Tuesday, November 12, 2019

Is CMS's Value-Based Healthcare System Already Being Gamed?

Take a look at the address of the American Board of Medical Specialties (ABMS) that owns the Maintenance of Certification (MOC®) trademark that is the subject of at least six anti-trust lawsuits (see here, here, and here for instance) underway because MOC binds physicians to their hospital privileges and insurance payments to made to hospitals on behalf of their employed physicians:

Now look at the address of the American Medical Association (AMA)-sponsored PCPI Foundation with board members from UnitedHealthcare, Premier, the American College of Cardiology, the American College of Physicians, several trustees of the AMA, and others:

Recall that the AMA maintains a monopoly on the procedure codes (CPT® codes) for every medical procedure performed in the United States and sells the rights to use that database to insurers and electronic medical record companies. Each of the AMA codes, then, have particular "value" to hospitals and insurers.

The AMA also determines the "relative value system" used by the government coding for weighting physician compensation that strongly incentivizes physician behavior. Some procedures, then, have more "value" to physicians than others. Hospitals know this, too.

Gee, I wonder, with all these codes and friends that stand to profit on the backs of working physicians and our patients, is the Affordable Care Act's value-based healthcare already being gamed?


Saturday, November 09, 2019

MOC®: It's All About Physician Data

The Facebook–Cambridge Analytica data scandal was a major political scandal in early 2018 when it was revealed that Cambridge Analytica had harvested the personal data of millions of peoples' Facebook profiles without their consent and used it for political advertising purposes. The scandal, first exposed by The Guardian in 2015, revealed that Cambridge Analytica had managed to obtain data on millions of Facebook users in the UK, US, and beyond, made possible through "improper sharing" practices conducted between the "This Is Your Digital Life" Facebook app developer and the company. By giving this third-party app permission to acquire their data, back in 2015, this also gave the app access to information on the user's friends network; this resulted in the data of about 87 million users, the majority of whom had not explicitly given Cambridge Analytica permission to access their data, being collected.

Because patients do not give consent for the use of their data, who better to target for access to sensitive patient-related information than those entrusted with their care? As details come to light about the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) program that has plagued physicians since 1990, many similarities to the Cambridge Analytica data-sharing scandal are appearing. The adhesion contract that forms the basis for MOC and is increasingly tied to physician hospital privileges and insurance reimbursements, assures this data pipeline remains open:
I also understand that ABIM may use my examination performance, training program evaluations, self evaluations of knowledge and practice assessment, and other information for research purposes, including collaboration with other research investigators and scientific publications."
Unbeknownst to most physicians, the ABMS has been involved with the sale and sharing of physicians' demographic and sensitive MOC data with third parties for years. Each clinical physician in the United States may see 2000-3000 patient's each annually. Marrying physician data with their patient's data and targeting patient markets becomes possible with physician-specific MOC information. Procedural and pharmaceutical data allows medical suppliers, pharmaceutical companies, device companies, and others virtually unlimited opportunities to sell their products while optimizing most their bottom lines through increased sales and offering rebates to health care facilities (aka, kickbacks).

Group purchase organizations (GPOs) and Pharmacy Benefit Managers (PBMs) decide what equipment appears on a database for hospitals to purchase. Companies pay those GPOs and PBMs to be on the list. Doctors' equipment choices and pharmaceutical preferences influence that list. Companies want to know what doctors are using and who doctors are seeing. By knowing their patterns and knowing the procedures performed on patients, highly sensitive patient information can be deduced. Registries owned by procedurally-heavy specialty societies (like the American College of Cardiology) are a particularly ripe source of procedural data, particularly when it can be made doctor-specific (where MOC comes in). More data sales occur. Repeated MOC testing and demographic data entries required by physicians assures these physician-specific databases are kept current. Having the President and CEO of the American Board of Internal Medicine on the President's Council of Advisors for Science and Technology assured uninterrupted marketing access to physicians and their patients.

