Friday, January 20, 2017

ABIM Stationary Sidebars: MOC and UCSF

I attended the University of California, San Francisco's (UCSF) electrophysiology program from 1993-1994. As I continue to explore the myriad of conflicts of interest inherent to the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program, it has come as quite a surprise to me that so many members of my alma mater (and the institution itself) were either passive or active participants in  the strongman tactics used by the American Board of Internal Medicine (ABIM) as a "message and deterrent" (as explained by former President and CEO of the ABIM, Christine Cassel, MD) to control the ABIM/ABMS monopoly on continuing medical education in the United States.

Let me explain.

In a retaliatory letter dated May 8, 2012, authored by Ms. Lynn Landon, the non-physician Chief Operating Officer of the ABIM at the time, Jaime Salas-Rushford, MD was accused of forwarding, prior to ever taking the ABIM Board certification exam, board review questions to the ABIM-certified instructor of the CME-accredited Arora Board Review course. About three years after the fact and after 139 others had already been sued or sanctioned for attending the same course (or at the very least, like a flashback to the McCarthy era, had warning letters "added to their file") this retaliatory letter declared that ABIM imposed an immediate, unlimited revocation of Board certification of Dr. Sala-Rushford and to "notify the Medical Board in every jurisdiction in which you are licensed" without due process.

On the stationary sidebar of that letter appear the names of the officers of the ABIM and it’s board members at the time: Chair Catherine R Lucey, MD, Chair-Elect Robert M Wachter, MD, Secretary-Treasurer Talmadge E King, MD, and President and CEO Christine Cassel, MD among others. Were these leaders listed in the sidebar mere figureheads of the ABIM when this occurred or were they ultimately responsible for the organizations' actions as their positions suggest?

It is remarkable that three of the above senior ABIM leaders were on staff at UCSF at the time. These same individuals now hold significant leadership positions at the USCF medical school. Dr. King serves as Dean of the UCSF Medical School since 26 May 2015, Dr. Lucey as the Vice Dean for Education, and Dr. Wachter serves as Professor and Chair of the Department of Medicine. In addition to their current academic positions at UCSF, these same individuals hold leadership in other organizations within the Accreditation Council for Graduate Medical Education (ACGME):
  • Dr. Lucey serves as an at-large board member of the American Board of Medical Specialties 2016-2017 and on the Board of Directors of the of the Association of American Medical Colleges (AAMC).

  • Dr. King has a long history of serving on the Board of Directors of the National Committee for Quality Assurance (NCQA) from 2010-2017 as an unpaid board member and currently works alongside the organization’s founder and President, Ms. Margaret E. O’Kane. Remember that NCQA, under Ms. O'Kane's direction, developed, maintained, and expanded the Healthcare Effectiveness Data and Information Set (HEDIS), the nation's most widely used quality measurement tool and has grown to a $50 million company with almost 300 employees. NCQA is also the main accreditor of recognized medical homes and one of two accrediting organizations permitted by federal law to accredit plans in the new health insurance exchange marketplaces that came online October 1, 2010, under the Affordable Care Act (ACA). Because the NCQA also credentials insurance providers as part of the ACA, one insurer quality metric they created requires physicians to "maintain" their certification via ABMS MOC programs if they want to receive payments from those insurers. Furthermore, the NCQA and the ABMS will continue to directly benefit from "quality" rules that they have put into place and lobbied Congress to enact laws such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA's Merit-based Incentive Performance is MOC on steroids (see comments to the final rule). While NCQA maintains the quality measurement tool that is used in MACRA to determine US physician pay based on their notion of care "value," much of the NCQA's own IRS 2015 Form 990 is redacted. Who is protecting our patients' interests when even the IRS allows this to occur?

  • Dr. Wachter has his own financial conflicts with MOC that also benefitted the UCSF. According to IRS Form 990's, in 2012 when the above sanction letter was issued, Dr. Wachter served as 'Director-Chair" of the ABIM earning $38,888 from the ABIM and $6,626 from the ABIM Foundation.

