Medical Societies Side with ABIM at the Expense of Their Members

Yesterday in a coordinated blow, the American College of Cardiology (ACC), Heart Rhythm Society (HRS), Society for Cardiovascular Interventions (SCAI), the Heart Failure Society of America (HFSA), and the American Board of Internal Medicine (ABIM) turned to their marketing muscle, funded in large part by the medical device industry, to issue a joint letter to their respective physician memberships that they stand with the nations' consolidating hospital systems in requiring Maintenance of Certification (MOC) for working physicians:

Dear Member:

We are writing to provide information of interest regarding cardiologists' American Board of Internal Medicine (ABIM) certification status.

On Jan. 1, 2014, ABIM Maintenance of Certification (MOC) requirements changed. In addition to the 10-year assessment requirement, diplomates wanting to maintain their certification are required to complete 100 MOC points every five years. The end of the first five-year period for many diplomates was Dec. 31, 2018.

Early in 2018, ABIM noted that a number of diplomates were at risk of missing the 100-point requirement. ABIM initiated an intense effort to communicate with these diplomates. This resulted in a high percentage of cardiologists across all specialties obtaining enough points to remain certified before ABIM updated its public reporting in February 2019. When looked at through the lens of specific certificates, 94 percent of cardiovascular medicine certificates, 88 percent of electrophysiology certificates, 84 percent of interventional certificates and 100 percent of heart failure certificates were held by diplomates who met the 100-point threshold. Additionally, physicians who had not met their points requirement saw their certification status change to "Not Certified."

The leadership of the four major cardiovascular specialty societies – the American College of Cardiology (ACC), Heart Rhythm Society (HRS), Society for Cardiovascular Angiography and Interventions (SCAI), and Heart Failure Society of America (HFSA) – realized that many cardiologists who had intended to remain certified were somehow unaware of the new process and missed the deadline. Therefore, they initiated a call with the ABIM leadership to discuss opportunities for those cardiologists to bring their certification into good standing.

If you are one of those whose certification status has changed – or if you'd like to confirm what you need to do next – please follow these steps...

This letter was issued despite physicians losing their ability to practice medicine solely because they did not complete "MOC points" before an arbitrary five-year deadline imposed by the ABIM. Physicians across the country are receiving letters from their hospital systems threatening them with "automatic retirement" for allowing their board certification to "expire." Worse still, some of those letters were issued in states where anti-MOC legislation exists, thanks to loopholes conveniently added by hospital lobbyists.

So what do our specialty societies recommend physicians do? Ask the monopoly ring-leader for a letter:

If your hospital, payer or employer credentialing committees have raised concerns, ABIM will work with you to provide a letter that can be shared with them outlining what you need to remedy any temporary loss of certification. To discuss such a letter with ABIM, please see the contact information below.

In other words, pay up, get your MOC points, or shut up and lose your job.

-Wes

Please donate to the GoFundMe page created by Practicing Physicians of America to end this discriminatory educational monopoly and racketeering. It is clear now that state legislation created to outlaw MOC in most states means nothing to our nation's consolidating hospital systems.

Addendum: 29 May 2019 @ 1:18 PM CST - Link to physician letter fixed.

The Bizarre Week of Pro-MOC Activities

"ABIM is disappointed to learn of a lawsuit filed on behalf of four diplomates. The organization will vigorously defend itself, recognizing that doing so will consume resources far better dedicated to continuous improvement of its programs."

- ABIM blog

What a bizarre week it has been by those who support Maintenance of Certification (MOC). Despite the growing uproar in the working physician community, it is becoming clear that the proponents of MOC are circling their wagons in an effort to go "all-in" on the program.

1. First came the article by highly conflicted members of the ABMS Vision Commission that was published in JAMA by Christopher C. Colenda, MD, MPH, William J. Scanlon, PhD, Richard E. Hawkins, MD.
   
