The Canary in the American Board of Family Medicine's MOC Gold Mine

In an editorial in the Mayo Clinic Proceedings this month entitled "The Evolution of Physician Certification and the Canary in the Coal Mine," James C. Puffer, MD, President and CEO of the American Board of Family Medicine (ABFM), reviewed a recently published survey on Physician Attitudes About Maintenance of Certification (MOC) by Cook, et al. that appears in the same issue. To his credit,  he acknowledged the following:

"Physicians today are overburdened with the vagaries of their electronic health records, endless reporting requirements, and the demands of multiple payors. The amount of time that they are spending with patients continues to dwindle, and the last thing that they want to do is spend additional time, meeting yet another set of requirements that they find burdensome.

Unfortunately, Dr. Puffer couldn't bring himself to admit that the costs for MOC are excessive, both in fees paid and the time required to perform this unproven exercise, and he failed to call for an complete moratorium on the unnecessary MOC requirement for the many family medicine diplomates his organization certifies.  Instead, he glowingly reviews the survey's "methodological approach," "meticulous design" and "rigorous analysis of the data," despite the survey being designed by an American Board of Medical Specialties (ABMS) employee and reviewed by a mysterious "anonymous external reviewer" (see Acknowledgements). As a result of the survey findings, he calls on "modifications" to MOC because the results of the survey represent the "canary in the coal mine" of how physicians will accept the current iteration of the MOC physician re-certification "quality" metric going forward.

But by merely disclosing that he is an employee of the American Board of Family Medicine (ABFM) in the Mayo Clinic Proceedings editorial, Dr. Puffer carries his own canary into the hallowed financial walls of the ABFM's MOC gold mine. It should come as no surprise for readers of this blog that MOC has opened all sorts of wondrous financial opportunities for the ABFM (and all of the member boards of the ABMS) at practicing physicians' expense.

For instance, while the public only has access to the ABFM's tax forms to disclose the financial dealings of the organization, we quickly see that MOC continues to be a windfall for the ABFM. In fact, in 2014 MC-FM fees (the ABFM's MOC program equivalent) contributed 46.4% ($12,776,905) of their $27,525,430 annual haul from ABFM diplomates. These fees helped support Dr. Puffer's $803,687 annual compensation and the organizations' $3,521,629 "donations" made to their "ABFM Foundation" and "Pisacano Leadership Foundation."  (In 2012 and 2013 these "donations" were even larger: $6,147,376 and $7,878,535 respectively). MOC also helped fund the ABFM Executive's first class and companion air travel and their Directors' first class air travel and a  $1,449,525 retirement package with $435,000 in post-retirement medical benefits. No wonder MOC is such a great deal and needs to continue!

The ABFM is a tax-exempt 501(c)(6) tax-exempt organization that has accumulated a remarkable $130,082,516 in assets on the backs of working physicians that is offset by "liabilities" that fund the salaries of 75 people and other "projects" in the amount of $45,838,832 yeilding a net asset balance of $84,243,684 at the end of 2014. Rather than offset the fees that diplomates have to pay the ABFM for MOC, these fund transfers show the ABFM would rather continue to plow this money into itself (rather than defraying costs to its members) by growing its supporting "Foundations."

But careful review of the ABFM Foundation's tax forms shows it carries many similarities to the infamous ABIM Foundation that gained considerable notoriety after its condominium purchase (complete with a chaueffer-driven town car) was disclosed on these pages and elsewhere.

According to the ABFM Foundation's most recent IRS Form 990, it exists for the "Fostering of Education and Scholarly Analysis or Research in Family Medicine." Like the ABIM Foundation, it seems that "scholarly analysis and research in family medicine" actually involves (in part) managing potentially lucrative real estate investments for themselves.

The ABFM Foundation is the controlling entity of ABFM Realty LLC (created in 2010) and ABFM International LLC (created in 2013), both based at the ABFM's office in Lexington, KY and lead by Dr. Puffer.

