The Maintenance of Certification Controversy 2015: The Year in Review

With so much controversy surrounding the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) program in 2015, especially as it pertained to the American Board of Internal Medicine (ABIM), I thought it would be helpful to recap some of the earlier announcements about the ABMS MOC program, and then summarize this year's most pertinent developments to serve as a springboard for 2016. To keep it simple, I will use a timeline approach of the developments as I've seen them occur. (Remember: hind sight is always 20:20.)

• 24 July 2012 - ABIM announces Medicare payment incentives for participation in their MOC program on their website.


• August 14, 2012 - Robert Wachter, MD assumes chairmanship of the ABIM, writes missive on his industry-sponsored blog justifying why board certification "matters more than ever." This post shows anticipated collusion for acceptance of MOC as a "quality measure" between Medicare, the Joint Commission, the Federation of State Licensing Boards, and the ABIM Foundation's Choosing Wisely campaign. Wachter fails to mention his simultaneous affiliation as director of IPC The Hospitalist Company, Inc., a company that "is the nation's leading national physician group practice focused on the delivery of hospital medicine and related facility-based services" in that announcement.


• 27 Apr 2013 - Drs. Wachter and Cassel named to Modern Healthcare's "Most Influential Physician Executives."


• 1 Aug 2013 - Robert Wachter, MD receives 1,355 shares of IPC The Hospitalist Company stock options valued at $50.68 per share (Market Value: $68,671.40).


• 12 Jun 2013 - ABMS lobbies Chairman Upton and Ranking Member Waxman of the US House of Representatives Energy and Commerce Committee to have MOC program included in MACRA (the SGR Fix bill) as a physician quality measure.


• 30 June 2013 - Christine Cassel, MD to step down from ABIM as President and CEO of ABIM and ABIM Foundation. Earns $1.7 million as she leaves to begin work at the National Quality Forum.


• 1 July 2013 - Richard Baron, MD becomes ABIM and ABIM Foundation President and CEO


• 25 Sep 2013 - Christine Cassel, MD issued 3706 shares of Premier, Inc (PINC) stock


• 31 Dec 2013 - Physicians who participate in MOC program by Dec 2013 are able to claim 0.5% payment incentive from Medicare


• 1 Jan 2014 - ABIM offers either one-time (every 10-years) or annual payment plan option for its MOC program.


• 2 Jan 2014 - Robert Wachter, MD receives another 2,640 shares of ICP The Hospitalist Company stock options valued at $58.50 (Market value: $154,440)


• 10 Dec 2014 - Study appears in JAMA showing no effect of MOC program at improving patient outcomes.


• 16 Dec 2014 - The first detailed review of the MOC corruption appears on this blog with the publishing of "The ABIM Foundation, 'Choosing Wisely' and the $2.3 Million Condominium."


• 30 Jan 2015 - The ABIM is caught in the act if omitting 6 key financial schedules from its 2014 Consolidated Financial Statement that it released to the public.


• 31 Jan 2015 - A virtual tour of the ABIM Foundation's condominium is published.


• 3 Feb 2015 - ABIM issues previously unimaginable apology to the physician community stating "ABIM clearly got it wrong" but fails to mention the financial, tax filing, and financial conflicts of interest of its President and CEO and members of its board leadership.


• 3 Feb 2015 - Physicians (especially this one) are not impressed with ABIM's announcement that failed to acknowledge ABIM's history of serious financial and public reporting actions. Work continues to uncover what's being hidden.


• 16 Feb 2015 - ABIM initially fails to publish full financials for 2014 until pressured to do so. Apparent cover-up continues.


• 10 Mar 2015 - Veteran Newsweek reporter Kurt Eichenwald publishes his first take on the MOC controversy with his article entitled "The Ugly Civil War in American Medicine."


• 11 Mar 2015 - ABIM Board Chairman David H. Johnson, MD issues statement attempting to discredit Eichenwald's article claiming "numerous and serious misstatements, selective omissions, inaccurate information and erroneous reporting." Johnson disputes claims that ABIM pass rates have fallen, that ABIM has a monompoly on re-certification, claimed that Eichenwald was "selective" about the data presented and has a "poor understanding" of the tax records, and that Eichenwald had failed to disclose his wife was an internist.


• 30 Mar 2015 - New board (NBPAS.org) formed and doctors are moving on after more of the financial transgressions come to light.


• 3 Apr 2015 - Dr. Robert Wachter, the former chairman of board at the ABIM, tops Modern Healthcare's Top Fifty Most Influential Physician Executives and is "not afraid to challenge the status quo." Not surprisingly, Dr. Christine Cassel again makes the list as well.


• 7 Apr 2015 - Kurt Eichenwald's next Newsweek article on the ABIM MOC program, "A Certified Medical Controversy," is published and begins to target many of ABIM Board Clair David H. Johnson's criticisms.


• 8 May 2015 - Consequences to physicians who fail their unproven MOC re-certification secure examination published online.


• 21 May 2015 - Kurt Eichenwald's third expose on the ABIM's finances called "Medical Mystery: Making Sense of ABIM's Financial Report" hits the pages of Newsweek disclosing the unreported lobbying efforts and the convoluted and large payments made to the ABIM leadership including $1,712,847 made to Christine Cassel, MD in fiscal year 2014.


• 22 May 2015 - Richard Baron, MD publishes another official ABIM response to Kurt Eichenwald's articles claiming "we have never made any effort to obfuscate, hide or delay ABIM's financial information." Baron did not acknowledge that they failed to release all of their audited financials (see 16 Feb 2015 entry on this timeline). Baron also fails to mention that the ABIM failed to release 12 years of audited financials requested by a reporter from the Wall Street Journal in August 2014. Additional attempts to obtain the reports from the PA Attorney General's office were also unsuccessful. Financial data were only obtained after a request was made to the office of the Pennsylvania governor's press secretary.


• 23 May 2015 - ABIM, it's finances, and the great revolving door collusion between the National Quality Forum, the ABIM, ABIM Foundation, and other specialty organizations published.


• 31 May 2015 - The ABIM's tax-filing cover-up of its lobbying activities with Congress exposed.


• 29 June 2015 - Robert Wachter, MD attempts to defend the actions of the ABIM on his blog after leaving his post as Chairman and speaks out. No corporate conflicts of interest are specifically mentioned by Dr. Wachter. Comments to his post are worth a read.


• 28 July 2015 - An independent cost analysis of the ABMS MOC program in published before print in the Annals of Internal Medicine.


• 15 Aug 2015 - ABIM Foundation tries to bury its old "About Us" webpage that claimed the creation date of the Foundation was in 1999 by editing the page to disclose the correct date of origin (1989) and then includes information regarding "$55 million" that was transferred from the ABIM to its Foundation from 1989 to 2007. The amount transferred was actually much larger and made secretly without disclosing the Foundation's existence to the physician community or public until 1999. The reasons for the secrecy and large annual payments made to the now defunct 1838 Investment Advisors (a spin-off of Drexel Burham Lampert financial fiasco - most of whom were indicted) made during that time have never been investigated or disclosed. One thing is now clear: it does NOT appear the sole reason for creation of the ABIM Foundation was to define and promote the term "medical professionalism" as originally claimed by the Foundation.


• 9 Sep 2015 - The ABIM's prior activities stumping for Big Tobacco in 1963 are revealed, lending less credibility to their claim that their certification program is for "public good."


• 15 Sep 2015 - Veteran Newsweek reporter Kurt Eichenwald publishes his last installment of a four-part series on the ABIM scandal entitled, "To the Barricades! The Doctors' Revolt Against ABIM is Succeeding!" highlighting how the ABIM MOC program has hurt physicians and patient care and what doctors are doing about it.


• 23 Sep 2015 - Graph of the growth in ABIM MOC Fees from 2000-2014 published showing at least 244% growth in cost (16.3%/year - far exceeding inflation) to internists over that 15-year time period.


• 25 Sep 2015 - ABIM's own Maintenance of Certification First-Time Pass Rates from 2000-2014 are published and document a negative pass rate trend line over that period of time in every subspecialty of internal medicine except Geriatric Medicine. The data trend stands in stark contrast to ABIM Board Chair David H. Johnson, MD's statement regardng MOC pass rates made 11 March 2015.