   The authors listed the following conflicts of interest:
   

   "Dr Colenda and Dr Scanlon served as co-chairs on the Continuing Board Certification: Vision for the Future Commission. Dr Colenda is president emeritus of West Virginia University Health System and founder and principal for Christopher C. Colenda, LLC, a firm that provides consulting services to academic health care institutions and organizations, reported receiving personal fees from the Association of American Medical Colleges (AAMC), The Ohio State University, Virginia Tech/Carilion School of Medicine, and Loyola University School of Medicine, and serves as the "of counsel" role with Witt/Kieffer Search, an executive recruiting firm. Dr Hawkins reported receiving personal fees and royalties from Elsevier."

   Of course the authors failed to mention their other significant conflicts. Dr. Colenda was a member of the Board of Directors of the Accreditation Council on Graduate Medical Education (ACGME), the National Board of Medical Examiners (NBME), the American Board of Psychiatry and Neurology (ABPN), the AAMC's Administrative Board of the Council of Deans, Health Systems Governing Council of the American Hospital Association (AHA), and the LCME, where he was chair from 2012-13. Dr. Scanlon served as a "Consultant" to the now-obsolete National Health Policy Forum, a group created to help the government determine how doctors should be paid that was funded (in part) by Blue Cross Blue Shield, the Robert Wood Johnson Foundation, and the Josiah Macy, Jr. Foundation. Both the Robert Wood Johnson Foundation and Josiah Macy Jr. Foundation have donated significant funds ("grants") to the ABIM Foundation to foster the "Choosing Wisely" campaign and "team based" health care delivery. Dr. Hawkins, currently serves as President and CEO of the American Board of Medical Specialties (the owners of the MOC® trademark) and ABMS Solutions, LLC that sells physicians ABMS certification status, updated daily, to third parties.
   
   God forbid they mention these facts or the editors of JAMA provide professional scrutiny over disclosures.


2. Second came the plethora of new, costly MOC-preparation materials offered by the American College of Physicians and American Board of Internal Medicine. The business of re-certification is stronger than ever!


3. Thirdly, the Heart Rhythm Society suddenly became "concerned" that HRS members are losing their ABIM certification. (Who knew?!?) In an announcement to their members after siding with the ABIM and the ACC to create the CMP pathway, they "woke" from their slumber and said:

   "There has been some confusion among members who are not participating in MOC that they should be listed as "Certified, Not Participating in MOC," This has been the case, however, for those last certified in 2014 or later, certification will be forfeited after 5 years of non-participation in MOC. To reiterate, if you certified after 2014 and you have not been participating in MOC, you will be listed by ABIM as "Not Certified" after 5 years. While this has been communicated by ABIM since 2014, we are now seeing the first of our members being negatively impacted by this requirement."

   It's a bit hard to believe that they were unaware of this little right-to-work "problem" with MOC. How did they turn a a blind eye to the many MOC problems as they forged ahead to create the EPSAP educational product for MOC re-certification and the ACC's CMP pathway? Where is their concern over the discrimination against younger physicians certified after the 1990 "grandfather" date? Is another layer of discrimination for those re-certified after 2014 and threatened with losing their certification any different? HRS members on that forum have spoken clearly to the HRS leadership: "Collaborating with corruption is to condone it."
   
   
4. Perhaps the most entertaining thing that appeared this week, however, was an anonymous Twitter account created by an professor at a major academic medical center who serves in a senior leadership position at the American College of Physicians. (Remember, nothing is truly anonymous on the Internet). That account aggressively trolled/baited/harassed anti-MOC working physicians online. Here are a few of the best tweets:
   • "I'm not going to discuss GF (grandfathers). Get over it. What a false flag."
   
   
   • Or when responding to concerns about the purchase of a $2.3 million condominium purchased by the ABIM Foundation: "Ignorant comment. Knew you'd go there. That was not corrupt. They used it as a cheaper alternative to hotel stays. Once it went, they had to pay more of your money to house people. Nice job zealots!"
   
   On and on the tweets went in an unbridled, unprofessional and immature fashion until the account creator was exposed. Then the account went private. As Shakespeare's Hamlet famously said: "The lady doth protest too much, methinks."


