Monday, July 06, 2015

Case Study: Palpitations Following Pacemaker Implantation and AVJ Ablation

A 70 year old woman underwent a DDDR pacemaker implantation (Medtronic Versa DR) and AV junction ablation for chronic atrial fibrillation refractory to medical therapy six months after she presented to the pacemaker clinic.  She returned complaining of intermittent palpitations, usually worse at night.  An interrogation of her permanent pacemaker demonstrated the following:

(Click image to enlarge)
Her P waves are interrogated and appeared to be of a sufficient amplitude of 1.4-2.0 mV:

(Click image to enlarge)




Likewise, her Cardiac Compass plot of the duration of atrial fibrillation each day showed the following:

(Click image to enlarge)

Upon seeing these data, it was felt the patient may be undersensing her fibrillatory P waves (formally known as F waves). To improve her pacemaker's atrial sensitivity, the sensitivity threshold was changed from 0.5 mV (her initial setting) to a more sensitive setting of 0.25 mV.  Here is how the device responded to this change in sensitivity:

(Click image to enlarge)



Even a more sensitive setting of 0.18 mV showed similar results:

(Click image to enlarge)

Here's her sensing at the original (less sensitive) setting of 0.5 mV. Unfortunately, occassional atrial pacing was still seen:

(Click image to enlarge)



Programming to an even less sensitive setting of 0.7 mV appeared to paradoxically have improved sensing of her atrial fibrillation:

(Click image to enlarge)

How do we explain what is happening here?   Would you revise her right atrial lead?  If not, what atrial sensitivity setting would you use for this patient and why?

-Wes

PS:  Give it your best shot to see if you can explain what is going on with this patient's atrial pacing sensitivity setting.  When you finally give up and want the answer to what's going on: consider clicking here.

Helping the ACP Define "Professional Accountability"

Over the weekend, the Executive Vice President and CEO of the American College of Physicians (ACP), Steven Weinberger, MD, sent an email to update their members about the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. In that email, Dr. Weinberger said that "the ABIM MOC program continues to be an area of concern for many ACP members, so I'm writing to update you about ACP's ongoing work in this area and our efforts to improve ABIM's MOC process. I also want to reassure you that reforming the MOC process continues to be a top priority for ACP."

It appears the ACP is happy with applying more lipstick on the ABIM MOC pig. It is sad that the ACP, an important primary care physician professional organization, continues to side with the grossly corrupt MOC program marketed by the American Board of Medical Specialties.

But the email didn't stop there.

Rather than take accountability for actions like accepting grants from the corrupt ABIM Foundation that grew from the covert collection of physician re-certification fees, the ACP has instead decided to re-define what it means to be "accountable" by "updating" its "Professional Accountability Principles."  By doing so, it appears the ACP continues to believe such self-proclaimed edicts will appease their membership and they should just look the other way and be reassured that the ACP has their membership's best interests in mind.

Of course for practicing physicians, it now appears clear that nothing could be further from the truth.

True accountability involves meaningful reform and transparency and consequences when the trust of their practicing physicians is violated. Given what we now know about the interconnected non-profit lives of the ACP, the ABMS, the ABIM, and its Foundation, we are seeing the underbelly of a patronage system that benefits the leaders of these organization with little regard for practicing physicians. 

For instance, does the ACP acknowledge the money they received from the ABIM Foundation to "promote awareness in the area of internal medicine" and offer to refund these funds to their members in a gesture of apologetic good will?

No.

Does the ACP offer to ask the ABIM why there is no concern of what happens to patients who lose their ability to receive care from a physician because the corrupt MOC program fails them and they can no longer practice their trade or retain hospital credentials?

No.

Does the ACP have any concern whatsoever about the unaccountable self-appointed nature of bureaucratic non-profits who can change their policies to meet their own needs instead of the needs of practicing physicians without recourse from their membership?

No.

By continuing their insistence on "reforming" the corrupt MOC program, the ACP risks becoming just as irrelevant as the ABIM. 

So here's my suggestion how internists can help the ACP define "accountability:" resign their membership and don't renew.  Then the ACP might learn what real "professional accountabilty" as defined by their membership really means. 

-Wes

Friday, July 03, 2015

Lipstick: ABIM Announces Changes to MOC Program

A coordinated announcement between medical specialty societies and the American Board of Internal Medicine (ABIM) was made recently changing the American Board of Medical Specialty's (ABMS) trademarked Maintenance of Certification® program requirements (again) for select subspecialties in Internal Medicine. "Unanimously passed" by a group of well-meaning physicians in a new creation within the ABIM called the ABIM Council, diplomats in nine subspecialty areas of internal medicine will no longer need to maintain underlying certifications in those areas as of 1 January 2016.

Unfortunately, you can't put lipstick on a pig.

The regulatory world of medicine has become a self-reinforcing, patronage system consisting of multiple non-profits and regulatory professional organizations. When fifteen professional societies  collaborate with the ABIM to spit out a sacrificial lamb in an apparent act of appeasement, practicing US physicians are supposed to relax, shake hands and move on. Appeasement is not transparency. Minimal change is not profound reform.

This testing issue is just the tip of the iceberg in the exploitation of practicing physicians. The ABMS MOC® program is a complicated, intricate physician re-certification scheme that appears to be little more than a special interest employment bureau happy to shower itself with creature comforts and benefits at the expense of those who do the dirty work of patient care. As such, the MOC® program has created a corrosive divide within our profession that has even gained notoriety in the New England Journal of Medicine. It also now regulates the employability of an increasing number of physicians. The ABMS and American Hospital Association,  both part of the Accreditation Council on Graduate Medical Education (ACGME), have required this unproven MOC® metric for hospital credentialing of physicians dependent on employment by those hospitals. The program has become so embedded in the medical regulatory culture that it's even found its way into our new health care reform law. When examined on this scale, removing a requirement for taking two MOC® re-certification examinations instead of taking just one seems aimed at deflecting further scrutiny.

