Wednesday, July 27, 2016

Moving Forward With Ending MOC

Legislative action at the level of state medical societies to end requirements for participation in the unproven American Board of Medical Specialties (ABMS) /American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program is moving ahead swiftly nationwide. Draft proposals for language for resolutions to end MOC at both state and federal levels can be found here (state - Word file - Enter your state name/medical society name at asterisks as appropriate) and here (federal - pdf file draft copy). BOTH are important.

I would encourage all working physicians to adapt these proposals presented by Ellen McKnight, MD of the Florida Medical Association and present them to your state medical society/association so they may be  adopted whole or in part.

Together, working physicians can end this unnecessary requirement imposed unilaterally by members of the ABMS, ABIM, and collaborators within the Accreditation Council of Graduate Medical Education (ACGME) and Accreditation Council of Continuing Medical Education (ACCME).

Wes Fisher, MD

Thursday, July 21, 2016

The Untold Story of Three ABIM-Sanctioned Physicians

He was a bright medical resident in his third year of internal medicine residency - industrious, committed, a team player. He never thought of himself as special. He had studied hard and achieved much in his short 30 years. Not only was he nearing the end of his residency training in Philadelphia, he was married and had his first child about to be born July 19, 2007. Like most first-time wage earners, his $42,000-a-year resident salary didn't go too far as a result.

As a US medicine resident in his third year of training, he would soon be sitting for his Internal Medicine Board examination in the Fall, a requirement to assure his later employability. So he began the process of registration with the American Board of Internal Medicine (ABIM). He read the requirements and the ABIM "Agreement of Conditions" statement on the their website at the time:
Before electronically signing your application, you will be asked to read the following statement:

"By this application to the American Board of Internal Medicine (the "ABIM"), I agree to be bound by the terms, conditions, and rules set forth in the ABIM's Policies and Procedures for Certification and in this Web site, as they may be amended from time to time. I understand that by applying, I am entering into a contract with the American Board of Internal Medicine to provide certain health care operations services, including practice assessment and evaluations. The ABIM HIPAA Business Associate Agreement is a part of this contract.

I agree to indemnify, release, and hold harmless the ABIM, its employees, officers, directors, members, agents, and those furnishing information about me to the ABIM from any claims, liability, or damage by reason of any of their acts or omissions, done in good faith, in connection with this application, information furnished to the ABIM, the evaluation of my qualifications, and examinations. I agree that the ABIM may use my examination performance, training program evaluations, self-evaluations of knowledge and practice performance, and other information for research purposes, including collaboration with other research investigators and scientific publications. In such research, the Board will not identify specific individuals, hospitals, or practice associations. All practice performance data is HIPAA compliant.

I hereby declare under penalty of perjury that the information given in my application is true and correct to the best of my knowledge and beliefs.

I agree to be legally bound by the foregoing."
This statement represented the entirety of his "informed" consent for the ABIM's "research" - and from the looks of things, he was "legally bound" to comply. On the web page this  "Copyrighted Materials" clause was included as well:
Copyrighted Materials

The Board's examinations are confidential and copyrighted under the Federal Copyright Act. Candidates agree not to copy, reproduce, reconstruct by dictation or other means, or disclose examination content in any manner. Board Self-Evaluation Process (SEP) modules are also copyrighted works. Candidates agree not to copy, reproduce, or make any adaptations of the modules in any manner; or to assist someone else in the infringement of this or any Board-copyrighted work.

Professionally and financially unable to do otherwise, he completed his application and paid his $1,135 registration fee for the examination.

A short time later, he turned to his program director to inquire which board review course he should attend. He was recommended to attend the "Arora Board Review" course led by Dr. Rajender Arora MD. Others had gone there and given it good reviews. His Pennsylvania residency program thought highly enough of the Accreditation Council of Graduate Medical Education (ACGME) sanctioned course that they paid his $1000 registration fee. He decided to attend the board review course offered in June 2007 just before his scheduled board examination in August 2007.

