Sunday, March 24, 2019

Suddenly, Some Specialty Societies Might Be Listening

From the American College of Radiology blog:
"In response to a recent request from the American Board of Medical Specialties (ABMS), the (American College of Radiology) ACR created a work group to comment on a report on the status of (Maintenance of Certification) MOC® across all specialties. That group worked tirelessly over the winter holidays to prepare a detailed comment letter (ed. note: a portion of which is highlighted here):"

(Click to enlarge)
The blog post continues:
"The ACR also signed on to a letter from the Council of Medical Subspecialty Societies (CMSS), which represents approximately 800,000 physicians from 43 medical subspecialty societies.

Both the ACR and CMSS letters call for an immediate moratorium on MOC® until many programmatic deficiencies are corrected.
. . .

These important ACR member issues have recently been amplified by the backdrop of various ABMS member boards coming under intense scrutiny and even legal actions for financial practices, lack of transparency, non-democratically elected leadership, high-stakes non-validated psychometric testing and concerns about monopolistic behavior. The American Board of Radiology (ABR) was named as a defendant in one class action suit and a “co-conspirator” in another.

Our Task Force is studying these issues and preparing to make recommendations to the BOC and CSC at both the ACR 2019 and ACR 2020 annual meetings."
Mind you, these cases have not been brought before the court yet, but there now appears to be a serious level of introspection and concern at the highest level of some specialty societies as to what transpired to get us where we are with "continuous" ABMS Board certification.

Colleagues, now is not the time to back off our funding campaign to support the litigants in this anti-trust battle. In fact, we need more physicians from ALL specialties frustrated with the current MOC® status quo to join us to keep the pressure on ALL of the ABMS member boards.


Thursday, March 21, 2019

The Astronomical 10-year Cost of ACC's Continuous Maintenance Pathway

Since the inception of Maintenance of Certification (MOC®) by the American Board of Internal Medicine (ABIM) tied to our initial board certification credential in 1990, the costs of "maintaining" initial certification through "continuous certification" have steadily climbed by way of the threat of invalidating our initial certification credential.

Nothing is different with the new "Continuous Maintenance Pathway" proposed 15 Mar 2019 by the American College of Cardiology (ACC). In fact, the monetary demands are an order of magnitude greater for working heart specialists and cloaked in smooth propaganda published in the Journal of the American College of Cardiology.

To compare apples to apples, it is important to compare 10-year out-of-pocket costs required from physicians participating in MOC®. By way of background, the cost for "Maintenance of Certification" from the ABIM in 2000 was $795 every 10 years.

Here is a breakdown of the costs cardiologists and cardiac electrophysiologists will incur by participating in the "Continuous Maintenance Pathway" proposed by the ACC and the ABIM:

(Click to enlarge)

If you are an ACC member, you get to pay even more to the ACC, despite what their website says.

Here's the breakdown for ACC members:
  • $795 initial ACC membership fee + $150 admin fee x 10 years LESS $400 credit on CMP program every 5 years x 2 = $1495
  • PLUS $1500 every 5 years to ACC for CMP x 2 = $3000
  • PLUS $160 per year to ABIM x 10 years = $1600
  • GRAND TOTAL = $6095 every 10 years of MOC/CMP (or $609.50 / year)
And let's not forget this VERY important adhesion condition for these fees:
(Click to enlarge)
In summary, the ACC's new Continuous Maintenance Pathway is one of the most shameful money grabs from US cardiologists and cardiac electrophysiologists imaginable and represents a remarkable 654% increase in fee payments for MOC® since 2000 for non-ACC members and an incredible $766% increase in fees for ACC members for MOC® since 2000. More importantly, the ACC leverages (ties) CMP to the threat to a physician's ABIM board certification status (and therefore their right to work) and I believe represents a restriction of trade and is in violation of US anti-trust and racketeering laws.

It is truly unbelievable that the ACC and the Heart Rhythm Society would do this to their own membership, but then again, given their prolific financial balance sheets, maybe it's not so unbelievable after all.


PS: Please help support the federal antitrust class action lawsuit against the American Board of Internal Medicine by contributing here.

Wednesday, March 20, 2019

ABIM Gives First Public Legal Response to Lawsuit

On 18 March 2019, the American Board of Internal Medicine responded for the first time in opposition to the federal class action lawsuit filed against it by four internists in early December 2018. The 39-page memorandum accompanying their proposed motion to dismiss is re-published here without comment for physicians to read themselves.

Physicians wishing to contribute to the support of the four internists involved in this case are encouraged to donate to this GoFundMe page.


Monday, March 18, 2019

The Big Easy: The ACC, HRS, and the ABIM

This weekend, at the American College of Cardiology (ACC) Scientific Sessions in New Orleans, the ACC and the Heart Rhythm Society (HRS) announced their commitment to the American Board of Internal Medicine's (ABIM) continuous certification financial shakedown of US cardiologists and cardiac electrophysiologists. Taking a playbook from the American Medical Association, their leadership has realized the financial milk and honey for their business rests squarely alongside the business interests of US hospitals and the powerful device industry, not the physicians for whom they pretend to advocate.

So they have reached out to their academic colleagues, many of whom are medicine's leading industry thought leaders, teachers, and spokespersons, to create yet another Maintenance of Certification (MOC) testing "pathway" (called the "Continuous Maintenance Pathway" (CMP)). This "pathway" requires purchase of the ACC Self-Assessment Program (ACCSAP) to extract cash from their own colleagues and more vulnerable, younger cardiologists. As always, failure to participate some way with "continuous certification" will always be met with the threat of pulling a cardiologist's credentials to practice medicine if they don't comply. The CMP will only be valid if physicians continuously purchase the ACCSAP study materials. How much will that cost? Well, the ACCSAP used to cost a cool $400 per year and the 2019/2020 prices have yet to be announced, but was promised to be "less than $500 annually").

And why not?

With its Harry Houdini-like balance sheet where over $25 million in assets exactly matches its expenses, we see the value of numbers to the ACC. We also see, like the ABIM, the "value" of a Foundation.