• 11 Nov 2015 - Concerning conflicts of interest with Christine Cassel, MD and the little-known company CECity, Inc. are published. Cassel's long-standing relationship with Premier, Inc. raises real questions regarding possible insider funding of CECity to prop up its value prior to its purchase by Premier, Inc. on 4 August 2015 for $400 million.


• 23 Nov 2015 - TeamHealth (TMH) acquires IPC The Hospitalist Company for $80.25 per share netting Dr. Wachter and his university, the University of California, San Francisco, a comfortable profit.


• 23 Nov 2015 - Graph of ABIM legal fees pre-ABMS MOC program (instituted in 2005) vs. post-MOC (ongoing) appears.


• 29 Nov 2015 - ABMS's income stream for selling daily updates of physician certification status from the unproven and un-vetted data gathered from its member boards via ABMSSolutions.org disclosed bringing the legitimacy of the entire ABMS MOC empire sharply into question.


• 6 December 2015 - A copy of the physician sanction letter issued June 8, 2010 surfaces on this blog and gives a glimpse into the strongman/boss tactics used by the ABIM to protect their certification monopoly. The tactics used to track down physicians late after they participated in a board review course years before are now coming under intense scrutiny.


• 16 Dec 2015 - ABIM announces its intent to extend its practice assessment decision through 2018.


• 17 Dec 2015 - Christine Cassel, MD leaves her role as the President and CEO of the National Quality Forum (in charge of setting "quality" standards for the nation's hospitals) to join the leadership team of Kaiser Permanente's School of Medicine. Dr. Cassel had long-standing financial dealings with Kaiser since at least 2003.

Yes, folks, it has been quite a year. Still, various member boards of the ABMS continue to try to modify and "improve" the highly conflicted and ethically corrupt ABMS MOC program. While I would like to have other things to write about on this blog from time to time, I find it important to continue to expose the corruption and financial conflicts created by the ABMS and their member boards. 2016 promises more developments as others begin to dip their toe into exposing this complex and unfortunate story.

My prediction for 2016: the ABIM collapse under its own spending weight but not before "grants" are issued from the ABIM Foundation back to the ABIM to support its operations.

If the ABIM does collapse, what happens to the certification process for US internal medicine physicians? Clearly, significant change (including electable board members and disclosure of conflicts of interest publicly) are of paramount importance. Returning board certification to a lifetime designation also seems paramount since the MOC program continues to prove itself as highly destructive to our profession.

So stay tuned in 2016. It promises to be an interesting year as more revelations regarding the ABMS MOC program develop.

-Wes

Addendum: 28 Dec 2015 @13:04 - Post updated to include 27 Dec 2012 and the failure of Dr. Baron to report his conflicts as Director of the Seamless Care Model Group in the NEJM publication. Also, 28 July 2015 was added to include the cost analysis of the ABMS MOC program published in the Annals of Internal Medicine.

Addendum: 28 Dec 2015 @ 13:21 - 27 Dec 2015 deleted from timeline - Author of the NEJM piece was Robert Baron from the University of California, San Francisco, not Richard Baron, MD - hence why there was no disclosure of this conflict on the NEJM publication. I regret the error.

Addendum 30 Dec 2015 @ 10:45 - Timeline updated with additional information revealed on 23 Sep 2015 and 23 Nov 2015 regarding growth of costs and legal fees.

The ABIM Maintenance of Certification (MOC) Controversy a Year Later

It has been one year since the story of the ABIM Foundation, Choosing Wisely, and the $2.3 million Condominium appeared on this blog. It has been one year without answers to the many financial, conflicts of interest, and likely illegal tax dealings of the American Board of Internal Medicine discussed within this blog's pages.

But as this story has unfolded, it is clear that this story is much more than a story of the purchase of a luxury condominium by a little known non-profit organization. It has been the story of betrayal of the entire practicing physician community in the United States and their patients everywhere in the name of self-serving power and greed by a relatively select few.

The story is also an embarrassing demonstration of the inability of our professional medical societies to deal forthrightly and honestly with all that has transpired. The vast network of the interconnected medical Specialty Board System led by the American Board of Medical Specialties in the United States that earns hundreds of millions of dollars annually from physician testing fees is incredibly wasteful and counterproductive. Instead of honest examination and disclosure of the facts, the ongoing deception, double-speak, and cover-ups of this system continues.

To date this story has also been about the failure of our legal, government, and law enforcement agencies to investigate the secret financial and tax filing discrepancies of the American Board of Internal Medicine and the ABIM Foundation. This has created a colossal erosion of physicians' trust with our US medical regulatory agencies, especially when doctors can't trust these agencies to protect them from fraud and abuse.

Why the lack of governmental investigation into over $70 million of physician testing fees that were secretly funneled from working physicians (preoccupied with the real work of patient care) into a shadow "Foundation" hellbent on making shady investments and enriching its leadership? The wanton disregard of the basic tenets of law and a civil society displayed by the ABIM is an anathema to honest physicians. Most physicians would prefer to believe that we do not work in an environment that rewards deception, theft, and greed. Yet here we are.

Finally, with the notable exception of a veteran Newsweek reporter, Kurt Eichenwald (see here, here, here, and here) and the tireless efforts of a single forensic accountant, Mr. Charles P. Kroll with whom I have had the pleasure to meet, there has been precious little true investigative reporting into the financial and anti-trust activities of the ABMS and their member boards by major outlets of main stream media. "It's a doctor problem" or "it's too complicated," I've been told. Is that the reason?

We'll see.

One thing's for sure: there's a lot of money at stake in the testing and control of practicing physicians and it is increasingly clear that these organizations (and even some segments of government for which they now work) won't open up willingly or relinquish their lucrative MOC re-certification program without a fight. They know they simply can't afford to maintain their current ways without it.

Getting It Wrong Again

Because of this reality of cover-up and backed by remarkable hubris and ego, the ABIM leadership appears to have made a more recent critical error - another little thing it appears they got "wrong." The ABIM decided to track down and hunt a young physician attendee of the Arora Board Review course attended in 2009 using an email that was found on the server at the residence of Dr. Arora and sued him almost five years later. These guys are serious.  It seems maintaining monopoly control of the lucrative board re-certification process using threats and intimidation (aka, The Chicago Way) was just too important to the ABIM.  But what the ABIM didn't expect is that this young man had at least one parent who was a lawyer,  and he sued back. Time wil tell if this brave man dealt the ABIM (already in the midst of their own financial and ethical mess) a potentially mortal blow.

This case is about to get interesting. So interesting, in fact, that it appears the ABIM's legal team will stop at nothing to try confuse and deceive the judge or magistrate who will soon hear oral arguments in late January 2016 about the case.

Perhaps then the truth will come out: all of the facts of the business of testing physicians; all of the tactics used to bully physicians into compliance with the ABIM MOC program; everything laid bare.

For this story is similar to the disturbing story of a subcontracting security firm that works with Pearson (a company reviewed earlier on this blog) and paid by the state of New Jersey that has been spying on children to protect their monopoly interest in the content of the national Common Core test. For physicians, it is no coincidence that a different division of Pearson, PearsonVue, is the professional testing division of Pearson that the ABIM uses to secure its examinations and cherished test questions.

When the facts come to light about the spying, the tracking, the hunting of physicians by an organization profiting handsomely from intimidation and thuggery, it will be hard for the ABIM and its Foundation to survive. So, too, the basic construct of the ABMS and our entire professional specialty board system.

It is increasingly clear that the ABMS MOC program is about threats and intimidation so people can enrich themselves selling unproven quality data to unwitting customers, and little more.  Physician education, if it happens, is really secondary. Is this what the physicians need from these sheltered and unaccountable non-profit organizations? How much time, energy, and money have we already wasted and turned from the delivery of health care with this program?  How many physicians' lives has the current system in its perverted construct ruined?

When all of the facts of the MOC program become known, maybe, just maybe, the ongoing fleecing of US physicians by the corrupt and misguided ABMS MOC progam and the irresponsible Code of Silence held by their subordinate member boards will end and our profession can get back to doing what its meant to do: treat patients.

One can only hope.

-Wes

PS: By the way, today in history on December 16, 1773, the Boston Tea Party took place.
Seems apropos, doesn't it?

