Monday, November 23, 2015

ABIM Legal Fees: Pre-MOC vs Post-MOC

Pre-MOC Average: $146,073/year
Post-MOC Average: $1,090,184/year
This graph sums up another reason the American Board of Medical Specialties' Maintenance of Certification (MOC) program (implemented by the American Board of Internal Medicine in 2005) is such a mess.

(h/t @CharlesPKroll via Twitter)


Sunday, November 22, 2015


Two days ago after a typical day performing procedures in the EP lab, doing inpatient consults, fielding patient messages, attending administrative and research meetings, reading EKGs, Holter monitor recordings, and co-signing device clinic charts, I opened my email and saw this:

ABIM Email to Diplomats 11/20/2015

I was appalled. MOC is not longer about "keeping up" for physicians. It is a major distraction. This program is of unproven benefit to my patients and me. Thanks to haphazard and self-serving rule changes by the ABIM and their member boards over the past 25 years, the US Specialty Board system has become increasingly coercive. In fact, MOC program now threatens my ability to practice the work that I love because I could lose my facility privileges and ability to receive payments from insurers on December 31, 2015. That is my reality. This is the reality of every physician subspecialist who participates in the ABMS MOC program in US medicine today.

Remarkably, I just re-certified in Cardiovascular Diseases and Cardiac Electrophysiology in 2013 for the third time.  I have never failed. I have over thirty years of experience treating patients and standing in the cross hairs of what it means to be truly accountable to those I treat. I have had over thirty years of nights when I lie awake at night worrying about by patients, about if I did enough, about why a patient had to die. My family, too, has endured years of being woken in the middle of the night or seeing their father have to leave a school play, holiday concert, or friend's dinner party to place an emergency pacemaker.

I am not unique. I am a practicing physician everyman. I stand in unison with hundreds of thousands of others here in the United States just like me who get up every day, kiss their loved ones, and head off to do their favorite job in the world - a vocation so completely immersive and rewarding that we gladly give up a part of ourselves to earn the trust and faith of our patients and fellow physicians.

And because I've been practicing medicine so long, I know I do not need a private, unaccountable, and irresponsible organization to tell me how to behave. I am better than that. After experiencing the busywork of the evolving MOC program and its lack of value for the time spent, I looked into the corporations who promote this exercise. I had the help of accountants and fellow physicians who were similarly upset and uncovered a vast array of hidden financial activities of the ABIM and their collaborators. There is so much financial corruption it is mind-boggling. The conflicts of interest that are never acknowledged and corrected make my stomach churn. The practice of medicine is better than this. Practicing physicians are better than this. We do not need some dystopic corporate Big Brother watching over us to assure we log into a computer every so often to enter data that can be used against us. We do not need webcams, video monitors, body inspections, keyboard tracking, and palm scans to prove we are honest and ethical and won't cheat on examinations. But this is what the ABIM has become: some new form of quasi-police state for monitoring physicians.

Working in fear is not what I want for medicine. It certainly is not how I want my youngest colleagues to grow up learning and practicing medicine. But the ABIM and their parent organization, the American Board of Medical Specialties (ABMS), seem to love fear, humiliation, and intimidation to get doctors to participate in their lucrative MOC program. It is sickening. It is also the height of hypocrisy for these organizations to claim to run an organization that attempts to "Choose Wisely" when that same organization funnels tens of millions of dollars for itself from hard working physicians so they can choose an investment portfolio with multi-million dollar condos, meet at swank meeting venues, pay for spousal travel fees and first class airfares as they preen themselves in front of media lights. The ABIM Foundation "created to define medical professionalism" for the public? Give it a break.

Rest assured I am not naive. I know how important this MOC program is to certain investors. As I peel back layer after layer of the interconnected workings of these ABMS member boards and the ACGME, I know how high this MOC program goes and how dark this MOC program and its tactics have become. I completely understand that these specialty board organizations have managed to wedge themselves into our new health care law that calls itself "Affordable," wedged there by undisclosed lobbying efforts funded by the very doctors whose blinded trust was violated beyond comprehension. Just because these corporations want to make a buck.