Practicing physicians need to remember that there is much more to the MOC® program than computerized educational modules, secure examinations and paying fees. The program affects physicians' ability to practice their trade and leaves physicians at risk of sanctions for revealing trade secrets of the ABMS and ABIM. Until the anti-trust suit against the ABMS and ABIM is resolved and the IRS fully investigates the fraudulent reporting of the origination date and domicile of the ABIM reported on tax forms, subspecialty organizations should not require re-certification programs created by the ABMS or ABIM.  Are we holding our specialty societies to this standard?

Otherwise, they're wearing lipstick, too.

-Wes

Tuesday, June 30, 2015

Medical Board Re-Certification and the ABIM Financial Cover-up

“Oh, what a tangled web we weave...when first we practice to deceive.”

― Walter ScottMarmion

Integrity and trust in medicine are vital. What other profession is granted the awesome responsibility of caring for a fellow human's life? In what other field do people allow a stranger to listen to their most intimate secrets, examine their bodies, or care for people's most cherished possessions, their children? Likewise, trust in communications that occur between physicians on a patient's behalf are equally important.  Only through the implicit values of integrity and trust would patients allow us to do what we do when managing their care.

Clinical medicine has no room for lies, half-truths, or deception. Yet for nearly twenty-five years, I believe the American Board of Internal Medicine (ABIM) has been involved in a massive financial cover-up involving the redistribution of physician testing fees.

Why does it matter whether physicians are safe placing their trust in the ABIM? Because if the ABIM physician credentialing standards are corrupt, then standards for quality metrics contained in modifications to Social Security Law 1848 made by the Affordable Care Act, hospital credentialing rules requiring Board re-certification by the ABIM, and insurance physician payment rules are also corrupt.

I will say at the outset that I do not think that most of the physicians and staff who work at or for the ABIM are bad people. I suspect many of them have the highest of integrity and trustworthiness as any physician. For instance, on 10 Feb 2015 in response to the growing re-certification controversy, Jim Stackhouse, MD, a former member of the Board of Regents of the American College of Physicians (ACP) left a blog comment to the current Chairman of Board of Regents of the ACP, Robert Centor, MD that described his efforts to challenge the status quo before he resigned from the Board. It is also likely that the financial actions of this organization were not disclosed to all. But I am also not so naive to believe that certain members of ABIM worked in isolation from other professional societies and organizations. The intricate use of non-profit organizations and regulations present here is simply not the domain of most straight-forward practicing physicians.

The ABIM will likely deny or ignore some or all of the charges made here.  If they take notice, they may say they told the government everything they've done in tax filings. They will say that their financial dealings are above board, just as Bob Wachter, MD, the first former board member at the ABIM and ABIM Foundation to break the silence on the organization's financial dealings, mentioned in his nicely crafted blog post yesterday:
"... the Board took the bulk of its reserves (about $55 million, when all the contributions are added up) and placed them in a Foundation, whose charge was to support the Board’s work and serve the broader medical community. This is a standard practice for most large societies and accrediting organizations. The accounting involved is completely legitimate and has been vetted by yearly audits conducted by national accounting firms."
It is possible that the ABIM's financial actions have been perfectly legal. After all, I am a practicing physician with limits to my time, not a lawyer or accountant specializing in non-profit tax law. But this fact is clear: until yesterday's explanation by Dr. Wachter, the ABIM has consistently and repeatedly denied the existence of their Foundation to the public, the Internal Revenue Service, and practicing physicians between 1989 and 1999 and by doing so, I believe the ABIM's actions in regard to board re-certification have been deceptive, discriminatory and have violated the integrity and trust of the public and our profession. I intend to show using the ABIM's own documents, archived and current web pages, literature review, scoring data, tax records for the ABIM and ABIM Foundation from 1997 to present and public record (all heavily linked here) why I feel this way.

Background

The American Board of Internal Medicine is a physician-led 501(c)(3) tax-exempt independent organization that derives 98% of its revenues from physician testing fees and was founded in Des Moines, Iowa in 1936. Originally Board certification served as a marketing tool for independent physicians eager to grow their practice. Obtaining a Board certificate established a baseline level of competence to practice in one's field allowing physicians who trained at lesser-known medical training programs to establish their credibility against doctors from more well-known training programs. Like the Bar examination for the legal profession, the Board certification examination was a rite of passage for establishing credibility amongst the physician community that a physician had obtained a certain level of medical knowledge adequate for patient care. Originally, the secure examination for Board certification was performed once and considered a valid credential for a physician's lifetime.

The backdrop of medicine was very different when this story began. Cell phones had not been invented, the World Wide Web as we know it was just coming of age, communication was comparatively slow, and the majority of physicians were in independent practices outside of hospital employment. There was already a wide divide in medicine between the entrepreneurial private practice physician community and academic physicians who enjoyed the protected time and prestige of the academic environment, usually at a lower salary.  But not all academic physicians suffered financially due to lucrative speaking arrangements and consulting fees. For a very select chosen few, the "academic elite," the non-profit world was especially enticing because it provided shelter from the demands of "publish or perish" with promises of mahogany desks, first-class air fares, fancy hotel venues and prime consultant positions as they entered the bureaucratic sphere of public policy and academe. One only has to view the American Medical Association's corporate headquarters in downtown Chicago to understand the potential revenue involved in such a career path.

