Fail Maintenance of Certification? I Need Your Help

With the increasing failure rate of first-time test takers of the American Board of Medical Specialties' Maintenance of Certification program, no study of the impact of failing the examination upon physicians (and the patients they serve) has occurred.  Specifically, I am interested in the economic, professional and psychologic consequences of failing the Maintenance of Certification examination for previously board-certified practicing physicians.

To that end, I'd like to compile the stories of people who have FAILED their Maintenance of Certification examination.  I would like to know the cost in both time, money and consequences that was impacted by the failure, whatever they were or were not.  I hope to publish a paper in a major medical journal on my findings.  Commentary can be sent to me one of two ways: (1) private e-mail (wes -at- medtees dot com) or  (2) by placing a comment to this post (since all comments are moderated, I will only publish those that I am granted specific permission to publish) here. 

I would like to know the following:

(1) A bit about you: your age, gender, specialty, years in practice, practice setting
(2) Number of patients you treat annually
(3) A description of what it was like to learn you failed, actions taken (re-score request, additional review course, repeat testing, retirement), loss of income.
(4) Impact to ability to practice, if any (loss of privileges, etc)
(5) Cost, but in time and money spent for the various parts of the process.
(6) Did your results appear on the website "CertificationMatters.org"
(7) Willingness to co-author a manuscript
(8) THIS ONE'S IMPORTANT: Willingness to have your name mentioned publically.  ALL RESPONSES WILL BE KEPT STRICTLY CONFIDENTIAL otherwise.
(Any other data you think is important and I have missed and would like included or NOT mentioned)

I will compile the data I receive, both as discrete variables and comments that allow publication.

It is quite possible that many academic journals will not publish the results obtained in this survey and, if so, I will co-publish the composite data on this blog for all to review.

I appreciate any and all feedback I might be able to obtain.  The face of the dark side of Maintenance of Certification needs to be understood and reported.

Thanks for your coooperation in this effort.

Sincerely,

Wes Fisher, MD

Should Cardiologists Boycott the 2014 TCT/ACC Conference?

Yesterday, I noticed a tweet from @angioplastyorg announcing that former Secretary of State Hillary Clinton will be this year's keynote speaker at the Transcatheter Therapeutics Conference (TCT) in Washington, DC.  The TCT occurs each year in partnership with the American College of Cardiology.  Most doctors probably won't think much of this, but for many who spend 12 hours or more each day in a dimly lit cathlab , the prospect of sharing the bright wattage of Ms. Clinton radiating down upon them is seductive indeed! And look how the ACC is helping cardiologists: they were able to land the presumptive next President of the United States to speak at their conference!  Can't you just see the event planners giving each other high fives!  Who can beat that?

In reality, most cardiologists couldn't care less about Ms. Clinton.  They'll oversleep or consider her address as nothing more than marketing theater.  But to dismiss Ms. Clinton's presence at this event misses some important considerations.

Is the purpose of the TCT conference to hobnob and aggrandize politicians, especially one who could become President, or is to educate and inform physicians?  Is the purpose of paying Ms. Clinton's hefty speaking fee about gaining her ear, or to make a political contribution from Big Business and the crony capitalism that pervades health care now?   Is the real purpose to of her presence as keynote speaker to address cardiologists real concerns or so that ACC leadership can position their proprietary NCDR databases and "Appropriateness Criteria" as quality metrics to permanently pad their bottom line?  Suddenly, Ms. Clinton's appearance takes on more cardiovascular gravitas.

Every cardiologist sitting in that hall will have just come through a year experiencing less time with their patients, less clinical autonomy, intrusions on their practice, while increasingly being coerced to perform bureaucratic tasks that mean little to patients yet everything to corporate interests.  What do we imagine will, in fact, be addressed by Ms. Clinton as we buy our plane tickets and carefully pack our suitcases? Do we think for one moment that Ms. Clinton or the ACC will have the slightest compunction to address the serious concerns of the cardiology community?  What do we imagine the ACC will address about these concerns in the rest of the meeting?

ACC should wake up to a new reality.  Recall that it was a small group of cardiologists who started the anti-Maintenance of Certification (MOC) petition against the new, more onerous MOC program devised by the privately held American Board of Medical Specialties and the American Board of Internal Medicine.  Over 18,000 doctors of all types have signed that petition now.  In response to that petition, the ACC performed a survey of their member chapters nationwide.  The anti-MOC sentiment from this survey was overwhelming.  Many senior doctors even mentioned it might make them consider early retirement.  In turn, the ACC's response was lukewarm at best.  This was likely because the ACC's history has been to support the lucrative review courses this program requires.  These courses are so important to the ACC's bottom line that they even devoted an entire "MOC Complex" hall at their last scientific session to promote the MOC program and still aggressively market the program on their website.  This is hardly a show of solidarity with their member cardiologists'.