According to tax records, ABFM Realty LLC purchased a 22,793 square-foot office building (pictured here and whose location relative to the ABFM corporate headquarters is pictured here) at 1500 Aristides Blvd in Lexington, KY for $4,245,074 on June 26, 2012 from the $6,147,376 (page 11, Line 24a) of  diplomate fees "donated" by the ABFM to its Foundation that year. It appears this transaction happened about the time a large law firm, Bingham McCutchen planned to move hundreds of its employees to Lexington, KY the same year. The deal was consumated by a promise of $6.5 million in tax breaks from the Kentucky governor and anticipated revenues of $22.5 million over 10 years in rent and building improvements. Unfortunately, it seems Bingham was struggling financially and was "absorbed" just two years later by Philadelphia's Morgan Lewis and Bockius LLP law firm. Google's street view still shows Bingham's Global Services Center sign outside the ABFM's building as late as December, 2015. What this loss meant to the ABFM (and its many diplomates) is unclear, in part because to the best of my knowledge and belief this transaction was never been disclosed to ABFM's practicing physicians. Roger Bean, the Chief operating officer for ABFM at the time, "couldn't be reached for comment" either.

Here we are in late 2016 and the 2015 tax forms for the ABFM and the ABFM Foundation still have yet to be disclosed publicly.  Perhaps their recent real estate snafu explains why these forms aren't available and why the ABMS still feels compelled to continue the highly conflicted ABMS MOC program publicly in the Mayo Clinic Proceedings.

Or maybe Dr. Puffer is positioning himself as the heir apparent to the ABMS now that Lois Margaret Nora, MD JD has announced the end of her tenure at the organization.

One thing's for sure: with his editorial Dr. Puffer's own canary in the ABFM's MOC gold mine just died and many more US family physicians are now officially on notice.

-Wes

Are Hospitals Hurting Their Physicians?

It's becoming a near daily event for my email in-basket: receipt of another real-life story describing how the American Board of Medical Specialties (ABMS) and US hospitals are joining forces against capable doctors:

I am trying to find physicians in FL who have unfairly lost ABMS certification and as a result have been unable to find reasonable positions in Medicine.

I am a radiologist certified by ABR in 2002, the first year to require 10th year (re)certification. I lost my contract with a hospital in 2010 and took locums positions as I could find them after that. I have passed the recertification exam, for which I paid $2000, but because of short term locum positions, was not able to complete PQI requirements and consequently lost my certification. Now, unless I sign a promise to never sue the board (emphasis mine), I cannot even sign into my page on the ABR website to see my status. Since losing the certification the only work I have been able to find is a bottom-feeding imaging center where I earn less in a year than the MRI and CT technicians, while working 55-hour work week with no more than 3 unpaid weeks of vacation per year.

I am certified by the National Board of Physicians and Surgeons thru March of 2017 but this is not recognized by most locations. I was turned away at the door when I drove to NC after being invited to interview for a position. The reason -- the certification I had was not recognized except for by a handful of places.

What is going on?

It appears the ABMS Maintenance of Certification (MOC) recertification requirement is creating the situation where capable, experienced physicians are losing their job on the basis of this unproven "quality" metric.

I am sure similar stories are occurring elsewhere. There are only about 809,845 US physicians active in patient care nationwide. Many of these board-certified physicians, formerly a lifetime credential, are now receiving letters from their hospital credential committees insisting they recertify thanks to a unilateral rule change implemented in 1990 by the ABIM strictly for their financial benefit.

Why would hospitals (who need physicians to staff their hospitals) do this?

As usual, I believe it's about the money.

Many physicians are employed by hospitals that help train medical school graduates in their specialty. To do so, their post-graduate training program must be accredited and approved by the Accreditation Council on Graduate Medical Education (ACGME). Hospitals that are not ACGME "approved" cannot receive additional Medicare revenue for training these residents in medicine. The ACGME (and Joint Commission) accreditation process requires program directors to be ABMS board certified. And wouldn't you know: both the ABMS and JCAHO are member boards of the ACGME.

Appropriately experienced and trained physicians should have the right to work without having to pay into a corrupt system that funnels their money toward non-clinical executives' lavish salaries, luxury condos with chauffeurs, first class airfare, health club fees, and other delightful creature comforts, including world travel. I believe hospitals would be wise to side with their practicing physician staff on this issue. Don't hospitals need these experienced physicians to staff their clinics and to do the necessary work of training residents and caring for patients? Or do they just plan to hire less experienced (but cheaper) program directors instead? What would such a move mean to tomorrow's caliber of physicians?