Strongmen, Bosses, and the American Board of Internal Medicine

From John Kass, political reporter from the Chicago Tribune, this morning:

"Chicago is the most American of American cities," Emanuel has said, repeatedly. "It's not just any city. If you want to come and see America, you come to its heartland. And what is the capital of that heartland? Chicago."

Democratic political stars with Chicago ties — from his old boss President Barack Obama to presumptive 2016 Democratic nominee Hillary Clinton — must enjoy hearing it.

Politicians running for the office of emperor in a Republic just love fairy tales.

But there's one thing wrong with the mayor's favorite saying: It's wrong.

Chicago is not the most American of American cities. Chicago is the most Soviet of American cities.

The people of Chicago know this and it's time the rest of the nation understands it, too.

Chicago may appear to be an American city. But it is actually run on the old Soviet model, where the people were bossed for generations by ruthless and cynical strongmen.

The Russians call them strongmen. In Chicago, we call them bosses. But strongman-boss, boss-strongman, what difference, at this point, does it make?

The strongman of Chicago rules by fear. He holds the terrible hammer of big government in his hand. And if you're a corporate titan or a corner shopkeeper, you don't want that hammer to strike you down.

While Chicago is embroiled in a horrible police scandal uncovered by the flow of information via the digital age, I couldn't help but think how true Mr. Kass's words were in terms of US medical care and the control of practicing physicians on the front lines of health care today.

While nowhere near the seriousness of the police story in Chicago, the story of similar strongmen/boss tactics used against practicing physicians is a sad story that has been growing for years. Until recently, physicians have been oblivious to these tactics used by the American Board of Medical Specialties (ABMS) (based in Chicago) and the American Board of Internal Medicine (ABIM) who used their political and professional connections to foist their Soviet-style strongmen tactics on practicing physicians via their board re-certification requirement called "Maintenance of Certification®."

Participate every two years or lose your job.

Participate every two years or never see another penny from a major insurer.

Attend a board certification course that does not bow to the ABMS/ABIM strongmen?

Get sued or sanctioned.

Here's a redacted copy of the ABIM sanction letter sent to a physician who attended the former Arora Board Review course.  It came FedEx to the physician labeled with the instructions "destroy if undeliverable." To my knowledge this letter, sent to some 2000+ physicians who attended the Arora Board Review Course over the years it operated, has never been made public by the ABIM:

ABIM Sanction Letter issued by Lynn O. Langdon, MS,
Chief Operating Officer, ABIM (Click to enlarge)

It is a threatening letter, issued by a non-physician Chief Operating Officer of the ABIM who served as strongman for the ABIM and ABMS and later earned a $297,646 bonus from the ABIM in FY2012 (Page 22). The letter suggests the physician-attendee of the Arora Board Review Course violated a "Pledge of Honesty" and failed to call the obscure and unvetted ABIM Exam Integrity Hotline. And because the ABIM now has "ethical and professional concerns" about that physician, it is "placing a copy of this letter in your file."


Threats. Intimidation.  Strong-arming.

Maintenance of Certification®: the Chicago Way.

To think this whole process was been transported from Chicago to Washington, DC and is now deeply embedded in the Affordable Care Act as a physician quality registry, courtesy of heavy lobbying by the ABMS (and likely the ABIM), is sickening and wrong.

Practicing physicians, like the citizens of Chicago, deserve to know the truth of how and why this occurred.

-Wes

PS: Ms. Langdon no longer serves as Chief Operating Officer of the ABIM. She was quietly replaced by Nkanta “Nick” Hines, MSc, MBA. Ms. Langdon now serves as a board member of the American Board of Medical Specialties.

Edging Toward the Tipping Point

We've seen the "We got it wrong" messages."

We've seen the "We're listening to our members" messages.

We've seen the "changes" to board certification: from the change from permanent certification to time-limited in 1986, from dropping the requirement for dual board certification for subspecialists to the requirement for just one subspecialty certification, and from board certification being about a more "continuous" requirement for education.

And we keep hearing the excuses by all 24 ABMS member boards that they really want to change the MOC program after all of the corruption of the system has been exposed over the past two years.

But what you won't hear about from anyone involved with the Accreditation Council of Graduate Medical Education (ACGME) is anything about the money involved.

Practicing physicians are funding a profiteering racket.

This is what time-limited board certification is about, nothing more.

Proof of this can be found quite plainly at this website run by the American Board of Medical Specialties that promotes "ABMS Solutions." (video here).

ABMS "Solutions"sells "CertiFACTS Online®," "ABMS Certification Profile Service®," and "Direct Connect Select™" through Cactus, CredentialSmart, MD-Staff, and Vistar software systems.

We can see how the ABMS colludes with the Federation of State Medical Boards' (FSMB) newly-launched DocInfo service that "provides professional information on physicians and physician assistants licensed in the United States including information on disciplinary sanctions, education, medical specialty, licensure history and locations."

And now we see clearly how all of these privately-held non-profits of the 24 ABMS member boards are colluding together to prop up the very broken ABMS Specialty Board System financially:

Only CertiFACTS’ products connect professionals with board certification information that is updated daily with data provided by the 24 certifying ABMS Member Boards.

Physician ABMS board certification status, updated daily, and shot to a certification database near you. All for the low, low price of hundreds of millions of dollars a year and funded (in part) by every US physician.

It doesn't matter what new changes each of the member boards of the ABMS propose to change Maintenance of Certification (MOC).  The whole time-limited ABMS board certification is all about the money.

Always has been.

This is just one example of how the money pipeline overrides the welfare of the physician and their patients.

Between surveys, productivity ratios, data entry requirements, and now the board certification monopoly created by the ABMS,  I wonder how far the System thinks it can go before our new nation of employee-physicians unionize.

-Wes

ABIM Legal Fees: Pre-MOC vs Post-MOC

Pre-MOC Average: $146,073/year
Post-MOC Average: $1,090,184/year

This graph sums up another reason the American Board of Medical Specialties' Maintenance of Certification (MOC) program (implemented by the American Board of Internal Medicine in 2005) is such a mess.

(h/t @CharlesPKroll via Twitter)

-Wes

Labels

Two days ago after a typical day performing procedures in the EP lab, doing inpatient consults, fielding patient messages, attending administrative and research meetings, reading EKGs, Holter monitor recordings, and co-signing device clinic charts, I opened my email and saw this:

ABIM Email to Diplomats 11/20/2015

I was appalled. MOC is not longer about "keeping up" for physicians. It is a major distraction. This program is of unproven benefit to my patients and me. Thanks to haphazard and self-serving rule changes by the ABIM and their member boards over the past 25 years, the US Specialty Board system has become increasingly coercive. In fact, MOC program now threatens my ability to practice the work that I love because I could lose my facility privileges and ability to receive payments from insurers on December 31, 2015. That is my reality. This is the reality of every physician subspecialist who participates in the ABMS MOC program in US medicine today.

Remarkably, I just re-certified in Cardiovascular Diseases and Cardiac Electrophysiology in 2013 for the third time.  I have never failed. I have over thirty years of experience treating patients and standing in the cross hairs of what it means to be truly accountable to those I treat. I have had over thirty years of nights when I lie awake at night worrying about by patients, about if I did enough, about why a patient had to die. My family, too, has endured years of being woken in the middle of the night or seeing their father have to leave a school play, holiday concert, or friend's dinner party to place an emergency pacemaker.

I am not unique. I am a practicing physician everyman. I stand in unison with hundreds of thousands of others here in the United States just like me who get up every day, kiss their loved ones, and head off to do their favorite job in the world - a vocation so completely immersive and rewarding that we gladly give up a part of ourselves to earn the trust and faith of our patients and fellow physicians.

And because I've been practicing medicine so long, I know I do not need a private, unaccountable, and irresponsible organization to tell me how to behave. I am better than that. After experiencing the busywork of the evolving MOC program and its lack of value for the time spent, I looked into the corporations who promote this exercise. I had the help of accountants and fellow physicians who were similarly upset and uncovered a vast array of hidden financial activities of the ABIM and their collaborators. There is so much financial corruption it is mind-boggling. The conflicts of interest that are never acknowledged and corrected make my stomach churn. The practice of medicine is better than this. Practicing physicians are better than this. We do not need some dystopic corporate Big Brother watching over us to assure we log into a computer every so often to enter data that can be used against us. We do not need webcams, video monitors, body inspections, keyboard tracking, and palm scans to prove we are honest and ethical and won't cheat on examinations. But this is what the ABIM has become: some new form of quasi-police state for monitoring physicians.

