Tuesday, March 03, 2015

Why the IRS Should Investigate the ABIM and Its Foundation

This morning, I woke to this remarkable comment to Dr. Robert Centor from Charles Koo, MD on Dr. Centor's blog, Medical Rants.  I republish it here for all to read for it precisely and professionally articulates what many of us have been trying to say to the public about the corrosive nature of the ABIM scandal that has erupted over the ABMS Maintenance of Certification program:
Dr. Centor,

In an email to me regarding the ABIM and the ABIM Foundation financial behavior, Dr. Baron stated in the email that the ABIM has never had any inappropriate financial behavior.  (I can send you the email from Rich Baron if you would like to read it yourself) 

Is that so?  

Myself and folks like Dr. Fisher, Dr. Cutler and legions of other hard working clinicians take great issue with a group of aloof administrator physicians spending vast amounts of money on themselves via Mercedes Limo Service, Condos, and "retreats" to the Four Seasons.  Is it appropriate to pool the fees from graduating housestaff and hard working clinicians so they can reward themselves with nauseatingly gaudy creature comforts?  

How can an organization designed and run by non-clinicians tell the rest of us to "Choose Wisely" and to embrace cost efficiency/austerity while making themselves multi-millionaires off the sweat equity of the everyday clinician and graduating house staff?  Would you trust such an organization?  

Dr. Fisher's point is very, very well taken.  More so since the ABIM and the ABIM Foundation are both registered "non-profit" organizations.  In essence, the American Taxpayer is subsidizing their operational status and their capital budget when in fact the ABIM is totally, hugely, and utterly profitable.  That hypocrisy has never been fully addressed by Dr. Baron or any other ABIM representative.
Can you trust an clinical regulatory organization that is utterly devoid of any contemporary clinicians?  Dr. Cutler pointed out that Dr. Zeke Emanuel is "not certified" by the ABIM continues to be "not certified" and yet remains as a leader for ABIM Assessment 2020.  According to the 2012 Medicare database, Dr. Krumholz has no patient E/M contacts and read a handful of echos.  Yet he is another leader of ABIM Assessment 2020.  

Isn't the lack of inclusion of active, high volume clinicians into the structure of the ABIM and the ABIM Foundation patently wrong?  And yet you trust and "hope" this clubby cadre of "ethical" non-clinical physicians will magically do the right thing when it is clear they been doing it wrong for almost a decade.  The irony of this oxymoronic situation is troubling and sickening.

Even more ironic and more sickening is the ABIM's driving point- that their mission is somehow a product of pure altruism and promoting honesty and integrity to its Diplomates.  If that were to be true, the ABIM leaders should immediately vow to take an oath of fiscal modesty and financial mediocrity.  

Do you think the ABIM leaders would ever take a significant pay cut and promise never to abuse the money from an impoverished senior resident on Mercedes limo service?  When you look at your residents at Morning Report, can you honestly and whole heartedly tell all these young folks that your friends at the ABIM are doing them right?

Do you think the ABIM has the courage to set aside their own financial interests and to show leadership when they are apt to state their financial misbehavior were inherited?  How cowardly is the ABIM to place all the blame on Christine Cassel?

Would you have to courage to ask the ABIM and the ABIM Foundation to take such an oath of modesty and fiscal/financial mediocrity? Or is your sense of cronyism clouding your judgment?

In the end, we have a growing schism between those who are placing their bets on a sclerotic ABIM whose leadership has failed its Diplomates and those who welcome change, competition and Darwinian evolutionary forces in Medicine.  The loss of trust and faith in the ABIM cannot be ignored by their leaders and the proof in the pudding will be when the Diplomates who are sick and tired of the ABIM selling them out will defund this organization and turn to more responsible organizations willing to document their lifelong learning without pricing in a condo, a limo, a retreat to the Four Season, and massive salaries for themselves.

At low tide, everyone will find out who is swimming naked.
It's time the IRS takes notice.


Sunday, March 01, 2015

New York Times Shamefully Panders to Aetna's Management Style

In this morning's New York Times, David Gelles, writes a gushing piece on how Aetna is using meditation and mindfulness to "reshape his company's future."

Much of the article idealizes the management approach of Aetna's 58 year-old CEO, Mark T. Bertolini, and tugs at the heart strings of America by focusing on his near-death experience after an unfortunate ski accident he suffered in 2004.  The crux of the article focused on how Mr. Bertolini became "enamored with yoga's intellectual and cultural history," and how "Mr. Bertolini found that difficult thoughts and emotions became easier to manage" with mindfulness techniques.  He later expanded these practices to the rest of his employees on a voluntary basis, using metrics of heart rate variability and cortisol level measurement ("common measures of anxiety") to assess the efficacy of his programs to his company's bottom line.  Most remarkable, Mr. Gelles implies that "productivity gains" and cost savings were attributed, in part, to his practices.  In fact, if it weren't for these practices, we are told, he might "not have been inspired to act on his impulse" to raise their lowest paid employees salaries from $12 an hour to $16 dollars an hour as the "latest phase of Mr. Bertolini's grand experiment."