By using physician information and their patient care information for these corporate purposes, the ABMS/ABIM MOC® product looks more like Cambridge Analytica than a physician education tool and affects far more people's health care than the Cambride Analytica ever did.

So how how do all these organizations coordinate and connect their MOC data, registries, and corporate databases?

Through a virtually undisclosed tax-exempt AMA-funded private foundation shamelessly called the Physician Consortium for Performance Improvement (PCPI).

Reportedly formed in 2000 with the help of the AMA, the PCPI Foundation is located just blocks away from the AMA's corporate headquarters in downtown Chicago. The organization describes itself as follows:
The AMA-convened PCPI, in partnership with its members, has developed more than 350 measures, many of which are used in the Physician Quality Reporting System (PQRS) and Meaningful Use, as well as private health plan payment models. (emphasis mine)

In 2011, American Medical Association staff to the PCPI worked with a group of committed volunteer leaders to launch the NQRN®, a national, multi-stakeholder network of clinical registry stewards and others interested in registries. The NQRN has created tools and educational opportunities and increased the visibility and value of clinical registries as reporting and improvement systems. In 2016 NQRN was merged into the PCPI as a key program. In 2013, the AMA-convened PCPI launched the PCPI Quality Improvement Program to support its members improvement needs beyond measurement.

In 2014, the AMA and AMA-convened PCPI leadership undertook an evaluation to determine the optimal governance structure to meet the growing demand for value-based health care. The result of this evaluation was the adoption of new By-Laws in June 2015, which set the course for the PCPI Foundation (PCPI), an independent organization with an expanded membership.
Not surprisingly, it's Board of Directors is lead by John S. McIntyre, MD of the American Psychiatric Association, who has never participated in MOC and is not required to do so:

The remainder of the Board of Directors include:
  • Thomas Granatir, MD, Senior Vice President for Policy and "External Relations" of the ABMS (formerly from Humana)
  • Lewis G. Sandy MD, FACP of the UnitedHealth Group
  • Non-physician Nancy E. Lundebjerg, MPA of the American Geriatric Society (Vice Chair)
  • Non-physician Laura J. Cranston, RPh of the Pharmacy Quality Alliance (Secretary)
  • Non-physician Dianne V. Jewell PT, DPT, PhD, FAPTA of the American Physical Therapy Association (Treasurer)
  • Larry A. Allen, MD, MHS of the American Heart Association
  • Bruce S. Auerbach MD, FAECP of the American College of Emergency Physicians
  • Arlene S. Bierman MD, MS of the Agency for Healthcare Research and Quality
  • Claire Bradley, MD, MPH who oversees "Quality Improvement"
  • Non-physician Carol A Cronin MA, MSW of the Informed Patient Institute
  • Non-physician Melissa Danforth of the Leapfrog Group
  • E. Scott Ferguson, MD - A radiologist on the AMA Board of Trustees and AMA representative to the National Quality Forum but does not appear to participate in MOC.
  • Deeraj Mahajan, MD FACP, CMD, CIC, CHCQM ("Certified Medical Doctor, Certified Infection Control, Certified Health Care Quality Measures") of the Medical Specialty
  • Lawyer Melanie G. Phelps JD of the North Carolina Medical Society who previously worked in the Government Affairs Department of Blue Cross Blue Shield
  • Non-physician Aisha T. Pittman MPH of Premier, Inc, the largest hospital Group Purchase Organization
  • Amir Qaseem MD, PhD, MHA, FACP of the American College of Physicians
  • Martha J. Radford, MD FACC, FAHA of the American College of Cardiology
  • David Shahian MD of the Society of Thoracic Surgeons
  • Computer Scientist Kurt Skifstad, PhD CEO of ArborMetrix, a data analytics company
  • Sandra Adamson Fryhofer, MD MACP from the Board of Trustees of the AMA
  • Richard D. Zorowitz MD, FAAPMR of the American Academy of Physician Medicine and Rehabilitation

Members get to "access the latest tools and insights on performance measurement, clinical registries, and quality improvement" as well as "influence through representation on the PCPI board, committees, advisory and other, as well as expert panels and task forces."