The Board Review Course

Five hundred economically vulnerable residents were in attendance at the Arora Board Review course in June 2007.  The young doctor thought the course was taught well and helped him gain confidence for the exam questions he might encounter. Dr. Arora was a dynamic teacher and the examples and commentary he provided were helpful at teasing out the critical concepts for the examination. At the end of the course, it was mentioned that if he'd like, he could help "pay-it-forward" to his fellow colleagues by sending Dr. Arora information about the topics and questions he could recall that he encountered on his Board examination.

He studied hard for his examination for the next several months, rising early and staying up late and foregoing other social obligations. He reviewed his texts, journal articles, and board review materials. Then the day came for his examination.

He arrived at the test center, checked in, had his biometric palm scan recorded, deposited his wallet, car keys and mobile phone in a locker, was later searched, and finally admitted into the PearsonVue examination computer room. There beside him were others, pounding on their keyboards taking examinations for other trades. He sat and got comfortable. On his computer screen was a big ABIM logo with his name below and a set of instructions. Just before the timed test began, he read a document that threatened him if he shared content of the test. He had the choice: either click "I Decline" and be escorted out of the examination center and thereby waste his test preparation and potentially sacrifice his career as a physician or click the "I Accept" button to start his examination. He accepted and took his test, yet never received a copy of the agreement that he had just electronically "signed."

He thought he did well on his certifying examination. He remembered the general concepts of the questions and while he couldn't remember all of the questions and distractors, he was eager to share what he remembered of the test with the person who helped him prepare, Dr. Arora. After all, others likely did the same for him. He decided to communicate with Dr. Arora via e-mail to thank him for his help and share with him what he could recall as a way to "pay it forward" to others as requested.

Time passed. In late October, 2007 he received notification that he had passed his boards and felt relieved that he had at least secured himself the potential for gainful employment as a "Board certified"  internal medicine physician. He had no intention of repeating that ordeal, at least not in the immediate future. As life would have it, his medical passion had evolved to physical medicine and rehabilitation. His second child was born November 10, 2009 and because residency slots were tough to obtain, he moonlighted to bridge the gap before his second residency in his chosen field began.

On June 8, 2010, he received a sanction letter from the ABIM. In that letter the young doctor learned that the ABIM had suspended his certification for three years because they alleged that he had shared question content from memory with Dr. Arora in violation of the ABIM's "Pledge of Honesty." His board certification status was immediately revoked without due process.

His mind spun. "How in the world?... What happened?" His life, quite frankly, had gone from idyllic to uncertain in an instant. He couldn't sleep. He was humiliated and had to tell his wife. But one thing he was sure of: he didn't want to have to take the test again. Four years of medical school. Three years of residency. Night call. Sleepless nights. Finally, realizing the magnitude of what had happened to him and the possible lifelong ramifications, he retained a lawyer.

He spoke with his lawyer - someone he'd worked with earlier. She was sympathetic. So calls were made to the ABIM's lawyers. At first, ABIM lawyers were unyielding: it was a three-year sanction and then he had to retake the examination.

A short time later, his lawyer called him to tell him about this article that had appeared in the Wall Street Journal June 9, 2010. He was not the only one; there were 138 others. His penalty could have been worse, he was told. At least he wasn't formally sued but his privileges to practice medicine were temporarily suspended at one of his hospitals from 2010 through part of 2011 and compromised his ability to moonlight to pay for his children's daycare.

"I can't take that test again. I just started my residency!" he thought. After pleading with ABIM, the sanction was reduced from three years to one on July 28, 2010, but he appealed this decision since the financial and professional implications of even a one-year sanction were devastating.

Months later after more letters and were exchanged a plea "deal" was struck with the ABIM April 5, 2011 - the ABIM agreed to settle with the doctor for a $5000 fine along with 20 hours of community service in a medical-related charity and proof of completion of an ethics course.

What choice did he have but to agree to those terms?

Cancelled Check Paid to ABIM to Reinstate Board Certification*
(Click to enlarge)
Finally on 1 Sep 2011, the young physician's Board certification was reinstated but the scars linger. From now on, he must always explain that he was "sanctioned" by the ABIM when completing a hospital credentials' packet or being licensed by his state. Needless to say, he no longer practices in a hospital setting.

