A Rebuttal to ABIM President and CEO's Defense of MOC

In August, Medical Economics published an interview with Richard Baron, MD entitled: "The Man Behind MOC Defends the Program Against Critics." Medical Economics then solicited practicing physicians to write a rebuttal. I accepted, but with a warning:

@MedEconomics @DrLaurieG Happy to do so but come with a warning label: I will not mince words.

— Westby Fisher, MD (@doctorwes) August 7, 2016

After exchanging a series of Twitter direct messages and e-mails with the staff at Medical Economics, much to my surprise they seemed agreeable to publish my piece  and promised to move forward with the rebuttal for both print and online versions of Medical Economics.  So I signed a "Contributor License Agreement" with UBM LLC, a nearly $2.8 billion owner of Medical Economics (among lots of other throw-away publications) and proceeded to spend the better part of an evening composing my rebuttal and submitted it a few days later.

That was August 12, 2016.

I reached out to Medical Economics yesterday to inquire where things stood on the rebuttal and received a phone call a short time later from a more senior editor that they would be unable to publish my work, especially the part that dealt with the ABIM, but would be willing to write about modifications I might suggest for the MOC program. I thanked them for their review but saw no utility in promoting "modifications" to MOC over ending the program entirely. We parted company politely.

Needless to say, I'm frustrated, but this isn't the first time this has happened. (Welcome to the realities of the Medical Industrial Complex!).

*sigh*

But one of the beauties of social media and the disruptive force of the Internet is that anyone can be their own publisher. Glenn Reynolds famously coined our ability to compete with larger publishing firms "An Army of Davids."

And so, thanks to the wonders of technology, I present my rebuttal to Dr. Baron below.

* * *

Richard Baron, MD, President and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, was recently interviewed by Jeff Bendix of Medical Economics and once again attempted to defend the ABIM's Maintenance of Certification (MOC) program by rehashing his usual talking points. Dr. Baron argues that because there is an explosion of medical information out there, doctors should use ABIM recertification metric to prove to themselves, patients, and institutions that they are staying current in medicine. Dr. Baron also seems to believe that taking computerized tests assembled from a database of rehashed test questions every ten years is superior to gaining 10 years of direct patient care experience.

Unfortunately, Dr. Baron and his bureaucratic colleagues at the ABIM seem to have forgotten that practicing physicians are committed to caring for patients, not to supporting Dr. Baron’s retirement fund.

While endlessly promoting their Maintenance of Certification (MOC) program to the public, the truth is that the potential adverse effects of ABIM re-certification on physicians and their patients have never been studied, nor has the American Board of Medical Specialties (ABMS) MOC program ever been shown to improve the quality or safety of patient care (See here, here, and here), especially as it pertains to a physician's specific practice environment. Their form of assessment is, in effect, a one-size-fits-all assessment of a physician's ability to retain facts and take a test, little more. Despite these facts and thanks to heavy lobbying to the medical community by those who stand to profit from the program, practicing physicians certified after 1990 must perform this ritual every 10 years to retain their hospital privileges or be allowed to be providers for many large insurance plans while physicians certified before 1990 do not - a discriminatory practice against younger, more economically vulnerable physicians.

As a triple "Board-certified" physician in good standing who has experienced the transition of the ABIM "Board certification" credential from a voluntary once-in-lifetime designation to a time-limited one, I have experienced first-hand the irrational and humiliating process of re-certification that makes a mockery of the entire health care accreditation process. After spending nearly $10,000 to "maintain" my certifications in cardiovascular diseases and cardiac electrophysiology in 2013 for the third time and having to be scanned, searched, and videotaped to assure my integrity in a PearsonVue testing center, I decided to study the finances, practices, and financial conflicts of interest that have come to define the ABIM and (as I have since learned) much of our physician credentialing system in the United States. Some of my earlier work has already been published. In the financial analysis of the ABIM, I was joined in my effort by Mr. Charles Kroll, a certified public forensic accountant specializing in health care non-profit organization accounting who has donated over 1500 hours of uncompensated time to this review. As our analysis has continued, other physicians have quietly come forward with additional information and personal stories of the impact of an ABIM sanction when the organization targets practicing physicians they feel are cheating while attempting to study for their unproven quality metric. I have reviewed the ABIM's federal Forms 990 from 1997 to the present and other sources including the internet archive (archive.org), IRS Form 1023, Guidestar.org, Brightscope.com, Pacer.gov, and called and emailed Dr. Baron to understand why my fees were so high and better understand why Dr. Baron is able to pay himself $812,000 per year (nearly four times the typical US internist salary) while the ABIM is $50,642,980 in debt according to its most recent Form 990 (line 22, "net assets and fund balances").

By expanding my review to the ABIM Foundation and other member boards of the American Board of Medical Specialties (ABMS) (of which the ABIM has the most physician diplomats), it became obvious that the problems I found at the ABIM were endemic to most of the United States physician credentialing system under the direction of the American Board of Medical Specialties (ABMS). For instance, the American Board of Pediatrics paid a $2.4 million golden parachute to their retiring 20-year veteran President and CEO, James A Stockman, III in 2012, yet still employed him two years later for $793,438 for working just eight hours a work-week: an almost incomprehensible $2066.24 per hour. Worse still, to the best of my knowledge and belief, all of these transgressions appear to have been conveniently ignored by the leadership of US medicine’s associated member organizations of the Accreditation Council of Graduate Medical Education (ACGME), including the American Medical Association, the Association of American Medical Colleges (AAMC), and the Council of Medical Subspecialty Societies (CMSS). The House of Medicine has become deeply divided between the bureaucratic elite of these organizations and those who struggle every day to do the real work of hands-on patient care.

