The Alamo Reenacted: Texas Senate Bill 1148

Texas Senate Bill 1148 was a simple, hardly-noticed bill, one that promised to prevent the age discrimination against younger physicians inherent to the trademarked American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program. The bill prevented the proprietary and unproven MOC program from being required for a physician to obtain or maintain hospital credentials, insurance panel participation, or state licensure.  It was so simple, so clear, and made so much sense, that it passed 31-0 in the Texas State Senate.

Then the bill moved to the much larger Texas House and got noticed. Like the Alamo, the bill was quickly recognized as a threat to the multi-billion dollar-a-year health care academic, quality, and safety industries. The American Hospital Association (AHA) and ABMS and American Board of Surgery (ABS) lobbies descended on the halls of unsuspecting Texas Representatives with whom they've had long-standing relationships. The legislators were caught between appeasing physicians and appeasing the largest employers in the state of Texas. Dazed and confused about what "MOC" even was, the representatives caved to the inclusion of special clauses that left loopholes for the rich and powerful organizations to re-gain control. The bill's sponsor and anti-MOC physicians who met with as many representatives as they could, fought valiantly to stem the oncoming legislative changes that weakened the bill but were outnumbered. The bill advanced to the Calendar Committee to schedule a date for a vote at the end of the crammed legislative session. The bill could have died in Committee and not gotten a date for the vote, but the word had spread. The Committee received so many calls and emails from physicians across the country they had to close their office to calls. Even the bill's sponsor pleaded to hold off on further calls. Remarkably, the bill went to the floor for a vote. Before the vote, five "points of order" arose, forcing the bill back into committee. There, more changes were made, and eventually exceptions granted to the richest, most powerful institutions in Texas on the basis that MOC was important to assure physician quality and its "practicing improvement projects" were legitimately valuable exercises to improve patient care. Only the last wall of the Alamo, the inability to use MOC for state licensure, remained as a testament to the battle.

The final wording of the bill moved on to the governor's desk for signature, cementing the MOC program as a required educational program for physicians in many of the states' largest hospital centers.

With all this happening in Texas, it was hard not to "remember the Alamo."

But while this legislative Alamo battle may have been lost in some ways, it was won in others. Practicing physicians learned a lot from this battle, no doubt patients did too. We learned firsthand who really feels MOC should succeed. We heard our fellow physicians who defended MOC on Twitter conflate initial certification with MOC, as they often do. We were struck when members of the American Board of Surgery (ABS) rallied to MOC's defense on Twitter, even as the ABS fails to disclose how much of their relatively small $8M/year revenue they earn from MOC on their tax forms.  When the legislative battle ended and the dust settled, we saw those same outspoken critics to the anti-MOC movement gleefully proclaim on Twitter that Senate Bill 1148 "excludes those world class med centers....doesn't apply to #Medschools #cancer centers #trauma centers. #NICU docs...." as if more discrimination was a good thing. No doubt the far more numerous family practice physicians, pediatricians, and internists in Texas who don't have full time nurse practitioners, residents, fellows, political sway, and NIH grants at their disposal think differently.

It remains to be seen if the Texas SB 1148 will really have an impact for practicing physicians increasingly forced to comply with MOC as doctors point to the legislation in the Medical Executive Committees and can't change their bylaws because of the loopholes for some, but not all.

As patients and physicians learn of the realities of the ABMS MOC program and are caught in its regulatory grip, they are flocking to the anti-MOC effort, not running from it. Physicians understand that those that support MOC support corruption, political cronyism, and even tax fraud. To that end, we understand MOC is not about patient quality, but instead about money. The AHA and the ABMS know this, but have to support each other as member organizations of the Accreditation Council for Graduate Medical Education. While losing MOC would mean little to the AHA, the program is critical for the ABMS's survival due to their long-standing overspending, political agendas, and pension programs.

Texas has taught us that the physician anti-MOC movement is unstoppable. It is coming, whether the insurance companies or hospital lobbies like it or not. It is just a matter of time before we educate every legislator in every state, the IRS, and the Federal Trade Commission about what MOC was and what it has become.

But unknowns remain. We want to know what the ABMS International agenda that we pay for really is, we want to know why we fund real estate companies like ABFM Realty, LLC that no-one mentions, we want to know why the leadership of these independent non-profit agencies have to make such exorbitant salaries and benefits, and we want to know why contracts to Premier, Inc, and PearsonVue and hundreds of other contractors are more important to satisfy than time with our patients. Our patients have the right to know. It is time to stop the cover-up.

We are on the right side of this and we know it, whether Texas Senate Bill 1148 matters or not.