It is time front line cardiologists put action behind their anger over the MOC process and the ACC's indifference.  It is time to consider a boycott of the ACC/TCT meeting in Washington.

To that end, the ACC leadership needs to stop pandering to politicians and corporations eager to profit on doctors and instead start advocating for their own members.  The preeminent assumption in program planning at events such as these appears to be that physicians are passive, apolitical, and unaware.  Why would the ACC or any other physician membership organization feel the need to change?  For this reason, the time to boycott is now.  If the boycott is successful, perhaps the ACC leadership will take the concerns of the member cardiologists' more seriously than the politics of creating public-private partnerships that threaten to compromise, rather than promote, the care of our patients.  Does the ACC really believe they can remain relevant without physician participation?  We should note that alternative professional organizations are beginning to evolve.

Whether the ACC has realized this or not, they are coming to a juncture where they will have to decide whether they represent physicians and their patients or the Iron Triangle.  Physicians are not lawyers, they are uncomfortable acting collectively or politically, much to their detriment in this era of rapidly morphing health care regulation and intrusion.  I can still hope that the ACC and other organizations such as state medical societies will have the capacity to represent the real interests of their physician members.  But increasingly I am concerned they won't.

But we should be clear: physicians' actions mean something.  So this doctor will not be attending this year's meeting because it's one of the only ways I have left to send a message.

I hope others will consider the same.

-Wes

MOC Points: The New Physician Currency

"Oh my God, I can't believe how complicated the American Board of Medical Specialties and the American Board of Internal Medicine has made this whole Maintenance of Certification (MOC) process!"

"Yeah, pretty amazing, isn't it?  10 points here, 10 points there, 20 points for a (required) Practice Improvement Module, then another 10 points if you complete another module online.  And after all that, you're only half way there!"

"Where am I going to find the time?  They need to make this process easier!"

"Face it. That isn't going to happen.  Look at the ineffectual ideas the member board members are telling the ABIM  leadership in their precious '3-5 minutes' of feedback: making sure physicians can get 'credit' for patient surveys and quality assurance projects they already do, making the ABIM website 'easier-to-navigate,' making patient surveys 'more flexible,' lowering costs, and 'providing more transparency from ABIM on how requirements are created.'  I'm not seeing any cuts to any of this, I'm just seeing different versions of the same old same-old."

"Dude, you just completed your MOC process, how did you do it?"

"I'll tell you a secret, but you have to promise TOTAL secrecy."

"I promise!  I'll do ANYTHING to get this MOC monkey off my back!"

"Okay, here's what you do.  Remember that research project you wanted to do on kids but never could get off the ground because the IRB stonewalled you, claiming  lack of consent in minors and all that red tape regarding research in minors?"

"Yeah."

"Well, just call your work a 'quality assurance project' you have to do for your MOC points!  No one would dare question your intent, after all, it's to improve quality care and patient safety!"

"I can't do that."

"Sure you can!  No one dares question the lofty ideals of the ABMS/ABIM's MOC program.  After all, they interconnected with the ACGME, the Joint Commission, American Medical Association, the American Hospital Association,  the whole works!  You just do your thing and no one will think anything of it except 'you're the MAN!'  I mean these MOC points are our new hall pass to do anything you like on people in the name of quality of care!  It just has to sound reasonable.  And man, you need those points, don't you?  You'd be killing two birds with one stone and potentially get a publication out of it to boot!  Better yet, you can claim "no conflicts of interest" because you never receive a dime for your efforts.  Your IRB will never look, trust me.   Paraphrasing a former famous politician: 'I've got this MOC thing, and it's f*%^in' golden!"

"I see.  And if we do it your way, we can even get paid more, thanks to that CMS incentive they've created!"

"Now you're catchin' on.  It's our new currency.  I'm telling you, it's f*%^in' golden!"

-Wes

h/t: IP4PI blog

What Main Stream Media Misses in the MOC Debate

This morning the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) program debate reached a larger mainstream media audience when the Wall Street Journal published their article by Melissa Beck entitled "Skill Reviews Upset Doctors."