Commentary: In retrospect what this young doctor didn't realize at the time was that the Arora Board Review course was secretly recorded as part of an ABIM-sanctioned "investigation," apparently without law enforcement  oversight.  On the basis of that recording and evidence gathered by a undisclosed ABIM employee that secretly attended the review course, this "evidence" was presented before a federal judge by Christine Cassel, MD, Ms. Rebecca Baranowski, and A. Benjamin Mannes (the ABIM's currently employed "Director of Investigations" who carries two felony convictions (for impersonating a police officer and carrying an unregistered firearm) and has unfettered access to the ABIM diplomat's files and personal information). On the basis of that information, the ABIM was granted a writ to seize under seal after providing $10,000 in collateral so Federal Marshals could secretly invade Dr. Arora's residence with ABIM attorneys accompanying them. According to court documents, the ABIM obtained images of Dr. Arora's computers, hard drives, and 36 boxes of course materials. To the best of my knowledge and belief and on the basis of this ABIM "letter of concern," only after obtaining those computers did the ABIM discover the emails of who attended the Arora Board Review Course course and had communicated electronically with Dr. Arora.  The earlier communications with Dr. Arora were thought to be private and occurred without financial renumeration to either party of any kind. As such, it appears the raid was little more than a fishing expedition for physicians' emails and addresses who attended the board review course. It appears to me that because the young doctor's email to Dr. Arora was found on one of those computers, and he represented a vulnerable target, he was immediately sanctioned without due process. Dr. Arora, on the other hand, worked a separate settlement deal with the ABIM that has never been made public.

Same Course, Different Doctors, Different Sanctions

Another Arora Board Review sanctioned physician-attendee had a different penalty imposed.  Not only was this physician sanctioned for three years initially, this physician was later forced to sign an agreement with the ABIM that he had committed an ethical violation, had his upcoming subspecialty medical board examination cancelled, and was required to re-take his internal medicine certification examination. But this was not his most difficult problem.

After learning of the ABIM's sanction, his state licensure board also required the physician pass a "maintenance of certification" examination, take an ethics course with an "unconditional pass," do 50 hours of community service, pay a $1000 fine, and provide peer review references before state would re-issue this state license to practice medicine. His online credential verification still documents his sanction today. All of these actions did not include the legal expenses the physician incurred to defend himself with two separate state licensure boards (WA and TX) and the ABIM itself.

Ongoing Litigation

Some nine years after the June 2007 Arora Board Course, the ABIM has still not finished sanctioning physicians. Jaime Salas Rushford, MD, a Puerto Rican physician who attended the same Arora Board Review course, learned of his sanction by the ABIM on 8 May 2012. In his sanction letter, his certification was revoked indefinitely. Shortly thereafter, Salas Rushford also learned that he had been sued by the ABIM as well. What the ABIM had not anticipated was that Dr. Salas Rushford's parents are lawyers. They filed a counter-suit (begins on page 32). The case has been ongoing four years later and full details of the ABIM's operations and tactics are being systematically uncovered in documents on Dr. Salas Rushford's website, doctorsjustice.com. Millions of dollars in legal fees paid by physician diplomats continue to flow to the ABIM's legal team. Unfortunately for all US physicians, this story is far from over and will likely become, as described by the Pennsylvania Medical Society in their recent vote of no confidence (more here), "the most expensive medical mistake in the history of medical education."

Epilog

Given what we now know about the ABIM's long-standing tenuous financial condition, the "research" the ABIM performed and funded from these vulnerable diplomat's exam fees without true informed consent, the undisclosed lobbying that ABIM participated in as a non-profit outside of federal regulations, the years of fraudulent tax filings, the funneling of $55 million of ABIM diplomat fees to fund the ABIM Foundation that performed additional "research" and purchased a luxury condominiums for its use, it is hard to imagine the ABIM has physicians' or our patients' best interests in mind. Furthermore, the American Board of Medical Specialties' (ABMS) (who overseas all of the ABMS member boards, including the ABIM) earlier Senate testimony that claimed they are expanding "new kinds of (undisclosed) partnerships with public payers, private payers, and particular patients and consumer groups who represent them to get a deeper appreciation for the kinds of information they seek and their expectations for care..." with numerous undisclosed revenue streams, there is only one question to ask of these unaccountable cartel-like physician credentialing "non-profit" organizations now.