    While serving as "Director-Chair" of the ABIM and Director of the ABIM Foundation, Dr. Wachter was also simultaneously serving as Director of the IPC The Hospitalist Company, Inc, reportedly running a “leadership development course (at UCSF) for their practice group leaders.” Dr. Wachter's financial haul from his relationship with IPC was significant. He pocketed 1,355 shares of IPC stock valued at $50.68 on 1 Aug 2013 and another 2650 shares of stock valued at $58.50 on 2 January 2014. According to SEC filings, he earned $210,586 in 2014 ($ 108,000 as cash, $ 55,000 in stock and $ 47,526 in options). USCF benefitted from a fellowship grant with IPC brokered by Dr. Wachter that began sometime in 2010 or 2011 (Dr. Wachter's description of the program was published on his blog 18 November 2011.) On 17 June 2014, the Department of Justice filed suit against IPC Hospitalist Company alleging the company overbilled federal health insurance systems for physician evaluation and services. Nonetheless, it appears Dr. Wachter still received a stock option award of 2186 shares of IPC on 2 Jan 2015. Undeterred by the DOJ suit (or perhaps because of it), TeamHealth acquired IPC Hospitalist Company for hefty $80.25 per share on 23 Nov 2015, again profiting Dr. Wachter and UCSF (with whom he had a publicly-disclosed sharing agreement where he kept 80% and UCSF received 20% of this relationship). As of 17 Jan 2017, it appears a settlement agreement in the DOJ's suit against IPC The Hospitalist Company will be reached soon. In retrospect, watching Dr. Wachter doing an Elvis impersonation at Mandalay Casino in Las Vegas on behalf of corporate medicine at patients' expense with the tacit approval of the Dean of the UCSF Medical School reflects poorly on the University. These activities also serve to erode any remaining trust practicing physicians have on the unproven ABMS MOC program to serve in our patients' best interest.
It is remarkably coincidental that on 27 December 2012, an article appeared in the New England Journal of Medicine by one of Wachter’s colleagues at UCSF, Robert B. Baron, MD written in conjunction with John Iglehart, a “national correspondent” for the New England Journal of Medicine, explaining the controversy surrounding MOC and reinforcing the need for it. Dr. Robert Baron (no relation to Richard Baron, MD of the ABIM) never disclosed his simultaneous collegial associations with so many in leadership positions of the ABIM at the time, nor did either author mention the fact that the "NEJM Group" would be announced in March, 2013 to profit the Massachusetts Medical Society that included the launch of their Knowledge+ Maintenance of Certification “state-of-the-art adaptive learning” educational product April 16, 2014.

Who wouldn't want to join such a financial and reputational party bestowed upon these former ABIM leadership physicians? What medical center wouldn't like to benefit from the ABMS MOC system so many from UCSF have? How many other institutions are? Given what we now know about these colluding private organizations and their ethical and financial tactics, why haven't these respected leaders come forward to denounce the activities of the ABIM for which they served? Perhaps these leaders are fearful UCSF would lose their ACGME accreditation as a teaching institution eligible for additional Medicare training funds if they did. Or perhaps these individuals saw little risk of collateral damage to their professional reputation if ABIM used its strongman tactics against a small number of vulnerable, less prominent physician colleagues.

The irony of the ABIM requiring doctor clients of Arora Board Review subject to the sting operation organized by an undisclosed convicted felon to participate in “ethics” courses and pay additional fees to the ABIM before their board certification credential could be reinstated should be lost on no one.

According to USCF's own Faculty Code of Conduct: "The integrity of the faculty-student relationship is the foundation of the University’s educational mission. This relationship vests considerable trust in the faculty member, who, in turn, bears authority and accountability as mentor, educator, and evaluator. The unequal institutional power inherent in this relationship heightens the vulnerability of the student and the potential for coercion. The pedagogical relationship between faculty member and student must be protected from influences or activities that can interfere with learning consistent with the goals and ideals of the University." I would argue that the unequal institutional power carried by the ABIM (and other ABMS member boards) that can revoke a physician's ability to practice or earn a living on the basis of an unproven repeated testing is even larger and warrants even greater scrutiny.

It is clear that the complex financial interrelations of many tax-exempt private organizations that require the ABMS MOC credential have developed over the years to monopolize the physician continuing education process. In my opinion, it is far too coincidental that all of these physicians a single institution just happened to hold unelected leadership positions in so many of these interrelated private entities that financially benefit from MOC at the same time. I also believe the fact that another physician from the same institution published a manuscript in the New England Journal of Medicine while his colleagues stood to benefit politically and financially from their positions gives the appearance of collusion. I believe the UC Board of Regents, Attorney General of California, and/or even the Governor of California have a responsibility to investigate the use of public monies and academic positions to benefit these many non-governmental private entities that act outside of University responsibilities and act, as one independent journalist described them, "more akin to a protection racquet."

The ABMS Maintenance of Certification controversy and those culpable for its strongman tactics extends far further than just the ABIM. When respected leaders of the academic community fail to speak out about the irresponsible activities that occurred during their tenure with the organization, I believe they passively condone them. I suspect this is why we have heard little from other members of the academic community since the collusion extends to current board members of the NCQA, AAMC, ABMS, the New England Journal of Medicine, and other prominent academic institutions like UCSF.

