Combating MOC Abuses

Thanks to the Orlando Medical News for their comprehensive coverage Tuesday on the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) scandal.

Physicians' best approach to collapse the current ABMS monopoly on credentialing standards remains mass non-compliance.

Employed physicians (like myself) are finding noncompliance impossible without jeopardizing their employment, since many hospitals require their physicians to be "board certified" in their specialty. Since ABMS no longer "recognizes" lifetime certification as a valid credential (except for older "grandfathered" physicians who obtained their board certification before 1990), younger (more economically vulnerable) physicians risk the loss of employment if they do not participate in MOC and agree to the ABMS's "HIPAA Business Associate Agreement," becoming little more than data entry clerks for the lucrative insurance, pharmaceutical, and hospital industries.

Is this really what our patient's want?

I don't think so. Most patients I know would like to see their doctor look them in the eye rather than at a computer screen. Most want to be viewed as humans rather than a data profit center. And all of them want to spend more than 8 minutes with their physician.

So how do physicians combat MOC? How do we preserve our ability to work without having to make extortion payments to the ABMS and their member boards just for their political and personal benefit?

The fight against MOC continues on many levels, but it is a long, difficult, and expensive David-vs.-Goliath battle:

1. The development of an alternate certification board that is affordable and does not require physicians to comply with the ABMS/ABIM HIPAA Business Associate Agreement and comprised of highly-respected unpaid members of the physician community who understad the conflicts of interest inherent to the ABMS member board construct and is gaining acceptance hy hospitals accross the country.


2. State-by-state legislation efforts outlawing the use of MOC as a condition of insurance panel participation, hospital privileges, or state licensure.


3. Persuing other legal avenues, including anti-trust and class action suits against members organizations of the Accreditation Council for Graduate Medical Education, among others.

I would encourage employed physicians who are given a professional stipend from their hosptial systems for professional society memberships to seriously consider using some of those fees to join Practicing Physicians of America in lieu of other conflicted professional and subspecialty organizations as we continue to push back against the MOC mandate (an example of to testimony and evidence provided the Ohio Health Committee here). Other areas to contribute include becoming certified by NBPAS or contributing to their advocacy efforts. It costs nothing to join the Facebook group Physicians Working Together, too. That group offers lots of productive ideas on how we can work collectively to restore the integrity of our profession.

It is only through a corrodinated effort from a large portion of the working physician community that our freedom to truly work in our patient's best interest without unnecessary and unproven third party interference can be restored.

-Wes

The Hidden Message Coming From the AMA

This morning I received a press release from the American Medical Association (AMA) that said "New AMA Research Finds One in Five Physicians Ready to Reduce Clinical Work Hours." The press release pointed to "new research" (sorry, it's behind a pay wall) that appeared in the Mayo Clinic Proceedings from "experts" from the AMA, Mayo Clinic and Stanford University. The lead author of the research was Christine A. Sinsky, MD of the AMA.

But what Dr. Sinsky fails to disclose in her article in the Mayo Clinic Proceedings, is she is also a Director of the American Board of Internal Medicine (ABIM) and a member of the Board of Trustees of the ABIM Foundation, serving as the Vice Chair. This is not a minor lapse in disclosure, since the ABIM Foundation and the entire national Maintenance of Certification debacle may become one of the largest medical education corruption stories in modern medical history. Funneling over $78 million dollars for ABIM testing fees behind physicians' backs to fund the ABIM Foundation appears of little importance to Dr. Sinsky. She is more concerned about our psychologic well-being rather than the behavior of the Foundation she runs with our Maintenance of Certification (MOC) cash. This corruption renders Dr. Sinsky's arguments why physician burnout is at an all-time high mute moot. Turning a blind eye to the facts only deepens physician frustration with our current bureaucratic leadership.

If Dr. Sinsky is so concerned about physician burnout, why isn't she the leading spokesperson at the AMA insisting the leadership there end MOC as it was resolved by the AMA House of Delegates in 2016?

Perhaps it's because she's too conflicted to understand the problem.

-Wes

ABIM and the Human Diagnosis Project

Just when you thought it couldn't get worse, look what your ever-increasing American Board of Internal Medicine test fees are paying for now:

Fostering broader access to affordable, trustworthy, and meaningful artificial intelligence is a key goal for many in the industry, including an international group of stakeholders working on the Human Diagnosis (Human DX) Project.

Spearheaded by prominent organizations including the American Medical Association, American College of Physicians, and American Board of Internal Medicine, the initiative plans to bring quality specialty care, backed by artificial intelligence, to underserved patients around the globe.

... yet another unproven political agenda.

-Wes

ABIM Foundation - Five Years Later

A new public relations push for the ABIM Foundation and its Choosing Wisely campaign recently circulated in the press and MedPageToday. This quote from Richard Baron, MD, president of the American Board of Internal Medicine (ABIM) and the ABIM Foundation (which created and promoted the "Choosing Wisely" campaign) caught my eye:

"Here we are 5 years later; today, 80 [medical] societies have lent their intellectual capital to thinking about this," Baron said. "How do we judge success? We go back to the idea that this is about supporting people having difficult conversations ... [and] health systems around the country are using this as a structure to have these conversations."

Health care organizations ARE using this as a structure to have these conversations. In fact, as has been systematically uncovered in this blog and elsewhere, the ABIM Foundation has spend the last five years spending our secretly funneled testing fees for themselves. Look at the data, pulled from IRS tax forms by Mr. Charles P. Kroll, to understand the magnitude of what has occurred:

Money Laundering Scheme? ABIM Off-Loads $57.2 Million in Program Expenses to ABIM Foundation 1998-2016
🤔Program Revenue? $0 #MOC #HB273 pic.twitter.com/86noWgzYRY

— Charles P. Kroll CPA (@CharlesPKroll) October 4, 2017

While few can argue with the well-meaning effort to limit procedural overuse in medicine, but using physicians' testing fees to promote this program and to line its supporter's pockets without earning any program revenue could be one of the largest white-collar medical education Ponzi schemes (as Elizabeth Rosenthal, formerly from the New York Times, suggested) in the history of US medicine.

-Wes

Kroll: How the War Against MOC® is Being Won

The war against Maintenance of Certification® (MOC®) is being won through social media and "memetic warfare." Spend 23 minutes to fully comprehend what's happening to the ABIM, the ABMS, and their member boards, including the American Board of Surgery, and the American Board of Pediatrics.

Forensic accountant, Mr. Charles P. Kroll, explains:


-Wes

ABIM Tax Filings Show More Important Discrepancies

When was Christine Cassel, MD ever the Senior Vice President and Chief Financial Officer of the American Board of Internal Medicine?

ABIM 2011 Form 990, Page 1 - Signature Line

McGladrey LLC has a long history of accounting deficiencies, but this one might take the cake. ABIM's paid McGladrey LLC a whopping $361,753 for "accounting/consulting" services in fiscal year 2011. This amount is over three times the usual accounting fees ABIM historically paid. 

Why? 

Was there such significant cover-up that ABIM's true Chief Financial Officer at the time, Vincent Mandes, wouldn't sign the tax form?

-Wes

PS: Recall that the AMA House of Delegates requested a formal independent audit of the ABIM. The AMA asked Richard Baron, the President of CEO to respond to that request. An independent audit was never granted. Instead, Richard Baron, MD issued this statement.

What ABIM and Theranos Have In Common

Mr. Chris Jennings
(photo from their company website)

Meet Mr. Chris Jennings, a "consultant" to American Board of Internal Medicine (ABIM) in fiscal year 2010. Mr. Jennings has also served as an advisor to Theranos, the health care technology company recently labeled as a fraud.

Mr. Jennings is the founder and President of Jennings Policy Strategies, Inc., a company with whom, according to their 2010 Form 990, the ABIM "consulted" for a cool $120,000 for fiscal year 2010. (Here's documentation of a portion of that amount).

There's only one problem.

According to the Center for Responsive Politics, Jennings Policy Strategies, Inc was not really a "consultant," but rather a registered lobbying firm in Washington DC in 2010. Just as before, it appears the ABIM has failed to disclose lobbying activity with this firm on their 2010 Form 990 disclosures, choosing instead to label the activity as "consulting." Given this, it appears fraud may involve more than Theranos.

This begs the question: where's the IRS?