Members of this organization, according to the revolving banner on the PCPI website, include:
AvaMed, FigMD (MOC data collectors), AMA, ACP, ACC, ABMS, Informed Patient Institute, CMSS, Am Society of Clinical Oncology, The American Health Quality Association, Am College of Occupational Medicine, Primaris (A healthcare consulting and data abstraction company), American Academy Foot and Ankle Orthopedics Society, UnitedHealth Group (Market cap: $262B), The Society of Thoracic Surgeons, Pharmacy Quality Alliance, American Gastroenterology Association, Health Care Services Platform, American Optometric Association, Academy of Nutrition and Dietetics, American Heart Association, American College of Radiology, and on, and on...

It's handsomely paid CEO and Executive Director, Kevin Donnelly, is a non-physician, too. Here's their latest 2017 IRS filing that confirms a cool $2.78M contribution from the AMA to the PCPI and contains this explanation why the organization is not a true public "charity" after all:
The organization is filing this 990PF after the extended due date of November 15, 2018 (extension was for Form 990). Upon completion of schedule it was determined that the public support test had not been met for the second year. Research into IRS code and regulations was done to determine the next steps, which took the organization past the due date. The organization did not intentionally disregard the filing requirement, but rather, took time to ensure that that (sic) the appropriate filings were being made. Going forward, now that the requirements are understood, all 990PF filings will be timely. Additionally the organization properly extended the 2018 return as fling a Form 990PF.
I'm sensing some BS here, but I'll leave that to my readers (and the IRS) to decide.

Are UnitedHealth, Humana, Blue Cross Blue Shield, Premier, AvaMed (and all the medical device companies they represent), FigMD, and Primaris really about "quality" or their own bottom line?

Is there any wonder, then, that when a physician points out certain conflicts to medical editors of the Journal of the American Medical Association (JAMA) or the New England Journal of Medicine (owned by the Massachusetts Medical Society), he can't get a straight answer and is referred by the conflicted party to IRS tax filings?

One thing's for sure, to the best of my knowledge and belief, these multiple organizations are colluding with each other for their own best interests ("covert rationing" - a concept coined by the prescient Dr. Richard Fogoros) and using our physician MOC® data to drive their bottom lines while hiding behind non-profit tax law and the ruse of assuring the public it's all in the name of "quality."


Wednesday, October 30, 2019

What Gives?

WHAT GIVES the American Board of Internal Medicine the ability to take away years of schooling, mountains of prior testing, sleepless nights of residency, and months of study for initial Board certification that we all had to pass?

WHAT GIVES the American Board of Internal Medicine the authority to magically un-certify physicians for not purchasing or their Maintenance of Certification program?

WHAT GIVES the American Board of Internal Medicine the right to take away over 25 years of my expertise with catheter ablation or pacemaker implantation when they've never once examined the quality of my work or spoken with my patients?

WHAT GIVES the American Board of Internal Medicine the right to tell insurance companies and hospitals when my board certification expires so those companies can suddenly refuse to issue payments or revoke my hospital privileges claiming by skills as a physician have expired?

The American Board of Internal Medicine says it is developing new strategies of physician testing in the name of improved patient care, but WHAT GIVES for those physicians it has de-certified and are now jobless?

Removing physicians with years of patient care experience because they refuse to pay a fee or perform needless computer tasks is not in the best interest of patient safety or quality of care.



PS: Please help support the legal efforts underway to end Maintenance of Certification for all subspecialties by contributing to at https://www.gofundme.com/practicing-physicians-of-america
(Every dollar helps. Please share this video with your colleagues, too.)

Friday, October 25, 2019

A Case Study in the Wrong Way to Fix Clinician Burnout

Asking the system to fix the system in regards to physician and nursing burnout is like asking the fox to watch the henhouse.

They have no clue.

Case in point: the recent article published online before print in the Journal of the American Medical Association (JAMA) (where else?) preaching a "systems-based approach to clinician well-being and provide better patient care."