How long before the growing frustration of residency training program directors swells to the point that they refuse to participate or just retire early?

I would hope that the leadership in the American Hospital Association (AHA - another member board of the ACGME) is considering these issues. Physicians unjustly targeted should come forward and join the AAPS anti-trust suit already filed against the ABMS. And currently employed physicians who have not yet had to endure this hassle should work with their Medical Executive Committees to incorporate alternatives to the ABMS MOC program in their hospital bylaws now.

-Wes

It Just Takes One

A physician pushes for reform in Maryland to make ABMS Maintenance of Certification (MOC) voluntary:

I have just got off the phone with Mary Beth Carozza, my State Delegate. Following in the wake of legal actions against MOC in OK, MI, Florida, and others, I expressed to her that I wish to have her champion legislation ending compulsory MOC in Maryland. The bill I’d offer basically says, if you wish to participate in Maintenance of Certification efforts, you are welcome to, if you do NOT, no employer, payer, etc. can use your board certification status to hire, fire, pay, not pay, promote, demote, etc. you. It makes MOC voluntary.

If you love MOC, truly believe that it’s improved the quality of your patient care, made you a better doctor, and that it’s completely worth the time, effort, and $$ you’ve invested, and you care not one bit how your board has used that tremendous surge in their income, then I apologize for having bothered you with this, feel free to delete without reading further.

If you disagree with the essentially obligatory nature of MOC, then the time has come for you to do something. ...

Read the rest here.

Each state can do this, and it just takes one dedicated physician at a time to move the needle. Kudos to Dr. Fernley.

-Wes

ABMS IRS Form 990's and the Art of Dodging Disclosures

For years physicians, hospitals, the insurance industry, and "the public" have endured the American Board of Medical Specialties' (ABMS) and the American Board of Internal Medicine's (ABIM) breathless calls for repeated physician "re-certification" under the trademarked Maintenance of Certification (MOC) banner. What is uniformly never mentioned in the myriad of press releases or articles that support the ABMS MOC program are the multitude of financial incentives to market this program to physicians and the public.

It was with that as a background that I wrote my post on these web pages entitled "How the ABMS MOC Program Threatens Major Medical Journal Integrity" on September 5, 2016. I was concerned that the ABMS President and CEO, Lois Margaret Nora, MD, JD and her colleague Thomas Norris, MD had failed to disclose financial conflicts of interest in a letter that they had published in the New England Journal of Medicine (NEJM). I felt it was also clear that Dr. Nora had a similar lapse of failing to disclose financial conflicts in her pro-MOC article that she was invited to pen for the NEJM and in another promotional article published in the Journal of the American Medical Association (JAMA) in August of 2015.

Specifically, I felt Dr. Nora disclosure as an employee of the American Board of Medical Specialties was insufficient as it relates to collecting third-party revenues from it's separate for-profit Georgia-based corporation, ABMS Solutions, LLC. The revenues received by ABMS from ABMS Solutions, LLC are above and beyond fees paid by physicians who participate in ABMS MOC re-certification. Also, no mention of lobbying activities the organization engages in for the corporation's financial benefit was made in either journal as well.

Because of these concerns, I sent an email to the editors of JAMA and the NEJM, asking them to investigate the failure of Dr. Nora (and in one case Dr. Norris) to disclose the conflicts and to consider retraction or a correction for the failure to disclose these conflicts.

Both journal editors were responsive to my concern, but in different ways.

Journal of the American Medical Association

The Editor in Chief for JAMA, Howard Bauchner, MD responded felt that Dr. Nora's financial disclosure as President and CEO of ABMS was adequate because "professional societies and organizations, medical societies, medical schools, hospitals, and industry stakeholders in healthcare employ lobbyists on their behalf. We suspect our readers are aware of this and we do not expect authors to separately declare that their employers engage in lobbying efforts." No mention of my specific concerns regarding the money received by the for-profit subsidiary, ABMS Solutions, LLC, was made, but he did copy his email to me to the journal's editorial counsel, Mr. Joseph Thornton. When I inquired why the issue ABMS Solutions, LLC was not addressed in a subsequent email, I received no reply.