Practicing US physicians voted to end the ABMS MOC program before the AMA House of Delegates meeting in June 2016 because of the unexplained financial dealings and the strongman tactics employed by the organization, yet it continues, even now. This no longer surprises us since the AMA is a member organization of the ACGME, too.

How high do the conflicts go in the US medical education system?

It is now clear they go all the way to the top. It is also clear why.

It's time for the AMA to shut the ABMS MOC program down as practicing US physicians have voted because it's doing more harm than good, not only to reputable practicing US physicians nationwide, but to their patients and academic institutions (like my alma mater) that purport to train and educate physicians to become ethical, hard-working, trustworthy doctors without fear of reprisal for educating themselves any way they choose.

-Wes

Disclaimer: I serve as an expert witness on behalf of Jaime Salas-Rushford, MD.

6 comments:

  1. Nothing so enrages as the greed, hypocrisy and political underhandedness of the ABMS and the web of crony deceit they helped spin.

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  2. Wes tweeted, "IMO MOC is the largest medical education scandal in the history of medicine."
    MOC is a dangerous criminal enterprise with patients and physicians on the line.
    Can we get an executive order on MOC (and MACRA) today! This is public fraud.

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  3. Btw, I saw "Elton John" at Mandalay Bay, LV. Wachter with UCSF, ABMS,
    and AHRQ--which is fed-money--is an entire scandal unto himself. What a piece of work! Will be interesting to see the settlement between Wachter's company, IPC, the Hospitalist, and the DOJ. Timing is fascinating because the settlement could have been greater for DOJ "we the people" if the case got the full review from the new AG and HHS head. I hope Sessions and Price can work together going forward for the next eight years (with successors) to see what the real story is in "quality assurance" land and get a handle on the bigger picture.
    Wachter's IPC squeaked through the cracks of the SEC's complaint box and pending shareholder lawsuits like a greased pig as Bob and company stole millions of dollars from taxpayers and shareholders. And they may have thought they were cheating the grim reaper, nobody would see, but I encourage whistleblowers and families of victims who died from negligence/malpractice to come forward. The deaths and morbidities increases were a direct result of IPC's conscious and volitional executive policy of greed.
    Statute of limitations might spare IPC and Wachter on the financial end, stock haul and bonuses, but there are a lot of unhappy people in Texas and elsewhere that think IPC and Bob Wachter came short for them when there loved ones died needlessly. Wachter never said a word about the "leadership training" failures at IPC, nor criticized the CEO's greed and overly aggressive incentive plans that put stock and bonuses in the executive's pockets as priority number one and patient safety pushed to the rear of the hearse.

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  4. Punitive Wars: Bishop Baron's witch hunts, inquisitions and sanctions "Panel"

    Dickey-gate break-ins . . .
    Dr. Richard Baron should have been listed on the sidebar of the punitive letters sent to phycians who attended a competing board preparation course. Rich rode in the "side-car" with Ariel Benjamin Mannes, Christine Cassel, Eric Holmboe, Bob Wachter, Rebecca Baranowski, Hara Jacobs, Marc Weinstein, and Lynn Langdon in waging a war on physicians callously demolishing their lives and dreams.

    Dr. Baron was ABIM board treasurer in 2007 and chair in 2008. Afterward he was also a trustee before being "appointed" to be ABIM CEO and President. We'd like to hear the story from Baron's own lips how zealous he was in being a good servant to special interests, just to stuff his expensive Brooks Brothers pockets. We want to know why Baron went outside his job description to persecute physicians and competing board prep courses using Ballard-Spahr's dirty attorneys?

    Now matter how hard Rich Baron's multi-million dollar press corp and struggling makeover politicos try, they can't make a crook into a nice guy.

    https://www.abim.org/news/richard-baron-president-CEO-ABIM.aspx

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  5. ABMS' RECKLESS MANDATES, BLIND POLICIES, AND NEGLIGENT LACK OF ACTION TO END MOC (AND OPPOSE MACRA ON BEHALF OF CLIENTS) HAS LED TO LAWLESSNESS AND ANARCHY IN MEDICINE