The ACC Foundation has $113,934,622 revenue (and $231,442,569 in assets), over one third of which funds the organization's salaries. The ACC Foundation has also created the ACC Political Action Committee (the ACC-PAC) under the umbrella of the Foundation, "as part of a multi-pronged approach to expand its advocacy program to support incumbent and prospective candidates who are supportive of patient access to care and promotion of quality cardiovascular care."

You are reading that correctly. Leveraged MOC dollars and the fees paid for physician education materials will now be used, in part, for the ACC's support of political candidates.

But if that's not enough, there's this little gem.
In 2018, the Accreditation Council on Graduate Medical Education (ACGME) published a revision of program requirements for accredited internal medicine residency programs. At the same time, the Internal Medicine Board had decided to revisit the procedural requirements for graduating residents, presenting a timely opportunity to make changes to these requirements.
With the announcement yesterday of the CMP physicians will be required to perform two tests, one given by ACC and one given by ABIM EVERY YEAR and much of it for their political gain.

If this new collaboration between the ACC , HRS, and the ABIM sounds problematic to you, you might want to join our effort to end this shakedown of your dollars for political purposes.


Saturday, March 16, 2019

Wednesday, March 06, 2019

MOC Legal Battle Broadens to ABPN

Today in the Federal District Court of Northern Illinois, another class action lawsuit on behalf of over 25,000 psychiatrists and neurologists was filed against the American Board of Psychiatry and Neurology (ABPN) by two psychiatrists.

In a script we have seen before, the Plaintiffs brought the action pursuant to the Clayton Antitrust Act, 15 U.S.C. §§ 15 and 26 to recover treble damages, injunctive relief, costs of the suit, and reasonable attorney’s fees arising from violations of Sections 1 and 2 of the Sherman Act (28 U.S.C. §§ 1 and 2). The suit alleges that there is illegal tying of the ABIM’s initial board certification product to its maintenance of certification® (MOC®) product in violation of Section 1 of the Sherman Act and illegal monopolization and monopoly maintenance in violation of Section 2 of the Sherman Act. In addition, the suit alleges that ABPN's conduct has caused it be be unjustly enriched at the expense of the Plaintiffs and the other Class members.

The Complaint details the alleged harms experienced by the Plaintiffs and the numerous changes to ABPN MOC® the Plaintiffs and Class members endured since its implementation. In addition, the Complaint alleges:
"Between 2004 and 2017, after the advent of ABPN MOC, ABPN’s “Program service revenue” account exceeded its “Program service expenses” account by a yearly average of $8,777,319, as reported in its Forms 990 for those years. During that same period of time, ABPN’s “Net assets or fund balances” account skyrocketed 730%, from $16,508,407 to $120,727,606. In other words, at year-end 2017, as ABPN MOC revenue continued to grow, ABPN net assets (assets less liabilities) more than septupled, which included, according to its 2017 Form 990, almost $102 million in cash, savings, and securities."
The Complaint also details allegations of unjust enrichment by the President and CEO of the ABPN, Larry R. Faulkner, MD:
In 2007, he was paid total compensation of $500,726 as Executive Vice President. Dr. Faulkner became ABPN President and CEO in 2009. In 2017, the last year for which data could be located, his total compensation as President and CEO was $2,872,861, including a bonus of $1,884,920.
This lawsuit follows on the heels of two other class action antitrust lawsuits filed against the American Board of Internal Medicine and the American Board of Radiology.

As I've said before, it is critical working physicians see the legal battle against MOC® for what it is: not a campaign against continuing medical education, but rather a campaign against the massive runaway train of economic exploitation, self-enrichment, and micro-management of our professional lives that are now the hallmark of ABMS and its member boards.

I encourage all working physicians donate to our GoFundMe page to help support the next phase of the litigation as ABIM, ABR, and ABPN prepare their responses to the lawsuits.


Saturday, March 02, 2019

Maryland Board of Physicians Rejects NBPAS

In November 30, 2018, the National Board of Physicians and Surgeons (NBPAS) and the National Board of Osteopathic Physicians and Surgeons (“NBOPAS”) requested the Maryland Board of Physicians ("Board") formally recognize them as a specialty certification board for continuing certification. Armed with a 17-page letter from the DOJ, they were hopeful, but the outcome of their request they just received from the "Board" was almost predictable:
As a policy matter, board certification or re-certification is not a requirement for licensure. Board certification, however, may be a requirement for employment, hospital privileges, insurance carriers, etc. In that regard, the Board does not believe that it is the appropriate entity to evaluate re-certification or continuing certification boards for approval.

The Board believes, consistent with the DOJ opinion letter, that board certification and the approval of a certifying board for recertification is a business decision to be made by hospitals, insurers, and employers. Even if the Board approved the NBPAS or NBOPAS as a continuing certification board, hospitals, employers, and insurance carriers would still be able to make their own determinations about which boards they choose to recognize for purposes of meeting any eligibility requirements.

Given the inconclusive findings of the MHCC workgroup and the lack of data on quality of care, the Board believes that approval of the NBPAS and NBPOS as a certifying board is premature. The Board will continue to monitor the discussions and research projects regarding maintenance of board certification, including the recommendations from the Continuing Board Certification: Vision for the Future Commission, which are expected to be released in a final report sometime this year.
It is a shame this fight has come to this, but it has. Maybe now the leadership of the National Board of Physicians and Surgeons will recommend their diplomates join our nationwide, multi-specialty legal fight to end "Maintenance of Certification."


Addendum: Maybe Maryland joining the Interstate Licensing Compact (with the help of Kaiser Permanente, a fond bedfellow of ABIM's former President and CEO, Christine Cassel, MD), had something to do with this decision.

Why the ACC Threw Cardiologists and EPs Under The MOC® Bus and Why We Let Them

In its latest update with Maintenance of Certification (MOC®), the good ol' boy network of the American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), Heart Rhythm Society (HRS), and Heart Failure Society of America (HFSA), announced their commitment to "continuous certification" and MOC® and all its lucrative trappings for US cardiologists and cardiac electrophysiologists.