New England Journal of Medicine

The editors of the New England Journal of Medicine forwarded by communications to Dr. Nora and Dr. Norris of the ABMS.  Here is a copy of the short email I received from Mary Beth Hamel, MD, MPH, the Executive Deputy Editor of the New England Journal of Medicine in response:

(Click to enlarge)

The New England Journal of Medicine editor sided with Dr. Nora that her financial disclosure was adequate after reviewing this letter they received from Dr. Nora. In her letter, Dr. Nora stated my concerns of failure to report financial conflicts were "incorrect" for the following reasons:

"The operations, activities, and finances of ABMS Solutions, LLC and the other subsidiaries of the ABMS are consolidated for accounting purposes with those of the ABMS. Likewise, the operations, activities, and finances of ABMS, ABMS Solutions, LLC, and all other subsidiaries are consolidated for tax purposes and publicly reported on a combined basis on the IRS Form 990 for the ABMS. The references in our disclosure to ABMS refer to the consolidated entity, as publicly reported, and as such our disclosures were full and complete."

The problem is, when physicians or the public go to the ABMS website, you will notice that their Form 990 and "consolidated financials" are nowhere to be seen. Instead, it appears the NEJM expects its readers to check financial dealings themselves.

So I did.

Thanks to my familiarity with reviewing IRS Form 990's, I knew to go to Guidestar.org to look up the ABMS's latest-available 2014 ABMS Form 990 (pdf). From that, I found the following publicly reported just as Dr. Nora suggested:

ABMS Solutions, LLC earned ABMS $3,469,401 in 2014 (see page 44). Also note that ABMS claims ABMS Solutions, LLC is domiciled in Illinois (it is not, it is domiciled in Georgia). (We've seen this misreporting of the state of domicile of affiliated corporations on IRS forms dealing with the ABIM Foundation, too.)

ABMS International, LLC, a "holding company" for the ABMS, earned $5,034,433 in 2014. (see Page 44. While it not itemized in their form 990 or "consolidated financials,"  practicing physicians should note that employees of the ABMS attend posh conferences in Qatar (video) and Venice, Italy to promote their credentialing program to other groups outside of the United States. ABMS International LLC is the "Direct Controlling Entity" of ABMS Singapore, LLC that earned $0 in 2014 for ABMS in 2014. Dr. Eric Holmboe, the ABIM's former medical director (before he moved on to the Accreditation Council on Graduate Medical Education) can be seen promoting (video) the ABMS/ABIM MOC program with Singapore physicians here for an undisclosed sum).

Dr. Nora earned a remarkable $763,005 from ABMS in 2014 (and at least 11 other officers of the organization earned over $200,000) - a sum that eclipses the vast majority of practicing physicians in the United States.

These ABMS "related" organizations' revenues represented 47 percent of the ABMS total Program Service Revnue (of $18,128, 145) in 2014 - certainly not a "de minimus" amount. Why are U.S. physician fees supporting overseas marketing of this program to other countries?

But there's more.

ABMS is also the controlling entity of  the American Board of Medical Specialties Research and Education Foundation, whose principle officer is also Lois Margaret Nora, MD JD and has it's own separate IRS Form 990.  That Form 990 claims the ABMS Research and Education Foundation's mission "shall be to support the scientific, scholarly, and public education purposes of the American Board of Medical Specialties (1) by encouraging and conducting research to improve the capacity to measure, assess, and evaluate the educational scientific, clinical, and professional qualifications and performance of physicians engaged in the practice of medical specialties and (2) by conducting educational programs and disseminating information to the public to assist its recognition, evaluation, and underdstanding of the significance and importance of initial certification, of subcertification and of maintenance of certification of physicians engaged in the practice of medical specialties (3) by fostering national and international cooperation and the exchange of information related to initial certification and maintenance of certification."

Items (2) and (3) appear to represent little more than a marketing mission for ABMS certification and MOC propaganda. Item (3) further supports the the promotion of ABMS Solutions, LLC sale of physician credentialing status as well.