A Brief History of Board Re-certification

 In 1986, after two decades of “discussion and debate,” the American Board of Internal Medicine (ABIM) board decided to limit the validity for all Board certificates to ten years. The rationale for this change was: “The rapidly changing scope of medical information, evidence that the knowledge and skills of practicing specialists decline with time, and growing public concern over the need to periodically re-credential physicians were the major determinants in the Board's decision.” Nowhere did the ABIM mention the significant financial benefits to the organization inherent to this policy change. Board re-certification was also a concept unique to US medicine; while the US and other countries require continuing medical education, no other country in the world requires their physicians to repeatedly re-certify in their specialty. The re-certification policy became effective in 1987 for critical care medicine, 1988 for geriatric medicine, and 1990 for certificates in internal medicine, each of the subspecialties in internal medicine, and all other added qualifications. At that time, certificates in internal medicine or a subspecialty issued prior to 1990 were not time limited and, therefore, were valid for life. Individuals holding these certificates were encouraged (but not forced) to re-certify and could do so without placing their time-unlimited certificate at risk.

In 1995, the ABIM launched their re-certification program called "Continuous Professional Development (CPD)" that involved a secure examination.  The first CPD examination was administered to 306 physicians in 1996 and the overall pass rate was 93% with 8 of 12 internal medicine subspecialties having a 100% pass rate. (For comparison purposes, in 2014 (the most recent year examined) the number of re-certifying physicians had mushroomed to 11,371 physicians with a much lower 83% pass rate overall).

In 1997 the Institute for Clinical Evaluation was created (Foundation fees funded this effort to the tune of about $3 million and were only disclosed on tax forms) with its initial aim to test physicians on their  ECG-reading skills. Repeated testing of varying clinical skills was envisioned, but perhaps because of the work involved to test various clinical skills for all subspecialties, this new non-profit was later dissolved back into the Foundation in 2004 with Cristine Cassel, MD signing as the President of both organizations.

In 2000, the ABIM announced the existence of the ABIM Foundation to the public on their website and launched their “Medical Professionalism Project” spearheaded by ABIM member Troy Brennan, MD, JD to define “medical professionalism.” The directors of the Foundation, the ABIM, American College of Physicians – American Society of Internal Medicine, Robert Wood Johnson Foundation, and the European Federation of Internal Medicine were responsible for the creation of the document. In 2002, a white paper entitled "Medical Professionalism in the New Millenium" was simultaneously published without peer review in the Annals of Internal Medicine and The Lancet. The paper centered on three fundamental principles that the authors felt defined “medical professionalism:” (1) the primacy of patient welfare, (2) patient autonomy, and (3) the principle of social justice – that is, “the medical profession must promote justice in the health care system, including the fair distribution of health care resources” (emphasis mine). As part of this social justice imperative, the hard-to-disagree-with Choosing Wisely® program was later launched, but the source of funds for the Foundation or Choosing Wisely® was never disclosed publicly.

In 2005, the ABIM website announced its affiliation as a member board of the American Board of Medical Specialties (ABMS) - a 501(c)(6) organization that is now comprised of some twenty-four subspecialty member boards across all disciplines of medicine and includes the ABIM. The ABMS had  more monopolistic control of the re-certification process across the various disciples in medicine and could more heavily lobby Congress on behalf of physicians with its less restrictive tax-exempt status. With their announcement, the ABIM began using the more complicated four-part ABMS Maintenance of Certification® (MOC®) program in lieu of its simpler CPD program. Importantly, the newly required "Part IV" of the MOC® program involved completion of a "Practice Improvement Module" or "Patient Voice" component that included the collection of unscientific survey data from a physician's patients and their referring physicians.  Practicing physicians were also changing from paper records to electronic medical records at this time and found this added requirement redundant, time-consuming and irrelevant to their practice and professional needs. While voiced opposition to this change in re-certification was made from the practicing physician community, it appeared to fall on deaf ears.

In 2012, the process for "maintenance of certification" became "continuous." Because physicians now had to demonstrate participation in the MOC program every two years, and because they either had to pre-pay the full re-certification fee or pay a portion of it every two years, physicians became more active in their pushback against this change in policy that appeared to be driven more by finances than clinical value. A petition to change board re-certification quickly garnered nearly 23,000 signatures.

In December 2014, the ABIM Foundation, Choosing Wisely® and the $2.3 million condominium came to public attention. As part of this research, I asked Richard Baron, MD, the President and CEO of the ABIM to explain the high annual condominium expenses and the discrepancy I noticed on their tax forms regarding the Foundation's date of creation and legal domicile.  Tax records suggested the ABIM was created in 1999 in Iowa whereas public record suggested the ABIM was created in 1989 in Pennsylvania. In response to my inquiry, Dr. Baron e-mailed me this statement that explained the condominium expenses included the depreciation for the condominium (despite being a separate line item (Part IX, Line 22) for depreciation on Form 990) and this statement:
"Regarding the 1989/1999 question - In 1999 ABIM Foundation became a separate operating foundation."
As a result of this deflection, I have continued efforts to uncover the reason for the ABIM's date and location tax filing discrepancy.

Shortly thereafter, the ABIM made immediate changes to their MOC program. Whether this announcement occurred because of the details outlined in my prior report, or because the ABIM realized their Part IV survey collection was to be required as part of the new physician payment reform legislation recently passed by Congress, or because these non-scientific surveys qualified as "research" for the organization's benefit and was in violation of federal statutes for the Protection of Human Subjects is unclear. It is interesting to note, however, that the ABIM changed their domicile disclosure with the IRS from Iowa to Pennsylvania after my inquiry with their most recent 2014 Form 990.