So let me take the stick a moment.  Let me be perfectly clear and I don't say this lightly. I'm sure I say this on behalf of tens of thousands of other hard-working, honest, and ethical physicians. We have had enough of the ABIM and the ABMS MOC program. It is time to end it - completely.  No more "modifications" to make this broken program "easier." No more "listening" to our concerns but continuing this failed experiment. No more "MOCA Minutes" that we have to turn our gaze from our patients toward the computer screen or iPhone even longer. Continuing the ABMS MOC that has proven itself to be morally and financially corrupt, and exceedingly expensive to physicians, patients, and our health care system is ill-advised for our profession. The conflicts of interests alone are worth hundreds of millions of dollars to the corporations that stand to make millions from physician assessment, yet we never hear a word about this from them ABMS or the ABIM on this reality.

I am better than how the ABIM and ABMS threaten to label me. I served this great country for twenty-six years as a physician with the United States Naval Reserves and I continue to work every day to make sure I do the best I can for my patients in this increasingly difficult health care delivery environment. I worked then and work now beside hard-working corpsman, nurses, administrators and technicians who don't want to rock the boat and just want to do what's needed to finish our job every day. These people and the patients I care for are why I go to work every day.

So I ask the leadership of the ABIM: "Why does the ABIM insist on placing a "scarlet A" on my reputation by labeling me a "Not Participating in MOC?"  Such labels are offensive. I participate in ACGME-accredited CME as required by my license to practice medicine in the State of Illinois. I am not a slacker. I teach residents and fellows, for goodness sakes. I am certainly not one who doesn't mind working hard. I am a proud practicing physician with more years of clinical experience and direct patient care than any of you.

Please don't be libelous and cast aspersions my way with your on-line labels. I've got much more important things to deal with. Stop pretending that you speak for "the public" and know what's best for them in health care when you don't even crack the door of an examination room or know what I do. Proceeding to take away my hard-earned reputation and ability to practice medicine because of your little label is both threatening and hugely upsetting.

Think about these words. Think about them carefully.

I beg of you and your affiliated private organizations to stop the labels.

The profession of medicine is better than this.

Your everyman,


Wednesday, November 11, 2015

Concerning Conflicts of Interest at the ABIM, ABMS and NQF

By now various medical societies are telling the American Board of Internal Medicine (ABIM) their ship has sailed. The ABIM's worn mantra that the "public" demands their program is simply not supported by evidence. The tales of misguided incentives and corruption within the organization grow daily. The blatant avoidance of the egregious financial dealings and conflicts of interest outlined in this blog's pages and elsewhere simply cannot be ignored by the ABIM - yet they continue to do so.


Because there are millions upon millions of dollars at stake in areas of physician assessment and measurement.

When Christine Cassel, MD left the ABIM and began her work at the National Quality Forum (NQF), physicians learned of some of her conflicts of interest with other organizations, namely Premier, Inc and the Kaiser Foundation Health Plans and Hospitals. Dr. Cassel labeled these conflicts as "distractions" as she resigned her board seats with those organizations. What we do not know (and this is important) is did Dr. Cassel receive any stock or stock options from the organizations she was so cozy with as part of her compensation package? Given the usual and customary way of compensating corporate board members, I would not be surprised if she did. (Update 19:15 PM: h/t to Mr. Charles P Kroll for confirming that Dr. Cassel owns 3,704 shares of  Premier, Inc stock)

Recently, a Premier, Inc press release announced its plans to purchase a company called CECity, Inc. I suspect most practicing physicians did not notice this announcement. After all, why would practicing physicians be interested in a press release touting a new business opportunity for Premier as it expands its "performance improvement capabilities across the healthcare continuum?"

But practicing physicians need to be VERY wary if our fellow physician-bureaucrats (especially those from the ABIM) when they consider their prior conflicts of interest as "distractions." That word is a flag that everyone should look deeper at these conflicts first reported by ProPublica.