What "system" is recommending this "approach? None other than the Accreditation Council for Graduate Medical Education comprised of the American Medical Association (AMA), the American Hospital Association (AHA), and the American Board of Medical Specialties (ABMS), among others, with work performed by a committee comprised of friends from Blue Cross Blue Shield.

Most concerning, however, is this report was co-authored by one of the most conflicted authors in the health care business, Christine K. Cassel, MD. Recall that Dr. Cassel failed to disclose her board seats (and income) with Kaiser Hospitals and Health Systems and Premier (the largest health care Group Purchase Organization for the nation's hospitals) while serving as President and CEO of the American Board of Internal Medicine. 

Christine K. Cassel, MD was President and CEO of the ABIM from 2004-2014. During her tenure at the ABIM, Dr. Cassel received a highly influential political appointment on the President's Council of Advisors for Science and Technology under President Obama in April 2009, just before the Affordable Care Act was signed into law in 2010.

The same day she announced that political appointment, the ABIM contracted with Washington lobbying firm Jennings Policy Strategies, Inc. yet never publicly disclosed this relationship. Instead, ABIM tax forms from 2010 listed this firm as hired for "consulting services."  It appears to this lay physician that these "services" were in direct violation of IRS regulations concerning lobbying, especially given Dr. Cassel's substantial non-disclosed financial ties to Premier, Inc., one of the nation's largest Group Purchase Organizations for the nation's hospitals. At least one other lobbying firm was retained by ABIM (named Mehlman Castagnetti Rosen Bingel and Thomas, Inc.) until June 30, 2015, and this relationship was never publicly disclosed to ABIM's physician diplomates, the IRS, or the public either.

According to a Newsweek reporter, the ABIM used obfuscatory accounting techniques during and after Dr. Cassel's tenure: "I had an easier time figuring out the compensation of officials at Enron, WorldCom and Adelphia—all famous for lying on financial filings—than I did for those at the ABIM, where enormous effort seems to have been taken to make murky what should be crystal clear." The ABIM reportedly paid Dr. Cassel $1.7 million in her final year.

Some things never change: Dr. Cassel once again claimed "no conflicts" in the disclosures to this most recent JAMA article on physician burnout either.

Gaslighting physicians and nurses is not the way to fix burnout.

It would be far better for the members of the ACGME to hold a mirror before themselves to understand how their conflicts of interest have systematically done more to harm our profession over the years. Our current house of Medicine has gleefully created the world's most expensive typing pool with physicians and nurses as little more than data entry clerks clicking away whether home or at work. Our current non-transparent health care system has evolved this way thanks in large part to the AMA's behind-the-scenes business model dependent on licensing its ever-changing "Current Procedural Terminology" (CPT) codes for use by the electronic medical record companies and insurance companies to covertly ration care. At the same time, the ACGME supported and promoted the transition from lifetime ABMS board certification to an unproven and wasteful "continuous board certification" by insisting on lifetime testing and payments from physicians for themselves, the lucrative publishing and testing industries, and a vast network of physician specialty societies  without ever examining the harms this extortion has caused physicians and the patients they care for. It is telling there was no mention in the recent JAMA article of the "Maintenance of Certification" (MOC) controversy that has led to multiple ongoing federal class action antitrust and racketeering lawsuits, deprives physicians of personal and family time, and steals any semblance of self-educational autonomy from physicians for the benefit of the ACGME members and their collaborators.

To fix burnout we need doctors and nurses looking up at patients rather than looking down at computer screens. We don't need hand-holding wellness exercises, life coaches, and yoga classes. We especially dont need them right after witnessing the unfortunate death of a child or having a patient die beneath our hands despite our best efforts.

Doctors and nurses are not babies or widgets in an assembly line.We entered into this real-life drama of medicine with eyes wide open knowing full well that medicine and health care can be challenging.  Yet much of corporate medicine has taken on its role to push our limits to make the system more "productive" for the system at the expense of its caregivers.  Medicine is hard damn work that is both emotionally draining yet exhilarating all at the same time. We take the ultimate responsibility for our patients. The ACGME and their protected bureaucratic workshop do not. We risk falling prey to this exploitation if we fail to expose these many undisclosed conflicts of interest with the authors and "committee" wrote and published this paper in JAMA.