The Cudgel

As part of the ABIM credentialing process, physicians must agree to a memorandum of understanding that includes the following statement when they enroll in the re-certification program that must be signed again electronically just before they are granted access to the content of their computerized secure examination:
“I understand that ABIM examinations are confidential, in addition to being protected by federal copyright and trade secret laws. I agree that I will not copy, reproduce, adapt, disclose, solicit, use, review, consult or transmit ABIM examinations, in whole or in part, before or after taking my examination, by any means now known or hereafter invented. I further agree that I will not reconstruct examination content from memory, by dictation, or by any other means or otherwise discuss examination content with others. I further acknowledge that disclosure or any other use of ABIM examination content constitutes professional misconduct and may expose me to criminal as well as civil liability, and may also result in ABIM's imposition of penalties against me, including but not limited to, invalidation of examination results, exclusion from future examinations, suspension, revocation of certification, and other sanctions.”
Such strong-arm tactics and secrecy have been integral to Board certification and re-certification. Such a policy immediately constructs an adversarial relationship between the ABIM and re-certifying physicians that infer intimidating dominance and power, rather than collegiality, over the test-taker. It also demonstrates the ABIM's ability to negatively affect a physician's ability to practice their trade in the event of failure and without a transparent explanation of the material missed.  They also have no accountability for understanding a physician's practice circumstances.  In fact, this clause was the basis of the ABIM sanctioning 139 physicians on the basis of "ethical violations" in 2010.

The ABIM Foundation Financial Cover-up

In 1989, shortly after the decision was made to time-limit Board certificates, the ABIM Foundation (Foundation) was created. Tax forms before 2008 did not require the mission of the Foundation, its origination date, or domicile to be disclosed at the time. What was clear, however, was the Foundation shared the same address and had common officers with the ABIM in Pennsylvania. The Foundation is another tax-exempt 501(c)(3) organization that was granted its public charity status by the Internal Revenue Service (IRS) in 1990 as a Supporting Organization 509(a)(3) Type I. Other than tax filings, the existence of the Foundation before 1999 was never fully disclosed to the general public or US physicians. In fact, even the most recent tax filings of the organization continues to claim the Foundation was established in 1999.

Despite this fact, it is clear that the ABIM Foundation had $46,247,684 (line 21) in "net assets or fund balances" by 30 June 1998. We also see "contributions" from the ABIM to its Foundation in the amounts of $4,580,000 in 1997 and $5,400,000 disclosed on the tax documents when the Foundation changed its accounting method from cash to accrual in the fiscal year 1998. Even the revised bylaws of the ABIM which were adopted October 6, 1998 (and included with the ABIM's Form 1998 Form 990), incorporated the "ABIM Foundation, a Pennsylvania non-profit organization," as the sole voting member of the ABIM Board as a corporate entity in Section 2-8.  Hence, it is clear that the ABIM Foundation not only existed well before 1999, but was used to quietly funnel large amounts of money from the ABIM to their Foundation, much of it likely from the new-found wellspring of dollars earned from the re-certification requirement. I should mention that because I did not have access to tax data from 1990-1996, the number of financial transfers is unknown to me but the amount transferred was far greater than the $55 million mentioned by Dr. Wachter yesterday in his blog post. Importantly, these financial transactions establish that the ABIM Foundation was not a "supporting organization" for the ABIM, rather the ABIM was the supporting organization for the Foundation.

How Practicing Physicians Were Kept in the Dark: The ABIM and ABIM Foundation Web History

Reviewing of the Internet Archive of ABIM webpages, the ABIM published its first "ABIM.org" webpage on the internet on or about 6 Jul 1997. There was no mention of the existence of the ABIM Foundation on their website at the time. (Interestingly, Harry Kimball, MD, then CEO of the ABIM, disclosed the existence of a "Foundation" when he mentioned its role in creating the (now defunct) Institute of Clinical Evaluation in an interview with the ACP Internist in 1997). It is possible non-internet-based communications were held with select individuals or organizations about the existence of the Foundation at the time.

The first recorded appearance of the ABIM Foundation on the ABIM website as a "Liaison Organization" was on or about 4 Mar 2000.  Likewise, the instance of the "abimfoundation.org" website recorded by the Internet Archive was 17 December 2000 and its appearance coincided with the ABIM Foundations "Medical Professionalism Project." It is no surprise then that most physicians and the public were completely unaware of the existence of the ABIM Foundation before the year 2000.

Finally, the ABIM continues to deny the existence of the ABIM Foundation on their website and their most recent Form 990 tax form.  Claiming this oversight was "just a clerical error" won't suffice because too many lives have been adversely affected as a result of their tactics.

The Research Propaganda Campaign 2000-2015

With the changes to re-certification that became increasingly onerous, the publications by authors from the ABIM were voluminous highlighted on the ABIM's "Journal Articles Authored by ABIM Staff and Leadership web page. No articles independent of ABIM staff show improved patient outcomes for board re-certifying physicians on their web page and when studied carefully, the median Medicare payments made to 150 authors for a portion of one year was $0, suggesting a significant disconnect between practicing physicians and the authors from the ABIM. Because many of these articles reside behind pay walls, critical review by practicing physicians without free academic journal access would have been expensive for most non-academic practicing physicians to conduct. Because financial conflicts of interest of the authors and the source of funds for the "Medical Professionalism in the New Millenium" paper published in The Lancet and The Annals of Internal Medicine in 2002 were never disclosed, a retraction of this paper in both journals should be considered by these journals' editors, or at the very least, a formal apology issued.