It seems the authors of this announcement, all older white men without much to lose, just can't get enough of the money associated with locking their younger, more vulnerable colleagues into continuous participation in their expensive board review courses, scientific sessions, self-assessment programs, and pricey study materials. They convened a "Task Force" (or was it a "Committee?") some time ago to study the revenue lost without MOC® verses the money made with MOC®'s leverage on their programs, and it appears they have decided they just can't let go.

So they have a plan.
  1. First, make a lukewarm statement that is supposed to sound opposed to the ABMS Vision Commission, but really says nothing.

  2. Second, to co-brand their own version of "continuous certification" with the American Board of Internal Medicine (ABIM) and call it another name to assure annual payments continue.

They thought hard - really - and recruited lots of their well-respected academic partners and thought leaders in cardiology and EP - to create their own ABIM MOC® pathway called the "Collaborative Maintenance Pathway." (You can't make this stuff up.)

As if cardiologists are deaf, dumb, and blind.

But cardiologists and electrophysiologists have to be honest: we live with the reality that our skills and intellect are uniquely valuable to hospital and health care systems. Without us, they'd die. And now that 75% of cardiologists are employed by hospitals, hospitals need us just as we need them.

The ACC, tied irrevocably to the good fortunes of the Medical Industrial Complex and the realities of managed care data collection, knows this.

So they sugar-coat their decision to side with "continuous certification" as a "commitment to lifelong learning" instead of what it really is, an adhesion contract with the ABIM and the ACC, SCAI, HRS, and HFSA for their lifelong funding at our expense.

In effect, the ACC is saying "Cardiologists and EP's - get over it - you have no choice but to be the breadwinners for US hospitals and health care systems. We scratch their backs so they can scratch ours, so you have to pay up."

Ooops, I just said the unspeakable.

I can hear it now:

"But we are beneficent, selfless 'care providers' who do the work, take call, and save lives at 3 AM when we're dead tired, not just the funding vehicles for US hospitals! We are the good guys, need to keep up with the latest advances, and deserve what we get! How can you dare say such a thing?!?"

Because, deep down inside, it's the truth.

A growing tension is exacerbated by the ACC siding with the corrupt ABMS MOC® program: cardiologists serving hospitals' best interests verses cardiologists serving their patients' best interests. Certainly no one will argue with the benefit to a patient for stenting an occluded coronary at 3AM - it's the magic of what we do and why we do it. But there is also a growing conflict of interest that develops when we must live in fear of losing our credentials (and our jobs) because we don't participate in MOC® and MOC® is tied to our ability to make a living only at hospitals: that tie makes us beholden to our employer before our patient.

It has been revealing to be a student of MOC®'s evolution over the years. I believe there is are complicated psychological and economic principles at play with MOC® (or "continuous" certification).

First, MOC® forces the doctors to split. Psychologic splitting is commonly used to justify unreasonable behavior. Why else would highly intelligent people put up with the now highly public political, financial, and monopoly-making activities of the ABIM? Perhaps its because by participating in MOC®, we can remain the "good guy" in a guideline-directed decision making world of medicine while the ABIM can remain the "bad guy." No need to consider the realities involved with their conflicts of interests. By continuing to participate in MOC® (or it's latest "continuous" iteration, doctors don't have to worry themselves with the nasty details of the high cost of medicine, the waterfalls in the front lobby, and the big screen TV's in every patient's room. We are "just" the beneficent doctors working within the "guidelines." So we "keep up" with our education and those "guidelines" (thanks to the ACC and their "Collaborative Maintenance Pathway") to impress our patients (and truth-be-known somewhere deep inside, ourselves) by promoting this "board certified" marketing accolade and not dealing with its unpleasant realities.

Secondly, MOC® influences the "behavioral economics" of physicians in perverted ways. As an example, behavioral economics states that even if a doctor wants to lose weight and sets his mind on eating healthy food going forward, his end behavior will be subject to cognitive bias, emotions, and social influences. What is a bigger cognitive bias and social "influencer" than the fear of losing your credentials or ability to receive insurance payments because of lack of participation in MOC®?

So the next time you wonder why the GoFundMe page to fight Maintenance of Certification has been fairly slow to reach its ultimate goal, I believe this is why.

Many doctors are putting up with the MOC® charade because they are afraid of losing their job if they speak out and are not completely honest about the MOC®'s role in maintaining healthcare's costly financial status quo.

Perhaps it's time we be honest with ourselves. Who ultimately loses with MOC®'s perpetuation?

Not just younger, more economically vulnerable physicians, but our patients, too.


Wednesday, February 27, 2019

Doctors Take the MOC® Stick: Legal Avalanche Unfolds

Working doctors have made their dissatisfaction with the American Board of Medical Specialties' (ABMS) time-limited certification known for years. They have tried to reason with the American Board of Internal Medicine (ABIM). They have exposed the corruption for all to see. They have gone to Washington DC. They have presented these findings to the leadership of the American Medical Association, ABMS, American College of Physicians, and the AMA House of Delegates. They have tried to get meaningful legislation passed at the state level for years. They created their own competing non-profit "board" to offer an alternative to the time-limited credential. They contacted major medical journal editors about the lack of proper disclosure of financial conflicts of interest. They tried to publish an article documenting the harms caused by MOC® (and called "very important" by one reviewer) was repeatedly suppressed from publication. They contacted the Internal Revenue Service. Then they gave one last "Hail Mary" pass to the ABMS by submitting survey results organized by that alternate board from 21,000 physicians to the ABMS Vision Commission, all to no avail.

MOC® (or some bizarre, fractionated form of MOC® rebranded as "continuous certification") continues with all its lucrative trappings.

Now a new, tactic is unfolding to end ABMS time-limited certification nationwide: litigation.

A new free-to-join non-profit was created, run by a multi-specialty group of working physicians from across the nation (disclosure: I'm a co-founder). They created a GoFundMe page to fund anti-MOC litigation that has already raised over $200,000 and is supported by over 1000 physicians (and growing).