Did the ABIM act in the public's best interest by sanctioning the many vulnerable resident physicians who attended the Arora Board Review course or did they engage in extortion for the ABIM/ABMS's financial benefit as a result of the ABIM's financial largess using police-state tactics?

-Wes

“The arc of the moral universe is long, but it bends towards justice.”

― Martin Luther King Jr.

*The redacted canceled check and redacted documents above were all used with the ABIM diplomats' permission.

Wednesday, July 13, 2016

ABMS vs The Poor

The chilling reality of what is happening to patients when the ABMS changes the definition of what is required to be Board certified and ties it to Medicaid payments:
CMS officials disagree, saying in so many words that it's "unfortunate," but these Tennessee doctors skipped over the details on who, and what services, qualified for the additional pay.

First, CMS rules specified that Medicaid providers had to be board certified in internal medicine, family medicine or pediatrics. These doctors weren't, in part because in rural areas, hospitals often don't require board certification and, for older doctors, it wasn't a mandate after training.

Second, for doctors without board certification, their status as primary care providers could be documented if 60% of the codes they submitted in their claims were for a select set of primary care evaluation and management (E&M) or vaccination services, not specialty services.
So for those doubters out there that thought this "physician" Maintenance of Certification (MOC) discussion was a "physician issue" and did not pertain to patient care delivery, think again.

-Wes

Reference:

MedPageToday: Medicaid Boom Turns to Bust for Tennessee Docs - Lack of certification triggers payback requirement

Sunday, July 10, 2016

Too Little Too Late: The ABIM Foundation Sells Its Condo

It was a story that broke on this blog nearly two years ago when the American Board of Internal Medicine (ABIM) Foundation was putting their luxury condominium, complete with a chauffeur-driven Mercedes S-Class town car that was purchased with physician certification and re-certification fees, up for sale.

Over 550 days later, we find the notorious ABIM Foundation condominium was finally sold on 6/21/2016 for $1,650,000 representing an up-front cash loss of $650,000.

But let's not forget the other associated fees required to sell a condo:

Real estate commission (6%): ($99,000)
Transfer Tax as buyer (2%) (2007): $46,000
Transfer Tax as seller (2%) (2016): $33,000
Title insurance: $10,000
Other fees: deed preparation, attorney fees, recording fees, etc. $10,000.
Furniture expense: $56,267


And then there's the annual condo fees, cable, phone, electric, cleaning, etc., that came to $41,000-$50,000 annually (approximately $450,000 over 9 years) (Source: Richard Baron, MD, President and CEO of the ABIM and ABIM Foundation)

All told, ABIM took $2,356,267 million of ABIM diplomat's cash and lost at least $1,265,267 on our behalf.

So much for "Choosing Wisely®."

But let's face it, incurring a financial loss on an "investment" is not necessarily illegal. After all, any of us could have made a horrible investment decision.  Rest assured we'll soon hear the ABIM trying to justify their real estate loss because they would have lost this money anyway if they had to pay hotel costs for all of their out-of-town guests and programmers from India eager for a cheap place to stay.

But we should ask ourselves now with the sale of this condominium, what was illegal at the ABIM Foundation? Anything?

Tax Fraud

First, recall that Dr. Baron claimed in my communications with him that much of the condominium expenses they claimed on their tax forms as program service expenses was actually a depreciation expense they lumped into the "program services expenses" of the condominium. Yet the ABIM and their accountants never claimed depreciation under the separate line item on their federal IRS Form 990 for this expense.

Honest mistake?

Unlikely. After all, other tax filing discrepancies with the ABIM Foundation have occurred repeatedly and systematically over many years. Any credible accounting audit should have disclosed most of them.

For instance, surely someone at the ABIM knew the difference between the two states of Iowa and Pennsylvania, didn't they? So why was the ABIM Foundation domicile claimed as Iowa for years when, in fact, it was domiciled in Pennsylvania but never disclosed? And isn't it striking that the ABIM Foundation was claimed for years as being formed in 1999 until this blog disclosed that it was actually created in 1989, some ten years earlier? Only in its most recent tax filings has that little "oversight" miraculously been corrected without explanation to the Internal Revenue Service.