5. Finally, in a Medscape article, the former President of the American College of Cardiology, C. Michael Valentine, MD, suggested that the ACC is prepared to enter the physician certification business by issuing "certificates" for physicians participating in their new Collaborative Maintenance Pathway MOC product:

   "We feel that this gives our members the most options available," said Valentine. "If you decide that you don't want ABIM certification, you can opt out and just do ACCSAP or Cath SAP or EP SAP and we'll then give you a certificate from the College saying that you are engaged in online continuous learning through the College…but that may not be accepted by your hospital or your health system or your payment system. All it says is you're engaged in our SAP program and continuous learning."

   ACC Certification now? Really? For twice the price, too! Never mind that pesky little detail that hospitals and insurers don't currently recognize ACC's CMP without its tie to ABIM's MOC requirements.

It's a shame that the antiMOC battle has come to this, but its really not surprising.

A shift from the corrupt MOC status quo was (and continues to be) inevitable.

-Wes

Grandfathers, Lattes, and the ACC's CMP Pathway

Drs. Kovacs (L), Fisher (C), and Marine (R) discuss MOC and
the ACC/HRS Collaborative Maintenance Pathway (CMP)
at the Heart Rhythm Society's 40th Scientific Sessions

As I head back to Chicago today, I wanted to take a moment and reflect on my experience before, during, and after my opportunity to speak at the Heart Rhythm Society's (HRS) 40th Scientific Sessions in San Francisco yesterday.

Before I do so, I want to thank Tom Deering, MD, President of HRS, for reaching out to me and asking me to share the findings of a small survey I did on working cardiologists and electrophysiologists on the new "Collaborative Maintenance Pathway" (CMP) for "maintenance of certification (MOC)" that the Heart Rhythm Society and the American College of Cardiology have created.

It was clear this session was really an afterthought. It was organized about a month before the scientific meeting after I placed the survey I helped create to gather physician perspectives on the new CMP pathway on the HRS online discussion forum. Dr. Deering ask that I create the title for the talk while the HRS assembled the moderator and speakers.  Ken Ellenbogen, MD, longtime organizer of the HRS Board Review Course held each year in Chicago, was selected as moderator.  Bradley Knight, MD, member of the cardiology committee for the American Board of Internal Medicine (ABIM) was to participate (so I thought), as was Joseph Marine, MD, an EP from Johns Hopkins who helped create the ACC/HRS CMP pathway. It was held on the show room floor at one of those speaking "EPicenter labs" with a computer screen, pretty good sound system, and about 20-30 chairs before the speakers.

Despite the small venue, it was clear the talk was "important" to the ACC leadership. Both C. Michael Valentine, MD and Richard J. Kovacs, MD (out-going and incoming ACC Presidents) were there and warmly welcomed me. In our initial chat together, I learned they were both "grandfathers" to the MOC process but had worked hard to create another way physicians could comply with MOC using their cell phones. I had not met Dr. Marine before, but it was clear he really believed in the MOC process and the CMP program the ACC had created. Dr. Knight, I later came to realize, did not show, likely because of his work with the ABIM and the pending litigation against them.

Dr. Marine kicked off the session with a 15-minute talk describing the CMP program. To his credit, he included the costs circulated by HRS, regarding the program, and was quick to note that the costs really were acceptable, as he showed the relatively high salaries of cardiologists published recently and compared that cost a number of ways, including a comparison that it would only set back participants the equivalent of "2 or 3 lattes a week." It was like a line from the ABMS script.

Then I spoke. Gratefully, I was able to use slides (withheld from me in my discussion at the IL Medical Society) several weeks ago. As I looked around, there were plenty of people standing on the edges and reluctant to take a seat. As my talk progressed, I paused to have those in attendance answer one of the questions. It became clear they were reluctant to do so, but it was clear they sided with the sentiments of the first question - that the ACC should not leverage the sale of their CMP product to our certification. I did not press the audience to answer more questions since I did not want to put anyone on the spot. I continued on reporting the results, limitations, and my final thoughts on MOC in general.

