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