In light of the ABMS boards ignoring working physicians' demands to end MOC®, or even allow a meaningful alternative to MOC®, physicians across specialty boards have felt empowered to initiate litigation against time-limited certification. Rather than thinking of this as doctors suing other doctors, it is more accurate to say that this is doctors taking a collective stand against insulated, self-elected, answer-to-no-one bureaucratic bodies; organizations that hide behind humanistic slogans while churning billions of hidden dollars for themselves.

The recent litigation timeline:
  • 6 December 2018 - The first class action anti-trust lawsuit against the ABIM - the largest ABMS member board - is filed.

  • 23 January 2019 - The ABIM suit is amended to include racketeering and unjust enrichment claims.

  • 26 Feb 2019 - Yesterday, another class action antitrust suit  on behalf of approximately 25,000 US radiologists was filed in federal district court in Chicago against the American Board of Radiology.
How many more ABMS member boards will be sued?

ABMS and its member boards may claim to be nothing less than "a selfless ministry" in the service of medicine and that these lawsuits are frivolous, irresponsible, or even unprofessional. Nothing could be further from the truth. Those on the front lines of patient care fully understand the time and cost involved. But you can be sure of this: litigation was not the frontline physicians' first option. Far from it. All other less time-consuming and expensive alternatives have already been exhausted.

To paraphrase Theodore Roosevelt, justice consists not in being neutral between right and wrong, but upholding the right against the wrong. All working physicians should climb off the sidelines and join this fight to end the unproven MOC® and "continuous certification" programs and recognize the legal battle against MOC® for what it is: not a campaign against continuing medical education, but rather a campaign against the massive runaway train of economic exploitation, self-enrichment, and micro-management of our professional lives that are now the hallmark of ABMS and its member boards.


Addendum 6 Mar 2019 - The MOC® legal battle now includes the American Board of Psychiatry and Neurology, too.

Sunday, February 24, 2019

Examining the ABIM's Evidence for Maintenance of Certification®

In response to an recent article in MDEdge about the GoFundMe page supporting four plaintiffs who brought suit against the American Board of Internal Medicine (ABIM), Richard Baron, MD, President and CEO of the ABIM said:
“Valuable credentials with standards behind them gain market share because they are meaningful and say something important about the doctors who hold them,” Dr. Baron said in an interview. “There is evidence in peer-reviewed journals that doctors holding our credential are more likely to meet quality metrics throughout their careers [Ann Intern Med. 2018 Jul 17. doi: 10.7326/M16-2643], that they are more likely to order mammograms for women who need them [Womens Health Issues. 2018 Jan-Feb. doi: 10.1016/j.whi.2017.10.003], that they provide care of equivalent quality at lower total cost [JAMA. 2014 Dec 10. doi: 10.1001/jama.2014.12716], and that they actually earn higher salaries [Health Serv Res. 2013 Jun. doi: 10.1111/1475-6773.12011]. All doctors should be concerned if making evidence-based claims about our credential based on data published in peer-reviewed journals gives rise to litigation alleging fraud.”
Breaking Dr. Baron's comment down:

The first reference Dr. Baron cites is a retrospective report of an association (not causation) between Maintenance of Certification (MOC®) status and performing Healthcare Effectiveness Data and Information Set (HEDIS) measures for industry. The study's abstract states in its "Limitations:"
"Potential confounding by unobserved patient, physician, and practice characteristics; inability to determine clinical significance of observed differences."
The second reference cited by Baron is another retrospective review of two single-year cohorts of internists performing mammogram screening in a single year before and a single year after time-limited certification was implemented. This study is subject to innumerable biases (sampling, recall, and information). It is no wonder that the authors state in the study's limitations:
"Finally, more research is needed to fully understand the causal mechanism by which MOC® participation might impact mammography screening specifically and quality of care more generally. In addition, changes to the MOC® program have occurred since 2001, and future research is needed to determine whether associations with the MOC® requirement we report were sensitive to this."
From the limitations of the third retrospective study Baron cites above:
"...more research is needed to determine whether the negative associations we report between MOC® and growth in costs were due to improvements in care quality not captured by our quality measure, reductions in wasteful practices unrelated to patient outcomes, or negative consequences not captured by our outcome measures.
The last study Baron cites in his quote above pertains to initial board certification and only supports the supposition that doctors make more money if board certified - a finding that is not patient-centric at all, but physician-centric.

All of the studies cited by Dr. Baron were retrospective studies and therefore only hypothesis forming. None of the references he cites in his response to the interviewer were causal.

Finally, Baron said:
"All doctors should be concerned if making evidence-based claims about our credential based on data published in peer-reviewed journals gives rise to litigation alleging fraud."
I agree. All doctors should be concerned. What does this say about our journals that publish these studies? Why would a group of practicing physicians with full case loads create a wholly new non-profit (Practicing Physicians of America) to represent the interests of working physicians? Why would those same working physicians create a GoFundMe page to raise money to support litigation to end MOC®? Lastly, why would such an organization support four fellow physicians that dared to challenge those in positions of power by bringing unprecedented claims of antitrust, racketeering, unjust enrichment, wire fraud and mail fraud?

These are very important questions.

Especially when the President and CEO of the ABIM offers poor "evidence-based claims about (the ABIM certification) credential based on data published in peer-reviewed journals" that "gives rise to litigation alleging fraud" in response to questions posed of him.


Saturday, February 16, 2019

Grifters Will Always Be Grifters

On 12 Feb 2019, the American Board of Medical Specialties (ABMS) Vision Commission created 25 September 2017, issued its Final Report to the ABMS Board of Directors on its controversial and very lucrative "continuous certification" programs.

Not surprisingly, the self-appointed Commission thumbed its nose at the overwhelming majority (88%) of US physicians who find no value to continuous certification,  and instead relied on testimony of many ABMS Boards, members of the ACGME including the Association of American Medical Colleges, the National Board of Medical Examiners, "psychometricians," ABMS Portfolio Program Sponsors, eight (of 50) state medical associations, five subspecialty societies (Anesthesiology, Family Medicine, Internal Medicine, and Pediatrics), consumer groups like (AARP-funded by UnitedHealthcare, the conflicted Consumer Reports, and the problematic Leapfrog Group). Nowhere was the possibility of ending continuous certification ever discussed or considered.