We will never forget and neither will our patients.

-Wes

We Want to Know

Dear Richard Baron,

As President and CEO of the 501(c)(3) non-profit organization, the American Board of Internal Medicine (ABIM) and its affiliated Foundation, the ABIM Foundation, you are responsible for public disclosure of IRS tax forms 990 to the public. Those tax forms were due at the IRS office 15 May 2017 for the ABIM's 2016 fiscal year (1 July 2015-30 June 2016).

Where are they?

We want to know.

We want to know because the finances of the ABIM and its Foundation are of paramount importance to us, your diplomates. We believe those finances are the reason we are required us to participate in the ABMS trademarked Maintenance of Certification (MOC) program. Because of clever regulatory capture through this unproven and monopolistic educational program, your organization is responsible for the ability of one quarter of ALL US physicians to work.

We want to know where our money that we pay for your unproven testing is going.

We want to know how much you paid yourself and your officers.

We want to know your legal expenses.

We want to know if you lobbied last year and how much you paid for it.

We want to know if you purchased another condominium for your organizations.

We want to know how much your paid PearsonVue.

We want to know who were your revolving-door officers that year and how much you paid them.

Right now, seventeen states have brought forth legislation to combat MOC. Doctors are leaving work to testify against the requirement for MOC that has been carefully incorporated to our new payment formula (MACRA) and HEDIS requirements made by the National Committee on Quality Assurance for the nation's hospitals, courtesy to Ms. Margaret O'Kane (who doesn't even hold a medical degree), and her board participation with the American Board of Medical Specialties, of which the ABIM is one of 24 specialty organizations.

We want to know the ABIM's finances because our jobs depend on that information. We want to bring that information before state legislatures so we may objectively and factually highlight your spending.

We will not rest any longer, Dr. Baron.

We want to know and we have the right, by law, to know.

Westby G. Fisher, MD
ABIM Diplomate #127308

When JAMA Shows Who They Are

Front and back covers of the May 2nd, 2017 Issue of JAMA
on Physician Conflicts of Interest in Medicine

In the May 2nd issue of the Journal of the American Medical Association (JAMA), the American Medical Association (AMA) discusses the subject of physician conflicts of interest in medicine. This puts them at an interesting juncture when the editor-in-Chief and executive editor of JAMA failed to disclose their relationship with the AMA and the AMA's relationship with US physicians. The AMA still presents itself to the public and legislators as representing Americas' doctors, even though representing US physicians’ interests has not been their financial priority for many years. In fact, it is telling that their mission statement no longer includes the words doctor or physician. If they do represent US physicians as they often claim, then the AMA (and its publication JAMA) are rife with numerous conflicts of interest and public clarification of this fact is desperately needed.

Which is it?

In June 2016 at the invitation of the Pennsylvania Medical Society, concerns regarding the conflicts of interest inherent to the American Board of Medical Specialties’ (ABMS) Maintenance of Certification (MOC) program were brought before the interim national AMA House of Delegates meeting. The AMA and ABMS are co-member organizations of the Accreditation Council for Graduate Medical Education (ACGME) and each organization took interest. The room was full of concerned physician delegates who had taken time away from their practices to represent their colleagues, alongside the President and chief council of the AMA, senior executive officer of the American College of Physicians, and the President and CEO of the ABMS. These courageous practicing physician delegates issued a “vote of no confidence" in the American Board of Internal Medicine (ABIM) - the largest ABMS member board representing approximately 200,000 US physicians - during a national panel discussion. They later passed a resolution to end the ABMS MOC program, which is a laborious recertification process plaguing overburdened physicians across this nation. Unfortunately, the AMA leadership has yet to honor this resolution.

If the House of Delegates is little more than a figurehead that makes a mockery of representing practicing US physicians before the AMA, then the public, legislators, and participating physicians should be formally notified and the perceived conflict clarified. Likewise, when a physician notifies JAMA's Editor in Chief of ABMS authors that have consistently failed to disclose their affiliation with their own for-profit wholly-owned subsidiary ABMS Solutions, LLC in JAMA and elsewhere, a response and action addressing this specific conflict should occur.

However, if the AMA has chosen to serve as an independent business entity paying their journal's editor-in-chief (who also serves as their Senior Vice President) $687,290 while also earning $111.1 million from CPT code “royalties and credentialing services” and $20 million from advertisers, then there is no conflict and the editors can feel reassured their disclosures in JAMA were proper. The AMA is one of the largest nonprofit 501(c)(6) business leagues in the country and has accumulated assets of over $686 million for its purposes.