It is remarkable that any reporter, much less one from the New York Times, would attribute Aetna's windfall to mindfulness and meditation practices without even mentioning the impact that our new health care law and its higher premiums and co-pays has had to Aetna's bottom line. It doesn't take much digging to find in Aetna's own 2014 Investor Conference data that health care premiums have increased four times faster than inflation, employee costs are rising 50% faster than employer costs, and average deductibles to patients have increased over 50% in the past five years.  Nor did Mr. Gelles even deem it important to mention that Mr. Bertolini made over $30 million dollars in compensation and benefits in just one year (2013) on the backs of Aetna's own customers as well.

There his a mindfulness practice called "Mettā" where practitioners chant "May I be healthy. May I be happy. May I be well. May I be free from harm." Maybe Aetna and Mr. Gelles should practice a little "Mettā" on behalf of Aetna's customers rather than just for Aetna's bottom line.


Friday, February 27, 2015

On the Important Issue of Physician Trust

After a brief foray into the uncomfortable position of being publicly humiliated, the American Board of Internal Medicine is now telling is they have begun a "transformation" of their Maintenance of Certification program.  They said they got "it" wrong. But instead of understanding "it," they want practicing physician to forget "it" and, instead, refocus our efforts to redefine "it."

To begin that process, they are publishing seemingly heartfelt missives claiming they've been "thinking a lot ... about the values that we physicians share." Even after squandering any semblance of trust by their inexcusable financial behaviors, they pretend to understand how practicing physicians feel and claim "we are united in our passion to do right by our patients and our commitment to lifelong learning." This is a straw dog.  They have taken accountability for the most trivial component of what they did to the practicing physician community - as if they hired damage-control consultants.  Instead of coming clean, we now see they have begun a campaign to groom vulnerable physicians into believing their storyline so their largess can continue unabated.

For who is more vulnerable than a junior practicing US physicians saddled with huge educational debt?  Who is more vulnerable than the junior physician trying to find a job as an employee in a large health care system hell bent on cutting costs?  Who is more vulnerable than the majority of physicians who have lost their independent practices and now are placed in the ethically impossible position of serving two masters: their patients or their employers that insist they do more with less? Like a perpetrator trying to identify areas of psychological weakness in the vulnerable practicing physicians, they continue to attempt to position themselves as our savior, rescuer, and someone who holds us in the highest regard.

Trust between physicians is critically important.  We rely on our colleagues in matters of life and death every day.  Actively practicing physicians cannot tolerate faux trust or press-release trust. But the members of the ABIM wouldn't know about that.  They sit on their insulated perches forcing their colleagues to pay into their flawed system first every ten years and now every two.  They have assembled a rich war chest of cash assembled on the backs of their practicing colleagues and then proceed to self-select their finest sycophants to join their merry band of highly-paid regulators.  And remarkably, we now find that their unproven pay-to-play scheme uses the federal government as imprimatur.

But we should understand that this loss of trust goes much further.  Every professional organization that sides with the ABIM in support of the MOC program is also violating their own membership's trust of collegiality, professionalism, and support.  Nowhere was there a better example of the pathologic nature of the siding with the ABIM than that demonstrated by a recent letter from the American College of Physician's Executive Vice President and CEO, Steven Weinberger, MD, to their membership in response to the ABIM's "We Got It Wrong" admission.  Almost unbelievably, rather than acknowledging the realities of the ABIM's actions, Weinberger's letter openly threatens their membership with veiled threats of potential consequences of non-complicance with the ABIM MOC program if they choose an alternate certification pathway:
As many of you know, there has been a movement by some physicians to establish a pathway for “certification” that is independent of either ABIM or the American Board of Medical Specialties (ABMS, the umbrella organization over all specialty boards, including ABIM). We have been asked by a number of our members about “alternative pathways,” and I wanted to outline a series of questions that anyone must consider when assessing alternative options: Will an alternative pathway be credible to substitute as a credentialing requirement for hospitals and health plans? (For example, a requirement of 50 hours of CME credit over 2 years is a very low bar, in fact representing only half of the CME requirement for medical licensure in most states.)

  • If you are named in a medical liability lawsuit, how will it appear when it is noted that you have not recertified through ABIM but have instead tried to show that you are “certified” through a process that has not been widely accepted and whose requirements are minimal?

  • If you have a time-limited certificate from ABIM, are you willing to forfeit that primary certification in internal medicine and/or a subspecialty of internal medicine when that certificate expires? Recognize that, after your current certificate expires, not participating in ABIM’s MOC program means more than just being listed as “not participating in MOC.” It means that you are no longer certified, i.e. your initial certification is no longer valid.