While it is certainly nice to see an article reaching the main stream media concerning doctors' concerns with the MOC program, the issue with the MOC debate is not that doctors are upset.  The real issue is that doctors have been enslaved by special interests and crony capitalism to complete a MOC process that robs patients of more time with their doctors so that regulators and payers can enrich themselves.

One only has to see how certain aspects of the Wall Street Journal article were highlighted to see how Ms. Beck framed the debate toward business interests.  For instance, she quoted Ms. Lois Nora, president of American Board of Medial Specialties who said:

"Many practicing physicians have not had formal courses in patient safety or quality improvment."

Ahem.  I wonder if Ms. Beck or Ms. Nora have ever heard of the Hippocratic Oath? Doctors spend their entire careers (not to mention many sleepless nights) worrying about their patients' safety and care. Their livelihoods depend on it!

Yet there is never a moment of serious reflection regarding the sweeping hubris of Ms. Nora's statement. As spokesperson for the American Board of Medical Specialties, Ms. Nora suggests that without oversight, doctors are lax, uninterested in research or updating their techniques, inattendant to patient safety and unwilling to update their skills.  Instead, the ABMS welcomes the tripling of patient volumes, the cameo roles that doctors are increasingly asked to play in patient care, the refocusing of one third to one half of every patient visit staring into an electronic medical record so the ABMS can watch for flinches in quality of care.  The overseer who allowed this untenable health care scenario to transpire is effectively positioning themselves to patients that they are their last best hope. 

Ms. Beck's piece also ignored the existing CME requirements that physicians already must perform each year to remain licensed and the value of such truly voluntary learning.  Instead, Ms. Beck chose to highlight a quote from Richard Armstrong, MD - a board certified surgeon clearly without formal media training - who said:  "No one wants to come out and say we're against quality, but most physicians find these modules to be cumbersome and, frankly, a joke."

When doctors are quoted calling any quality process "a joke," it really doesn't matter what the doctor actually said, for few will take him seriously.  Let's be clear: the MOC process is not a joke, it's more like the twisted controlling strategy of the Hunger Games. 

Ms. Beck also ignored that some MOC requirements now involve enrolling patients into study groups without their consent, doing the study and then reporting the data back to the boards. According to one doctor, "there are nearly 400 research projects being done on children through part 4 of the ABMS MOC program. Not only is performing research on children without consent immoral, it is costly in both time and money for the patient."  Isn't this consideration important for patients?

Finally, Ms. Beck's article ends with the ABMS's claim that "500,000 of the more than 800,000 board-certified physicians have enrolled in MOC programs to date" implying that the majority of doctors support the program.  Yet this statistic completely ignores the fact that doctors had no choice but to sign up for MOC despite their better judgement. As Ms. Beck hesitantly acknowledges in her article, this unproven physician metric is now increasingly tied to measures of physician "quality," hospital privileges, legal standing in court, and insurance panels.  This unproven MOC program that was created by a self-appointed, private organization that is completely unaccountable to the public has also been indelibly etched into our new health care law.

No, it's better not to mention these unethical and extortionary tactics by the ABMS that threaten patient care.

Instead, it's far better to call doctors "upset."

-Wes

An Insider's Guide to a Health Care Policy White Paper

Do you want to "raise awareness" of how physician quality and value information impacts health care decision making?   Do you want to spin your data via the Associated Press internationally?

Just have the Robert Wood Johnson Foundation pay for a survey!

We all know how great surveys are, especially when you design it to "raise awareness" for the low, low price of $604,454!

For that price, you get:

(1) A nice glossy white paper that contains a concerned patient looking away while she's being examined by a doctor on the cover
(2) Lots and lots of numbers and scientific-looking charts.
(3) An NORC Press release (After all, it was laundered through the Associated Press-NORC Center for Public Policy Research!)
(4) A republishing of your "key points" by a few business-minded online health care journals eager to demonstrate relevance of using "quality measures" to determine health care "value."
(5) An opportunity to collaborate "on all aspects of the study!"

See how easy it is to make sure you get your major points out there to the decision makers!  (Never mind that a quality physician means many different things to many different people - stop being a perfectionist, okay?)

Look, these guys did a survey with 25% response rate that totaled a whopping 1002 people - or about 0.000000317 of the current US population!  Heck, no bias there, right?  Then they add a few "sampling weights" and calculate the survey response rate using the important sounding American Association of Public Opinion Research's Method 3!

What's that?  You're not familiar with Method 3?  What kind of scientist ARE YOU???? 