-Wes

References:
"Clinton Aide Joins Obama on Health Care," New York Times July 7, 2013.
"Clinton Campaign Advisor Also Advised Fast Faltering Health Care Company," Free Beacon 11/12/2015.
Health Care Affairs blog bio.
ABIM IRS Form 990 - 2010

What is MOC®? Why Is This Important?

What is Maintenance of Certification® (MOC®)?

Is it an educational program for physicians? If you think so, you are wrong.

MOC® has almost nothing to do with physician education, but according to the contract we must sign, involves "certain health care service operations, including practice assessment and evaluations." Most importantly, it allows physicians' personal and practice data to be shared with an unlimited number of third parties through a HIPAA Business Agreement.

Let me be clear. MOC® is not really about physician education. Instead, MOC® allows a physician's personal data to be shared with data registries and large corporations who profit from those data. For instance,  our MOC® and survey data are shared with (sold to?) Premier, Inc. (PINC, the $4.3 billion owners of CECity, Inc.), the largest healthcare performance improvement company that serves 3,900 hospitals and health systems and approximately 150,000 other providers and organizations." (Remember, Christine Cassel, MD, former President and CEO of the American Board of Internal Medicine, served on the board of Premier, Inc at one time and earned plenty of money and stocks in that capacity while at the ABIM.)

It also allows physician data to be sold to ABMS Solutions, LLC, a for-profit wholly-owned subsidiary of the American Board of Medical Specialties that is based in Atlanta, Georgia, who then sells your MOC® status, updated every 24-hours, to others, and a company never mentioned in disclosures published in our major medical journals. They will also plan to share these data with the Disciplinary Action Notification System database owned by the privately-held non-profit Federation of State Medical Boards that solicits "Affiliate Members, Official Observers, and Courtesy Members."

Again, MOC® is not about physician education. It is about collusion with multi-billion dollar companies, including Wolters Kluwer, and Pearson, LLC, and even our own politically-powerful American College of Cardiology that who owns the NCDR procedural registries and sells access to them to hospitals with MOC® as its demographics supplier (a full explanation of how this works is available here).

Why is the understanding of this "definition" of MOC® so important?

Multiple states are enacting legislation to prevent MOC® as a cudgel to limit a physician's ability to hold hospital credentials, be on insurance panels, or obtain state licensure. Our physician data are that important to these companies they will stop at nothing to be sure we sign that MOC® agreement.

What if the ABMS re-brands MOC® to some other "product" at their December 4th meeting with all of those state medical societies frustrated with what MOC® has become? Might the American Board of Medical Specialties and their collaborators skirt existing "anti-MOC®" legislation? Current anti-MOC® legislation must anticipate this and not include "MOC®" but "MOC® or any other health care serve operation that may include practice assessment or evaluations that requires a physician to sign a HIPAA Business Agreement to which they are not parties" in their language.

Physicians enacting anti-MOC® legislation need to understand the legal definition of MOC®. That way they can write legislation that is lasting, meaningful and enforceable, irrespective of how MOC® is ultimately re-branded.

MOC® is broken and must end. Not because it's a failed physician education experiment. It's broken because of its threats to physician civil liberties and threatens the doctor-patient relationship at it's most intimate level, thanks to the age old business motivators, money, power, and greed.

-Wes

Why the IRS Needs to Investigate the ABIM

Monday, the bureaucratic side of the House of Medicine, via the American Board of Internal Medicine, announced their new-and-improved fee structure for Maintenance of Certification®. Lots of fancy corporate spin was used to justify the need for cash, with even some "discounts" (that failed to include the test facility fee as before) were promised for those silly enough to pre-pay for their strongarmed fees.

According to ABIM's publicly reported mission statement:

"THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) SEEKS TO ENHANCE THE QUALITY OF HEALTH CARE BY CERTIFYING INTERNISTS AND SUBSPECIALISTS WHO DEMONSTRATE THE KNOWLEDGE, SKILLS AND ATTITUDES ESSENTIAL FOR EXCELLENT PATIENT CARE...MOST DIPLOMATES CERTIFIED PRIOR TO 1990 ARE STRONGLY URGED TO PARTICIPATE IN MOC BUT ARE NOT REQUIRED TO DO SO TO REMAIN CERTIFIED.FOR ALL DIPLOMATES, IN ADDITION TO REPORTING BOARD CERTIFICATION, ABIM WILL REPORT IF THEY ARE PARTICIPATING IN THE MOC PROGRAM (I.E., ENGAGING IN MOC ACTIVITIES FREQUENTLY)." (From their IRS Form 990)

Board certificaiton, and MOC® in particular, are no longer voluntary for US physicians. I believe (and I do not say this lightly) placing such a statement on an IRS form in this day and age constitutes fraud. MOC® has been cleverly incorporated into hospital bylaws and insurance panel requirements thanks to (1) the public sharing of Margaret O'Kane on the National Quality Forum and the American Board of Medical Specialties board and (2) Richard Baron, MD's work at the Seamless Care Model Group of CMS. Clever corporate inner dealings have benefitted their self-proclaimed corporate partners at FigMD, Kaiser Foundation and Hospital Group, the now defunct IPC The Hospitalist Company, Premier, Inc,, CECity, Inc., ABMS Solutions, LLC, the NEJM Group, Wolters Kluwer, and Pearson Education. As such, ABIM is no longer a charity organization, it is a for profit business. They have never shown improved quality of care no prevented injury to the public (state medical boards address poor quality and behavior by physicians). Rather, like many successful for-profit companies, the organization has promoted the self-inurement of its leadership, board of directors, and academic affilitates through political influence and self-dealing. It is now well-documented that at LEAST $78 million dollars from ABIM diplomates were secretly funneled to the ABIM Foundation for their benefit. Condominium purchases, health club memberships, spousal travel, Cayman Island Investments, a lavish $1.2 million golden parachute for Christine Cassel, MD and an annual salary from Richard Baron that approached $850,000 in fiscal year 2016 are realities and not usually the hallmark of a legitimate charitable organization that provides voluntary benefit to the public. Neither is the repeated convenient misreporting on tax forms from 2008 through 2013 that has occurred, including (at a minimum) misreported dates and place of origin of the ABIM Foundation, lack of disclosure of depreciation of the condominium or the disclosure of lobbying of Congress on those forms either.

At the very least, it is time for the Internal Revenue Service to reevaluate the non-profit status of the ABIM. Taxpayers (and physicians who have no choice but to participate in this costly charade) deserve no less.

-Wes

Hurting for Money, ABIM Raises Fees 12%

(Click image to enlarge)

The American Board of Internal Medicine, over $57 million in debt on paper (or, said another way, with only $13.6 million in remaining in its consolidated assets when combined assets of its shady ABIM Foundation are included), had the nerve to publish its 2018 fee schedule today and it's a doozy.

Without answering the evidence supporting corruption and self-dealing made before the Ohio legislature on 11 October 2017, the ABIM and its leadership continue to market their shakedown of US physicians as providing "Choice. Flexibility. Value." They're even bragging that if you bend to their extortion and pre-pay, you'll be getting a good deal.

Physicians are not idiots.

I would encourage physicians to use the National Board of Physicians and Surgeons (NBPAS.org) instead of the ABIM Maintenance of Certification for documentation of their commitment to life-long education. This ridiculous charade has to end.

-Wes

My Remarks Before the Ohio Health Committee On MOC®

Here is the testimony I delivered today at the Ohio Health Committee hearing on Ohio House Bill 273 sponsored by Representative Teresa Gavarone in Columbus, Ohio. (Each committee member was handed this evidence packet to refer to before I spoke):

Dear Honorable Committee Members:

Thank you for the opportunity to speak and to provide evidence to the citizens of Ohio regarding my remarks today. My name is Westby G. Fisher, MD. I am a triple ABMS Board-certified practicing internist, cardiologist, and cardiac electrophysiologist from the Chicago Metro area representing Practicing Physicians of America, a group I co-founded that represents over 40,000 frontline practicing US physicians of all specialties and from all 50 states (including Ohio). We vigorously support Ohio’s House Bill 273 that restricts the hospital and insurance industry’s ability to prevent experienced physicians from practicing their trade on the basis of an unproven, costly and time-consuming proprietary marketing product called “Maintenance of Certification.”