And why didn't the ABIM disclose that it was lobbying Congress on its tax forms when it had been doing so for years? Was this merely a mistake? Or was it because the ABIM and their Foundation would have opened themselves up to closer scrutiny and lost their tax-exempt status if they had?

Unethical Research Practices

Finally, we have to ask ourselves just what kind of research on physicians for the betterment of health care requires a $2.3 million condominium? After all, the ABIM Foundation has always heavily touted their research work and publications.

Some may argue there wasn't "research" being conducted at the ABIM Foundation but rather "quality assurance" or "Quality Improvement" exercises performed there. If so, then why did the ABIM Foundation promote it's pioneering research by using the term at least five times on a single web page in May of 2007?

Archived Screen May 2007 - ABIM Foundation
(Click image to enlarge)
We also find that the ABIM funded "various research projects" at its Foundation in the fiscal year 2008 with the transfer of $6,000,000 of ABIM diplomat fees:

Evidence of ABIM Funding "research projects" at the ABIM Foundation
for $6 million in Fiscal Year 2008
(Click image to enlarge)

There is no escaping the fact that this was a very serious effort at conducting "research" on physicians.

Or not.

Was the whole "research" story told by the ABIM and ABIM Foundation just a front for other activities? I wish to bring my reader's attention that the ABIM Foundation no longer has the word "research" appear anywhere on its website. Instead, there are only words like "Medical Professionalism Charter," "Initiatives," "Grants" and "Choosing Wisely®." The cover-up continues.

Credentialing of physicians involves human testing. As such, it appears the ABIM Foundation unilaterally decided to perform research on physicians without informed consent, without an impartial Investigational Review Board, and without a clear research hypothesis, method, or analysis of the harms they might cause.

"Research" conducted in such a manner is dangerous for many reasons and some of the most egregious examples of dangerous research have happened in government agencies or when the individual or collective social beliefs or dogma were imposed on others as justification for "research."

The Nuremberg Doctrine which rose from the World War II war crimes is very clear in its requirements for human subject research, especially as it pertains to proper consent. From my recently conducted bi-annual CITI Training:
"The voluntary consent of the human subject is absolutely essential.

This means that the person involved should have the legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements the subject matter involved, as to enable him to make an understanding and enlightened decision. This latter element requires that, before the acceptance of an affirmative decision by the experimental subject, there should be made known to him the nature, duration, and purpose of the experiment; the method and means it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person, which may possibly come from his participation in the experiment.

The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs, or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another with impunity."
It goes without saying that human subject research that involves real estate investment strategies to fund research on practicing physicians is unethical (at least) and likely highly illegal. As we have seen, the MOC recertification program can cause significant harm to physicians, their patients, and their families, especially when this credential is tied to physician employment and remuneration. Worse still, the average failure rate of the unproven "Maintenance of Certification" re-certification metric has averaged 13.2% over the past 10 years with wide year-to-year volatility in pass rates using an inconsistent metric. Was the impact of funneling money from the ABIM to the ABIM Foundation for the ABIM Foundation's "research" really that harmful?

Absolutely.

But this story isn't about a condominium or its sale, is it? It's about the wholesale sell-out by some in Organized Medicine that have systematically and repeatedly turned their back on their fellow practicing physicians and the doctor-patient relationship for their own political and financial benefit. For this story is not just restricted to the ABIM or its Foundation. This story extends to all member organizations of the Accreditation Council for Graduate Medical Education (ACGME) that tie the ABMS Board certification credential to medical training program directors, lab certifications, and a host of other regulatory traps, too. So it should come as a surprise to no one that we find more recently that each of these organizations appears to have been complicit with the ABIM Foundation moving funds derived from practicing physicians' "research" fees offshore.

In the end, the entire American Board of Medical Specialties' Maintenance of Certification® story has alway been about making money for their coffers at the expense of practicing physicians, irrespective of the specialty.

Always has been and always will be.

It's NEVER been about "Choosing Wisely®."