In the end, this was the conclusion from 17 months of testimony for ABMS Vision Commission:
"The Commission thanks the presenters who came and provided valuable testimony about their perspectives of continuing certification. The information will inform the next steps of the process. What is clear is the majority of the presenters recognize the necessity of lifelong learning. While they appreciate the innovation and engagement of the Boards as changes are made to continuing certification programs, they look forward to seeing how the programs continue to evolve. All are interested in being part of the future of continuous certification."
In other words, grifters will always be grifters.


Maintenance of Certification: Do We Have a Certified Crisis in Medicine?

From Paul G. Mathew, MD in Practical Neurology:
Between the growing number of states adopting laws to protect physicians from forced MOC compliance, the increasing number of hospitals/institutions accepting NBPAS as an alternative to ABMS recertification for physician credentialing purposes, and the potential ramifications of a decision in favor of the plaintiffs (practicing physicians) in the ongoing class action lawsuit against the ABIM, practicing physicians everywhere may at some point in the near future witness meaningful reform or possibly an end to forced MOC compliance.
Additional leverage against the forced Maintenance of Certification (MOC) compliance imposed by the American Board of Medical Specialties and their member boards can be achieved by contributing to the legal effort underway (click here).


Sunday, February 03, 2019

Evolving Board Certification

From the New England Journal of Medicine and the American Board of Anesthesiology, the MOCA Minute® (Cost $210/yr + 100/yr for subsequent certifications):
The MOCA Minute, a longitudinal assessment program introduced in 2016, enables anesthesiologists to identify their scope of practice and answer 30 practice-relevant multiple-choice questions per calendar quarter to continually assess their knowledge and problem-solving skills (see table). The questions focus on relevant information that physicians should know without having to consult references, so only 60 seconds is allotted for answering each question. After responding, physicians rate their level of confidence in their answer using a three-point scale (very confident, somewhat confident, or unsure). This system helps clarify what physicians know, when they are merely guessing, and where their blind spots lie. When physicians realize they have responded confidently yet incorrectly, they are more likely to engage in further education and retain knowledge. This process creates a data-driven basis for seeking out and completing appropriate CME. Questions answered incorrectly or with low confidence are repeated at varying intervals to maximize reinforcement and retention. After each response, physicians are told whether their answer was correct and are given a critique that includes the key point of the question and offers more information about the topic, literature references, and connections to corresponding CME.

From the American College of Cardiology, come the proposed Collaborative Maintenance Pathway® (CMP) (cost <$500/year):
Under the proposed CMP, the respective SAPs (self-assessment program) are expected to consist of 3 components: 1) a comprehensive didactic review of the entire discipline including written material, videos and slide decks that the learner may access in his/her own style and at his/her own pace; 2) a library of several hundred practice questions presented in a modular format corresponding to the topic area under study; and 3) a set of “performance” questions requiring a passing score, which will be made available on a modular basis when engagement with the learning material has been documented and when CME credits have been granted for the module. The didactic material of the SAP will be divided into 5 modules of approximately equal length, so that yearly assessments will cover approximately 20% of the discipline’s knowledge.

The entire CMP process is expected to provide, in a 5-year cycle, all the CME required for licensure in most states (∼25–30 h per year), all the medical knowledge (Part II) points required for MOC (100 points per 5 years), and a convenient, online assessment activity that will complete the MOC requirements for participating cardiologists (assuming a passing score on the performance questions for each of the annual modules).

It is anticipated that the discounted fee for the SAP component of the CMP will be priced approximately 25% lower than the cost of the current ACCSAP product. Members in good standing of the ACC, SCAI, HRS, and HFSA will all be eligible for the planned discount. ABIM fees will be assessed by the ABIM separately from the SAP component. The entire CMP (ABIM and ACC) process is expected to cost <$500 per year.
Finally, from the American Medical Association / American Board of Medical Specialties "Vision Commission" member and former Executive Vice President of the American College of Physicians:
The response to the MOC controversy has varied across the physician community from the extremes of acceptance of MOC to outright anger, with the flames of discontent often stoked by blogs and comments on social media. Within this spectrum of responses is a more centrist position, accepting the need for some sort of process that ensures ongoing professional development and competence as medical science evolves, but acknowledging that significant reforms are needed in the current MOC requirements.
Despite the many efforts to "modify," "adapt," "reform," Maintenance of Certification to new models, each of them has three huge flaws.
  1. There is no independent evidence-based proof that "maintaining" our initial board certification improves patient care or safety. Instead, there are now real examples before a federal judge of harm Maintenance of Certification has caused physicians.
  2. All of these programs result in little more than glorified rent-seeking that has proven remarkably lucrative for the ABMS, it's member boards, and physician specialty societies. Each proposed program fails to mention how testing data are shared with third parties, including (but not limited to) insurance companies and group purchase organizations like Premier, Inc. It is troubling that these demonstrated conflicts are never disclosed.
  3. Any computerized educational program that can restrict a physician's right to work based on completion of certain computer tasks is not acceptable to working physicians. This is not what education is about. "Centrists" are willing to accept voluntary, self-directed CME. They are not willing to accept a lifetime of expensive, coerced, directed CME on behalf of unaccountable and undisclosed third parties. Using the threat of loss of credentials and one's ability to work as a cudgel for physician participation not only is immoral and harms morale, it may be illegal and harmful to patients struggling to access their physician.
In summary, forcing physicians to look at more computer or cell phone screens for the financial benefit of medical bureaucrats distracts from what is really important: patient care. This has not changed. As such, Maintenance of Certification (MOC) - in whatever form proposed - must end.


P.S.: Please help support the legal fund created by Practicing Physicians of America to combat MOC.