I stand before you, on behalf of my working colleagues, as a bedside treating physician with a valid state license. I am not a paid lobbyist. I do not have a political agenda to serve. I do not have hundreds of millions of dollars of funding behind me. I represent the doctor see when you walk in a hospital or a clinic office, feeling scared, vulnerable, or sick.

The issue pertinent to this legislation is the proprietary product owned by the American Board of Medical Specialties (ABMS), a private non-profit corporation, and marketed by their 24 subsidiary specialty boards, as “Maintenance of Certification.” Maintenance of Certification is sold above and beyond physician’s initial lifetime Board Certification, a voluntary credential physicians obtain by taking a test to demonstrate competence in their specialty. I stress again, Maintenance of Certification is NOT to be confused with initial ABMS Board Certification, a voluntary once-in-a-lifetime credential analogous to the “bar” examination performed by the legal profession. Most physicians I know, including me, understand the value of initial, lifelong certification with ongoing Continuous Medical Education training. We should note that Ohio physicians have a proud tradition of supporting one of the strongest Continuing Medical Education (CME) requirements after their initial Board certification for maintaining their licensure, requiring 100 hours of CME every two years.

Maintenance of Certification was conceived by the American Board of Internal Medicine, the largest member board of the American Board of Medical Specialties that certifies on quarter of all US physicians, they claimed, to assure “continuous professional development.” Initial voluntary attempts to market this extra distinction failed because doctors already took responsibility for their own Continuing Medical Education and did not see additional centralized Maintenance of Certification testing as helpful or appropriate.

Sadly, this initial failure to voluntarily engage America’s doctors resulted in a new chapter of coercion and threats to physicians that continues to this day. In 1990, the American Board of Internal Medicine abruptly announced the end of life-long Board certification, claiming doctors needed to “keep up” with medical advances and threatened “uncertain circumstances” if they did not participate in Maintenance of Certification. To avoid significant backlash of the entire physician community, they grandfathered senior, predominantly male physicians certified before 1990. Younger doctors, closer to training, reluctantly complied.

Despite 30 years of existence, time-limited certification has never been proven to improve patient safety or care outcomes compared to lifetime Board certification. To be even more clear, let me emphasize that doctors are not picking up their Maintenance of Certification board review packet in order to figure out how to deal with a complicated patient down the hall. This is not the way it works on the ground. Instead, younger, more economically vulnerable, and increasingly female physicians were discriminated against with this change that persists today. The change also converted the once “voluntary” aspect of lifetime board certification to a mandate, since more hospitals insisted their physicians be board certified (as did insurance companies), thanks to their lobbying efforts. Through this clever regulatory capture, employed doctors were left with no choice but to sign a MOC contract that relinquishes their free speech rights and requires they become research subjects without informed consent.

Using the very real threat of the loss of employment, repetitive physician re-certification by way of Maintenance of Certification instantly became a remarkably successful business model for these non-profits, providing the American Board of Medical Specialties $343 million in revenue from certifying and recertifying US physicians in 2011 alone. In fact, the costs of board re-certification for the average physician have mushroomed 244% in the last 15 years, over 4 times the rate of inflation each year.

In 2005, the American Board of Medical Specialties registered the Maintenance of Certification® and MOC® trademarks and insisted all of their member boards end lifetime certification and would only recognize time-limited re-certification as valid while also adding the requirements to perform Practice Assessment, Patient Voice and Patient Safety exercises for physician to perform every 7-10 years, too. These represented even more precious hours of physician time as well as fees. The inevitable consequences of this monetary goldmine were predictable, especially when they operated with little to no oversight for years.

It is important to note that the requirement for time-limited Board certification (as opposed to lifetime Board certification) pre-dated the world wide web. But as the web grew, so did practicing physicians’ ability to fact-check the claims made by the ABMS and their member boards. Many of those facts uncovered are in the packet included before you. By 2013, physicians uncovered inconsistencies between tax filings and ABMS member board web page disclosures. They found bylaw changes that permitted unlimited conflicts of interest. They found undisclosed lobbying. They uncovered the secret funneling of over $77 million of their physician testing fees piecemeal from 1990 to 2007 to create the ABIM Foundation that was supposed to define and promote “medical professionalism.” Excessive salaries, multi-million dollar golden parachutes, first-class and spousal air travel, health club memberships, luxury condominium purchases, and off-shoring of our testing fees for retirement funds doctors learned, were all funded by us. Even a felonious ex-cop who had been fired from the Washington DC police force for inciting reprisals against a journalist was hired to serve as “Director of Test Security” for these organizations making them more akin to a protection racket than a protector of the public. It is no wonder, then, that legal fees at the ABIM and its Foundation have grown from an average of $146,000 per year before Maintenance of Certification was introduced to over $1 million per year after Maintenance of Certification was introduced for its defense against physician lawsuits. Ironically, we pay those fees as well. Anti-trust suits and class action law suits are pending against the ABMS and American Osteopathic Association. Rest assured anyone speaking in opposition to House Bill 273 somehow has a financial interest in the program or the data they sell. Keep that in mind in the weeks ahead.

Physician shortages and burnout are real problems today and affect every state in the union. How does Maintenance of Certification affect this? No one has bothered to conduct a study examining the psychological, economic, or employment outcomes of highly experienced physicians who fail a re-certification examination of which there are many. Nor has there been a study on the impact that Maintenance of Certification testing has on a doctor’s loyal patients. Hundreds of tweets and emails I receive each year speak to the reality of the tremendous negative effect on decent, highly-respected colleagues too embarrassed to go public with their failure, many of whom quietly leave medicine. The Maintenance of Certification profit-making machine is creating a physician brain drain and a shameful exodus of too many good people.

This is why 23,000 US physicians signed an online petition to end Maintenance of Certification monopoly. That is why the Pennsylvania Medical Society issued a formal “Vote of No Confidence” against the American Board of Internal Medicine in June of 2016. That is why the AMA House of Delegates (including the Ohio delegation) voted to end Maintenance of Certification at the same meeting. This is why a new, competing board called the National Board of Physicians and Surgeons led by unpaid board members to independently verify a physician’s participation in Continuing Medical Education was created and a growing number of hospitals accept as an alternative to participation in Maintenance of Certification. And that is why the Ohio State Medical Association has voted to support this bill. Physicians across the country are not blind to the corruption, and the burden to practicing physicians and their patients is not trivial. Twenty three states have introduced similar bills to this one, and 8 have enacted those laws.

Despite all of this, I am sure that opposition to House Bill 273 will remain strong. When one considers the numerous subspecialty board review courses that exist, and the gauntlet of tests a physician must endure to become licensed, certification of physicians is a $2 billion dollar-a-year enterprise. Our opposition will tout the duration, breadth, and scope of training required by ABMS member boards as the best validation of physician knowledge, while ignoring a physician’s clinical experience entirely. But as Dr. William Osler famously said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” The fact that this shameful bureaucratic continuous re-credentialing system has wrapped itself in a blanket of highly respected, well-meaning physician contributors should surprise no one, but it does not change the facts. In other states, opponents to similar bills as Ohio’s House Bill 273 have been strangely silent about the corruption, preferring instead to focus on the public’s “need to know” talking points as a way to spin away from the ugly truth. Why is that? Do they believe corruption is inevitable? Do they assume practicing physicians will just shrug and write another check?

Winston Churchill once said, “Criticism might not be agreeable, but it is necessary. It fulfills the same function as pain in the human body. It calls attention to an unhealthy state of things.” Maintenance of Certification is very unhealthy for our profession. The time we take away to defend our profession in this very sad chapter of our profession is time we take away from our patients, including your constituents. That is why we need your help and your attention to this uncomfortable matter.

In closing, of course initial board certification is important but this has nothing to do with repetitive re-Board certification known as MOC. Of course physicians want to self regulate and want to participate in CME, but they should not have to prop up coercive program based on threats to our integrity and civil liberties for their profit. Scare tactics about patient safety and physician self-regulation are just that; last ditch efforts of intimidation to prop up the gravy train.

Thank you for having the courage to vote against the status quo, against the multimillion dollar lobbyists, and thank you for protecting Ohio physicians and their patient’s access to them by voting in favor of House Bill 273.