Publishing an entire journal issue dedicated to the topic of physician conflict of interest while failing to acknowledge their own conflicts with physicians threatens to render JAMA's coverage of this topic to little more than ethical "fake news." The onus is on the AMA to clarify their role and potential conflicts with working US physicians or as Maya Angelou once said, “When a person shows you who they are, believe them.”

Westby G. Fisher, MD
Director, Cardiac Electrophysiology
NorthShore University HealthSystem
Evanston, IL and
(unpaid) Treasurer and co-founder,
Practicing Physicians of America, Inc.

Caption Contest: Twin Towers

Adjacent Towers in Chicago
(Click image to enlarge)

Okay internet: I need a clever caption for the above photo (note the building labels).

Have fun!

-Wes

Wingman

There is talk of quality in health care. There is talk of safety. Millions upon millions of dollars are spent on "quality and safety" in health care each year. After all, without "quality" and "safety," how can you have "value?"

Business people now call quality and safety "MIPS," "MOC," "MACRA," or "measures." To me, these are not quality, but rather very flawed attempts to define it. Acronyms and business strategies, no matter how well-meaning, can't define "quality" or "safety" or 'value" in health care. When it takes teams of consultants dispatched hospitals to explain how to make money with these new terms, that's called marketing, not "quality" or "safety."

The truth be known, "quality" is very difficult to define. That's because each of us brings a different perspective as to what defines health care "quality." A gruff neurosurgeon who is technically flawless in the operating room is likely perceived differently by the recipient of his services compared to his coworkers. Defining quality in medicine is like defining pornography - you just know it when you see it. The tricky thing about "quality," though, is that we often miss it when it lies right beneath our nose.

Last Friday I had the luxury of working with my favorite technician as we worked to install a pacemaker. For that short period of time, he was my wingman. I didn't really think about much. Neither did he. It was a quiet, pleasant moment as we complemented each others' skills: instruments assembled neatly on the table, soft music playing in the background, the ultrasound ready, a blade dispensed, a quiet whisper for another instrument that was already in his hand. A sheath, a suture, a steristrip, a gauze and Tegaderm - and a mutual respect that had quietly developed over our many years working together. A "quality" effort for sure.

Foolishly, I took it for granted.

I have been fortunate to work with great wingmen (and women, too) all my career. They know who they are. They never ask for accolades and are often embarrassed when they are passed along. They get up every day, report like clockwork to do their job, and do it really well. There is pride in their work because they know it matters. They treat others as they'd want to be treated themselves, and patients remember - maybe not their name - but their touch, their reassurance, their confidence, their kind words. I have learned you don't need an advanced degree to define "quality." Nor do you need a National Quality Forum or National Committee on Quality Assurance. It takes time and mutual respect to develop real quality, not checklists, metrics, or administrators.

So when the call came a few days ago that my wingman was sick - suddenly and unexpectedly - time stood still for all of us. This quiet, humble guy who knew the composer of every golden oldie that played in our lab. A guy who's stood at my side so many times, helped so many, now a patient himself. Why? Naively, I had convinced myself that things would always stay the same and only get better. Instead, life intervened and his vacation trip to California became a trip to the hospital - a scan - a serious cancer - and a life turned upside down in an instant.

Sometimes it takes tragedy to open our eyes and appreciate the small but important things we have. Sometimes it takes tragedy to help us acknowledge the real quality we have among our ranks. Quality metrics, by comparison, seem trite.

My wingman is back home now among family and friends. I went to check in on him and there he was smiling, with PICC line in place and chemo infusing. He spoke a bit and exchanged some pleasantries. As I turned to walk away, what did he say?

"Thank you, doc. It might be a while before I can come back."

Spoken like a typical wingman.

I thanked him back. "Take your time," I said. My response seemed so trivial compared to all he's done for me.

I returned to our lab and saw our closely-knit team working together on another difficult case - like flying in formation with one jet missing. The elephant in the room was standing there. We could feel it. No one said a word. They chose to focus instead.

Quality wingmen all.

-Wes

What JAMA's Editors Failed to Disclose

"The lady doth protest too much, methinks."
- from Hamlet, by William Shakespeare
An entire journal dedicated to a discussion of conflicts of interest was published yesterday in the Journal of the American Medical Association (JAMA). There is remarkable irony when the executive editor and editor in chief of JAMA fail to disclose JAMA's ownership by the American Medical Assocation (AMA), a 501(c)(6) non-profit membership organization that has amassed assets worth $684,343,310 and has significant conflicts of interest of its own.

Caveat emptor, dear reader. Form 990's should not masquerade as scientific "disclosure."

-Wes