Working in fear is not what I want for medicine. It certainly is not how I want my youngest colleagues to grow up learning and practicing medicine. But the ABIM and their parent organization, the American Board of Medical Specialties (ABMS), seem to love fear, humiliation, and intimidation to get doctors to participate in their lucrative MOC program. It is sickening. It is also the height of hypocrisy for these organizations to claim to run an organization that attempts to "Choose Wisely" when that same organization funnels tens of millions of dollars for itself from hard working physicians so they can choose an investment portfolio with multi-million dollar condos, meet at swank meeting venues, pay for spousal travel fees and first class airfares as they preen themselves in front of media lights. The ABIM Foundation "created to define medical professionalism" for the public? Give it a break.

Rest assured I am not naive. I know how important this MOC program is to certain investors. As I peel back layer after layer of the interconnected workings of these ABMS member boards and the ACGME, I know how high this MOC program goes and how dark this MOC program and its tactics have become. I completely understand that these specialty board organizations have managed to wedge themselves into our new health care law that calls itself "Affordable," wedged there by undisclosed lobbying efforts funded by the very doctors whose blinded trust was violated beyond comprehension. Just because these corporations want to make a buck.

So let me take the stick a moment.  Let me be perfectly clear and I don't say this lightly. I'm sure I say this on behalf of tens of thousands of other hard-working, honest, and ethical physicians. We have had enough of the ABIM and the ABMS MOC program. It is time to end it - completely.  No more "modifications" to make this broken program "easier." No more "listening" to our concerns but continuing this failed experiment. No more "MOCA Minutes" that we have to turn our gaze from our patients toward the computer screen or iPhone even longer. Continuing the ABMS MOC that has proven itself to be morally and financially corrupt, and exceedingly expensive to physicians, patients, and our health care system is ill-advised for our profession. The conflicts of interests alone are worth hundreds of millions of dollars to the corporations that stand to make millions from physician assessment, yet we never hear a word about this from them ABMS or the ABIM on this reality.

I am better than how the ABIM and ABMS threaten to label me. I served this great country for twenty-six years as a physician with the United States Naval Reserves and I continue to work every day to make sure I do the best I can for my patients in this increasingly difficult health care delivery environment. I worked then and work now beside hard-working corpsman, nurses, administrators and technicians who don't want to rock the boat and just want to do what's needed to finish our job every day. These people and the patients I care for are why I go to work every day.

So I ask the leadership of the ABIM: "Why does the ABIM insist on placing a "scarlet A" on my reputation by labeling me a "Not Participating in MOC?"  Such labels are offensive. I participate in ACGME-accredited CME as required by my license to practice medicine in the State of Illinois. I am not a slacker. I teach residents and fellows, for goodness sakes. I am certainly not one who doesn't mind working hard. I am a proud practicing physician with more years of clinical experience and direct patient care than any of you.

Please don't be libelous and cast aspersions my way with your on-line labels. I've got much more important things to deal with. Stop pretending that you speak for "the public" and know what's best for them in health care when you don't even crack the door of an examination room or know what I do. Proceeding to take away my hard-earned reputation and ability to practice medicine because of your little label is both threatening and hugely upsetting.

Think about these words. Think about them carefully.

I beg of you and your affiliated private organizations to stop the labels.

The profession of medicine is better than this.

Your everyman,

Wes

Concerning Conflicts of Interest at the ABIM, ABMS and NQF

By now various medical societies are telling the American Board of Internal Medicine (ABIM) their ship has sailed. The ABIM's worn mantra that the "public" demands their program is simply not supported by evidence. The tales of misguided incentives and corruption within the organization grow daily. The blatant avoidance of the egregious financial dealings and conflicts of interest outlined in this blog's pages and elsewhere simply cannot be ignored by the ABIM - yet they continue to do so.

Why?

Because there are millions upon millions of dollars at stake in areas of physician assessment and measurement.

When Christine Cassel, MD left the ABIM and began her work at the National Quality Forum (NQF), physicians learned of some of her conflicts of interest with other organizations, namely Premier, Inc and the Kaiser Foundation Health Plans and Hospitals. Dr. Cassel labeled these conflicts as "distractions" as she resigned her board seats with those organizations. What we do not know (and this is important) is did Dr. Cassel receive any stock or stock options from the organizations she was so cozy with as part of her compensation package? Given the usual and customary way of compensating corporate board members, I would not be surprised if she did. (Update 19:15 PM: h/t to Mr. Charles P Kroll for confirming that Dr. Cassel owns 3,704 shares of  Premier, Inc stock)

Recently, a Premier, Inc press release announced its plans to purchase a company called CECity, Inc. I suspect most practicing physicians did not notice this announcement. After all, why would practicing physicians be interested in a press release touting a new business opportunity for Premier as it expands its "performance improvement capabilities across the healthcare continuum?"

But practicing physicians need to be VERY wary if our fellow physician-bureaucrats (especially those from the ABIM) when they consider their prior conflicts of interest as "distractions." That word is a flag that everyone should look deeper at these conflicts first reported by ProPublica.

When we do, we find more concerning revelations about the ABIM and the American Board of Medical Specialties (ABMS)'s motives.

According to the press release, CECity, Inc is worth about $400 million (or more) to Premier, Inc. and who do we find has been using CECity as its consultant?

Yep. You got it: the ABIM.

In fact, the relationship with the ABIM has been nearly continuous since 2010. According to CECity, they are a CMS qualified registry that provides physician "quality reporting data" to CMS:

As a CMS qualified registry for the Physician Quality Reporting System (PQRS, ePrescribing, MOC-PQRS) and as the service provider for many physician certifying boards (e.g. ABIM, ABO, AOA) CECity is uniquely positioned to align professional and financial incentives with CQI to deliver ‘game-changing’ quality initiatives that have proven and measureable results.

According to the ABIM's Form 990's, they have already paid CECity the following: $600,000 in fiscal year (FY) 2010, $1,217,800 in FY 2011, $1,112,600 in FY 2012, $1,378,138 in FY 2013, and $1,260,000 in FY 2014 (an example of these payments can be found on page 8 of the ABIM's most recent published Form 990 - provided they do not change their Form 990 after this report).

That's right: $5,568,538 of physician testing fees to CECity from practicing US physicians over five years - all of it (so far) on Dr. Cassel's watch.

If Dr. Cassel holds stock in Premier, Inc. from her prior board position there, I wonder how much money she stands to make when this cozy deal with Premier, Inc. closes? Should the U.S. Securities and Exchange Commission investigate this transaction? We don't know, but even the apparent conflict of interest with Dr. Cassel, the president and CEO of an organization responsible for "quality" programs in our nation's hospitals, is very disturbing, indeed.

This is not a minor revelation as physicians continue their difficult task of managing patients in such an overbearing regulatory environment while our specialty societies continue to support the financially conflicted ABMS MOC program. I believe allowing independent and unaccountable third-party organizations (like the ABMS and ABIM) to collect and distribute physician and de-identified patient-related data without written consent of those who could have their ability to practice medicine or collect payment from insurance companies revoked if they don't participate in MOC is a clear violation of Department of Health and Human Services Protection of Human Subject statutes. It also remains to be determined if this violates the Sherman (antitrust) Act.

After all, it is now clear the MOC program is not a "quality assurance" exercise performed for "public's" benefit.

This is profiteering and financially conflicted research on physician subjects in its most fundamental form.

-Wes

Part III: Why Washington?

I woke early to review my notes; who was attending the gathering that day, the itinerary, the location.  Suit, tie, briefcase, cell phone, charger. Check.

Soon I stood in line with familiar faces at the Rayburn building waiting to pass through security, remembering my wife's comments about the DMV.  "Bags on the conveyor, folks.  Jackets, too. Sir, you can leave your suit coat on." Of course. What was I thinking? What about my coffee cup? Passing the bag check, the halls widened. Shiny grey linoleum, fluorescent lights, just as promised. Just like the Hart and Dirksen buildings.