When we do, we find more concerning revelations about the ABIM and the American Board of Medical Specialties (ABMS)'s motives.

According to the press release, CECity, Inc is worth about $400 million (or more) to Premier, Inc. and who do we find has been using CECity as its consultant?

Yep. You got it: the ABIM.

In fact, the relationship with the ABIM has been nearly continuous since 2010. According to CECity, they are a CMS qualified registry that provides physician "quality reporting data" to CMS:
As a CMS qualified registry for the Physician Quality Reporting System (PQRS, ePrescribing, MOC-PQRS) and as the service provider for many physician certifying boards (e.g. ABIM, ABO, AOA) CECity is uniquely positioned to align professional and financial incentives with CQI to deliver ‘game-changing’ quality initiatives that have proven and measureable results.
According to the ABIM's Form 990's, they have already paid CECity the following: $600,000 in fiscal year (FY) 2010, $1,217,800 in FY 2011, $1,112,600 in FY 2012, $1,378,138 in FY 2013, and $1,260,000 in FY 2014 (an example of these payments can be found on page 8 of the ABIM's most recent published Form 990 - provided they do not change their Form 990 after this report).

That's right: $5,568,538 of physician testing fees to CECity from practicing US physicians over five years - all of it (so far) on Dr. Cassel's watch.

If Dr. Cassel holds stock in Premier, Inc. from her prior board position there, I wonder how much money she stands to make when this cozy deal with Premier, Inc. closes? Should the U.S. Securities and Exchange Commission investigate this transaction? We don't know, but even the apparent conflict of interest with Dr. Cassel, the president and CEO of an organization responsible for "quality" programs in our nation's hospitals, is very disturbing, indeed.

This is not a minor revelation as physicians continue their difficult task of managing patients in such an overbearing regulatory environment while our specialty societies continue to support the financially conflicted ABMS MOC program. I believe allowing independent and unaccountable third-party organizations (like the ABMS and ABIM) to collect and distribute physician and de-identified patient-related data without written consent of those who could have their ability to practice medicine or collect payment from insurance companies revoked if they don't participate in MOC is a clear violation of Department of Health and Human Services Protection of Human Subject statutes. It also remains to be determined if this violates the Sherman (antitrust) Act.

After all, it is now clear the MOC program is not a "quality assurance" exercise performed for "public's" benefit.

This is profiteering and financially conflicted research on physician subjects in its most fundamental form.


Monday, November 02, 2015

Part III: Why Washington?

I woke early to review my notes; who was attending the gathering that day, the itinerary, the location.  Suit, tie, briefcase, cell phone, charger. Check.

Soon I stood in line with familiar faces at the Rayburn building waiting to pass through security, remembering my wife's comments about the DMV.  "Bags on the conveyor, folks.  Jackets, too. Sir, you can leave your suit coat on." Of course. What was I thinking? What about my coffee cup? Passing the bag check, the halls widened. Shiny grey linoleum, fluorescent lights, just as promised. Just like the Hart and Dirksen buildings.

We made our way upstairs to the Judiciary Hearing Room, Room 2226. An early-morning confab of the members of the GOP Doctors Caucus was in the hearing room, discussions underway. Microphones on. All of us listening. Real issues, real bills, sausage making at its finest. An urgency to their voice.  Meaningful Use Part III. Crazy. Not ready. What can we do?  Can we kill it? No? Push for a delay. H.R. 2603/S.1475: "The Saving Lives, Saving Costs Act" to permit safe harbor for physicians who follow guidelines. Add this, what do you think of that? Need to get things done by the 11th of December. A real-life physician-politician show and tell. Then when things concluded, the brief pitch: physician ranks were getting thin. You're needed. (It was not a younger crowd.) Then, off to more meetings before the debt ceiling vote. Got to go. Cynically to me it looked more like doctors were  being taste-tested for the menu rather than really being at the table.

