Saturday, February 16, 2019

Grifters Will Always Be Grifters

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

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

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

-Wes

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

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

-Wes

Sunday, February 03, 2019

Evolving Board Certification

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

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

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

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

-Wes

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

Friday, January 25, 2019

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

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

-Wes

Tuesday, January 15, 2019

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

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

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

WHAT THEY DID SAY

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


WHAT THEY DO NOT SAY

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

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

-Wes

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

Sunday, January 13, 2019

Physician Online Gaming for MOC Points

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


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

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

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

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

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

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

Follow this link join:
Signup and Access First Case

Or copy and paste the URL below into your internet browser:
http://ceoutcomes.qualtrics.com/jfe/form/********************************


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

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

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

Thank you for your participation.

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


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

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

You can't make this stuff up.

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

-Wes

Saturday, January 12, 2019

Proposed Maintenance of Certification Changes Ignite Controversy (Again)

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

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

Instead, you have to exterminate the Spider.

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

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

-Wes

Tuesday, January 08, 2019

The ABMS Spider and the Fly

Mary Howitt

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

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

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

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

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

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

~By Mary Howitt, 1829

* * *

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

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

Spiders can never stop being Spiders.

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

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

-Wes