Conclusions

In light of the continued cover-up of the first ten years of existence of the ABIM Foundation and the financial transfers that occurred to the Foundation to the ABIM during that time, Board re-certification was never about "evidence that the knowledge and skills of practicing specialists decline with time." Instead, it appears board re-certification was about assembling a financial war chest for the ABIM and its Foundation for their own agendas and avarice.  It is ironic, indeed, to think the ABIM Foundation's Medical Professionalism white paper published widely in 2002 that came from their own "Medical Professionalism Project" never considered its own agenda and source of funds as a severe violation of medical ethics, public trust, and their own "social justice" imperative.

If we include the $46.2 million dollars accumulated by 20 June 1998 in the Foundation and add the other $30.66 million in "grants" made from the ABIM to their Foundation between 1998 and 2007 (as public record demonstrates), the ABIM Foundation's war chest of over $76.86 million can be accounted by ongoing siphoning of physician testing fees to the Foundation. The additional interest revenue earned from this money helped fund the high salaries of their officers and staff, expensive condominiums, spousal travel fees, and facilitated extra time off for posh consulting arrangements that earned several more hundred thousand dollars for their former President and CEO, as well as undisclosed fund amounts to any organization with a "cost-saving" idea who applies to the Foundation for grants.

How Big is the Business of Board Re-certification?

A total of 120,242 physicians re-certified with the ABIM from 2000-2014 (personal data obtained from published pass rates for these years). Current fees paid by physicians for the re-certification program are $1940 for internal medicine doctors and $2560 for subspecialists.  Doctors with multiple sub-specialties must pay 100% of the most expensive specialty and 50% of the fee for the less expensive specialty examination. Therefore, for doctors re-certifying in one specialty, the fee to the ABIM is currently $1940, two specialties $3530 and for three specialties $4500. In 2000, those fees were $825 for one specialty, $1025 for two specialties, and $1225 for three specialties. Said another way, re-certification fees have increased 235% over 15 years for one specialty, 344% for two specialties, and 367% for three specialties. If we assume an average of these fees over the 15 years of testing, the costs each year would have averaged $1382.50 for one certificate, $2277.50 for two certificates and $2862.50 for three certificates. During this time frame, the ABIM earned on average somewhere between $166,234,565 (1 certificate: $1382.50 * 120,242)  and $344,192,725 (3 certificates: $2862,50 * 120,242 physicians tested). Note that this number does not include repeat testing, re-scoring fees, extra certificate fees, prep-course fees, travel, time away from work, etc. Given the number of physicians who are now employees, this also represents a massive waste of funds by hospital systems who may pay these fees. I estimate re-certifying physicians have wasted close to a quarter of a billion dollars to the ABIM and their Foundation for this fifteen year period of time with no evidence participation in this program affects patient outcomes. Given these revenues at its disposal, we should also question why the ABIM has allowed the organization to grow its deficit from negative $558,511 on 30 Jun 1998 to negative $47,866,654 as of 30 Jun 2014.

When Doctors Fail Re-certification

To the best of my knowledge, the ABIM has never studied the socioeconomic and psychological effects on physicians that fail their re-certifying examination. With the potential to lose hospital credentials, severe consequences for failure on the secure examinations are a real threat to physicians' ability to practice their trade. Based on the ABIM's published pass rates for all specialties between 2000 and 2014, of the 120,242 physicians who took the ABIM's Board re-certification examination, I calculated (using the ABIM's own pass rates published each year) that 15,832 physicians (13.2%) failed. What impact did the failure of these physicians have on their ability to care of their patients? Why don't we know? Might the failure of these physicians adversely affected patient care?  How many lost hours of work, anxiety, and frustration resulted? How many additional dollars were spent to sit for the next examination? How many repeat tests were performed by those who failed? How many physicians left medicine because of their failure?  Sadly, it seems none of these critically important issues are of concern to the ABIM or the professional subspecialty groups who support the proprietary ABMS MOC® re-certification program.

Other Participating Organizations

The American Board of Medical Specialties who holds the trademark for Maintenance of Certification® serves as a member board of the Accreditation Council for Graduate Medical Education (ACGME) and deserves responsibility for lobbying Congress to include their corrupt Maintenance of Certification credential in the Affordable Care Act as a physician quality registry.  Other member boards of the ACGME include the American Medical Association, the American Hospital Association, the Association of American Medical Colleges, the Council on Medical Subspecialty Societies, the American Osteopathic Association, and the Association of Colleges of Osteopathic Medicine. It is incredibly sad to think that our youngest and brightest physicians currently have to enroll in the unproven and grossly corrupt ABMS MOC® program before they have even received their first certification from their respective subspecialty board.

It is puzzling that the American Hospital Association (as a member of the ACGME) would support the inclusion of such a program for physician credentials given its 13.2% failure rate of this program. Don't hospitals need doctors, especially now that health care reform is providing an unprecedented influx of patients through their doors?  Perhaps they are looking for a way to substitute cheaper nurse practitioners with less clinical training for the physicians who fail their MOC® examination? For patients and hospital administrators dealing with physician recruitment challenges, this remains an important question.

The American Medical Association's role in the ABIM financial controversy has been fickle. On one hand the organization demonstrates an interest in practicing physicians' concerns, but is also supplying legal defense assistance to the ABMS who was sued by the American Association of Physicians and Surgeons in federal court for possible anti-trust violations relating to the MOC® program (the case is pending in Chicago).