But then a break for coffee and continental breakfast in Representative Sessions' office across the hall. Nice office, four-room suite. Spacious, with lots of Texas memorabilia on the wall. More time to mingle, connect. So many people to meet, so little time.  People circulating for a quick photo shoot with the Congressman. Graciously he invited all to pose. "Off with the name tag," he'd prompt. "Now, this is a good place to stand." Then a photo:

It was fun.  A very polite way to say "thanks for coming." Reminded me of my Navy days, just more casual. Then he was on to the next attendee. On and on, until most people that wanted to have a chance for a photo did so.

Then the main event.

We shuffled back to the Judiciary Room. Congressman Sessions made some introductory remarks.  Very likable guy. Top salesman for AT&T for years, he said. He could sell anything to anyone, he boasted while smiling. Admitted the didn't know a thing about being a doctor, but seemed well-informed on many of the issues doctors face and that our patients are facing right now: high deductibles, co-pays, co-insurance, especially for those just above the poverty brackets. You could see why people like him on the Hill. He explained be was working on a bill. Obamacare is going to collapse - too expensive, he said. Maybe it was designed that way. Not touching Obamacare or Medicare, just an alternative for Medicaid. Hasn't been filed yet. Preliminary, getting ideas. He realized more work is needed. He turned things over to this his legislative aide to explain. Wanted our input, ideas.

A doctor focus group of sorts...

The idea seemed realistic, not far-fetched. Practical option that sounded like a way to make health care sustainable for everyone, with much less gaming of the system. But was it going to be understandable? For some, maybe. For others, it would take some education. Eleven key points, detailed, spelled out with examples.  But I was interested that most doctors in attendance were independents or retired. There were few employed physicians there like me. After the seventh point in the midst of the explanation, a break.  We rose and stretched, I approached the Congressman with a thought.

"Representative Sessions?"


"Wes Fisher from Chicago, sir, interesting plan - very innovative alternative - like the concept - but I wondered if you were aware..." and bent his ear very briefly during our break....

"Are you kidding me? John, get over here." He waved to trusted orthopedic physician-colleague from his home state. "Have you heard about this?"

John listened.  "Not nearly as big a problem for orthopedists," he told him, but he'd heard something about it...

"Give me your cell phone...", Congressman Sessions said.

"Excuse me?"

"Give me your cell phone so I can put my contact information there. Here's mine.  Enter your contact information into mine."

Surprised by his response, I fumbled to enter my contact information.

"Send me the details."

Saturday, October 31, 2015

Part II: Why Washington?

I looked out the airplane window and saw we were approaching Reagan National Airport from the south. The crisp morning sun pierced the fluffy clouds and found its way through the slit of the partially-opened airplane window shade to momentarily blind me. A small apex of the Washington Monument could be seen in the distance. To its right, the US Capitol dome shrouded in scaffolding.

Washington DC.

Having my luggage, I Uber-ed my way to my hotel. Boutique hotel next to the Capitol. Nice place. Quaint pastel-painted row houses nearby. French bistro, too. A 30-somthing hipster lady was checking out as a host brought her a few knickknacks to munch on for breakfast. The smartly dressed man  behind the front desk had an Australian or South African accent. Or was he from Belize? I couldn't tell. Relaxed. Confident. Good eye contact. He checked me in.

 This is the life of a policy wonk, I caught myself thinking.

My room was larger than I needed, the bathroom tiny, but functional. I pulled back the curtain and saw the many marble buildings surrounding the hotel and blocked the viewed of the streets further away that I remembered weren't quite so inviting.  Lots of construction in view.  Booming. I wondered if any of the other people who frequented this establishment ever saw the very different life that exists in rural areas outside the Beltway.

Probably not.