After writing about by re-credentialing experience in 2013 on my blog, Dr. Wes (http://drwes.blogspot.com), my dive into the corrupt finances of the ABIM began in earnest 16 Dec 2014 with my article entitled "The ABIM Foundation, Choosing Wisely®, and the $2.3 Million Condominium." Since that time, a partial list of my ongoing investigation has uncovered the following:

• The ABIM Foundation, which was flush with over $47 million in cash when it was supposedly "created" in Iowa in 1999 (as disclosed on its tax forms from 2008 through 2013), was actually secretly created on October 17, 1989, in Pennsylvania. It has since been determined (and later acknowledged by the ABIM on their revised website) that the organization was funded by making multiple (undisclosed) transfers of ABIM diplomat fees from the ABIM (IRS Form 990's for the Foundation are unavailable for review because the ABIM had the IRS remove available tax forms after it changed the name of their Foundation from the "American Board of Internal Medicine Foundation" to the ABIM Foundation in 1999). Additional revenues were transferred from the ABIM from 1999 through 2007, culminating in the purchase of a $2.3 million luxury condominium complete with a chauffeur-driven Mercedes S-class town car in December of 2007. It remains unclear why a 501(c)(3) non-profit testing agency would purchase a condominium as an "investment" or for housing ABIM staff and directors when other cheaper options for housing exist in the Philadelphia area. The list of names of those who actually used the ABIM Foundation's condominium has never been publicly disclosed.


• One independent peer reviewed cost analysis of Maintenance of Certification has demonstrated the average cost for an internist to re-certify is $23,607 (95% CI, $5,380 to $66,383) and cost US physicians $5.7 billion in 2015. Despite all of these facts, the ABIM and ABMS managed to lobby Congress to have MOC included in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as a physician quality measure even though 501(c)(3) organizations like the ABIM should have lost their tax-exempt status when they covertly participated in this activity, according to federal law.


• ABIM's own published Maintenance of Certification pass rates from 2000-2014 have demonstrated 13.2% of physician first-time test-takers failed their examination with large and inconsistent year-to-year pass rate volatility raising significant concerns of how the pass rate cut-off point is determined each year and the ABIM's motives for testing.


• Christine Cassel, MD, the former President and CEO of the ABIM and its Foundation from 2004-2014 earned over $8.9 million dollars over 11 years she worked at the ABIM for 35 hours per week and never disclosed her financial conflicts of interest while she simultaneously served on the boards of Premier, Inc., and Kaiser Hospital Health Plans until these relationships were disclosed after she left the ABIM to serve at the National Quality Forum. Despite these ethical lapses, Dr. Cassel still describes herself as a medical ethics "expert" and still serves as a consultant to the highest office in the land: the U.S. President's Council of Advisors on Science and Technology (PCAST) without Maintaining her own Certification status.


• The ABIM showers their executives with lavish perks on the backs of their physician diplomat fees. For instance, ABIM paid for spousal travel fees for Dr. Cassel for the ten-year duration of her term, even as residents and fellows struggle with the high fees for their certification while having record medical education debt.


• The ABIM website registration requirements and registration agreement used for their MOC program, ABIM and the ABIM Foundation routinely conduct "research" on physicians and their practices without a research protocol, Investigational Review Board review, or informed consent in violation of FDA and Health and Human Services Protection of Human Subject statutes. Note that the enrollment agreement (no longer found on the current ABIM website) stated: "I understand that the ABIM may use my examination performance, training program evaluations, self-evaluations of knowledge and practice performance, and other information for research purposes, including collaboration with other research investigators and scientific publications." There is no mistaking the ABIM was (and still is) conducting "research" on their diplomats for their benefit.


• Robert Wachter, MD, former President of the ABIM Foundation, earned stock options from the IPC Hospitalist Company while serving at the ABIM Foundation. While it is unclear what role Dr. Wachter played at IPC Hospitalist Company, the company remains under federal investigation for Medicare fraud.


• From 2010-2014, the ABIM paid a little-known company to the practicing physician community, CECity, $5,568,538 for their services. Just before leaving ABIM, Dr. Christine Cassel received $130,000 in cash and $100,000 in stock from Premier, Inc, that then announced its purchase of CECity for $400 million a short time later on August 4, 2015.


• The ABMS plans to sell physician certification data to a multitude of parties at ABMSSolutions.com and offer subscriptions to its CertiFACTS Online product (video). Funny how Dr. Baron and his colleagues at the ABMS fail to disclose this fact to major medical journals and Medical Economics when they are interviewed or publish their articles promoting the need for physician re-certification.


• Since 1 January 2014, to facilitate the coverup of its operations and to limit transparency, the ABIM no longer permits archived webpages to be stored on a regular basis on the Wayback Machine at archive.org as seen by the absence of archived webpages after that date.

These are just a small sampling of the serious problems that have been uncovered by careful review of the ABIM's actions, ongoing cover-ups, and propaganda inherent to the ABMS MOC program that Dr. Baron supports. Legal fees (all paid by ABIM diplomats) are mounting against the ABIM and the ABMS member boards as they attempt to defend an antitrust lawsuit brought against them, attempt to sanction even more physicians, and have more threats legal action from the Pennsylvania Medical Society’s recent announcement of a vote of no confidence against the organization at the AMA House of Delegates Meeting in June of this year.

Practicing US physicians don't need any more propaganda from Dr. Baron in Medical Economics promoting the ABIM's Maintenance of Certification program, we need a careful independent audit of their finances and a thorough investigation of the ABIM and their collaborating organizations by appropriate authorities to end this unjustified, highly corrupt, and conflicted ABMS MOC program nationwide.

Westby G. Fisher, MD
Director, Cardiac Electrophysiology,
NorthShore University HealthSystem, Evanston, Illinois
Clinical Associate Professor of Medicine
Pritzker School of Medicine
University of Chicago