Friday, January 25, 2019

ABIM Class Action Lawsuit Against MOC Amended to Include Racketeering and Unjust Enrichment

On Wednesday, 23 Jan 2019, the class action antitrust lawsuit previously filed against the American Board of Internal Medicine (ABIM) in Pennsylvania federal court was amended to include claims under the RICO Act and state law unjust enrichment claims. From the 50-page amended Complaint:
Finally, this case is about ABIM’s violation of Section 1962(c) of the RICO (Racketeer Influenced and Corrupt Organizations) Act. As detailed below, ABIM has successfully waged a campaign in violation of RICO to deceive the public, including but not limited to hospitals and related entities, insurance companies, medical corporations and other employers, and the media, that MOC, among other things, benefits physicians, patients and the public and constitutes self-regulation by internists. Believing ABIM’s misrepresentations to be true, hospitals and related entities, insurance companies, medical corporations and other employers require internists to participate in MOC in order to obtain hospital consulting and admitting privileges, reimbursement by insurance companies, employment by medical corporations and other employers, malpractice coverage, and other requirements of the practice of medicine.
In addition, the suit claims violations of unjust enrichment laws:
Plaintiffs and members of the Class conferred a benefit on ABIM in the form of the money and property ABIM wrongfully obtained as a result of Plaintiffs and other internists being de facto forced to pay MOC-related fees, as described in detail above. ABIM has retained these benefits that it acquired from charging Plaintiff and members of the Class inappropriate, unreasonable, and unlawful MOC-related fees. ABIM is aware of and appreciates these benefits. ABIM’s conduct has caused it to be unjustly enriched at the expense of Plaintiffs and the other Class members. As such, it would be unjust to permit retention of these monies by ABIM under the circumstances of this case without the payment of restitution to Plaintiffs and Class members. ABIM should consequently be required to disgorge this unjust enrichment.
All physicians can follow the progress of the lawsuit at Physicians wishing to assist the plaintiffs in their effort to end Maintenance of Certification (MOC) are encouraged to donate to the GoFundMe page organized by Practicing Physicians of America.


Tuesday, January 15, 2019

Council of Medical Specialty Societies Weigh In on Their Vision for MOC

Just in the nick of time, the Council of Medical Specialty Societies (CMSS), another (smaller) member of the Accreditation Council on Graduate Medical Education (ACGME) that represents medical specialty societies, issued its public comment on the ABMS Vision Commission Draft Report on Maintenance (and Continuous) Certification on the last day the Commission is taking comments.

What is important is not only what the Specialty Societies said in the statement, but what they did not say.


  • That initial certification and continuing certification are two separate products offered by ABMS and their member boards and have "different purposes."
  • Specialty societies are in support of initial certification and the value of a secure examination for that purpose.
  • The recognition that boards have a responsibility to "inform organizations that continuous certification should not be the only criterion in these decisions" and further "encourage hospitals, health systems, payers, and other health care organizations to not deny credentialing or certification to a physician solely on the basis of certification status."
  • They had "serious concerns" with four issues:
    • Use of high-stakes, summative examinations as part of continuing certification
    • The practice improvement component
    • The role clarity between certifying boards and specialty societies
    • The timeline for implementation.
  • They likened the issue of trying to improve ongoing assessment of physician competence to "trying to change the tire on a moving car."
  • It was clear the specialty societies wanted to divorce themselves from the "assessment" side of continuous certification to the kinder and gentler "learning" side of "continuous certification."
  • And it looks like the specialty societies want to leverage the ABIM's earlier definition of "professionalism" created by the ABIM Foundation to leverage their own social justice imperative to participate in continuous certification, rather than just that needed by ABMS.
  • They acknowledge the high degree of physician burnout and the need to implement their recommendations in a timely manner.
  • They raised the "grandfather" and "grandmother" issue and voiced strong wording that the ABMS better not to mess with that exclusion, less the "grandfathers" at the specialty societies have to participate in continuous certification, too.
  • They thank the Commission and "require further collaboration and discussion prior to implementation."


  • They do not mention the finances of the ABMS member boards and the $5.7 billion dollars physician spend annually to participate in continuous certification.
  • They do not mention how the data collected from computerized testing of US physicians is used to ration their patients' care by insurance companies.
  • They do not mention how certification data are used to dovetail clinical registry data, physician data, and electronic medical record data, and the money earned by specialty societies for that collaboration.
  • They insist in continuous certification even though it has never been independently shown to improve patient care quality or safety over participation in independent physician-driven continuing medical education.
  • They do not address the excessive salaries and perks offered to the board members and officers of the ABMS Board system or the ACGME itself. (Should the head of the National Board of Medical Examiners really earn $1.2 million annually, for instance?).
  • No mention is made of the many conflicted parties that have benefited financially from the continuous certification process, including, but not limited to, PearsonVue, Premier, Inc., state medical societies (like Massachusetts Medical Society - owners of the New England Journal of Medicine), specialty societies (like ACC), medical publishers (like Wolters Kluwer and Elsevier), and the finances collected by AMBS Solutions, LLC.
  • Finally and most importantly in this CMSS comment letter, there was no mention (or acknowledgement) of the harms caused to physicians by "continuous certification" in terms of financial and psychological hardship, decreased patient access to physicians, strongman (coercive) tactics used to force participation, political motives that benefit these organizations, and the limitations that such a highly restrained and controlled educational product like "continuous certification" places on working physicians who must also deal with their overriding responsibility of caring for patients every single day.
In my opinion (as I've said all along), Maintenance of Certification was a clever shell game used to force physician purchase of a product created by American Board of Internal Medicine (ABIM). That product is far beyond any imposed by states to maintain licensure and requirements for Continuing Medical Education. MOC was rebranded and modified on multiple occasions by ABMS and its member boards to generate continuous cash flow to the ABMS member boards (and now specialty societies) without proof of its value to patients.

Without acknowledging and dealing with the corrupt realities of the MOC (and continuous certification), the recommendations issued by CMSS in their comment letter should be rendered moot.


Please give generously to our legal fund to end this corrupt educational product nationwide.