No matter. It was Washington. Time to explore. Crisp air. School kids bursting with excitement and rushing to the street corner, starry-eyed. Ever-patient chaperons shouting they could only see the Capitol if they made two parallel lines. "Quiet, please! Line up. Come on, now." Others in dark suits walking the streets. High heels with lanyards and  name badges. People walking in tandem, sharing secrets, telling jokes. Black Towncars, Escalades with tinted glass, Mercedes.  Large white buildings that dwarfed their visitors, like Poseidon looking down on a flotilla of tiny ships at sea.  Supreme Court. Library of Congress. Madison, Jefferson, Dirksen, Hart, Cannon, Longsworth, Rayburn. White. Marble. Big. Powerful. At least so it seemed. Certainly not for the faint of heart. Security everywhere. Metal detectors. Strange white mechanical roadblocks that clanked up and down to let the Important People drive their beat-up Subaru over it to head home.

A foreign land for a practicing doctor. Almost surreal.

I had arranged to meet two colleagues before the introductory dinner gathering. Each a name on The List. We never met before but shared some emails once. Nice to put faces with the names. They were more seasoned in this environment than me. But real doctors. Not pretend. Independents. Just came from work. Drove all day or flew from far away. Eager to meet others. Passionate. Each with their story - a reason to be here. Certain they could speak to a piece of the puzzle. Frustrated with things but determined to do something. I settled in. We exchanged numbers. You on Twitter? Defiantly: "Why should I use a smartphone when a tiny flip phone will do?"

* sigh * Reality.

Soon we headed to the introductory dinner. Staffers handing out sticky paper name tags that never seem to stick. (Except to things they shouldn't.) Pleasant smiles. A glass of wine. Pasta on the menu. Mingle. Where are you from? I see. The Congressman will be here a bit later. Then the Congressman arrived. Thanks for coming. Relax. Enjoy your stay. Tomorrow we'll show you our plan. Want to get your ideas, feedback. What brings you to Washington?

They all seemed to know. Me? Better to lay low for now. Who are all these people, really?

Would what I had to say make any difference? There was another plan. Another agenda.  Mine? Very small, unimportant. One doctor with a few others in a big very big pond, treading water, learning to swim. Would this be worth it? Others seemed to think so.

I still wasn't sure.

Friday, October 30, 2015

Justice Department Fines 457 Hospitals for Inappropriate ICD Implantations

From the Heart Rhythm Society via email today:
Today, the Department of Justice announced that it has reached settlements in its investigation of hospitals for billing Medicare for ICDs implanted in Medicare patients that did not meet Medicare coverage requirements. The announcement includes 70 settlements involving 457 hospitals in 43 states for more than $250 million.

The Heart Rhythm Society (HRS) has recognized that the misalignment between the Medicare National Coverage Determination and the clinical practice guidelines created gaps between the payment policy and clinical decision-making and places physicians and their patients in an untenable position. To help mitigate the problem, HRS published "2013 HRS/ACCF/AHA Expert Consensus Statement on the Use of Implantable Cardioverter Defibrillator Therapy in Patients Who Are Not Included or Not Well Represented in Clinical Trials”.

Moving forward, the Society’s priority is to do everything possible to assist the heart rhythm care community in managing the patient care pathway. HRS and other medical specialty societies are currently working with the Centers for Medicare and Medicaid Services (CMS) to identify the appropriate time to reopen the existing national coverage policy. The Society will provide CMS with recommendations to update the clinical indications for reimbursement. With this preparation, we stand ready to work with our partners to revise the Medicare coverage policy to reflect current clinical practice.
Outdated CMS National Coverage Decisions from 2005 just whacked hospitals. "Misalignment's" Catch-22. So much for evidence-based medicine. So much for practice guidelines. So much for innovation in health care.

CMS NCDs rule now, no matter how outdated, from now on.

The Justice Department has spoken.


References: Justice Department press release with list of hospitals affected.
More on the history of this action here.

Part I: Why Washington?

When I lived in Washington DC years ago, there was a saying my wife and I heard on occasion from our friends who worked on the Hill:
"In New York, it's about finance;
In Boston, it's about power;
In Washington (DC), it's about access."
* * *

The invitation came in a regular envelope. An invitation to go to Washington DC.  Who asked me? What was this for? Was it real?