Question and answer time arrived. Dr. Ellenbogen started off and again asked a version of the same hypothetical question Dr. Knight had tweeted earlier - if you had a loved one in another city that needed a cholecystectomy, who would you pick, a doctor who was board certified or someone who was not?" Of course, this question was a straw dog. We are not talking about initial board certification, we were talking about a re-certification product that, unless purchased, invalidates a physician's initial certification. Dr. Ellenbogen then urged one of the ACC Presidents to respond. I would see Dr. Valentine encouraging Dr. Kovacs to step forward, which he somewhat reluctantly did as he complained he really wasn't unprepared. But he sat down and shared the ACC's position: that CMP was a "different" pathway and that doctors have a commitment to show they "keep up."

Then several of the audience members stood up and gave emotion-packed questions of why only select sessions at this meeting are "approved" for CME while other, informative learning (like poster sessions) receive none? "We have to follow rule stipulated by the ACCME," was the (paraphrased) response. On and on it went, back and forth, but NOT participating in some form of MOC was never an option despite my seeming rational lines of logic ("Why grandfathers?", "Why no other country requires "maintenance of certification?", all falling on deaf ears.)

Afterward, I felt like I had just been through a few rounds in a boxing ring but had survived. Everyone left a bit worn, but unscathed.  Ethan J Weiss, MD tweeted from UCSF, "Who won?" I can honestly say that neither side "won." This really was not a debate. MOC continues and at least five antitrust lawsuits against the ABMS or its member boards are filed. But it was clear that working physicians and our little organization, Practicing Physicians of America, are having an impact.

I also came to realize that this battle's far from over.

-Wes

PS: Please consider donating to our efforts to support those trying to end MOC for all subspecialties nationwide.

HRS Scientific Sessions 2019: Science or Story-Telling?

I had just left the Opening Plenary Session at the 2019 Heart Rhythm Society (HRS) Scientific Sessions in San Francisco and was sitting my cup of coffee when he approached me.

"So, what did you think?"

I wasn't really sure how I should respond, so I was polite and spoke slowly.

"It was nice," I said, waiting to hear what he had to say.

"I thought it was kind of weird. The 'story-telling' theme felt a bit creepy -promotional and like a Ted Talk. I mean, don't get me wrong, I like that guy's podcast and all (Guy Raz from NPR was the keynote speaker), but the 'past, present, future' thing? That kinda left me cold."

"I think they were trying to be 'hip.'  And 40 years is a pretty long time," I said, smiling.

I felt a little more comfortable because I found the message of physician "story-telling" left me flat, too.

For those who weren't in attendance, the theme of the Opening Plenary Session this year was "The Importance of Story-telling."  A cool video of the pioneers of EP was displayed, along with the timeline of when the various EP innovations occurred (this was the best part, IMO).

Then, the lights dimmed just before Tom Deering, MD, the current President of the Heart Rhythm Society came. With lights rising and music playing, he welcomed the nearly 11,000 physicians in attendance this year. He didn't miss a beat (pun intended) as he delivered his message. It was then I saw the two, huge teleprompter screens, scrolling his lines before him. The message took on the look of an informercial. It was surreal. (I'm not sure why I've never noticed this before.) Scientific sessions are being carefully scripted.

The organizer of the Scientific Sessions was then introduced and similarly gave a teleprompter-assisted thank you the various folks who helped with organization of the meeting. Then Mr Guy Raz from NPR was introduced as keynote speaker.

I apologize that I may not be telling the whole story Mr Raz told correctly, but I hope you'll get the general gist of his message.

Mr Raz began his talk with a story of a recent illness and hospitalization he had suffered from a recent episode of cellulitis just before this meeting. Because of his fever to 103, he had missed the fact that he had a very red rash climbing his leg discovered after he presented to his local ER. He was recommended to be admitted for treatment. He was told he would likely be admitted for 48 hours. In his conversations with the ER doctor, as he tried to tactfully explain he really needed to be out of the hospital sooner because he had another speaking engagement for his friend, Jimmy Fallon. He described the excitement the ER doctor had over learning that he knew Jimmy Fallon ad how important the doctor made Mr. Raz feel. Mr Raz then delivered his message: that really, doctors are much more important than NPR hosts that speak on behalf of Jimmy Fallon. After all, they save lives and care for acutely ill patients every day. (Yeah, I thought the same thing: "This is the message?" We never really heard what happened next.)