-Wes

Ohio and the Embarrassment of MOC

Today Ohio legislators will be introduced to the concept of "Maintenance of Certification" or "MOC" when House Bill 273 is introduced by Representative Theresa Gavarone (R) to the Ohio Health Committee. Most of the Committee members won't have a clue what MOC is or why they should care.

Lobbyists from the American Board of Medical Specialties (ABMS) and the American Hospital Association (AHA) will claim "the legislation puts patients at risk" and that "patients deserve to know their physicians are up to date" even though this statement flies in the face of the ABMS's own data and that of independent researchers. They even have the nerve to make statements like this: "Faced with a physician who was certified after residency who has not kept the certificate current, patients will be in the dark."

Like the members of these corporations ever set foot in a patient exam room...

Here's ABMS's ACTUAL history of promoting patient "safety" and knowing what patients think.

Recall that in 1969, Dr. Thomas Brem, former Chair of the ABIM and President of the "Advisory Board of Medical Specialties" (our current ABMS) testified before the House Committee on Interstate and Foreign Commerce, stumped for Big Tobacco by testifying "neither can offer unequivocal scientific proof that smoking does or does not cause cancer of the lung." Dr. Brem conveniently failed to mention he was receiving payments from "Special Account No. 4" that was maintained by tobacco company lobbyists. How many lives were affected by this testimony?

While we'd like to think this is just an isolated event, it was not. In fact, such corporate collusion has been the hallmark of the ABMS and their member boards as they shower themselves with lavish salaries and perks at the expense of vulnerable work-a-day physicians.

For her entire career as President and CEO of the American Board of Internal Medicine, Christine Cassel, MD served on the board of directors of the Greenwall Foundation, Kaiser Permanente, Premier Inc and other organizations with quality health care agendas at diplomates' expense while never disclosing these conflicts of interest. It was only after she joined the National Quality Forum (that receives the majority of its funds from government contracts), that these financial relationships were exposed. Citing the "distraction" of it all, she quickly resigned her affilitation with Kaiser and Premier, but not before bilking her unsuspecting ABIM colleagues for over $8.9 million and free travel for her spouse and helping to facilitate the $400 million purchase of CECity, Inc. by Premier (in which she held stock).

Robert Wachter, MD, the golden-boy of corporate medicine and promoter of hospitalist medicine, was also former chairman of the board of the ABIM for a time. He, too, would rather not discuss his "love agenda" for medicine once his relationship with IPC The Hospitalist Company was exposed by the Department of Justice for overbilling patients. It is no wonder he brought down his industry-sponsored blog, Wachter's World.

Nothing to see here, folks.

Other ABMS member boards and their corporate partners would also not like legislators to examine the American Board of Pediatrics, who saw no problem giving James Stockman, III, MD a $2.4 million golden parachute to help fund his car collection and retaining him to work eight hours a week for a $793,438 annual salary. Who funds such largess?

Working pediatricians.

James Puffer, MD of the American Board of Family Medicine and their directors have also enjoyed high salaries while quietly funding his organizations' Foundation's purchase of corporate office buildings and running for-profit real estate management companies. I'm not sure I've ever seen a clearer quality and patient safety initiative funded by diplomates.

The truth be told, MOC is a horrible embarrassment to our profession. We are doctors, for goodness sake. We are not funding vehicles for political and corporate agendas. It is sickening to me that we continue to see medical specialty societies joining the ranks of these highly-conflicted organizations so they can dovetail their lucrative data registries with maintenance of certification as their next sure-fire business model. Is spending time, energy and money lobbying on Capital Hill to keep such registries funded on the backs of working physicians more important than supporting doctors' effort to remain at the patient's bedside rather than at the keyboard?

It seems so.

MOC is coercive, hopelessly financially conflicted, and corrupt. Working physicians need Ohio representatives (and all state representatives) to examine the facts, not cave to the hospital and insurance company lobbies. Working doctors know the score now. Many any are quitting rather than subjecting themselves to MOC again and again just to keep money flowing to the ABMS and their member boards so they can keep working. Patients, particularly those in rural areas, lose when this happens.

From it's inception, MOC was created from lifetime board certification, not for patient care quality or safety, but rather so ABMS officers and directors could pay themselves handsomely. It continuation is fueled by deception, political agendas, and cronyism. MOC also requires coercion and strongman tactics to keep the money flowing. No matter how our own bureaucratic colleagues might sugarcoat MOC on the pipedream of assuring patient care quality and safety, critical examination of the evidence clearly demonstates what an embarrassement the program has been to the integrity of US medicine.

It's time to end it.

-Wes

The American College of Cardiology and ABIM

I wonder how many American College of Cardiology (ACC) members are aware that the ACC entered into a "Memorandum of Understanding" with the American Board of Internal Medicine (ABIM), (along side the American College of Physicians and American Society of Clinical Oncology) "to explore development of collaborative pathways through which physicians can maintain board certification:"

“The ACC is pleased to join ASCO and ACP on exploring these additional pathways for cardiologists, oncologists and internists to maintain their certification. For cardiology, the ACC would provide clinicians with learning material and assessments modeled after its lifelong learning self-assessment program (ACCSAP). Helping our collective members in the provision of professional and compassionate care, while also keeping up with current knowledge, is a shared goal. We appreciate ABIM’s willingness to continue to listen to and engage with stakeholders in order to achieve this goal in a more effective manner.”

Mary Norine Walsh, MD, FACC
President, American College of Cardiology

What is not mentioned is the exchange of funds that will occur between organizations. How much will ABIM's inter-organization "certification" cost? Might this be one more financial bail-out strategy for the ABIM, given their long history of financial impropriety and rapidly depleting consolidated net assets? Why does the ACC insist on perpetuating MOC when the AMA House of Delegates voted to end the program? Might these organizations' own financial and political aspirations supercede the needs of their members? How much more money will practicing cardiologists have to spend to remain employed at their hospital systems now that MOC is increasingly tied to our credentials and insurance payments?

MOC has become one of the largest single causes of burnout and distrust in our professional societies that increasingly ignore their members' concerns in the name of political correctness and personal gain. This professional society collaboration is anything but helpful to resolving the MOC impass and only serves to strengthen our resolve to end it.

-Wes

Our Unsustainable Fear-based ABMS Physician Credentialing System

"... diplomats would be asked, but not required, to renew the validity of the certificates at periodic intervals or face the uncertain consequences of loss of their status as certified internists, subspecialists or holders of certificates of added qualifications."

(Glassock, R. J., Benson, J. A., Copeland, R. B., Godwin, H. A., Johanson, W. G., Point, W., Popp, R. L., Scherr, L., Stein, J. H., & Tounton, O. D. (1991). Time-limited certification and recertification: the program of the American Board of Internal Medicine. Annals of Internal Medicine, 114(1), 59–62.)

* * *

"Candidates for Board Certification and Maintenance of Certification agree that their professional qualifications, including their moral and ethical standing in the medical profession and their competence in clinical skills, will be evaluated by ABIM, and ABIM's good faith judgment concerning such matters will be final.

ABIM may make inquiry of persons named in candidates' applications and of other persons, such as authorities of licensing bodies, hospitals or other institutions as ABIM may deem appropriate with respect to such matters. Candidates agree that ABIM may provide information it has concerning them to others whom ABIM judges to have a legitimate need for it.

ABIM makes academic and scientific judgments in its evaluations of the results of its examinations. Situations may occur, even through no fault of the candidates, that render examination results unreliable in the judgment of ABIM. Candidates agree that if ABIM determines that, in its judgment, the results of their examination are unreliable, ABIM may require the candidates to retake an examination at its next administration or other time designated by ABIM.

ABIM also may evaluate candidates' or diplomates' fitness for Board Certification – including their professionalism, ethics and integrity – in disciplinary matters, and ABIM's good faith judgment concerning such matters will be final."

(ABIM Online Maintenance of Certification Policies. Available at http://www.abim.org/maintenance-of-certification/enrollment-cost/policies.aspx . Accessed 3 Sep 2017).

* * *

"ABIM's review of evidence seized from the Arora Board Review reveals you were a course attendee. As part of your Examination, you and all other examinees signed a Pledge of Honesty, agreeing among other things that you would not give or receive aid in your examination. The Pledge of Honesty also prohibits Examinees from disclosing, copying, or reproducing any portion of the material contained in the Examination. You were also provided with contact information for ABIM's Exam Integrity Hotline to report inappropriate behavior that occurred with the Arora Board Review course.