A Path Forward

What is needed now is a good housecleaning and an open and honest dialog about the financial practices of the ABIM. Before that can occur, I believe all types of Board re-certification should end immediately and conventional Continuing Medical Education (CME) credits suffice as evidence for a physician's commitment to lifelong learning. In my opinion, hospitals and insurance companies whose policies require re-certification to remain credentialed or to receive insurance payments should drop this requirement or allow competing boards that use CME alone to suffice as evidence for ongoing educational efforts of the physician. Unless and until the unproven and potentially damaging practice of MOC® re-certification of physicians ends, our House of Medicine will remain irreparably divided between the bureaucratic non-clinical physician idealists and the practicing physician community.

Such a path forward will be difficult due to the money involved and the entrenched status quo. However it is encouraging to see the Heart Rhythm Society recently take a leadership position in the re-evaluation and push-back to the status quo by exploring alternative pathways to the American Board of Medical Specialty's MOC® program. The American Association of Clinical Endocrinologists has also elected to abandon the ABIM Foundation's Choosing Wisely® campaign (funded almost entirely by physician testing fees) because the "AACE is concerned that the campaign's direction may lead to unintended consequences and drive a wedge between our members and their patients and become a barrier to open communication." Such moves show insight to the monetary conflicts that are increasingly being brought to light with the American Board of Medical Specialty's proprietary MOC® program, the ABIM, and the ABIM Foundation.

Hopefully with this post I have shed a very bright light on the MOC® controversy and financial actions of the ABIM and its leadership regarding the origin and distribution of their Foundation's funds. I would encourage patients and doctors to send the evidence contained here to your elected representatives and hospital Medical Executive Committees. Investigative journalists are invited to fact check the statements made here. Likewise, I welcome responsible comments from members of the ABIM and the ABIM Foundation and other medical societies to dispute or better explain the findings I have made public here in the comments section of this blog.

Too much money, time, and effort is being needlessly wasted by the proprietary, secretive, and unproven ABMS MOC® re-certification program that detracts from patient care. Physicians already have state licensure boards, hospital boards, the Drug Enforcement Agency, insurance companies, National Practitioner Data Bank, and the entire tort industry to oversee the appropriateness of our care.  Re-certification is redundant and has never been proven to improve patient outcomes over our current system of physician continuing medical education. Still, because of the revenue payments required by  the increasingly non-voluntary MOC® re-certification program, I believe that only a strong grassroots effort will end the unnecessary and burdensome program that has been foisted on physicians without clinical justification and may be deleterious to patient care, especially when we realize the untoward effects of this program have never been studied.

As thousands if my colleagues know, I have devoted countless hours of time to this research and I take no joy in these findings. I do this because I love my profession and believe it is the finest profession in the world. It breaks my heart to see it exploited. This corruption has no place in medicine. Period. We must believe this in order to see it end.

Here's just a step.

-Wes

Monday, June 15, 2015

CMS Issues National Coverage Decision for Pacemakers Dangerous To Patients

Who needs the Independent Payment Advisory Board to limit indicated care for patients when you have the Center for Medicare and Medicaid Services (CMS)?

Today I learned that CMS has issued a National Coverage Decision (NCD) for pacemakers effective 6 July 2015 that would restrict pacemaker implants to patients with "non-reversible symptomatic bradycardia" and require a so-called "KX" modifier to be added to codes for patients needing pacemakers.

That's right, even patients with asymptomatic complete heart block would not be covered.  Patients with asymptomatic Mobitz Type II heart block wouldn't be covered either.  Even though every piece of medical literature has supported the benefits of pacemakers in these indications, it seems doctors will be left with no choice but to lie in their documentation about patient symptoms to assure Medicare payment, or risk the government refusing to pay for their patients' medically indicated care.

Of interest is the fact that the change request for the new policy references a section of CMS’ claims processing manual. (The red italicized print in CR 9078) However, that section is now suddenly absent from the actual manual.

The Heart Rhythm Society and the American Medical Association (who forwarded this rule change) has been suprising silent on this new decision that was recently forwarded to our nation's hospitals and failed to included "exceptions" to their rules as part of their transmission. As of this morning, no mention of this transmittal has occurred on their website that I could find.

Practicing cardiologists and cardiac electrophysiologists everywhere should be outraged that such a document was circulated to Medicare billing coders everywhere, but not forwarded to US physicians given its implications to patient care. 

I have no doubt Medicare monies will be saved when people die as a result of this transmitted coverage decision as it currently exists. But we should ask ourselves who is responsible for such negligence on behalf of our patients?

-Wes

1930 PM CST - Link fixed (h/t to @drjohnm)

Sunday, May 31, 2015

ABIM Fails to Disclose Lobbying Efforts

Shhhh.

The public wasn't supposed to know.

Neither was the Internal Revenue Service (IRS).

According to the American Board of Internal Medicine's (ABIM) most recent tax forms, they never participated in lobbying, nor spent money to do so.

Yet, according to public record, it appears the ABIM most certainly did lobby Congress as a 501(c)(3) organization and has repeatedly failed to disclose this reality to the IRS.

The ABIM's Lobbying Disclosures

Here's the information the ABIM filed with the IRS on their most recent "audited" 2013 Form 990 which includes expenses paid from 1 July 2013 to 30 June 2014 as a 501(c)(3) organization:

ABIM 2013 Form 990 Lobbying Disclosure
(Click image to enlarge)

ABIM 2013 Form 990 Itemized Lobbying Expenses
(Click image to Enlarge)

The ABIM's History of Lobbying

But searching OpenSecrets.org, a website dedicated to transparent government spending, it seems the ABIM spent quite handsomely on lobbying during its fiscal year 2014:

ABIM Lobbying Expenditures for 2014 Election Cycle
(Click image to enlarge)

In fact, the ABIM has been lobbying for years (and continues to do so):

ABIM's History of Lobbying since at least 2009

When we delve into who the ABIM paid for these lobbying efforts, we find even more interesting information.  In 2014, the lobbying firm used was Mehlman Vogel Castegnetti, Inc. (Vogel later spun off in 2014 to create his own lobbying firm and the new firm is now called Mehlman Castegnatti Rosen Bingel and Thomas) and used the following list of lobbyists:

ABIM Lobbying Firm in 2014
(Click to enlarge)
Of these lobbyists, five have current or former ties to the insurance industry (Bingel, Castagnetti, Gupta, Rosen and Zook) and one (Thomas) to the Federal Trade Commission and one (Eastman) to the Ways and Means Committee in the House of Representatives.  Needless to say, 13 of the 14 have "revolving door" relationships with one or more government offices.