Sunday, January 13, 2019

Physician Online Gaming for MOC Points

This email was forwarded to my inbox from a colleague who was invited to play this "8-week online computer game and clinical care competition" with colleagues for 4 MOC® points from the University of California San Francisco in collaboration with the Accreditation Council for Graduate Medical Education (ACGME):

From: "Trever Burgon, PhD"
Date: January 12, 2019
To: *************
Subject: CME/MOC Online Clinical Competition: You’re Invited
Reply-To: "Trever Burgon, PhD"

Dear Dr. *************,

You are invited to participate in Quality IQ, an 8-week online game and clinical care competition with primary care providers across the country. Each week, you’ll have a chance to compete against your colleagues, with prizes available for the winners.

One case weekly: Every week you will work-up, diagnose and treat one virtual patient on your phone, tablet or computer. Each case should take you less than 10 minutes.
Compete: See how your care compares with your peers on a weekly leaderboard.

CME and MOC: Earn up to 4 Category I CME credits and 4 Part II ABIM MOC credits for completing your 8 cases.*
Prizes: Amazon gift cards for top performers.
Free: There is no charge to participate in this competition.
The competition is part of an evidence-based medicine study being conducted by academic researchers at UCSF, QURE Healthcare and CE Outcomes.
Your individual responses will be kept confidential, but the overall results are expected to contribute to improved patient care and to be submitted to a national journal for publication.

We will only enroll individuals who meet the specific study requirements below and will discontinue recruitment when the desired sample is achieved. You will qualify to participate if you:
    * Are board certified in internal medicine or family medicine
    * Have access to the internet
    * Read and understand English
    * Care for a panel of at least 1,500 patients

Follow this link join:
Signup and Access First Case

Or copy and paste the URL below into your internet browser:********************************

If you would like to recommend a colleague for the study please reply with the name and email address and we will send them an invitation to participate.

If you have any further questions about the study, please don’t hesitate to call 415-678-5328 or email

*CME and MOC Accreditation and Designation: This activity has been approved by The University of California, San Francisco School of Medicine (UCSF) which is accredited by the Accreditation Council of Continuing Medical Education to provide continuing medical education for physicians. UCSF designates this enduring material for a maximum of 4 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, will also enable participants to earn up to 4 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity.

Thank you for your participation.

Trever Burgon, PhD
Vice President
450 Pacific Ave, Suite 200
San Francisco, CA 94133
Office: 415-321-3388 ext 102
Mobile: 650-465-5982

Several interesting points to note:
  • This gaming research is being conducted by a QURE Healthcare that shares the identical address of two law firms, the San Francisco office of Thompson Welch Soroko & Gilbert LLP and JRA Law Partners. Is this company just a shell for data collection?

  • QURE Healthcare shares data with another company, From their website: "CE Outcomes is the premier independent evaluator trusted by CME providers and pharmaceutical/biopharma companies. Impact evaluations are cost effective and produce level 5 outcomes data."
Looks like the American Board of Internal Medicine Maintenance of Certification (MOC®) Product 3.0 is evolving to little more than a bizarre form of "Quality Hunger Games" on a computer between doctors.

You can't make this stuff up.

Please give generously to the PPA legal fund to support of our physician colleagues who have sued the ABIM to end this nonsense.


Saturday, January 12, 2019

Proposed Maintenance of Certification Changes Ignite Controversy (Again)

From MDLinx' PhysicianSense blog:
Dr. Westby Fisher, a vocal critic of MOC who has been investigating ABMS finances, referred PhysicianSense to this blog post when asked for comment. Fisher argues that public comment on the future of MOC is moot when there is no plan to end MOC outright.

You can't negotiate with a Spider when you are forced to be a Fly.

Instead, you have to exterminate the Spider.

Please give generously in support of our four colleagues. It's time to end this abusive MOC nonsense.

(Unless, of course, you want to do unproven, costly forced testing the rest of your career.)


Tuesday, January 08, 2019

The ABMS Spider and the Fly

Mary Howitt

“Will you you walk into my parlour, said a Spider to a Fly;
'Tis the prettiest little parlour that ever you did spy.
The way into my parlour is up a winding stair,
And I have many pretty things to shew when you get there.
Oh, no, no! said the little Fly; to ask me is in vain:
For who goes up that winding stair shall ne'er come down again.

Said the cunning Spider to the Fly, Dear friend, what can I do
To prove the warm affection I have ever felt tor you?
I have within my parlour great store of all that's nice:
I'm sure you're very welcome; will you please to take a slice!
Oh, no, no! said the little Fly; kind sir, that cannot be;
For I know what's in your pantry, and I do not wish to see.

Sweet creature, said the Spider, you're witty and you're wise;
How handsome are your gaudy wings, how brilliant are your eyes!
I have a little looking-glass upon my parlour-shelf;
If you'll step in one moment, dear, you shall behold yourself.
Oh, thank you, gentle sir, she said, for what you're pleased to say;
And wishing you good morning now, I'll call another day.

The Spider turn'd him round again, and went into his den,
For well he knew that silly Fly would soon come back again.
And then he wore a tiny web, in a little corner sly,
And set his table ready for to dine upon the Fly;
And went out to his door again, and merrily did sing,
Come hither, pretty little Fly, with the gold and silver wing.

Alas, alas! how very soon this silly little Fly,
Hearing his wily flattering words, came slowly fluttering by.
With humming wings she hung aloft, then nearer and nearer drew.
Thinking only of her crested head and gold and purple hue:
Thinking only of her brilliant wings, poor silly thing! at last,
Up jump'd the cruel Spider, and firmly held her fast!

He dragg'd her up his winding stair, into his dismal den,
Within his little parlour; but she ne'er came down again.
And now, my pretty maidens, who may this story hear,
To silly, idle, flattering words, I pray you ne'er give ear;
Unto an evil counsellor close heart, and ear, and eye,
And learn a lesson from this tale of the Spider and the Fly.

~By Mary Howitt, 1829

* * *

If you do Maintenance of Certification, you are just a silly little Fly.