ABIM has ethical and professional concerns from arising from your conduct described above. As a result, ABIM is placing a copy of this letter in your file."

(Lynn O. Langdon, MS, Chief Operation Officer, ABIM "Letter of Concern" dated 8 June 2010)

* * *

"The American Board of Internal Medicine is moving against nearly 140 doctors who it says cheated on the organization's certification exams by seeking out, sharing and in some cases purchasing actual test questions from a board-review company.

Board certification isn't required to practice medicine, but is commonly needed for doctors of all stripes to secure hospital privileges or participate in insurance plans.

In suits filed Friday in U.S. District Court for the Eastern District of Pennsylvania, the ABIM alleges that five physicians infringed the organization's copyright on test questions. The suits also accuse them of misappropriating trade secrets and breach of contract."

(Hobson, K. "Medical Board Says Doctors Cheated" Wall Street Journal 9 June 2010.)

* * *

"I must say, candidly, that with over 50 years of law practice I have never before seen the likes of the repeated attempts by Dr. Westby G. Fisher to malign a person based upon an 11-year old “blip” in his long and successful career of public trust. It is, to be sure, unconscionable, to be using invective to shame the ABIM and, along the way, destroying the career and good name of a very honest, competent person, I know that if a member physician were similarly treated you would be mounting the ramparts to obviate its harm to his/her career."

(Letter from Sidney Baumgarten, Esq., Attorney at Law, to Alan J. Miceli, Editor, Philadelphia Medicine Magazine dated 27 Dec 2016)

How much money does the trademarked time-limited ABMS MOC® program generate annually for the ABMS and its member boards?

$392 million. Per. Year.

(This amount does not include the revenue generated by board review courses and study materials sold by colluding state medical societies and medical subspecialty societies.)

Fear and intimidation might sell MOC® for a while, but when the US medical education and credentialing system in the United States relies on fear for little more than its bloated bureaucratic and political purposes, it is non-sustainable. Practicing physicians like myself will not be ruled by fear-based policies and politics, especially when those imposing the mandate are completely unaccountable to our patients and our families.

I would encourage all of my readers to boycott the ABMS MOC® program (irrespective of the "kinder and gentler" model MOC® pivots toward), remain board-certified with the National Board of Physicians and Surgeons, and to consider joining Practicing Physicians of America, to protect our civil liberties of free speech and Fourth Amendment protections against illegal search and seizure.

Our ability to care for patients without such intimidation demands nothing less.

-Wes

Who Will Be Dr. Nora's Replacement?

Ladies and gentlemen,

With the cooler temperatures, kids heading back to school, and a new fall season soon upon us, there's excitement building in the air! The much-coveted position at the American Board of Medial Specialties (ABMS), President and CEO, will soon be vacant. In October, 2016, Lois Nora, MD, JD, MBA announced her upcoming retirement in December of this year after six years of leadership and the political jostling for her comfy salary, first class travel, and health/social club membership perks have been underway for some time.

Who will be her lucky successor? For that matter, who might be potential candidates for her position?

This is an important consideration for US physicians who increasingly find their ability to practice medicine compromised by the proprietary ABMS Maintenance of Certification® (MOC®) program. Since working physicians in America have no control over the selection of this lucky person, we can only venture a guess who might be considered. But there have been several recent hints in various media channels who might be throwing their hat in the ABMS-leadership ring. 

Here is a recent sampling:

1) Hal C. Lawrence III, MD - Executive Vice President and CEO of the American College of Obstetrics and Gynecology (ACOG)

Dr. Lawrence has demonstrated leadership and political moxie drafting the recent letter reportedly "signed" by 38 state medical societies and 33 medical specialty societies in support of a "re-directed" form of MOC® that helps preserves our current highly conflicted method of "professional self-regulation." Dr. Lawrence has also proven himself capable at helping preserve the American Board of Obstetrics and Gynecology subcontractor role as test developers for the ABMS if the status quo is continued. For these reasons, Dr. Lawrence appears well on his way as a possible Dr. Nora replacement.

2) Yul Enjes, MD or 3) Eric Green, MD - a.k.a. "The Doctors Who Defend MOC"

Dr. Enjes has first-hand experience with political cronyism in non-profits serving on the ABIM Board of Directors and as former Chair of the American College of Physicians Board of Governors. Dr. Enjes has cleverly laid low on his important role with supporting MOC - until this article - and can't believe state legislators should have a role protecting the doctor-patient relationship when the ABIM's practices of strong-arming physicians to spend $23,607 every ten years for their condo puchases has been so effective. As such, Dr. Enjes seems like a real ABMS team player!

Dr. Green, on the other hand, might be an equally formidable candidate since he appears to be a strong proponent of income distribution in the form of a "minor" MOC "tax on our time to help the public." His convenient ability of forgetting to mention there is no independent proof that MOC® helps anyone except ABMS revenues makes him a strong candidate for Dr. Nora's position, or any other ABMS member board.

4) Richard Baron, MD - war-torn but time-tested President and CEO of the American Board of Internal Medicine (ABIM) and ABIM Foundation.

There isn't a handsome salary out there Dr. Baron would refuse without having to see patients and Dr. Baron's former work at the Seamless Care Models Group at the Center for Medicare and Medicaid Services to secure MOC® as an (unproven) quality metric gives him a leg up on the other candidates. The only problem now is that Dr. Baron would have to accept a pay cut relative to his robust $849,483/year haul he receives from the ABIM and ABIM Foundation. Still, the ability to spend more time away from the office without the frontline controversy created by the ABIM Foundation's $2.3 million condominium purchase, ongoing anti-trust and physician suits, Cayman Island fund transfers and controversial income redistribution plans using ABIM diplomate testing fees to provide "grants" for various forms of "professionalism" in our nation's medical schools might be welcomed as the heat continues to be applied at the ABIM.

5) Darryl S. Weiman, MD, Professor of Surgery, University of Tennessee Health Science Center and author of "Maintaining My Surgical Certification" in The Huffington Post.

Dr. Weiman, who conveniently fails to mention the American Board of Surgery's conflicts in test development for the ABMS in his HuffPo piece, might be a shoe-in for the position since he appears to be facile at spouting veiled threats in the politically liberal US news and opinion media outlets like the Huffington Post. No doubt the ABMS board of directors love hearing him threaten that loss of maintenance of certification would mean "the public may perceive this as a nefarious way for the medical profession to lower its standards." Wow. Powerful stuff that means nothing to real patients. Since Dr. Weiman seems blind to the nefarious ways the ABMS MOC® program discriminates against younger physicians, uses undisclosed strongmen for protection, and promotes the use of our testing fees for their personal use, it's hard to see how such a fine candidate for Dr. Nora's position could possibly be passed over.

It's a crowded field already.

So who will be Dr. Nora's replacement? Will it be one of these folks or someone else? (The ABMS really needs your help deciding. Comments open.)

-Wes

On State Medical Societies' Letter to End or "Redirect" MOC

On Tuesday of this week, a letter (with two appendices A and B) sent from 38 state medical societies and 33 professional medical associations to Lois Nora, MD, JD, MBA President and CEO of the American Board of Medical Specialties (ABMS) regarding the "contentious Maintenance of Certification (MOC)" issue was leaked to social media channels.  There are no signatures, no letterhead. Just a single contact person with a Washington DC phone number to control the message?* After brief background check, it appears the letter was legitimate and the product of several influential medical groups' efforts to alter the ABMS MOC program and coordinated by the Association of American Society Executives (AAMSE).

I was intrigued that a number of professional subspecialty societies joined with the state medical societies to request a meeting on 4 Dec 2017 with Dr. Nora to voice their concerns about MOC with the ABMS. Whether the ABMS will agree to a meeting or just use this meeting as another example of "listening" to more groups before fulfilling their own agenda remains to be seen. What is concerning to me, however, is that state medical societies felt they needed to ask Dr. Nora for a meeting when they are the ones that hold the ultimate accountability of self-regulation in their respective states. Shouldn't Dr. Nora be asking for a meeting with them? And why request a meeting with Dr. Nora on 4 December 2017 when she's planning on retiring later the same month?