These revelations are important. Recall that the American Board of Medical Specialties (of which the ABIM is but one of 24 "member boards") was magically inserted into Social Security Act 1848 (k)(4)  that deals with physician payment with passage of the Affordable Care Act in 2010. More recently in January of 2014 changes made to the ABIM's Maintenance of Certification (MOC) program that force doctors to pay them to remain "board certified" in good standing so they can remain credentialed to practice medicine with their employing hospital system and to receive insurance payments.
On January 1, 2014, the Organization revised the nature of the MOC program. The MOC program is now a continuous program based on a calendar year. Upon entering the MOC program, a diplomate must actively maintain their certification by completing certain requirements. These requirements are expected to be completed every two, five and ten years. Candidates choose to pay annually or to prepay for ten years for access to the program.
At the same time, CMS offered a payment incentive to physicians for participation in MOC.  Given the lobbying efforts uncovered here, no longer is the collusion between the ABIM 's MOC program and influential government personnel or agencies just a theory, it now appears (based on public record) to be a very real possibility. The ABIM's long-standing unreported lobbying history raises the very real possibility that the more recent leadership of the ABIM has been more concerned about creating a financial monopoly for itself (and trying to hide it) rather than truly improving patient care.

Further Questions Regarding the ABIM's Auditor

The auditing firm  McGladrey, LLC, appears to have audited he most recent financials for the ABIM. Their "responsibility statement" in the ABIM's financials states:
Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free from material misstatement.
Now I'm just a practicing cardiac electrophysiologist here in the United States, not an auditor and I have no idea what "opinion" was actually "expressed" to the ABIM board members by McGladrey's auditors. But if I can find these financial and tax filing discrepancies (among others) thanks to the wonders of the internet, I think the ABIM and the ABIM Foundation needs a new auditor...

… like maybe the IRS or the Office of the Inspector General of the Department of Health and Human Services.

-Wes

Saturday, May 23, 2015

The ABIM, Its Finances, and the Great Collusion

Yesterday, Newsweek Pulitzer-prize finalist and reporter Kurt Eichenwald pulled back the curtain on the Great and Powerful Oz of medical credentialing, the American Board of Internal Medicine (ABIM) when he meticulously dissected the organization's most recent financials. In his piece, Eichenwald laid bare the "trickery," cronyism, and greed that has come to define the ABIM that has been led by a few self-selected "Untouchables" of our profession.  The details are outrageous for a non-profit espousing "medical professionalism:" $1,712,846 million to the outgoing President and CEO Christine Cassel, MD, an estimated $860,926 to the current Present and CEO Richard Baron, MD, lack of disclosure of lobbying efforts, tax filing discrepancies, to name a few. The story is so disturbing on so many levels, yet so important, that I encourage all to read it.

In response, Richard Baron, MD sent an emotional  e-mail to all ABIM diplomats yesterday that was in large part a rehash of his disagreements with Mr. Eichenwald's reporting.  He also attempted to dispute two of the allegations made by the most recent Newsweek story:
First, we have never made any effort to obfuscate, hide or delay ABIM's financial information. It's publicly available on our website. Second, no one is trying to hide salaries. I earned $688,000 in compensation in 2014 and $55,000 in deferred compensation (payment of which is contingent upon completion of my five-year contract). That is more than I ever made in 30 years of independent community practice of internal medicine and geriatrics, but it is set by my Board to be comparable to what CEOs of similar-sized health-related organizations earn.
By now it is almost silly for Dr Baron to claim they "never made any effort to obfuscate, hide, or delay ABIM's financial information." No where does the ABIM website discuss its transfer of $30.66 million of physician testing fees to the suspect ABIM Foundation from 1998-2007, the purchase of a $2.3 million condominium complete with a chauffeur-driven Mercedes S class town car in December 2007, the continued contradiction in the ABIM Foundation's creation date (1999) that  conflicts with public record (1989), why the condominium's depreciation was lumped in with "condo expenses" and classified under "program service expenses", nor that the "rent" that the ABIM pays the Foundation for the condo's use does not show up on tax forms as such. I asked him to explain these issues in December of 2014 and only received world class obfuscation of the facts. (Update: And then there was the stunt where they tried to withhold six key schedules from their consolidated financials with Foundation, only to publish them after public ridicule). Was he aware of his actions? Given what we've repeatedly observed regarding his inability to address ABIM diplomats financial concerns regarding the ABIM, it's hard to think otherwise.

More telling was Dr. Baron's pitiful disclosure of his salary and "deferred benefits." It is clear that Dr. Baron is so far removed from the realities of patient care today that he has no concept how entitled he sounds, especially for someone running a non-profit organization that has crushed 139 physicians' professional lives with the past Arora test-preparation scandal to protect their monopoly while they enjoy their lavish salaries and creature comforts all provided with tax exempt status.