We made our way upstairs to the Judiciary Hearing Room, Room 2226. An early-morning confab of the members of the GOP Doctors Caucus was in the hearing room, discussions underway. Microphones on. All of us listening. Real issues, real bills, sausage making at its finest. An urgency to their voice.  Meaningful Use Part III. Crazy. Not ready. What can we do?  Can we kill it? No? Push for a delay. H.R. 2603/S.1475: "The Saving Lives, Saving Costs Act" to permit safe harbor for physicians who follow guidelines. Add this, what do you think of that? Need to get things done by the 11th of December. A real-life physician-politician show and tell. Then when things concluded, the brief pitch: physician ranks were getting thin. You're needed. (It was not a younger crowd.) Then, off to more meetings before the debt ceiling vote. Got to go. Cynically to me it looked more like doctors were  being taste-tested for the menu rather than really being at the table.

But then a break for coffee and continental breakfast in Representative Sessions' office across the hall. Nice office, four-room suite. Spacious, with lots of Texas memorabilia on the wall. More time to mingle, connect. So many people to meet, so little time.  People circulating for a quick photo shoot with the Congressman. Graciously he invited all to pose. "Off with the name tag," he'd prompt. "Now, this is a good place to stand." Then a photo:

It was fun.  A very polite way to say "thanks for coming." Reminded me of my Navy days, just more casual. Then he was on to the next attendee. On and on, until most people that wanted to have a chance for a photo did so.

Then the main event.

We shuffled back to the Judiciary Room. Congressman Sessions made some introductory remarks.  Very likable guy. Top salesman for AT&T for years, he said. He could sell anything to anyone, he boasted while smiling. Admitted the didn't know a thing about being a doctor, but seemed well-informed on many of the issues doctors face and that our patients are facing right now: high deductibles, co-pays, co-insurance, especially for those just above the poverty brackets. You could see why people like him on the Hill. He explained be was working on a bill. Obamacare is going to collapse - too expensive, he said. Maybe it was designed that way. Not touching Obamacare or Medicare, just an alternative for Medicaid. Hasn't been filed yet. Preliminary, getting ideas. He realized more work is needed. He turned things over to this his legislative aide to explain. Wanted our input, ideas.

A doctor focus group of sorts...

The idea seemed realistic, not far-fetched. Practical option that sounded like a way to make health care sustainable for everyone, with much less gaming of the system. But was it going to be understandable? For some, maybe. For others, it would take some education. Eleven key points, detailed, spelled out with examples.  But I was interested that most doctors in attendance were independents or retired. There were few employed physicians there like me. After the seventh point in the midst of the explanation, a break.  We rose and stretched, I approached the Congressman with a thought.

"Representative Sessions?"

"Yes?"

"Wes Fisher from Chicago, sir, interesting plan - very innovative alternative - like the concept - but I wondered if you were aware..." and bent his ear very briefly during our break....

"Are you kidding me? John, get over here." He waved to trusted orthopedic physician-colleague from his home state. "Have you heard about this?"

John listened.  "Not nearly as big a problem for orthopedists," he told him, but he'd heard something about it...

"Give me your cell phone...", Congressman Sessions said.

"Excuse me?"

"Give me your cell phone so I can put my contact information there. Here's mine.  Enter your contact information into mine."

Surprised by his response, I fumbled to enter my contact information.

"Send me the details."

Part II: Why Washington?

I looked out the airplane window and saw we were approaching Reagan National Airport from the south. The crisp morning sun pierced the fluffy clouds and found its way through the slit of the partially-opened airplane window shade to momentarily blind me. A small apex of the Washington Monument could be seen in the distance. To its right, the US Capitol dome shrouded in scaffolding.

Washington DC.

Having my luggage, I Uber-ed my way to my hotel. Boutique hotel next to the Capitol. Nice place. Quaint pastel-painted row houses nearby. French bistro, too. A 30-somthing hipster lady was checking out as a host brought her a few knickknacks to munch on for breakfast. The smartly dressed man  behind the front desk had an Australian or South African accent. Or was he from Belize? I couldn't tell. Relaxed. Confident. Good eye contact. He checked me in.

 This is the life of a policy wonk, I caught myself thinking.

My room was larger than I needed, the bathroom tiny, but functional. I pulled back the curtain and saw the many marble buildings surrounding the hotel and blocked the viewed of the streets further away that I remembered weren't quite so inviting.  Lots of construction in view.  Booming. I wondered if any of the other people who frequented this establishment ever saw the very different life that exists in rural areas outside the Beltway.

Probably not.

No matter. It was Washington. Time to explore. Crisp air. School kids bursting with excitement and rushing to the street corner, starry-eyed. Ever-patient chaperons shouting they could only see the Capitol if they made two parallel lines. "Quiet, please! Line up. Come on, now." Others in dark suits walking the streets. High heels with lanyards and  name badges. People walking in tandem, sharing secrets, telling jokes. Black Towncars, Escalades with tinted glass, Mercedes.  Large white buildings that dwarfed their visitors, like Poseidon looking down on a flotilla of tiny ships at sea.  Supreme Court. Library of Congress. Madison, Jefferson, Dirksen, Hart, Cannon, Longsworth, Rayburn. White. Marble. Big. Powerful. At least so it seemed. Certainly not for the faint of heart. Security everywhere. Metal detectors. Strange white mechanical roadblocks that clanked up and down to let the Important People drive their beat-up Subaru over it to head home.

A foreign land for a practicing doctor. Almost surreal.

I had arranged to meet two colleagues before the introductory dinner gathering. Each a name on The List. We never met before but shared some emails once. Nice to put faces with the names. They were more seasoned in this environment than me. But real doctors. Not pretend. Independents. Just came from work. Drove all day or flew from far away. Eager to meet others. Passionate. Each with their story - a reason to be here. Certain they could speak to a piece of the puzzle. Frustrated with things but determined to do something. I settled in. We exchanged numbers. You on Twitter? Defiantly: "Why should I use a smartphone when a tiny flip phone will do?"


* sigh * Reality.

Soon we headed to the introductory dinner. Staffers handing out sticky paper name tags that never seem to stick. (Except to things they shouldn't.) Pleasant smiles. A glass of wine. Pasta on the menu. Mingle. Where are you from? I see. The Congressman will be here a bit later. Then the Congressman arrived. Thanks for coming. Relax. Enjoy your stay. Tomorrow we'll show you our plan. Want to get your ideas, feedback. What brings you to Washington?

They all seemed to know. Me? Better to lay low for now. Who are all these people, really?

Would what I had to say make any difference? There was another plan. Another agenda.  Mine? Very small, unimportant. One doctor with a few others in a big very big pond, treading water, learning to swim. Would this be worth it? Others seemed to think so.

I still wasn't sure.

Justice Department Fines 457 Hospitals for Inappropriate ICD Implantations

From the Heart Rhythm Society via email today:

Today, the Department of Justice announced that it has reached settlements in its investigation of hospitals for billing Medicare for ICDs implanted in Medicare patients that did not meet Medicare coverage requirements. The announcement includes 70 settlements involving 457 hospitals in 43 states for more than $250 million.

The Heart Rhythm Society (HRS) has recognized that the misalignment between the Medicare National Coverage Determination and the clinical practice guidelines created gaps between the payment policy and clinical decision-making and places physicians and their patients in an untenable position. To help mitigate the problem, HRS published "2013 HRS/ACCF/AHA Expert Consensus Statement on the Use of Implantable Cardioverter Defibrillator Therapy in Patients Who Are Not Included or Not Well Represented in Clinical Trials”.

Moving forward, the Society’s priority is to do everything possible to assist the heart rhythm care community in managing the patient care pathway. HRS and other medical specialty societies are currently working with the Centers for Medicare and Medicaid Services (CMS) to identify the appropriate time to reopen the existing national coverage policy. The Society will provide CMS with recommendations to update the clinical indications for reimbursement. With this preparation, we stand ready to work with our partners to revise the Medicare coverage policy to reflect current clinical practice.

Outdated CMS National Coverage Decisions from 2005 just whacked hospitals. "Misalignment's" Catch-22. So much for evidence-based medicine. So much for practice guidelines. So much for innovation in health care.

CMS NCDs rule now, no matter how outdated, from now on.

The Justice Department has spoken.

-Wes

References: Justice Department press release with list of hospitals affected.
More on the history of this action here.