I studied the invitation: a "personal" invite from Congressman Pete Sessions (R-TX), dinner the first night (dutch treat), then meetings started the next day at 08:30 am in the Rayburn Building, presentations, other Senators and Congressman to be invited (names to be decided). New plans. Need input, discussion, dinner afterward.

I showed the invitation to my wife: "Do you think this is the real thing? Why would they ask me?"

"Looks real. Call them," she said. "Find out who's going.  Maybe there's someone you know."(My wife, unphased, used to testify on the Hill when I was a young staff doctor at the National Naval Hospital in Bethesda, MD many years ago).

I waited a few days, then called. "Well, fifty-five doctors have already RSVP'd so far," said the exasperated voice on the end of the line." Ugh, I thought. "We'll be sending out a revised agenda with a list of the attendees when the date gets closer."

Would it be worth it? Fifty-five doctors? Were doctors being asked to come to Washington at their own expense just so it would look like we were "at the table" when, in fact, we were "on the menu?"  Given health care's recent history and how things got to where we are now, it was very hard to suppress my cynicism. Who funds Representative Sessions, I wondered? I checked. Got it. Then I really pondered: why me?

My wife looked at me like I was an idiot. "You have to go," she said. "You can't go through all of these hours of investigation, research, fire, and brimstone, and not go to Washington. Make some appointments.  Maybe you could stay with our old friends Jack and Jill  (not their real names) while you're there."

"But the time from work... it's so expensive..."

"You decide," she said. "But if it was me, I'd make it worth every minute. Look, Washington is really kind of, well, government. Think DMV. Big hallways. Linoleum floors. Fluorescent lighting. All puffed up, but not that glamorous when you think about it, it's no big deal." My wife sure knows how to sell things...

That night, I stared at the computer screen on my desk. "How much does it cost to fly to Washington?" I searched Orbitz. I'd have to cancel a clinic day, maybe two. Maybe I could swing this if I only missed an extra half a day of my clinic. Folks at work won't like this. Oh heck, she's right. I'd never forgive myself if I didn't go.

After weighing things, I booked the flight, then rearranged and blocked my clinic schedule the next day, though I still wasn't sure. Will it be worth it?

A few weeks later a more finalized agenda came with the names of who would be attending. I googled everyone (this seemed to take forever). I made a list. 18 states. Most were practicing doctors. Most of those orthopedic physicians, (Huh?) a few AMA representatives (young and semi-retired), a few older retired doctors, a few lawyers, an economist, a doctor who ran an ICD-10 coding company, a person who owned a medical collection company, some physician advocacy group representatives, a lobbyist.


"Mouth of the lion," I thought. "How am I going to get a word in edgewise?" Fifty-five people had grown to sixty.  "It'll be a waste of time," I thought.  The next day I finished my overbooked clinic, then returned home to tell my wife what I had decided. I told her I probably won't go to Washington after all.

"You have to go," she reinforced.

"It's all about access."

Thursday, October 22, 2015


From Jonathan Edwards (video):
"Sunshine go away today
I don't feel much like dancing
Some man's gone, he's tried to run my life
Don't know what he's asking

He tells me I'd better get in line
Can't hear what he's saying
When I grow up I'm going to make it mine
But these aren't dues I been paying

How much does it cost, I'll buy it
The time is all we've lost, I'll try it
But he can't even run his own life
I'll be damned if he'll run mine, Sunshine

Sunshine go away today
I don't feel much like dancing
Some man's gone he's tried to run my life
Don't know what he's asking

Working starts to make me wonder where
The fruits of what I do are going
He says in love and war all is fair
But he's got cards he ain't showing


Sunshine come on back another day
I promise you I'll be singing
This old world, she's gonna turn around
Brand new bells'll be ringing."
I'll be heading to Washington, DC on my own dime next week. Seems there are plenty of people who want to know more about the American Board of Internal Medicine.

Who knows? Maybe I'll learn a thing or two, also.