I worry about the political and business naïveté' of these state medical organizations relative to the specialty societies who earn considerable annual revenues from MOC and may be recruiting them. It is concerning that the circulated letter uses the same talking points as the ABMS and their member boards. This letter quickly shifts from the concerns about MOC to the talking point that "this is not about MOC but professional self-regulation." The same concern of the potential loss of "professional self-regulation" recently appeared in a JAMA opinion piece supportive of MOC by a former American Board of Internal Medicine board director. It was also mentioned in an earlier May, 2017 email blast from the American College of Surgeons who opposed the anti-MOC legislation in Texas. Impressive "harmonization?"

There appears to be a consensus that using the strategy of holding loss of professional self-regulation over working physicians' heads will help us forget all that pesky corruption. Surely state medical societies do not want to buy into this kind of manipulation. Pity the poor physician who does not want to lose his ability to self-regulate his profession and rejects corruption. Where are they to stand? Might this talking point "harmonization" actually be a means to legitimize a "redirected" version of MOC?

The only thing I might say in reply is these organizations only took us half way there.

The current tone of this letter is not one of intolerance and repudiation of the corrupt ABMS MOC program, but rather a request to "redirect" it. In fact, this letter has a disconnect between wanting to "redirect" MOC with only two choices for practicing physicians: (1) propping up the current system of "professional self-regulation" or (2) something else. There is no clarity to the "something else." This is analogous to telling physicians that we'd better slip the Chicago alderman $200 per year, and be grateful for the protection. Why would state medical societies join in such a veiled threat?

Our current method of ABMS member board "professional self-regulation" using MOC has proven itself to be corrupt and laden with numerous undisclosed conflicts of interest, self-dealing, non-transparency, and intimidating strongman tactics. Should we be grateful to ABMS for this, given the nebulous alternative? Let's get the ominous alternative on the table. And why in this letter is there no possibility of a third choice when  an alternative model to MOC is developing in front of our eyes?

Naturally, the National Board of Physicians and Surgeons (NBPAS) has a monumental shortcoming. It fails to guarantee millions in educational fees to many of the subspecialty societies on this letter. One can see how this third possibility just isn't as, well, fun.

Perhaps that's the real reason this letter was released.

Physician members of these specialty and state medical societies should be aware they are playing into ABMS's hand with this letter and should be up to date on the options and the evolving consensus regarding legitimate professional self-regulation. To that end, the integrity and transparency of the NBPAS should be promoted in lieu of the ABMS. Indeed, the state medical societies of Texas and Pennsylvania have played important roles in placing physicians and their patients before the financial concerns of subspecialty organizations and ABMS member boards. This should set a precedent for state medical societies across the country. What they should NOT be doing is begging for a meeting with a lame duck President and CEO of the ABMS who are only looking to grow the frequency and cost of MOC in the name of "professional self-regulation" since the ABMS and their member boards are the ones that got us in this mess in the first place.

Radical reform of the corrupt MOC program is not paying the Chicago alderman $250 per year  instead of $200.

- Wes

Addendum 26 Aug 2017 06:23AM - Appendix B added and the origin of the letter (AAMSE) added.

* That individual, Hal C. Lawrence III, MD, ACOG Executive Vice President and CEO, has significant conflicts of interest with the ABMS. The American College of Obstetrics and Gynnecology (ABOG) are subcontractors for "Test Development" with the ABMS.

Fake News: Annals of Internal Medicine's Disclosures

On 15 Aug 2017, the editors of the Annals of Internal Medicine published the Study "Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination - Randomized Controlled Trial" that was heavily marketed front and center on their website using the happy physician testing picture shown to the left.

The article touted a comparison between open book vs. closed book testing that was conceived exclusively by the American Board of Internal Medicine and executed by their conflicted corporate partners at PearsonVue and a new $10.5 billion corporate heavyweight from the Netherlands, Wolters Kluwer. In a veiled attempt at full disclosure, the conflicts of interest of the study were carefully articulated in a lengthy disclosure statement hidden behind a paywall. True to form, nearly all of the editors of the article claimed "no financial relationships or interests to disclose."

Most internists in the U.S. know these editors' disclosure is little more than fake news. The Annals of Internal Medicine is an academic medical journal published by the American College of Physicians (ACP). On its last available Form 990, the ACP earned over $24.6 million in a single year selling their Medical Knowledge Self-Assessment Program to US physicians to study for their board certification and recertification examinations. Even the accompanying editorial was written by ACP's former senior executive vice president, Steven E. Weinberger, MD, who disclosed he was an employee of the ACP and earned royalties from authored material on UpToDate.

In addition, the supplement supplied by the authors had portions of the recruiting notice redacted so avoid true disclosure. But when a copy of the actual recruiting notice is revealed here, it is clear that PearsonVue had more than a minor role in the research and had access to the study registrants' names, addresses, and probably more.

Each of the 825 physicians enrolled in the study received $250, costing US physicians (who unwittingly funded the ABIM Foundation) $206,250 for "incentive payments" for this study, not including the time and salaries of those who conducted this study for the ABIM's benefit. None of the participants were told about the financial benefits to the ABIM, PearsonVue, Wolters Kluwer, or their content creators for participation in this study.

Such conflicted "research" published in an academic medical journal that misleads the public and US physicians represents little more than a free advertisement for the financial agendas of these colluding organizations and sets and incredibly low (and untrustworthy) bar for all of academic publishing.

-Wes

Texas to JAMA: A Lesson on Self-Regulation

Texas Medical Association (TMA) spent no time responding to David H. Johnson, MD's veiled threat of loss of self-regulation with the passage of Texas Anti-MOC legislation, SB1148, published in JAMA 7 Aug 2017:

In a letter to the editor submitted to JAMA but not yet published, TMA President Carlos J. Cardenas, MD, agrees on the importance of self-regulation to his profession.

"It encompasses our responsibility and our authority to establish and enforce standards of education, training, and practice," Dr. Cardenas wrote. "We routinely defend that responsibility and authority in advocating against the intrusion of all third parties — such as government, private insurers, hospital administrators — into the practice of medicine."

But physicians in Texas and across the country, he argued, do not see the certifying boards as "self."

"They are, instead, profit-driven organizations beholden to their own financial interests," Dr. Cardenas wrote. "In fact, they are now one of the outsiders intruding into the practice of medicine."

Until the boards "completely overhaul their processes, finances, and lack of transparency," he concluded, physicians "will have no choice but to continue to seek statutory defenses against these third-party intrusions into our noble profession."

Here's a link to the full statement.

-Wes

MOC and Recertification - As Predicted

David H. Johnson, MD, former board member of the American Board of Internal Medicine (ABIM), authored an opinion piece entitled "Maintenance of Certification and Texas Bill SB1148 - A Threat to Professional Self-Regulation" in the August 7th issue of JAMA. At the end of his article, Dr. Johnson discloses that he served as a member of the American Board of Internal Medicine board of directors from 2007 until 2015 and as board chair from 2013 until 2015.

Dr. Johnson's leadership and influence at the ABIM spanned the time of the purchase of the ABIM Foundation $2.3 million condominium in December 2007, the hiring of the ABIM's felonious "Director of Investigations" (formerly "Director of Test Security") in 2008, the Arora Board Review sting operation in 2009, blind approval of Christine Cassel, MD's conflicts as she simultaneously served on the boards of Kaiser Foundation and Hospitals and Premier, Inc., approval of a $1.2 million golden parachute for Dr. Cassell as she left for the National Quality Forum, and the appointment of Richard Baron, MD who served revolving-door positions from the ABIM, the Center for Medicare and Medicaid Services, the National Quality Forum, and back to the ABIM as he worked to create "seamless" care models for their organization and others.