Part I: Why Washington?

When I lived in Washington DC years ago, there was a saying my wife and I heard on occasion from our friends who worked on the Hill:

"In New York, it's about finance;
In Boston, it's about power;
In Washington (DC), it's about access."

* * *

The invitation came in a regular envelope. An invitation to go to Washington DC.  Who asked me? What was this for? Was it real?

I studied the invitation: a "personal" invite from Congressman Pete Sessions (R-TX), dinner the first night (dutch treat), then meetings started the next day at 08:30 am in the Rayburn Building, presentations, other Senators and Congressman to be invited (names to be decided). New plans. Need input, discussion, dinner afterward.

I showed the invitation to my wife: "Do you think this is the real thing? Why would they ask me?"

"Looks real. Call them," she said. "Find out who's going.  Maybe there's someone you know."(My wife, unphased, used to testify on the Hill when I was a young staff doctor at the National Naval Hospital in Bethesda, MD many years ago).

I waited a few days, then called. "Well, fifty-five doctors have already RSVP'd so far," said the exasperated voice on the end of the line." Ugh, I thought. "We'll be sending out a revised agenda with a list of the attendees when the date gets closer."

Would it be worth it? Fifty-five doctors? Were doctors being asked to come to Washington at their own expense just so it would look like we were "at the table" when, in fact, we were "on the menu?"  Given health care's recent history and how things got to where we are now, it was very hard to suppress my cynicism. Who funds Representative Sessions, I wondered? I checked. Got it. Then I really pondered: why me?

My wife looked at me like I was an idiot. "You have to go," she said. "You can't go through all of these hours of investigation, research, fire, and brimstone, and not go to Washington. Make some appointments.  Maybe you could stay with our old friends Jack and Jill  (not their real names) while you're there."

"But the time from work... it's so expensive..."

"You decide," she said. "But if it was me, I'd make it worth every minute. Look, Washington is really kind of, well, government. Think DMV. Big hallways. Linoleum floors. Fluorescent lighting. All puffed up, but not that glamorous when you think about it, it's no big deal." My wife sure knows how to sell things...

That night, I stared at the computer screen on my desk. "How much does it cost to fly to Washington?" I searched Orbitz. I'd have to cancel a clinic day, maybe two. Maybe I could swing this if I only missed an extra half a day of my clinic. Folks at work won't like this. Oh heck, she's right. I'd never forgive myself if I didn't go.

After weighing things, I booked the flight, then rearranged and blocked my clinic schedule the next day, though I still wasn't sure. Will it be worth it?

A few weeks later a more finalized agenda came with the names of who would be attending. I googled everyone (this seemed to take forever). I made a list. 18 states. Most were practicing doctors. Most of those orthopedic physicians, (Huh?) a few AMA representatives (young and semi-retired), a few older retired doctors, a few lawyers, an economist, a doctor who ran an ICD-10 coding company, a person who owned a medical collection company, some physician advocacy group representatives, a lobbyist.

Sheesh.

"Mouth of the lion," I thought. "How am I going to get a word in edgewise?" Fifty-five people had grown to sixty.  "It'll be a waste of time," I thought.  The next day I finished my overbooked clinic, then returned home to tell my wife what I had decided. I told her I probably won't go to Washington after all.

"You have to go," she reinforced.

"It's all about access."

Sunshine

From Jonathan Edwards (video):

"Sunshine go away today
I don't feel much like dancing
Some man's gone, he's tried to run my life
Don't know what he's asking

He tells me I'd better get in line
Can't hear what he's saying
When I grow up I'm going to make it mine
But these aren't dues I been paying

(Chorus)
How much does it cost, I'll buy it
The time is all we've lost, I'll try it
But he can't even run his own life
I'll be damned if he'll run mine, Sunshine

Sunshine go away today
I don't feel much like dancing
Some man's gone he's tried to run my life
Don't know what he's asking

Working starts to make me wonder where
The fruits of what I do are going
He says in love and war all is fair
But he's got cards he ain't showing

(Chorus)

Sunshine come on back another day
I promise you I'll be singing
This old world, she's gonna turn around
Brand new bells'll be ringing."

I'll be heading to Washington, DC on my own dime next week. Seems there are plenty of people who want to know more about the American Board of Internal Medicine.

Who knows? Maybe I'll learn a thing or two, also.

-Wes

Can Medical Knowledge Be Copyrighted?

A patient with a history of syncope, first degree AV block with evidence of a bundle branch block and 2:1 block on telemetry is examined and 1:1 conduction ensues with carotid massage. You recommend a pacemaker because you understand the electrophysiologic principle of "gap phenomenon" but realize that you had a question that looked just like that on a prior cardiac electrophysiology medical board examination. You recall that just prior to that examination, you electronically signed a statement that contained something like the following contract language just before the computerized examination started (but recall you were never given a copy of that mystical agreement):

I understand that all ABIM materials are protected by the federal Copyright Act, 17 U.S.C. § 101, et seq. I further understand that ABIM examinations are trade secrets and are the property of ABIM. Access to all such materials, as further detailed below, is strictly conditioned upon agreement to abide by ABIM's rights under the Copyright Act and to maintain examination confidentiality.

I understand that ABIM examinations are confidential, in addition to being protected by federal copyright and trade secret laws. I agree that I will not copy, reproduce, adapt, disclose, solicit, use, review, consult or transmit ABIM examinations, in whole or in part, before or after taking my examination, by any means now known or hereafter invented. I further agree that I will not reconstruct examination content from memory, by dictation, or by any other means or otherwise discuss examination content with others. I further acknowledge that disclosure or any other use of ABIM examination content constitutes professional misconduct and may expose me to criminal as well as civil liability, and may also result in ABIM's imposition of penalties against me, including but not limited to, invalidation of examination results, exclusion from future examinations, suspension, revocation of certification, and other sanctions.

Can you divulge this principle of gap phenomenon (and a similar example of this phenomenon) that once appeared in an almost identical way on your board examination to your residents?

According the American Board of Internal Medicine (ABIM) and the above agreement, it would seem that I cannot.

But is such a medical principle and my personal example displayed on this blog truly copyrightable by the ABIM?

According to prior court decisions, under the principle of the "merger doctrine" my example does not violate the Copyright Act. In fact, according to Mazer v. Stein, 347 U.S. 201, 217 (1954), the Supreme Court stated "Unlike a patent, a copyright gives no exclusive right to the art disclosed; protection is given only to the expression of the idea—not the idea itself." This protects my First Amendments' free speech right and the fact that this same principle was shown to me years before by my mentor, Mel Scheinman, MD at the University of California, San Francisco when I trained as a fellow in cardiac electrophysiology.

To be clear, the disclosure of an exact replica of a board question and its detractors (wrong answers) might be subject to a copyright dispute, but it is clear that simply mentioning to residents that you saw a "similar question" on your specialty board examination and providing an example to your residents and fellows does not compromise your ability instruct your residents about such an important electrophysiologic principle as "gap phenomenon." In actuality, it is hard to copyright medical information that is widely available in the medical literature.

But this has not deterred the ABIM from continuing its legal battles against physicians who they claim may have shared information about their certifying examination question content.

More Suits Against Physicians Filed

Currently, the ABIM is continuing to sue physicians for possible Copyright Act infringement of their secure board examinations from participants in the Arora Board Review course given in 2009 (!), this time a young internal medicine physician from Puerto Rico (the full text of this suit can be viewed here). While this trial has yet to be heard, it will be interesting to see if the ABIM's Copyright Act infringement claims have merit. The suit is interesting because it gives a detailed accounting of the ABIM's test creation methods and the damages they hope to recover. I encourage my physician readers to review the suit.

Even more interesting to me, however, is the answer to the claims made in the ABIM's suit by the defendant and the countersuit filed against them (seen here). The claims of the "ABIM Individuals' Illicit Conduct" (beginning on page 22) are important to review, for if they are found to be true, they offer insight into the extent ABIM will go to protect their intellectual property and the damages they inflict of physicians that might be wrongly accused, including the use of a "spy," claims fo the violation of a "Pledge of Honesty" that the defendant never saw, public claims that he was "unethical and unprofessional," and having only 10 days before every medical licensing board in his jurisdiction would be notified of the ABIM's decision, leaving (in my view) no opportunity for due process.