  • Is the fee for an alternative pathway reasonable considering both what you are getting as well as the expenses of the group that has developed the alternative pathway? For example, a fee of $169 every 2 years is almost half of the ABIM’s internal medicine MOC fee, but the alternative organization has no program or product development costs, as all it is doing is sending an electronic certificate (there is an additional charge for a paper certificate).
(Update 2/27/2015 @ 12:07 PM CST: See the NBPAS.org's response to the ACP)

And as if this were not bad enough, the ABIM Foundation continues to use Christine Cassel, MD, former President and CEO of the ABIM, as their spokesperson on matters of waste in our health care system in their highly-produced videos to the public when they themselves have squandered millions.

The ABIM Foundation never mentions they used coerced physician testing fees to fund their Choosing Wisely Campaign and to purchase lavish condominiums for themselves.  They never disclose (and have no future plans to disclose) their many years of conflicts of interests with consulting groups, think tanks, hospital groups and little sweetheart government agency grants (kickbacks?) with practicing physicians or the public. They see no problem squandering $3.3 million dollars of physician testing fees on a contrived promise of psychometric testing techniques to add value their system. They see no problem collecting and circulating practice and meaningless survey data to their many corporate affiliates. And worst of all, they have no plans to examine their sister organization's practice of failing as many as 22% of their test takers without ever evaluating the impact of their actions on a physician's ability to practice or the impact such an action has on the doctors' patients.

The ABIM and their professional society supporters have irrevocably lost the trust of America's practicing physician community.  They can't just "groom" this away hoping for its preservation or offer threats in the MOC program's defense.  What's done is done.

The question now becomes, can they and their many supporters ever earn it back?


Related: (registration required) "Physicians are Outraged Despite ABIM Apology for MOC Mess" Medscape - Note: 237 332 comments and growing.

Tuesday, February 24, 2015

Why the ABIM Foundation Wants Us to Ignore 1997

Why would the American Board of Internal Medicine (ABIM) leadership want the world to believe that their own ABIM Foundation was created in 1999?  Might it have been because they didn't want to reveal their past?

Based on public record, it appears they have repeatedly misrepresented the date and location of origin of the ABIM Foundation on Internal Revenue Service Form 990 tax forms since at least fiscal year 2009 and did so to shelter multimillion-dollar write-offs for their investment portfolio on the backs of physician testing fees.

Recall that both recent ABIM Foundation's Form 990's and their website have claimed that the ABIM Foundation was domiciled in Iowa and established in 1999.  Recall also, that in my prior research on the ABIM and their Foundation that I asked the current President and CEO, Richard Baron, MD, to explain the discrepancy between the tax form filing information and public record that claims the Foundation was created on 10/17/1989 in Pennsylvania, yet I received no clear explanation for the discrepancy.

This date of origination of the ABIM Foundation is important, because if it was created in 1989, the origin of the Foundation would precede 1990, the first year that medical board certification was changed from a life-long designation to a 10-year time-limited status by the American Board of Internal Medicine.

The ABIM Foundation and the Institute for Clinical Evaluation

Careful review of the ABIM Foundation's fiscal year 2004 tax forms shows the ABIM Foundation and a separate little-known 501(c)(3) organization, the Institute for Clinical Evaluation (ICE), merged.  It appears ICE was created in Pennsylvania in 8/25/1997 by the ABIM Foundation "to assess the usefulness of proficiency testing to the profession."

Harry R. Kimball, MACP, the former President of ABIM, was interviewed by Jennifer Wilson of the ACP Internist in 1997, and was quoted as saying:
"Several months ago, the ABIM decided to create, through its Foundation, an independent non-profit organization called the Institute for Clinical Evaluation (ICE), which will assess the usefulness of proficiency testing to the profession.

In this context, ICE has the potential to positively influence the development of these standards. At the same time, we can be sure they are compatible with broad-based certification and recertification programs. The Board thinks that ICE can develop collaborative arrangements with professional societies to bundle education and evaluation into a single process. This process would be educationally efficient, credible to patients and acceptable to agencies and institutions responsible for the health and safety of the public.

For the recertification program, the Board is developing a series of practice-assessment modules that allow diplomates to assess their preventive practices, receive feedback from patients and their colleagues about the quality of their professional services and assess the effectiveness efficiency of their clinical practice. The first of these modules is on clinical prevention and will become available this month."
But when that organization could not prove such usefulness and spent funds like a drunken sailor to support its non-physician Chief Operating Officer, John J. Norcini, PhD, it appeared the leadership of both organizations later deemed it "in the best interests of their corporations to merge ICE into Foundation."  Christine Cassel, MD signed the "Agreement and Plan of Merger" as President of both organizations.