This is not to say I see a day where medicine will occur without the use of computers. But computers and secret sharing of data health care data can have its consequences if patients and physicians are kept in the dark. The depersonalization that computers bring to medicine has a nasty side effect on the care we provide: physicians and nurses need face-to-face, hand-to-hand, and heart-to-heart time with patients and their colleagues, not computers, procedure codes, and recommendations from people who foisted MOC upon us, stood to gain financially from it, but never participated in MOC themselves.

Distrust of our self-imposed corporate overlords is a large part of why we're where we are currently, particularly when they insult us with their self-serving "mission" to have physicians help themselves. What do these physician-bureaucrat posers know what's really happening on the front line of health care today?

Humility at admitting mistakes would go a lot further at curing physician burnout than beating the same corporate drum that wedges itself between what really matters: doctors and nurses caring for patients without the self-appointed, politically- and industry-funded National Academy of Medicine and their cronies telling us how to do our jobs.  It would be far better if they took off the chains they bind us with and let us do what we do best.


Saturday, October 12, 2019

Plaintiffs to Appeal ABIM Class-Action Lawsuit in Full

With the time to amend the earlier class action antitrust and racketeering lawsuit against the American Board of Internal Medicine (ABIM) past, this statement was issued by C. Phillip Curley, the Plaintiffs' lead attorney:
“Plaintiffs plan to appeal in full the dismissal of their case. While we respect the district court, we believe it was wrong at this early stage of the litigation to dismiss Plaintiff’s case and deprive them of their day in court. Plaintiffs look forward to the vindication of their claims on appeal.”
ABIM may have thought they won this case on dismissal, but it looks the plaintiffs' claims will get a second more critical review of the case with the 3rd Circuit Court of Appeals.


Physicians wishing to support the plaintiffs in this unprecedented action are encouraged to contribute here.

Saturday, October 05, 2019

You Know There's a Problem with MOC When...

... yet another antitrust lawsuit is filed against ANOTHER American Board of Medical Specialties' member board.  This time, the American Board of Orthopaedic Surgery joined the antitrust litigation fray on September 11, 2019.

Look for those Maintenance of Certification® (MOC®) fees to continue to skyrocket as the certification cartel extracts more fees from working stiffs doctors to help pay their mounting legal bills.


PS: Want to help with this David vs Goliath battle to help end MOC®? Click here.

Wednesday, October 02, 2019

Why Working Physicians Deserve Their Day in Court

Ask any physician who shares 24-hour call with his colleagues: what time is the worst time to get called into the hospital? Most will tell you just before midnight.

That's because you miss out on those most precious first few hours of deep sleep needed for the next day.

For me, the call this particular evening came at 10:47 PM. Seventy-nine years old. Complete heart block. Wide complex escape rhythm at 34. Started to feel poorly early that morning. Stable blood pressure: 134/60.

A decision was needed.

So, I pulled my head off the pillow, glanced at the clock, grabbed by cellphone, and stumbled toward the other bedroom where the home computer rests. Giggling the mouse, the 45,000 watt screen light illuminated, blinding me as I struggled to type in the cellphone-derived time-sensitive passcode needed to log into EPIC alongside my username and password. I entered by username and password again (once is not enough, I guess), then found the particular hospital (I cover four at night when on call), then the Emergency Room patient list, then the room, and there it was: just as advertised, but with the dreaded one-triage note entry in the chart that basically just noted the time the patient arrived. That is the tell-tale sign that no real decision-making is needed for the ER staff. Just "call EP" (aka, me.)

The decision: pacemaker now or pacemaker later?