It is chillingly apposite: for the American Board of Medical Specialties (ABMS) and their 24 member boards' to live, autonomous independent-thinking physicians must die.

Spiders can never stop being Spiders.

"And now, my pretty MOC maidens, who may this story hear,
To silly, idle, flattering words, I pray you ne'er give ear;
Unto an evil ABMS counsellor close heart, and ear, and eye,
And learn a lesson from this tale of the Spider and the Fly..."

... then donate to Practicing Physicians of America's expanded legal fund drive.


Monday, January 07, 2019

Giving Credit Where Credit Is Due

Why does a physician who is strong-armed into participating in Maintenance of Certification (MOC®), pays for MOC®-eligible educational materials, studies and performs the online testing to receive "MOC®-points" from the American Board of Internal Medicine, not get credit for the work completed?

I received a threatening notice from the American Board of Internal Medicine (ABIM) with the loss of my ABMS board certification credential in November 2018 via mail if I did not acquire 100 MOC points by 12/31/2018.

Given the ramifications to my ability to retain credentials at my hospital system that requires "ABMS Board Certification" for its credentials, I did not feel I could risk the implications of this change to my original understanding of MOC® when I originally purchased the product in 2013. Consequently, I tried to find enough educational materials with sufficient MOC® points to meet that requirement in the short time I had left to complete this requirement that was appropriate for my subspecialty. Unfortunately, only the ACCSAP-9 had enough MOC® points (at about $10 per point) to reach that goal, so I spent $1600 to purchase their product.

I began working on ACCSAP9, spending hours reading and answering the questions provided so I might be able to acquire enough "points" to reach 100 by the deadline. Needless to say, because of clinical and family demands, I didn't reach that goal.

I never received "credit" for rounding at four hospitals before 12/31/2018.

I never received "credit" for spending time with my kids and only remaining father-in-law before 12/31/2018.

I never received "credit" for trying to balance work and family life before 12/31/2018.

And despite completing 100 points on 1 January 2019 (the day after they were due), I now find I didn't received "credit" for the hours spent completing even more questions on the one day I had off from work on 1 January 2019:

Documentation of work performed for MOC® 1 Jan 2019
Documentation on ABIM Physician Portal that no credit was received for MOC®
points earned on 1 Jan 2019, despite itemized list above.
Nor did my family receive "credit" from the ABIM for my time spent in front of my computer at home on New Years' Day 2019.

But at least I'm still "certified" by the ABIM and "participating" in MOC® despite their threats and not completing 100 MOC® points by 12/31/2018!

* * *

It is clear to me by all that has transpired in this latest shakedown of physicians by ABIM, that they could care less about MOC® points, they just want our money will stop at nothing to secure funds for themselves and their collaborating professional societies.

That's why I'd like to give "credit" to the four physicians who bravely filed suit against the ABIM in December.

I'd like to give "credit" to the one Puerto Rican physician who still has a pending countersuit against the ABIM that still has not had a chance have his case heard in court.

I'd like to give "credit" to the 750 physicians, many of whom remain "anonymous" out of fear of retribution, and helped fund the investigation that led to the antitrust suit filed against the ABIM in just over four months.

And I'd like to announce that an additional $250,000 is being sought to continue our investigation against the ABIM to consider additional claims against them (see "Update 18").

It's time to give credit where credit is due: to the working physicians who continue to try to do their job caring for patients without coercive education tactics for funds that result in no credit of any kind to them.

Please give generously to our new campaign to end this corruption.

It is time to end, once and for all, the deceptive ABMS "continuous certification" scam for all physicians nationwide.


Wednesday, January 02, 2019

Happy New Year, MOC!

As many of us head back to work to start a New Year, let's not forget that physicians have until January 15, 2019 to "comment" on the ABMS Vision Commission's (un-editable) Draft Report.

While Paul Teirstein, MD and his colleagues at the National Board of Physicians and Surgeons (NBPAS) did a nice job dissecting many of the problems with the Vision Commission's report and made it easy to "comment" to the Commission's Draft Report using SurveyMonkey, I would like to add a few important observations about the Vision Commission's report (and the response by NBPAS) that are not mentioned and remain stumbling blocks for me.

First of all, should physicians be bound by an adhesion contract (seen here) with Board Certification and MOC (or whatever "continuous certification" becomes called) that can change on the whim of the ABMS and their member boards "from time to time?" This gives unilateral control to ABMS and prevents appropriate checks and balances. How is this helpful to anyone except the ABMS member boards and their collaborating corporate entities - all of whom already enjoy a substantial position of power and monetary influence. Remember the history of MOC reviewed in the antitrust complaint (starting on Page 5) filed five days before the Vision Commission's "Draft Report" appeared.

Also, those corporate entities that collude with MOC are not mentioned and are extensive. A partial list includes ABMS Solutions, LLC, hospitals and the ABMS Multispecialty Portfolio Program, publishers like the Massachusetts Medical Society and Wolters Kluwer, Pearson LLC, CECity, Premier, Inc, PriceWaterhouseCooper, and subspecialty societies like the ACC and ACP - all who stand to benefit financially from MOC. Remember, a significant portion of the ABMS Vision Commission are not practicing clinical physicians and are deeply conflicted with corporate entities.

And let's not forget that the Commission's report leaves the harms already experienced by physicians and their families unmentioned (for obvious reasons) - again, see the recent antitrust Complaint filed. MOC was always about money and power for the ABMS and their member boards. The ABMS fully intends for MOC (soon to be rebranded as CertLink®) to shift from a desktop platform at a PearsonVue testing center to a mobile platform in the palm of our hands as "MOC pilots" become permanent in 2019! This translates to more distractive screen time for physicians away from patients and a lucrative life-long money stream to ABMS and their collaborators.

I would encourage physician to consider copying the content of this blog post and morph it into your own "comment" to the Vision Commission if you feel it would be worthwhile.

Also, consider donating to Practicing Physicians of America's legal fund. I believe you'll get more for your hard-earned money that protects your interests that way.