With the merger the ABIM Foundation wrote off a $3,347,109 loss from ICE. It appears that grants were made from the ABIM (who receives 97% of its funds from physician testing fees) to the ABIM Foundation in the three years preceding the merger to handily offset this loss: $1,600,000 in FY 2002, $1,000,000 in FY 2003, and $1,760,000 in FY 2004.

So what we now know, is that the ABIM Foundation clearly existed before 1999 counter to what its many tax forms and webpage suggest. In my opinion, this misrepresentation on their tax forms and webpage was not just a simple mistake, but was used as a cover-up to the physician community and the public (and perhaps the IRS?) of a $3.3 million dollar loss so they could avoid ridicule over their lack of proof of the value of their testing program while continuing to justify their high salaries and ever-higher testing fees while simultaneously leaving the multimillion dollar investment portfolio held by the ABIM Foundation untouched.


The ABIM Foundation, Choosing Wisely, and the $2.3 Million Condominium
The ABIM Pleads for Mercy

Monday, February 16, 2015

Under Pressure, ABIM Posts Missing Financials

When the American Board of Internal Medicine initially posted their 2014 audited financial report, they neglected to publish the itemization of how finances were split between the ABIM and its Foundation with the most recent financial disclosure.

Now it seems the most recent ABIM consolidated financial statement was revised and posted online. The breakdowns that were neglected offer additional insights into the lavish spending of the ABIM, including over $20 million of their $54.5 million physician-paid revenues on salaries (37% of annual revenues and far different than disclosed on their webpage), a $591,389 fee for "recruiting and employment agency fees," a $348,060 "special severance payment" (page 25, perhaps for Dr. Cassel's departure from the organization in 2013?), $2,677,600 in payments to consultants (page 24), and $234,884 paid to "publications and subscriptions" - page 24).

I would like to commend the ABIM for taking this action.  However, this action does little to quell the concerns of the practicing physician community of the legitimacy of the ABIM's MOC program in improving patient outcomes and opens additional concerns regarding tactics used to promote their MOC product for which they, themselves, provide little to no educational content.


h/t: MedCity News

Wednesday, February 11, 2015

How Do I Say Goodbye?

So what does a son say to his mother for the very last time?  What does he whisper in her ear?

I will say "I love you."  I will say "thank you."  I will say "God bless you." I will say "I'll miss you."  I will say "You've been the best mother a son could ever hope for." I will say nothing, probably, and cry.

Go in peace knowing you gave your family more than they can ever repay. Know we'll always be reminded of your kindness, your tenderness, your gentleness and care. Be proud of what you've accomplished in your 89 years, especially with your family. You were our glue and always made your home so welcoming.  You taught us the art of the written word and the special place for whimsy. Hundreds of kindergartners and first-graders that you taught all those years will miss you too.

Thanks for being so wonderful to my kids - they will always remember your kindness, thoughtfulness, compassion, warm home and tender words.  Give Dad a high-five when you see him for me. We'll think of you every time we water the flowers, tend the garden, make a fire, cook a meal, attend the theatre, play guitar or gather as a family.

Our "Blessed."

Until we meet again, God bless. Thank you for everything you've taught me, showed me, and gave to me all these years. You'll always be my compass.

I love you, Mom.


by Sara Teasdale

Life has loveliness to sell,
  All beautiful and splendid things
Blue waves whitening on a cliff,
  Soaring fire that sways and sings,
And children's faces looking up
Holding wonder like a cup.

Life has loveliness to sell,
  Music like a curve of gold,
Scent of pine trees in the rain,
  Eyes that love you, arms that hold,
And for your spirit's still delight,
Holy thoughts that star the night.

Spend all you have for loveliness,
  Buy it and never count the cost;
For one white singing hour of peace
  Count many a year of strife well lost,
And for a breath of ecstasy
Give all you have been, or could be.


At our last concert together

Saturday, February 07, 2015

American Board of Medical Specialties Circles the Wagons

Actions speak louder than words.

Imagine, a piece about unsavory financial practices and possible corruption is published about one of the members of your flotilla. That member of the flotilla responds, but the response it met with pushback by the practicing physician community.

The Mothership, already nervous, gets more nervous.

The Mothership calls her public relations firm to ask what to do.  Things must be neat and tidy, just like their "new and improved" webpage.  "We can't be lost on our messaging to the public," they say to the PR firm.  "We need to have 'alignment' with our core values and motives."

So, the public relations firm proposes a strategy.  It is reviewed by the leadership of the Mothership.  They like how it sounds.  So they send a boilerplate press release to each member of the Mothership's flotilla.

And this is what happens.


No, there's no collusion going on among professional societies.  None at all.  Nothing to see here folks.

Now, can we move along and just ask doctors to keep paying those high re-certification fees?