The mind does strange things with little sleep, but the decision at that time of night was mine and mine alone. No one else was there. No one else in medicine has this much responsibility. No nurse practitioner, medical administrator, or bureaucrat could make this call, but there I was: dead tired with my mind playing tricks on me. I would hear my inner-self rationalizing with the rapid-fire voices dancing in my head:
"Really, now?" ("Yeah, now")

"His blood pressure is stable, and the ER doctor says he looks fine, maybe this can wait until the morning?" (But that nice escape rhythm could quit, the pacer pads might not work, and you'll have to scramble those 10 miles up the road to make it in time.")

"The rep on call lives far away." (Too bad.)

"The staff will be spent, too. They are overstretched and need their sleep." (But this is why we're on call.)

"Maybe just a temp wire, then pacer in the morning daylight hours? (I have to drive there anyway. The temp wire might dislodge, then the patient has NO rhythm... )

"Dude, just do it. It'll save time in the long run and let you sleep without worrying."
So the pacemaker representative and the rest of the team were called as I drove to see the patient (none are happy, but they understood). I placed a temporary pacing wire for backup (thank goodness), implanted the pacemaker, spoke with the grateful family, then drove home for my head to finally meet my lonely pillow at 2 AM. Thankfully without another interruption that morning.

After a few hours sleep I woke, knowing I did the right thing. But reflecting back to that brief moment of decision-making the night before, I wondered to myself. Could things have gone differently?

Which brings me to the point of this blog post.

For the past five years, there has been tremendous uproar about the payments and unproven requirements of the Maintenance of (Board) Certification (MOC) mandate for US physicians created out of thin air by the American Board of Internal Medicine (ABIM) and marketed by the American Board of Medical Specialties (ABMS) to fund their bloated salaries, lobbying activities, and for-profit corporate subsidiaries that sell data. Thanks in part to the ACA law that includes the MOC mandate as a "quality" metric included by their lobbying, MOC's payments and needless exercises have became mandatory for employed physicians without their knowledge or consent. And with every passing day, the programs and exercises are promised to be easier, faster, less intrusive, because these bureaucrats continuously claim to know what's best for working physicians on the front-line of 24-hour patient care. They wallow in a sense of schadenfreude as they wield their undeserved power over their working colleagues, purposely naive to the most dangerous side effect their unwarranted and potentially illegal actions risk creating.

Longtime readers know that at least five different antitrust lawsuits have been filed against various non-profit entities that comprise the ABMS member boards in regards to MOC. The largest member board of that consortium is the ABIM, who recently breathed a partial sigh of relief when a Pennsylvania judge dismissed most of the claims of anti-trust tying, monopolization, racketeering, fraud, and unjust enrichment brought by four working internists. While the monopolization, fraud, and racketeering claims remain unresolved at this time, we should note that there might be significant consequences if working physicians don't get their day in court, and it's not what most people expect.

Not having an unbiased judgement in court before a jury of one's peers in these untested legal waters risks the development of US physician apathy.

Too many examples of lying, cheating, and stealing physicians' certification fees for political and economic purposes have occurred since MOC was mandated by the ABMS member boards in 1990. From the quiet movement of nearly $70 million from the ABIM to the secretly created ABIM Foundation from 1990-2007 in the name of "Choosing Wisely," the falsification of tax forms, holding political and corporate appointments while serving as the President and CEO of the ABIM, performing undisclosed lobbying, transferring funds to the Cayman Islands, and using felonious strongmen to invade doctors' houses with Federal Marshals and lawyers, were all accomplished just so their monopoly and partnership with insurers, hospitals, and medical specialty societies could flourish. By quashing the chance for justice against these actions, the courts risk irreparably damaging the integrity of the entire US medical profession and crushing the souls of those who make huge sacrifices on behalf of their patients every day.

This whole ABMS MOC fiasco, especially with the recent opinion to dismiss doctors claims of impropriety against this racket of monied tax-exempt corporations so broadly, risks making doctors apathetic. Could such apathy lead to less-than ideal decision-making in the wee hours of the morning?

I wonder.

For the sake of our profession and our patients, it's time to make sure working physicians get their day in court.