Dr. Johnson tries to defend MOC by referring to an opinion piece published in 1979 by Arnold S. Relman, MD (who as the editor of the New England Journal of Medicine at the time and a staunch single-payer advocate). But Dr. Johnson failed to mention Dr. Relman's prescient predictions for recertification shortly after introduction of the exercise over 40 years ago:

"Now there are signs that the boards and many of the specialty societies are beginning to have second thoughts about the whole idea of recertification. At the meeting last March of the American Board of Medical Specialties, delegates had such misgivings that they could not agree on whether a specialist's recertification status should even be mentioned in the Directory of Medical Specialists. The Council of Medial Specialty Societies reports that at least four of its constituents societies (representing dermatology, neurological surgery, orthopedic surgery, and radiology) now oppose the idea of recertification, and other societies are said to have 'sizable blocs of members with serious reservations.' At the recent meeting of the AMA's House of Delegates in Chicago, a resolution was taken under consideration that recommends that all specialty boards except Family Practice call a moratorium of recertification. The intent of the resolution is to put an emphasis on mandatory continuing medical education (CME) as a preferred alternative to any kind of recertification program. It is still too early to know whether these developments portend a decisive change in organized medicine's attitude toward recertification, but what seems clear is that the recertification process no longer commands widespread confidence, if it ever did. ... Many doctors are worried that many perfectly competent and conscientious practitioners might be unable to pass recertifying examinations that emphasize arcane facts and the latest literature rather than the practical management of patients. Many doctors also suspect that even voluntary programs would inevitably become compulsory and that the whole recertification process would soon come under government scrutiny and ultimately government control. Reimbursement schedules and hospital staff appointments might then be determined by recertification status; in consequence specialists unable to meet arbitrarily imposed examination standards might find their livelihood in jeopardy."

Dr. Relman's prescient predictions are now most practicing physicians' reality. There is a certain schadenfreude that exists with the physician community toward the ABIM since passage of Texas anti-MOC legislation, SB1148. The ABMS Member boards (and the ABIM in particular) are responsible for Texas Bill SB1148, not practicing physicians. The threat to practicing physicians is not the loss of self-regulation, as Dr. Johnson surmises. Rather, it is loss of trust in the US physician credentialing system that has been spawned by the threats, intimidation and indifference to fraud by members of our bureaucratic physician academic elite within the credentialing community because of the huge profits and control over physicians it generates for their own purposes...

... just as Dr. Relman predicted.

-Wes

ABMS Reacts to JAMA MOC Financial Study

It didn't take long for the American Board of Medical Specialties (ABMS) to issue a statement via MedPageToday on the ABMS member boards' fees and finances for physician certification and re-certification, claiming their fees are "reasonable." In my view, they would have been smarter to say nothing, especially since their entire non-profit status may come under scrutiny when all the facts and conflicts of interests inherent to the US physician Board certification system are carefully considered by the Internal Revenue Service.

Let's fact-check their public statement line by line:

"The research letter entitled 'Fees for Certification and Finances of Medical Specialty Boards' published in the Aug. 1, 2017 issue of JAMA offers an aggregate view of the fees charged by the 24 ABMS Member Boards for more than 860,000 physicians to obtain initial Board Certification and as well as continuing certification throughout a physician's career.

Note the ABMS rebuttal statement was careful not to use the term Maintenance of Certification® (MOC®), but rather used the term "continuing certification." That's because it would hint at the existence of their for-profit wholly-owned subsidiary, ABMS Solutions, LLC, domiciled in Atlanta, GA, that makes money selling physician MOC® certification status to third parties, generating revenues in excess of those disclosed in their rebuttal statement or in the original JAMA research letter.

"According to the letter, the 2013 Member Boards' revenue represents approximately $313 per ABMS Board Certified physician. This is a reasonable amount to support a nationally recognized credentialing program that is both respected and valued by physicians, healthcare providers, and institutions, and most importantly, patients and their families.

In fact, 81% of physicians feel MOC® is a burden and only 15% felt recertification was worth the effort. Independent studies have failed to identify a difference in time-limited versus lifetime-certified physicians, reinforcing the fact that MOC® is little more than a revenue generator for the ABMS. Also, the ABMS is careful not to mention the word "annually" in their statement when they describe the revenue generated per ABMS Board Certified physician. It is also strange that the ABMS would call their fees "reasonable" when those fees only apply to new, younger, often debt-burdened physicians and not to older physicians certified before 1990. Older physicians are not required to participate in MOC® to keep hospital privileges or insurance panel payments. Age discrimination - a hallmark of the ABMS MOC® program - is not "reasonable" to any ethical working physician or member of the public.

"In addition, the estimated annual cost for continuing certification of $257 per ABMS Board Certified physician is an acceptable cost for physicians to demonstrate that they have the current knowledge, judgment, and skills to provide the highest level and most up-to-date care to their patients.

Funny how this number that pays salaries that are over four times the average physician's salary are deemed "reasonable" for member boards of the ABMS. $257 stands in stark contrast to the competing certifying board, the National Board of Physicians and Surgeons (nbpas.org) whose fees are only $84.50 per year and is equally credible - if not more so - since their Boards' leadership are unpaid.

"IRS Form 990 provides information regarding revenues, expenditures, and assets. However, they do not outline the actual operation cost involved in creating, sustaining, and implementing a rigorous and comprehensive process of Board Certification and continuing certification for the nation's physicians. ABMS Member Boards rely on a highly trained and specialized work force including psychometricians, assessment professionals, and medical educators to develop, evaluate, and administer Board Certification programs.

Those fees also paid for a felonious strongman to overstep their authority to intimidate vulnerable physicians by secretly audiotaping a competing ACGME-accredited board review course. Using those audiotapes the ABIM obtained permission to raid the course director's home to seize his computers so the ABIM staff could track physician attendees' email addresses and accusing them of violating ABIM's "pledge of honesty." These activities are more akin to a protection racket rather than a physician continuing education/credentialing system.

The ABMS member boards also have numerous large, undisclosed financial conflicts of interest. For instance, in fiscal year 2013, the ABIM paid their non-physician Chief Operating Officer, Ms. Lynn Langdon, over $464,747 while Christine Cassel, MD (President and CEO of the ABIM and its Foundation) earned $838,603 from physicians while she simultaneously served on the Boards of Kaiser Foundation and Hospitals and Premier, Incorporated, the largest hospital purchasing agent that also does "performance improvement consulting" for over 2,900 US hospitals. True to form:  the ABMS never mentions these additional conflicts of interest in their statement.

"For this reason, the greatest expenditure is appropriately in the area of staff salary and compensation, as noted in their 990 reports. "The assets reported on the IRS Form 990 that the ABMS Member Boards currently maintain are crucial to sustain and evolve vibrant and innovative Board Certification and continuing certification programs. ABMS Member Boards are continually reinvesting in program improvements and enhancements to transform their certification and continuing certification programming, including the development of quality improvement and longitudinal assessment programs.

Those "vibrant and innovative enhancements" include a $2.3 million condominium complete with a chauffeur-driven town car, investments in the Cayman Islands, for-profit real estate ventures, and even a pond. The largest member board, which secretly channeled over $77 million of physician testing fees to create their ABIM Foundation from 1990 through 2007, now only has $13.6 million remaining in their latest consolidated financials thanks to high salaries and mounting legal fees. I'm not sure I can remember a time of so much innovation (and cover-up) in physician certification!

"These investments will ensure that ABMS Board Certification continues to be a relevant, valued, and important quality indicator for those who hold the credential as well as those who rely upon it for the highest standard of quality care."

Unfortunately, the ABMS member boards have enjoyed a sheltered workshop for years that the internet has thoroughly disrupted. Sadly, physicians no longer trust the ABMS and their member boards to act in their interest or in the interest of the public. Instead, the data are overwhelming now that the ABMS and their member boards are more concerned about themselves than the public. As such, their tax exempt status should be challenged.

The question now is, are there any investigators/prosecutors at the IRS that will investigate this potential fraud, or are they beholden to the highly political Medical Industrial Complex, too?

-Wes

Image credit: Medscape.

Direct Adverse Effects of MOC® on Patients

The American Board of Medical Specialties (ABMS) successfully lobbied to have their proprietary Maintenance of Certification® (MOC®) program included in the new Merit-Based Incentive Payment Program of the new Center for Medicare and Medicaid Services (CMS) "quality payment program" within Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation. Hospitals and insurers continue to demand MOC® recertification of their physicians without asking a most important question: has MOC® been harmful to patients or their physicians?