The finances of the ABMS Research and Education Foundation demonstrate it has a deficit of $573,644.  In FY 2014, the ABMS issued $2,115,569 grant to this "education and research" Foundation (Page 46 of the ABMS Form 990) to cover their loss.

ABMS is also the controlling entity for Multi-Specialty Portfolio Approval Program whose finances are under a separate Form 990 (website here), the first of which appears to have been created in 2014. In FY 2014, the ABMS issued $217, 548 to this organization as a "gift, grant, or capital contribution" (for "promoting physician participation and competency") (Page 46 of the ABMS Form 990). 
What does the Multi-Specialty Portfolio Approval Program do?

It seems it loses money. After all, the organization is still $181, 423 in debt after the ABMS granted it $217,548 that same year).

And what what THAT money transfered for?  The "mission" of the Multi-Specialty Portfolio Approval Program is "To promote physician participation and competency in quality improvement efforts by granting maintenance of certification credit for quality improvement efforts in local enviroments that improve quality care." Closer inspection of its website seems to hint at promoting the suspended "Part IV" of the old MOC program that Dr. Baron halted when the controversy and physician frustration with MOC began. In reality, it appears the mission of this 'Portfolio Program' is to issue funds to other "exempt non-charible related organizations" (line 49a of its own Form 990)."

I wonder who decides which "local environments" should receive that money and how it is distributed?  Really, this seems like a slick way to pay money to others that support institutions that the ABMS deems worthy of their support.

In summary, it took reviewing three Form 990's (one from ABMS and two from "related" organizations) to uncover the "disclosed" conflicts of Dr. Nora's.  As we can now see with the travel of ABMS members, "consolidation" of financials has a funny way of disclosing details.

Still, there they are. I suppose I should apologize to Dr. Nora for the fact that I was unaware of this network of spending using our re-certification fees for the benefit of ABMS and I appreciate her openness for "disclosure" in her publications and engaging with this discussion.

As an aside, it was telling that the editors of the New England Journal of Medicine never mentioned their own financial conflicts with the ABMS MOC program. (I brought this to Dr. Hamel's attention but never received a reply.)

Live and learn, colleagues.

-Wes


Addendum: On 10/17/2016 after sharing this blog post privately with the editors a week before it was published and receiving no response, the same day the post was published I received an email from Lauren Lindenfelser, Manager of Editorial Administration at the New England Journal of Medicine  that stated "Thank you for your email. Your comments were received and shareed with the editor. We have no further comment at this time."

MOC and DINOs Limit Patient Care in Michigan

Marc Keshishian, MD
BCBS - Michigan

Meet Marc Keshishian, MD.  He's a DINO - a Doctor in Name Only - who is the Medical Director of Blue Cross, Blue Sheild, Michigan.

Marc (aka "Dr. Keshishian") believes in the ABMS Maintenance of Certification (MOC).  At least in principle. You see, Marc does not participate in MOC himself.  Instead, after a two-step "careful review," he just decides that those who do not participate in MOC are not worthy of his blessing to participate as a BCBS-Michigan provider, even if they have 10 years experience and are a minority physician provider.

Here are the letters from that physician who refused to participate in the ABMS MOC program in Michigan and instead credentialed with the National Board of Physicians and Surgeons (NBPAS.org):

Initial notification of revocation of insurance panel participation by Blue Cross Blue Shield of Michigan
(Click to enlarge)

Second Appeal Letter from Dr. Keshishian dated 8 Sep 2016

Michigan patients should be furious. After all, these corporate DINOs are limiting patient access to physicians because credible physicians who refuse to participate in the unproven, costly, and corrupt ABMS MOC re-certification process. Because MOC has been documented to be more interested in its political and financial agenda than patient care, the AMA House of Delegates resolved to immediately end MOC. It is clear that corporate DINOs at Blue Cross Blue Shield Michigan don't care.

As we can now clearly see, MOC helps preserve the DINOs income and the company's bottom line by restricting access to hard-working (yet expensive) patient-care physicians.

-Wes


PS: Remember, while it is unsaid in his letter, there may be other conflicted DINOs responsible for Blue Cross Blue Shield's policy of requiring MOC for insurance panel participation.