He then introduced three series of physicians and allied professional leaders at HRS whom he interviewed. It was like a polite, handsome Ebenezer Scrooge interviewing the Ghosts of Electrophysiology Past, Present, and Future in a scripted, "fireside chat" kind of format. (We've seen this format before. It seems very popular right now with corporations.) We heard about the $1 registration fees and the hope that physicians would show up for their first meeting while we reflected on the $1800 registration fee today. We then watched a video for the future where nothing was impossible; the entire interconnected world's health problems, and even catheter ablation, treated from the comfort of your living room provided, of course, you had an iPhone. (Call it "editorial license run amok.")

I wonder: is "the importance of story-telling" really the right message we want conveyed to a room full of gullible young EPs and allied professional there for their first meeting? Or do we want them to see and interact with leaders in science learn critical review without the bright lights and teleprompters?

Lately, what we've seen as patients and physicians is that not all corporate and personal stories are benign. Some can even be harmful. The stories of the measles vaccine. The stories of the promise of flying a plane with computer software alone. The stories of your "value" or "quality of care" as a physician being quantified by  Maintenance of Certification (MOC) testing and the ACC/HRS Collaborative Maintenance Pathway.

Stories, as important as they be at times, can also be spun.

Physicians will get much further if we remember who we are and who we serve and just keep it real.

-Wes

Physician Plaintiffs Counter ABIM's Motion to Dismiss

Following the Dec 6 2018 filing of a class action antitrust lawsuit against the American Board of Internal Medicine (ABIM) by four internal medicine physicians (that was later amended to include fraud, RICO and unjust enrichment claims), the ABIM filed a motion to dismiss the physicians' Complaint. Much of their argument hinged on the ABIM's supposition that

"... plaintiffs cannot establish that initial certification and MOC are two separate products capable of being tied; plaintiffs’ own allegations demonstrate that initial certification and MOC comprise complementary, continuous components of ABIM’s certification. They are not separate products. For that reason as well, plaintiffs’ claims that ABIM has unlawfully created and maintained monopoly power in violation of Section 2 of the Sherman Act fails. Because they have not met their burden of plausibly alleging the tying of two products, they cannot point to any unlawful (i.e., anticompetitive) conduct.

In defense of their argument, the ABIM attorneys attempted to use two franchise analogies citing Krehl v. Baskin-Robbins Ice Cream Co. and the rejection of a tying claim brought by a Subway franchisee to plead the case that initial certification and MOC are not separate products, but rather one product.

On 30 April 2019, the plaintiffs' opposition to ABIM's Motion to Dismiss was filed. The plaintiffs' attorneys wasted no time countering ABIM's motion to dismiss (starting on page 2 with references removed):

"ABIM relies mostly on franchise cases to argue MOC is not a separate product. Putting aside for the moment that all of the cases it cites were decided on a fully developed factual record at summary judgment or after trial, ABIM’s franchise analogy misses the mark. Physician care is not Baskins Robbins ice cream, and patient treatment is not a Subway sandwich. Hence, the notion that ABIM can force MOC on internists in service of an illusory nationwide standard unilaterally imposed by ABIM offends the free market principles that are the hallmark of medical care in this country. Plain and simple, MOC is a failed and extremely costly product that ABIM, using its undisputed market power, forces internists to buy. Its exploitation of internists is further aggravated because while ABIM deceptively wraps itself in the mantle of self-regulation, it has no legislative, regulatory, or administrative authority at all and answers to no one, and certainly not to the internist community it misleadingly claims to be self-regulating."

Read the whole rebuttal.

-Wes

P.S.: Unless you feel your medical practice is  just a fast food franchise, please support the physician-plaintiffs in this important legal effort to end MOC nationwide for all subspecialties.