Here are real life examples of how the ABMS MOC® program has been harmful to patients:

Example #1, Dr. J.E. of New Jersey

From antitrust legislation before the Northern District of Illinois Federal District Court, Case 1:14-cv-02705:

Association of American Physicians & Surgeons, Inc. v. American Board of Medical Specialties
Assigned to: Honorable Andrea R. Wood
Case in other court: New Jersey, 3:13-cv-02609
Cause: 15:1 Antitrust Litigation

"
Exclusion of an AAPS Member from Somerset Medical Center (SMC)
29. Defendant ABMS’s foregoing agreements and actions resulted in the unjustified exclusion of a physician member of Plaintiff AAPS (“J.E.”) from the medical staff at SMC, a hospital located in Somerville, New Jersey.
30. Physician J.E. had been on the SMC medical staff to treat patients there for twenty-nine (29) years.
31. J.E. had been board certified by The American Board of Family Practice, which subsequently changed its name to The American Board of Family Medicine (“ABFM”).
32. In 2011, SMC refused to allow J.E. to remain on its medical staff unless he complied with an extremely burdensome and impractical recertification procedure under the ABMS MOC®.
33. ABFM is one of the 24 corporations identified above that has agreed with Defendant ABMS to implement ABMS MOC®.
34. Although J.E. had been fully certified in good standing with the predecessor to ABFM, Defendant’s agreement with ABFM required imposing the following extremely burdensome requirements for recertification under ABMS MOC®:

• Completion of fifty (50) MC-FP points (acquired by doing modules)
• Minimum of 1 Part II Module (SAM)
• Minimum of 1 Part IV Module (PPM or approved alternative)
• One (1) additional module of [his] choice (Part II or Part IV)
• Completion of one hundred fifty (150) credits of acceptable CME (minimum 50% Division I), acquired in last three (3) years
• Compliance with ABFM Guidelines for Professionalism, Licensure, and Personal Conduct which includes holding a currently valid, full and unrestricted license to practice medicine in the United States or Canada
• Submission of three (3) MC-FP Process Payments; one (1) payment at the start of each module
• Submission of application and accompanying full examination fee for the MC-FP Examination
• Successful completion of the MC-FP Examination (Viewed April 23, 2013)

35. The foregoing requirements demand far in excess of 100 hours for a typical physician, with the possibility of an unjustified rejection of recertification for reasons having no proven connection with patient care.
36. The foregoing requirements further impose many thousands of dollars in fees and travel expenses.
37. The foregoing requirements take physicians away from providing care for patients.
38. In addition, the ABMS has entered into agreements with many of the above-referenced 24 specialty organizations to require even more expenditures of time and money by physicians. According to an email sent to physicians by the American Board of Internal Medicine (ABIM) on or about April 6, 2013, Defendant “ABMS is requiring more frequent participation in MOC of all board certified physicians.”
39. Like many other AAPS physician members, J.E. spends a substantial percentage of his time providing charity care to patients who would not otherwise have access to medical care.
40. J.E. manages and works in a standalone medical charity clinic for a substantial part of each week.
41. Requiring J.E. to spend hundreds of hours on requirements for recertification under ABMS MOC® would result in an hour-for-hour reduction in his availability to provide medical care to his many charity patients, who recently surpassed 30,000 patient visits in total number.
42. Patients of J.E. typically lack any alternate means of obtaining comparable medical care.
43. J.E. continued to serve his charity patients rather than comply with the foregoing burdens of recertification demanded by Defendant’s agreement with ABFM to implement ABMS MOC®.
44. Effective June 24, 2011, SMC excluded J.E. from its medical staff, as a result of Defendant ABMS’s agreements with other entities to require the ABMS MOC® program.
45. Patients are now denied the benefit of being evaluated and treated by J.E. when taken by emergency to SMC.
46. There is no value to patients in the completion of the above litany of onerous recertification requirements.
47. The lack of any genuine value of ABMS MOC® as a measure of professional skill or competence is demonstrated (viewed March 4, 2013) by how ABMS itself selected and appointed as its new President/CEO in 2012 someone who was “Not Meeting MOC Requirements,” but had an exemption not available to younger physicians.
48. J.E. is unquestionably a first-rate physician who continues to practice in good standing in New Jersey.
49. Whether J.E. purchases and complies with ABMS MOC®, as implemented by the ABFM, has no bearing on his medical skills as a physician.
50. Like J.E., other members of AAPS face imminent injury from Defendant’s agreements to impose ABMS MOC®, and Defendant’s concerted actions to require physicians to purchase and comply with its proprietary product.
51. Defendant’s agreements and concerted actions limit the supply of physicians available to hospitalized patients, thereby denying patients care by their choice of physicians."

Example #2 Megan Edison, MD of Michigan

"Regarding opting out (from MOC®), I can demonstrate harm to my patients. As you know, I did not pay the $1300 to the ABP. I have no educational requirements due until 2023. Within weeks of not paying, Blue Cross/Blue Shield of Michigan (BCBSM) sent me a letter dated 19 January 2017 (and received by my office 28 Feb 2017) telling me to pay by 20 March, 2017 or I would be kicked off their panel. I mailed my appeal letter 1 March 2017.  When I did not pay, BCBSM did not contact me to initiate the appeal process detailed in my contract ( which involves two peer-to-peer hearings where I can explain by case). Instead, they sent letters directly to my patients telling them I was no longer a qualified in-network physician and they would be reassigned to another doctor. I was not allowed to see my patients without having another physician in the room with me. Even if my patients decided to pay cash to see me, any prescriptions or studies ordered would not be covered by BCBSM. On March 10, 2017, I received notice that my appeal hearing was granted for 5 April 2017.

They refused to stop sending the letters pending my active appeal case. They said they would continue sending letters until I complied, or my appeal was done, whichever happened first. Obviously, this caused extreme distress for my patients and my staff.  I contacted a lawyer with the Michigan State Medical Society, who told me to pay the money. I did.

Within seconds I had my board certificate in hand. Within hours BCBS re-instated me and never sent out another letter. Of course, they never sent letters to the hundreds of patients letting them know of their error. I am not the only one this has happened to, it happens all the time. To opt out of MOC®, docs are hiring NPs to see their BCBS patients because they will credential a NP...but not a MD opting out of MOC®. It's madness that MOC® is now more important than a MD."

As seen in these examples above, the American Board of Medical Specialties' MOC® program is not a benign recurrent educational exercise for physicians. Rather, MOC® is a means of assuring a continuous cash flow to ABMS member boards using threats and intimidation by unaccountable ABMS member board members and insurers that adversely affects patients as well.

- Wes

JAMA: The Certification Fees and Finances of US Medical Specialty Boards

Today in JAMA, a partial list of the fees and finances of the ABMS member boards were disclosed in a research letter to the editor from Brian C. Drolet, MD and Vickram J. Tandon, MD of the Departments of Plastic Surgery from Vanderbilt University and the University of Michigan. Their summary of those finances is remarkable:

In total, the boards reported $701 million (85% CI, $644 million-$758 million) in assets and $65.6 million (95% CI, $60 million - $71 million) in liabilities (difference, $635 million (95% CI, $584 million - $687 million))(Table 2). Six boards reported no debt; and the remaining 18 held reported assets that substantially exceeded liabilities. Between 2003 and 2013, the change in net balance (ie, the difference of assets and liabilities) of the ABMS member boards grew from $237 million (85% CI, $232 million-241 million) to $635 million (95% CI, $584 million - $687 million). ... As a result of such margins, the member boards saw a mean annual growth rate of 10.4% during the decade studied.

Importantly, these financial assets are significantly underreported. As the authors mentioned in their letter:

This study is limited by the data source. Although IRS Form 990s includes major funding sources and amounts of revenue, expenses, liabilities, and assets, it does not contain complete and specific financial accounting for the ABMS member boards. Also, board subsidiaries and foundations were not included. (Emphasis mine).

Given these data, justification for Maintenenace of Certification for anything other than financial renumeration for the ABMS member boards and their supporting organizations is impossible to dispute. Their windfall is a direct result of the creation of Maintenance of Certification and their monopolization of the physician credentialing market by regulatory capture.

Please consider joining Practicing Physicians of America, Inc. to help end the extortion of practicing US physicians by the ABMS specialty boards and their collaborating organizations at the Accreditation Council of Graduate Medical Education.

-Wes

Reference: Drolet BC and Tandon VJ. Fees for Certification and Finances of the Medical Specialty Boards. JAMA 1 Aug 2017; 218(5): 477-479.

Update: (video via MedPageToday) Where Do all Those MOC Fees Go?

StatNews: Medical Boards Ring Up Big Margins by Charging Doctors High Examination Fees