These are extremely important issues for physicians to understand as the "restructuring" of the ABIM continues in light of the ABIM getting it "wrong" and the financial revelations and deceptive disclosure practices of the ABIM raised on this blog and elsewhere.  If the court finds in favor of the defendant in many of the claims made by him, I have a feeling there will be many more suits against the ABIM to follow.

It also raises the very real possibility that the ABIM Foundation was not created as a means to define and promote "medical professionalism," but rather to serve as a legal defense fund for the ABIM as they protect their monopoly interest in the physician specialty accreditation process.

-Wes

Every 10-year ABIM MOC Exam On It's Way Out? Careful What You Wish For

According to MedScape:

The American Board of Internal Medicine (ABIM) has announced that it will consider replacing its 10-year maintenance of certification (MOC) exam with shorter, more frequent testing that physicians could take home or in the office.

The proposal to eliminate the 10-year examination is one of several recommendations issued today by ABIM's "Assessment 2020 Task Force," convened in 2013 to improve its controversial MOC progam for internal medicine (IM) physicians and IM subspecialists. ABIM released the task force report less than a week after the American Board of Anesthesiology (ABA) announced that it would replace its 10-year MOC exam with continuous online testing next year.

"The results of the smaller, more frequent lower-stakes assessments would provide insight into performance and accumulate in a high-stakes pass/fail decision," the task force said in its report. "A failure at this point may necessitate taking a longer exam or another form of assessment in order to maintain certification."

Let's think about this a moment.

ABIM's Task Force 2020 wants to replace MOC with MORE testing, more often, and still reserve the right to force a physician to take a "longer exam or another form of assessment in order to maintain certification?"

This isn't better, it's worse. Much worse. Instead of every 10-years, it will be daily or weekly MOC-minutes!

More MOC distraction pushing physicians away from their patients and toward even more computer time.

What are these "Task Force 2020" members smoking?

Of course the money can't be denied. Pharmaceutical companies are licking their chops. Think how many MOC® questions we'll soon have to answer on novel oral anticoagulant use instead of that old, cheap, outdated warfarin! Pushed to our iPhones, these new MOC-minute® questions are sure to turn your head away from patient care toward an easy payment plan! I wouldn't be surprised that thanks to the ABMS stumping for Big Tobacco in the sixties, we'll all be answering questions on the praises of e-cigarettes and pharmaceutical aids for smoking cessation, too!

It's truly fascinating to watch these attempts at social engineering of practicing physicians by the ABIM. But the ABIM has already tried voluntary re-certification and knows it failed miserably. They had to make it mandatory by veiled threats over what the loss of Board certification might mean or no one would pay into their scheme.

Want proof that the ABIM isn't serious about ending their MOC® exam?  Read the contract physicians must sign before entering into the ABIM MOC® program. Read about "trade secrets" and "federal Copyright Act, 17 U.S.C. § 101, et seq." and "forensic techniques" they use to protect their products. And let's not forget that "disclosure or any other use of ABIM examination content constitutes professional misconduct and may expose me to criminal as well as civil liability, and may also result in ABIM's imposition of penalties against me, including but not limited to, invalidation of examination results, exclusion from future examinations, suspension, revocation of certification, and other sanctions."

These guys and gals of the ABIM mean, er, BUSINESS!

All this for a costly and completely unproven metric foisted on physicians to assure the ABIM's cash flow.

MOC® isn't about physician education or patient welfare, it's about intimidation, $2.3 million condominiums, $1.7 million golden parachutes, and secret transfers of millions upon millions of physician testing fee dollars to the ABIM Foundation in the name of "social justice."

It's about an organization that has allowed itself to sink $47 million in the hole (Fiscal Year 2014 Form 990 line 22) and balances its financials on a whopping $94 million in deferred revenue (Form 990 Page 11 of the pdf, Form X, line 19).  

That $94 million will be coming from somewhere (can you say "ACA?") and since the ABIM gets 98% of is fees from practicing physicians, you can bet your last silver dollar that these totally  unproven MOC® programs will be paid for by practicing physicians, one MOC® exam or MOC-minute® at a time.

And the ABIM is SERIOUS. Recently, despite all that has been uncovered about the ABIM, they continue to sue doctors over their intellectual property, just as before, this time in Puerto Rico (case 3:15-cv-01016). Oh, golly, what's a few more million dollars in legal fees to protect your income stream, right?

If you believe there will be no MOC® exam of any type, ever, and given the honesty and integrity the ABIM has demonstrated over its finances over the past 30 years, I've got some ocean-front property in Arizona I'd like to sell you.

-Wes

9 Oct 2015 06:00AM Link to ABIM's Puerto Rico case fixed.

Heart Rhythm Society and ABMS: Friends for Life

Patients are dropping like flies in Electrophysiology Laboratories across the country. Death and destruction everywhere. Poor quality. Unsafe standards. Pitiful results.

What, you haven't heard? 

Clearly this MUST BE THE CASE! That's why it's SO important that the Heart Rhythm Society and the Intersocietal Accreditation Commision (IAC) INSIST (seriously) that EVERY electrophysiology laboratory in the United states have a MEDICAL DIRECTOR certified by the American Board of Medical Specialties.  Otherwise, your electrophysiology laboratory will be labeled as "NOT UP TO STANDARDS." And we wouldn't want that now, would we?

I just received this disappointing e-mail from David Haines, MD, president of the "IAC Cardiac Electrophysiology Accreditation" on behalf of the Heart Rhythm Society (who is clearly colluding with the American Board of Medical Specialties to assure regulatory capture of every electrophysiology laboratory in the United States) under the guise of EP laboratory standardization:

Last week, I sent an email discussing the recent partnership between the Heart Rhythm Society, the Intersocietal Accreditation Commission (IAC), and other key stakeholders to develop and operate an EP Lab Accreditation Program. Developed by the IAC Cardiac Electrophysiology Board of Directors, the draft IAC Standards and Guidelines for Cardiac Electrophysiology Accreditation are now available for public comment and I am requesting your assistance on this important initiative. Please review the draft standards and provide feedback to ensure that they meet the expectations and the field’s needs.

Listed below are the instructions to provide comments. The IAC Comment Form must be completed and submitted electronically by December 1, 2015.


To submit a comment on the proposed IAC Standards:

• Visit the IAC website.
• Click on the proposed Standard you wish to review and/or comment from the menu.
• A window will expand with the description of the Standard and a PDF to view the section of the Standards available for comment.
• Click on the PDF to open it in a separate window for review.
• On the right, fill in your name and provide your comments about the proposed Standards in the boxes provided.
• Push submit.

At the close of the comment period, the IAC Cardiac Electrophysiology Board of Directors will review all submitted comments, consider modifications, and vote on the Standards final approval. The new Standards will be posted to the IAC Cardiac Electrophysiology website and available for download in late 2015.

Don't you get it?  The new "Standards" are coming whether you like it or not.

I would suggest every electrophysiologist comment on this decision by the Heart Rhythm Society to insist that EP laboratories must meet certain "standards" regulated by yet another unaccountable body to the physician and patient (who the heck is the "Intersocietal Accreditation Commission?") After all, this is ALL about regulatory capture and the money generated for the ABMS and their member boards.

Where's the proof that patient care will be improved as a result of such standardization?

Instead, everything (including our "re-certification" expenses) will cost us more and more as the regulatory capture of medicine by the ABMS and the IAC/ and their pals continues unabated.

-Wes

ABIM Maintenance of Certification: The Gift That Keeps on Giving

The incredible growth in American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) fees from 2000 to 2014 in one graph:

The growth of these fees far exceed the growth of inflation and the stock market over the same period of time.

-Wes

P.S.: The fee for certification by the ABIM in 1936 was $40. It cost $10 more to obtain your "certificate."

ABIM First-Time MOC Pass Rates 2000-2014

I reviewed the past 15 years of first-time pass (and therefore failure) rates of the American Board of Internal Medicine (ABIM) MOC secure examination for every internal medicine subspecialty.  Because of the work involved, I wanted to see if I could get these data published in a major peer-reviewed journal nearly two months ago to no avail.

I first submitted a manuscript with these data to the New England Journal of Medicine and it was rejected immediately before the manuscript even reached the peer review process.  (I even gave the editor access to a password protected webpage containing the infographic you will see below).  They weren't interested. (Perhaps because this is a retrospective review?)

