American Board of Medical Specialties" that meets the criteria for a registry or physician quality and efficiency measurement" for physician payment. It is now clear this "specialty body" is the American Board of Internal Medicine (ABIM).3
  5. CMS will receive a portion of $5 million dollars in 2014 from the Federal Hospital Insurance Trust Fund and $15 million from the Federal Supplementary Medical Insurance Trust Fund for the first 6 months of 2015. The National Quality Forum also receives a potion of these funds5
  6. The Administrator of the CMS shall through contracts develop quality and efficiency measures (as determined appropriate by the Administrator) (editor's note: along with "multi-stakeholder group input into selection of quality and efficiency measures")6
  7. The current President and CEO of the American Board of Internal Medicine, Richard J. Baron, MD served as Chair of the ABIM Board of Directors in 2008 and as Treasurer of the Board in 2007 and later as a Trustee for the ABIM Foundation while also serving as the Group Director, Seamless Care Models, at the Innovation Center at CMS.
  8. The former President and CEO of the American Board of Internal Medicine, Christine Cassels, MD, left the ABIM to join the National Quality Forum, another "consensus-based entity," and also had significant conflicts of interest with the group purchasing and performance improvement firm Premier, Inc and Kaiser Foundation Health Plans and Hospitals which she later relinquished. Despite these conflicts, she retains her current position.
  9. An unfinished public webpage (Here's a backup screenshot in case this webpage disappears) raises speculation that current ABIM President and CEO, Richard J. Baron, MD might be slated to sit (or may currently sit) on the National Quality Forum's Board.

Crony capitalism is pervasive in Washington, DC and nowhere is this more evident than the American Board of Medical Specialties and the American Board of Internal Medicine incorporation into our new health care law. The conflicts of interest contained within the Affordable Care Act's requirement of Maintenance of Certification as a basis to assess physician quality are increasingly harmful to physicians.  Given the conflicts of interest between the American Board of Internal Medicine, National Quality Forum, and the Center for Medicare and Medicaid Services, paired with the growing Maintenance of Certification failure rates of physicians without a clear explanation, the specter of cost control at the expense of patient care must be considered.

Only by understanding the environment of government cronyism and regulatory entrapment created by our new health care law can  physicians begin to address these very real concerns for patient care.

-Wes

References:
 1 Full text of Affordable Care Act: (pdf 2.1 MBytes)  
 2  42 U.S. Code § 1395w–4 - Payment for physicians’ services
 3 ACA law pdf above, page 247 (124 STAT. 365)
 4 ACA law pdf above, page 845 (124 STAT. 963)
 5 42 U.S. Code § 1395aaa - Contract with a consensus-based entity regarding performance measurement
 6 42 U.S. Code § 1395aaa-1 - Quality and efficiency measurement

6 comments:

SM said...

Dear Dr wes
Thank you so much for another excellent article on MOC.

To physicians who did not pass this stupid test: PLease learn from my experience and do NOT pay them any more money for re-score.
I paid additional $250 for re-score and got a generic response in 8 weeks (which was past the deadline to register for next test). ABIM sends a generic response that they never make a mistake!! as follows"

".....ABIM is entirely satisfied that there was no error in scoring your examination. The scoring process is a meticulous one. A rigorous set of quality control steps are carried out on every examination. Before final scores are approved, the reliability, validity, and fairness of the examinations are verified by the ABIM. ABIM will not release results until it is satisfied that a reliable instrument has been administered and data are accurate. .....” blah blah ...

Dr Wes how can i send you an emaill?

Anonymous said...

MOC as it stands now, does not guarentee anything except they passed a test. I've seen board cert'ed docs make mistakes. $$$ racket.

If they find another way to see that docs stay up to date, fine. However, this method doesn't mean docs are up to date and I and other patients have seen it first hand.

Doing an excellent H&P, being able to understand basic bloodwork, those are some things I want to see them pass a test on. I've been able to out do a number of them with medical research because they didn't know how to do something or resort to u/s, MRI's, etc. when they are NOT necessary. Yes, even with my reading, I can figure it out. If I ask the background and can't get it, and I can produce those figures, yes I can figure it out.

Anonymous said...

Crony capitalism, regulatory capture? For sure. On the other hand, there is a silver lining in re-certification failure. Hopefully you have a good disability policy. One can now legitimately claim cognitive decline in the form of short term memory loss and punch out of this South African diamond mine of a job. The only test you would have to "study" for would be a neuropsychological one. Then develop a new cognitive skill set while your bills are paid. Moral issues can be addressed to the ABIM or federal government.

james gaulte said...

Dr. Wes,

Please correct me if I have misread the regs and/or overlooked critical sections.
My reading is that achieving MOC status is one way to quality for
"additional incentive" payment and it not required for regular CMS payments. Of course that is bad enough.The way some of those sections are written, they could have been composed by folks at ABIMF and I suspect may have been.

Anonymous said...

The passing rate for the EP boards from May 2014 was 76%...I was relieved to have passed...

HaynesBE said...

Dear Dr. Wes -
I love your blog and am very grateful for the time and energy you put into writing these excellent posts.

One suggestion I would make is to substitute the term "cronyism" for "crony capitalism." Wikipedia aside, the proper definition of capitalism is "the economic and political system in which a country's trade and industry are controlled by private owners for profit, rather than by the state."[http://bit.ly/1qcxZ3L] Cronyism is actually the polar opposite of capitalism. To the extent that government is allowed to show "favoritism in the distribution of legal permits, government grants, special tax breaks, or other forms of state interventionism"[Wikipedia] is the same extent that capitalism is absent.
Until we have clear, precise use of terms, we can not have clear and meaningful discourse. What so many people hate about the US system is the cronyism which they erroneously equate with capitalism. It's actually "government cronyism" but "cronyism" alone should suffice.
Beth Haynes, MD