-Wes



Thursday, July 07, 2016

Pennsylvania Medical Society Spearheads Effort to End MOC Nationwide


Recently, the Pennsylvania Medical Society sent this letter to the executive vice presidents of all US state medical societies and many specialty societies regarding their vote of no confidence regarding the ABMS Maintenance of Certification® (MOC®) program and the current leadership at ABIM, stating specifically:

"... We believe that their current leadership is not capable of reforming the process in a timely, academically meaningful, and fiscally responsible way.

In keeping with the consensus of our members and physicians across the country, we call for the immediate replacement of the entire ABIM Board of Directors and leadership with new leadership, representative of physicians actively participating in the full-time practice of clinical medicine. The undersigned organizations would further offer to assist the ABIM and any of the ABIM subspecialties with the formation and transition to a new Board that is representative of and accountable to the physicians whom they will certify. ..."
For those interested in learning more or who's state is ready to sign on can email Dr. Scott Shapiro, President of the PA Medical Society at stat@pamedsoc.org‎ for more information.

Please forward a copy of this letter to all of your practicing physician colleagues (irrespective of specialty) and ask each of them to contact the leadership of their respective state medical societies and specialty societies to urge them to co-sign this letter and work with the PA Medical Society to end the corrupt ABMS MOC® re-certification requirement.

Only through aggressive, meaningful, nationwide collective action against this needless, unaccountable, expensive, and coercive ABMS re-certification program will practicing physicians restore sanity to our own life-long continuing medical education process.

Thank you-

-Wes

A copy of the letter to circulate to your colleagues can be downloaded here.

Wednesday, July 06, 2016

An Upcoming ABIM "Community Exploration" Day in Chicago!

(Click image to enlarge)

I just received the notice above in my inbox at work. It seems there's going to be an "ABIM Exploration Day" here in Chicago 26 August 2016. I requested an invitation but have a feeling I won't be sent one since I disclosed I was one of the ABIM's foremost critics of the ABIM MOC program. (That's right, you have to request an invitation at the link provided in this email blast)

Let's make this like open microphone night and feel free to leave your questions for the ABIM in the comments section on this blog. That way, no matter who goes to this hosted event, they'll have plenty of "exploration" questions to ask Yul Enjes, MD and Richard Baron, MD or their representatives. (Physicians are encouraged to identify themselves (and their ABIM diplomat number) so the ABIM knows you're real).

-Wes

Saturday, July 02, 2016

The ABMS MOC Contagion Spreads

It seems the humiliation of physicians to collect revenues by member boards of the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program knows no bounds.

This time, we begin our focus on the American Board of Pediatrics (ABP).

First, take a moment to read what happened to a younger physician mother-of-three who tried to re-certify in pediatrics when her child was 9 months old and still breast feeding.  Horrible.

Pediatricians are one of the lowest paid medical specialties in medicine. Yet like all US physicians, the must pay thousands to "re-certify" with the American Board of Pediatrics every 10 years.

And why must they pay such high fees?

Perhaps there's no better example than James A. Stockman, III, MD.

Dr. Stockman worked for the ABP for 20 years, retiring 31 Dec 2012.

Dr. James A Stockman III, MD Retires from ABP 31 Dec 2012
(Click image to enlarge)

As part of that retirement, we see the ABP paid him over $2.4 million:

(Click to enlarge)

(Click to enlarge)

But this, you see, wasn't enough. Despite often earning over a million dollars a year prior to his retirement while working for the ABP, and then making a $2.4 million golden parachute on his retirement, Dr. Stockman stayed on as a "consultant" for the ABP. His first year there, he earned a cool $861,820 working 45-50 hours a week.
(Click image to enlarge)


But the next year was even better. On their most recent 2014 Form 990, we see that Dr. Stockman earned $793,438 for working just eight hours a work-week:
(Click image to enlarge)

If we assume there are 48 work weeks in a year and Dr. Stockman works just eight hours a week for a total of 384 hours, then in 2014 Dr. Stockman earned a whopping $2066.24 per hour.

I think it's time pediatricians join internists and cry foul loud and clear.

The ABMS Maintenance of Certification extortion of US physicians has to go.

-Wes