Mr. Eichenwald learned of Dr. Baron's follow-up e-mail to ABIM members and broadcast his rebuttal via Twitter. In that thread he gave details on his interaction with the ABIM and their avoidance of the issues. (Details can be read on Jay Schloss's Storify of the tweets.) I'd like to think Baron will accept and offer to be interviewed by Eichenwald, but I know it will never happen - the ABIM's lawyers won't let him.

It's Not Just the ABIM

As twisted, deceptive, corrupt and disappointing the financial story of the ABIM and its Foundation has become, it's only the tip of the iceberg. We should recall that the American Board of Medical Specialties (ABMS - a separate 501(c)(6) non-profit) owns the trademarked Maintenance of Certification® program which the ABIM as one such member board helps administer. The ABMS serves effectively as a "business league" for its 24 member boards, much like the NFL lobbies for its football franchises (in fact, the NFL has the same tax-exempt designation). The ABMS lobbied Congress about the self-proclaimed merits of their branded MOC® program while paying their director,  Lois Nora, MD, JD $779,487 to earn government contracts and to assure the ABMS (with the ABIM as a testing entity) remained in the Affordable Care Act as a physician quality registry (see Social Security Act 1848, Section (k)(4)). The monopoly power of the ABMS regarding physician credentials prompted a pending suit alleging possible anti-trust violations. The fact that the ABMS or the ABIM has never studied the socioeconomic, psychological or physical toll upon physicians (and their patients) who fail the trademarked MOC® re-certification examination is telling and speaks to the blatant disregard of those tested.

(Click to enlarge)

The interconnected relationships of Christine Cassel, MD, Richard Baron, MD, the National Quality Forum, the ironically named "Seamless Care Models Group" in the Center for Medicare and Medicaid Innovation, a component of the Centers for Medicare and Medicaid Services (CMS), reeks of a sophisticated kickback scheme using doctors and their requirement to pay MOC® fees every two years to the ABIM (and other member boards of ABMS) that assures their largess and perpetual cozy employment opportunities. Why else are doctors increasingly required to  participate in MOC® to remain credentialed with their hospital employer? Might this have been the reason the ABIM board felt Dr. Cassel warranted her $1.7 million take from the ABIM for working just a thirty-five hour work week and serving as a consultant to Premier, Inc and Kaiser Foundation Health Plans and Hospitals?

Because of the revolving door between the members of ABIM, the American College of Physicians (ACP), the Accreditation Council for Graduate Medical Education (ACGME), Joint Commission on Accreditation of Hospital Organizations (JCAHO), ABMS, and the American Medical Association (AMA), (with the exception of ABIM, all of these organizations are located in downtown Chicago) is it any wonder that program directors in hospitals must participate in MOC?  Likewise, is it any surprise that our most vulnerable newly minted physicians must enroll in the unproven and heavily marketed  Maintenance of Certification® program before they are even "board certified" for the first time?

Mr. Eichenwald is correct when suggesting that it is time for the "Federal Trade Commission and the Justice Department to investigate whether the ABIM is engaged in a restraint of trade by driving doctors out of business if they don’t pay up. It is time for the IRS to investigate whether the ABIM is a nonprofit or a business." I would add that the ABMS and ABIM should be investigated by the OIG of the Department of Health and Human Services to determine if the MOC program is a carefully contrived pay-to-play scheme using the US government as imprimatur.

Irrespective of the legal plays that are now likely to take place,  US physicians must immediately stop paying for MOC® and insist their local medical executive committees remove MOC® as a condition for hospital credentialing or, at the very least, make enrollment in NBPAS.org an alternative to the corrupt ABMS MOC® credential. Otherwise, practicing physicians will be working to potentiate the existence of this very broken program.

-Wes

Saturday, May 16, 2015

The American Board of Internal Medicine's Land of Make Believe

Hi boys and girls!  My name is Christine Casell, MD.  I was once the President and CEO of the American Board of Internal Medicine, the ABIM Foundation, and the Institute of Clinical Evaluation.  Now I'm President and CEO of the National Quality Forum in charge of setting quality standards for every hospital in the United States. I'd like to tell you about a special place I know called The Land of Make Believe because I want you to sleep better tonight.

The Land of Make Believe is a magical place.  It has amazing superpowers and can do things no one else can.  For instance, it can telepathically transport from Iowa to Pennsylvania in the blink of an eye and without an explanation to the IRS.  And even more amazing, The Land of Make Believe has a time tunnel that can transport itself from 1989 to 1999 even though there was an IRS Ruling in 1990 without anyone knowing! That's because tax fraud doesn't exist in The Land of Make Believe.

By Choosing Wisely, The Land of Make Believe was able to use their amazing superpowers to use other people's money (like $30.6 million from practicing internal medicine doctors) to amass a pot of gold that has swollen to $79,409,497 with a fancy condo thrown in for everyone's benefit.

But the most amazing part?  In 2004 The Land of Make Believe merged with the mysterious Institute for Clinical Evaluation that was created in 1997 before The Land of Make Believe even existed!

Confused?  Don't be!  It's The Land of Make Believe!

The Land of Make Believe represents nothing but quality! That's because they don't have to worry about where money comes from or how much exists there.  Sweet-smelling smoke and mirrors are everywhere.  And those mirrors can teach you a lot about yourself. I discovered that I was so important  that I could pay myself (with the help of my many friends there) an annual salary and benefits worth $1,234,893 while also working the crowds at Kaiser Foundation Health Plans and Premier, Inc. 

"Let them eat cake!" I say. I'm from the Land of Make Believe!

But the best part, boys and girls, is The Land of Make Believe is REAL! No doubt the quality I gave to the The Land of Make Believe is why I'm in charge of the quality for every hospital in the United States!

See why you can feel safe?

Now get to bed.

-Wes