    ABIM's CHIEF SPOKESPERSON AND CONTRIBUTOR TO "THE HILL" SAYS MOC AND MACRA-LIKE BEAUCRATIC REDTAPE AND ILL-ADVISED POLICIES IMPOSED ON COPS BY OUT-OF-TOUCH CITY GOVERNMENT ADMINISTRATORS PREVENT POLICEMEN FROM DOING THIER JOBS PROPERLY. AS A CONSEQUENCE LAW ENFORCEMENT OFFICERS CAN NOT EFFECTIVELY PROTECT THE PUBLIC FROM GUN VIOLENCE. ONEROUS PAPERWORK REQUIREMENTS CREATED A SEVERE REDUCTION IN HANDS-ON POLICING AND NUMBERS OF MEANINGFUL STOPS. EXPERTS SAY THIS FUELED THE SPIKE IN GUN VIOLENCE AND GUN-RELATED DEATHS IN CHICAGO IN 2016. THESE POORLY-THOUGHT-OUT ADMINISTRATIVE POLICIES HAVE SUCKED THE SPIRIT OUT OF COPS. AS A RESULT THEY NO LONGER WANT TO NOR CAN THEY DO THEIR JOBS UNDER SUCH RESTRICTIVE AND ONEROUS CONDITIONS. MORAL IS LOW AND BURNOUT IS HIGH. MANY COPS DON'T SEE THE POINT IN PUTTING THEIR LIVES ON THE LINE ANYMORE. WHY? BECAUSE THEY ARE THE ONES THAT ARE BEING BLAMED AND SHAMED FOR WHAT IS REALLY CAUSED BY ADMINISTRATIVE BULLHEADEDNESS AND EXECUTIVE MALPRACTICE. FILLING OUT USELESS TIMECONSUMING PAPERWORK REMOVES ONE FROM THE JOB OF ACTUAL POLICING. LAW ENFORCEMENT OFFICERS ARE NOT LAZY FOR RESISTING THE BURDENSOME DOCUMENTATION. THEY ARE STREET SMART. THE RANK AND FILE OFFICER KNOWS FIRSTHAND WHAT THE ADMINISTRATIVE BUREAUCRAT CANNOT POSSIBLY FATHOM. THE LOSS OF EVEN ONE INNOCENT CHILD FROM GUN VIOLENCE CANNOT BE TOLERATED.

    A VERY SIMILAR CONDITION EXISTS IN HEALTHCARE. PHYSICIANS ARE BURDENED WITH ONEROUS, TIME-CONSUMING AND RESTRICTIVE BUREAUCRATIC RED TAPE SUCH AS MOC AND MACRA. THE RESULT IS SIMILAR TO INCREASES IN GUN VIOLENCE FROM THE LACK OF TIME FOR RELAVANT VITAL WORK. ACCORDING TO EXPERTS PATIENTS ARE DYING. MORBIDITIES AND CHRONIC CONDITIONS GET LEFT UNTREATED. HOSPITAL ADMISSIONS AND DISCHARGES ARE NOT CONFORMING WITH WHAT IS TRULY MEDICALLY NECESSARY BUT WHAT IS MANDATED BY PAYORS AND EXTRANEOUS STAKEHOLDERS.
    PHYSICIANS HAVE THEIR HANDS TIED BY MEANINGLESS FINGER CLICKS, PERIPHERAL QUALITY MEASURES THAT INTERFRE WITH HIGH QUALITY DIRECT PATIENT CARE. ADDING TO THE BURDER ARE THE ADMINISTRATIVE POLICIES AND MANDATES OF INSURANCE COMPANIES WHO USE PHYSICIANS AS UNPAID CLERICAL STAFF. ADD COMPUTER TAG WITH COMPUTER-GENERATED ERRORS AND AUTOMATED PRESCRIPTION DEMANDS/PRIOAUTHORIZATIONS, AND COUNTLESS OTHER CRIMINAL REQUIREMENTS THAT INCREASE MORBIDITY AND DEATH IN PATIENT POPULATIONS PHYSICIANS SERVE TIRELESSLY. PHYSCIANS ARE CLINICALY SMART. THEY ARE NOT LAZY AT ALL. LET THEM DO THEIR JOBS. END MANDATORY MOC AND ALL USELESS DISTRACTING BUREAUCRATIC REQUIREMENTS WHICH GET IN THE WAY OF PATIENT CARE.

    PERHAPS PHYSICIANS (AND COPS) NEED TO GET STREET SAVVY AND HIRE PROTESTORS TO LINE THE STREETS OF DC UNTIL THERE IS A LEGITIMATE RESPONSE FROM GOVERNMENT THAT ADDRESSES THESE TIME CRITICAL ISSUES AND CRISES IN HEALTHCARE (AND IN THE CRIMINAL JUSTICE SYSTEM).

    CAN WE AGREE TO AGREE TO DO SOMETHING ABOUT THESE ISSUES AND WORK TOGETHER? INTELLIGENT DISCOURSE IS PREFERABLE TO BLOCKING STREETS AND KNOCKING HEADS.
    VIOLENCE LEADS TO MORE VIOLENCE AND ANARCHY. UNDERSTANDING LEADS TO GREATER UNDERSTANDING AND ACCORD.

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  6. Some ABIM humor
    https://twitter.com/NotRichBaronMD

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