I then submitted a slightly revised manuscript to JAMA.  The after a preliminary review, the editor of JAMA would not submit my manuscript for peer review, but thought the work might warrant review as a 600-word "Research Letter to the Editor" that allowed only one figure and one table and no more than 6 references.  Needless to say, nearly a month later, I just learned that my "research letter" was rejected by both JAMA and JAMA Internal Medicine. The reviewers comments were helpful should I ever decide to re-submit these data to a peer-reviewed journal again in a different format. However, given the many changes occuring to the ABMS MOC program recently, I felt time is of the essence and elected to proceed with publishing my data here on this blog. I feel these data are too important to sequester behind a medical journal paywall and encourage physicians to use these data to question the credibility and reproducibility of the American Board of Medical Specialties' (ABMS) MOC secure examination and the remainder of the MOC program as a requirement for maintaining hospital practice credentials. By publishing my data on this blog, I can publish ALL of the data I collected and collated, not just a tiny fraction of it. Also, I have found that this blog's reach is equal to or larger than many medical journals, particularly when a post contains important and credible  information.

METHODS: The ABIM's first-time MOC pass rate data were gathered from current and prior archived ABIM web pages for each subspecialty between 2000 and 2014 using the Internet Archive Wayback Machine (https://archive.org/index.php).  (Only the past 5-years of pass rate data were available for Hospital Medicine and 10-years of  pass rate data were available for Interventional Cardiology because they were "newer" internal medicine subspecialties). The number of physicians failing their examination each year was then calculated by subtracting the product of the total number of physicians who took the examination by the published pass rate from the total number of physicians who took each subspecialty MOC examination. Linear regression trend lines of annual pass rates with their correlation coefficients over time were calculated for each subspecialty. Historical volatility of pass rates was calculated as the standard deviation of the data range of year-to-year percent change of pass rate. For example, published pass rates for General Internal Medicine from 2000-2014 were 89%, 92%, 91%, 85%, 86%, 84%, 79%, 83%, 92%, 90%, 88%, 87%, 84%, 78% and 80% respectively. The percent pass rate change from 2000 to 2001 was calculated as 0.92/0.89 - 1 = 3.37%. The 14-value dataset of  percent pass rate annual changes for the years 2000-2014 therefore was 3.37%, -1.09%, -6.59%, 1.18%, -2.33%, -5.95%, 5.06%, 10.84%, -2.17%, 2.22%, -1.14%, -3.45%, -7.14%, 2.56%. The historical volatility of pass rate percent changes for General Internal Medicine equaled the standard deviation of this dataset, or 4.93.

RESULTS: First-time ABIM MOC pass rate trends (and the raw data for each internal medicine subspecialty's first time MOC pass rate) with their linear regression trend lines can be displayed using the interactive infographic below (just click the specialty circle to display the detailed annual pass/fail data):

The total number of physicians who took the test over 15 years and the percentage of physicians who failed their MOC exam on the first try are shown by subspecialty in the table below. Year-to-year historical volatility of pass rates by subspecialty also shown (bolded historical volatility values exceed one standard deviation from the mean of all subspecialty volatilities):

Subspecialty	Physicians Undergoing MOC Examination (n)	Number of Physicians that failed MOC exam on their first attempt (%)	Pass Rate Historical Volatility (Minimum/Maximum annual percent pass rate change)
General Medicine	61,050	9,212 (15.3%)	4.93 (-7.14 / 10.84)
Cardiology	10,486	1,386 (13.2%)	3.23 (-3.53 / 6.10)
Cardiac Electrophysiology	1,398	113 (8.1%)	4.33 (-7.45 / 5.49)
Critical Care	5,596	552 (9.9%)	4.62 (-7.69 / 8.33)
Endocrine	2,308	310 (13.5%)	7.48 (-10.4 / 13.16)
Gastroenterology	6,255	770 (12.3%)	4.35 (-6.45 /4.71)
Geriatrics	6,559	539 (8.2%)	7.64 (-14.13 / 20.51)
Hematology	2,427	338 (13.9%)	7.11 (-9.76 / 13.51)
Hospital Medicine*	829	113 (13.6%)	1.09 (-2.27 / 0.00)
infectious Disease	3,520	312 (8.9%)	5.00 (-10.53 / 7.32)
Interventional Cardiology	3,182	244 (7.7%)	2.24 (-5.32 / 2.33)
Nephrology	4,129	466 (11.3%)	3.81 (-8.42 / 5.56)
Oncology	4,568	456 (10.0%)	3.87 (-8.79 / 6.90)
Pulmonary	5,792	803 (13.9%)	6.57 (-11.24 /13.92)
Rheumatology	2,143	217 (10.1%)	3.56 (-6.59 / 5.81)
TOTAL	120,242	15,832 (13.2%)

ABBREVIATED DISCUSSION:

• A very significant 15,832 physicians (13.2%) have failed their MOC secure examination on the first try. This has a significant impact on physician morale without justification and has affected patient access to their physician as a result.
• A large variation in year-to-year pass rates exists for many subspecialties, particularly Endocrinology, Geriatrics, Hematology, and Pulmonary suggesting inconsistent content, irrelevant content, and/or inconsistent setting of pass rate cut-offs year to year using the ABIM's modified Angoff method of determining pass rate cut-offs.
• First-time MOC failure rates vary by as much as 51% between subspecialties, with General Internal Medicine having the highest failure rate (15.3%) and Interventional Cardiology having the lowest (7.7%)
• Fourteen of 15 subspecialties had declining pass rate trends in this 15-year review of ABIM MOC pass rates (see infographic). Was this because the tested material is increasingly irrelevant to patient care? Or might there be another ulterior (financial?) motive for the decline? Or are most physicians simply unable to cram larger and larger amounts of information into their heads and regurgitate the proper answer in a limited time period thanks to the exponential growth of health care information over the last 15 years?
• Year-to-year first-time MOC pass rates could vary by as much as 20.5% (Geriatrics).
• The steepest pass rate decline was interventional cardiology (1.62% decline in pass rate per year), though low numbers of physicians took the exam the first several years it was offered.
• Since MOC participation is increasingly tied to hospital credentials as "board certification" became "time-limited" in 1990, what responsibility does the ABIM assume to patients when they fail a physician? How many physicians of each internal medicine subspecialty had to retake their examination (and how many times did each have to repeat)? What is the total cost to the doctor and the health care system for this unproven "quality" metric in terms of real dollars, patient access, and care delivery?
• Given the large number of physicians that have failed their MOC examination, why has the ABIM not studied the psychological, social, professional, and clinical impact their failure of physicians? Or don't they care?

These are just some of the questions these ABIM MOC pass and failure rate trends garner. I look forward to hearing what others think about these data in the comments of this blog - especially physicians and hospital administrators who might not understand the impact the MOC secure examination has had on physicians and their patients.

A word of caution: the American Gastroenterological Association (AGA) has recently posted a video promising to bring an end to the MOC secure examination for gastroenterologists.  Instead of ending the MOC program, however, (and after reviewing the full proposal about to be published in November) the AGA promises to replace MOC with an even more complicated "Continuous Professional Develppment" program "tailored to your needs" called "GAPP", the "Gastroenterologists Accountable Professionalism Pathway." This pathway promises to be an even more complicated 13-step program rather than MOC's 4-step program.  It is a spin-off from the ABIM's similar "Continuous Professional Development" program used before by the ABIM that still has no proof of its value to patient care and without any disclosure of the cost this program for working physicians. It maintains the need to participate in their program for physicians to remain credentialed to practice medicine in their hospital.  Before leaping for joy that the MOC examination is being phased out, realize that our specialty boards are reeling from the exposure of the financial reality of their "programs" to our health care programs and are creating new "programs" to assure ongoing financial and time-commitments from working physicians without proof that recertification is of any value to patient care over traditional self-directed Contining Medical Education. Worse yet: the AGA uses the term "Professionalism" in the title of their new re-certification proposal - a word defined via a "Task Force" of the corrupt ABIM Foundation.

Please feel free to share this post with interested journalists, friends, and colleagues. If you have further questions or ideas about these data, feel free to leave a comment or send me a note at wes - at - medtees dot com.

-Wes