Here. Let me help:  If Method 1,2, or 4 doesn't get you the desired number, you use Method 3!  The survey response rate for Method 3 is calculated from the handy, dandy Response Rate Method Calculator where:

I = Complete Interviews
R = Refusal and Break Offs
NC = Non-contacts
O = Other
e = the estimated cases of unknown eligibility that are eliglible! (In other words, a guess)
UH = Unknown Household
UO = Unknown Other

Using these definitions , the "Method 3" calculation for the survey response rate becomes:

I / (( I+P) + (R + NC + O) + e(UH + UO))

See? And that response rate, according to the white paper, after applying "sampling weights" had "an overall margin of error" of  "+/- 4.0 percentage points, including the design effect resulting from the complex sample design."

 Heck ya, I'm seeing accuracy there, aren't you?

These days, it's really important that lots of people see these data so policy makers (who have about as much scientific wattage as an LED), can turn to them to create controlling policy and regulations that benefit those who make - you got it - the policy and regulations!  Especially in US health care.  That's because doctors are getting a bit unruly and need to understand why they must fall in line on all this physician quality measurement stuff.  Perhaps one of the introductory paragraphs of the published white paper says it best:

"Major investments are being made in health care systems like Accountable Care Organizations and in tools like Physician Compare. Similarly, health insurers and employers are exploring new benefits designs that incentivize consumers to select providers and hospitals that provide the highest-quality care while reducing costs through value-based provider networks and tiered health plans."

So there you have it!

It's important that we all understand just how critical these surveys paid for by political organizations will be to health care in the years ahead.  Spin, you see, is everything.  Thank goodness the Robert Wood Johnson Foundation (who's CEO, by the way, has also partnered on other publications about patient safety and medical professionalism with members of the American Board of Internal Medicine and National Quality Forum) can show us the way!

I feel so reassured that this is the caliber of science being used to shape US health care now.

Seriously.

What could go wrong?

-Wes

The Game of Numbers

The dark underbelly of health care is becoming all too visible now.

Fresh faces in neatly pressed white coats are in the halls.  Eager.  Enthusiastic.  Clearly very bright.  All hoping for a moment, an experience, an encounter that makes all their hard work worth it.  Surely they'll have one, but not before the thousands of keyboard clicks, the mandatory lectures, rounds and lots of lengthy, lonely call nights.

He was a doctor from another time, well into his 80's.  Lovely man with an infectious smile, mesmerizing foreign accent, and almost regal presence. An authority in his time and still attends lectures to stay engaged, a question passed his way from time to time out of respect for his experience and insights.

But he kept nearly falling at night and became concerned; even confused once.  This was not like him.  So he was admitted, observed and had a heart rhythm that was not normal.  Blood thinners were started cautiously.  Surely he could manage them.  His wife, ever-present at his side, was equally engaging, concerned.  And so, as fate would have it, after hundreds of thousands of keyboard clicks, I came to know them and realize his heart beat was too slow at times, dangerously so.

After lengthy discussions of the good and bad, the options, the data, he agreed a pacemaker made sense.  Trustingly, he wanted it performed soon, eager to return to the lectures he loved.  So the next morning after a night of worry, we assembled.  His smile greeted me as I came to his bedside to obtain written consent, answer any last-minute questions, and silence the noise of concern.  He was ready to go.

So I left his bedside to change into my scrubs, trying to hang my newly pressed shirt and tie to the side to preserve it for later behind a changing room curtain, when I heard a voice.

"Dr. Fisher, I'm so sorry..."

"What's up?"

"We can't bring your patient in the room."

"Why not?"

"We didn't know he's UnitedHealthCare.  He's Medicare Part C!"

"Wha...?"

"You  placed your order after 4PM, and we didn't see it until this morning.  We have to get pre-approval from UnitedHealthCare for his pacemaker.  They said it would be two or three hours..."

"Seriously?"

"Yes.  It's his insurance.  If you don''t get pre-approval, you won't get paid and he might have to pay for the procedure."

I stood, pants in hand, dumfounded.  So I finished changing and exiting the changing area to clear my head.  I called our administrator.  She said, "Let me see what I can do.  I'll call you right back."  Within minutes a reply was sent: "You have to wait."

I thought of my frightened patient lying there vulnerable, so I went to his bedside to explain.  He looked at me as a fellow physician, and he shook his head in disbelief, all the while naked beneath the covers.  He agreed to wait - he had no choice.  I left to get a cup of coffee and to collect my thoughts.  What else could I do?  I put a detailed note, an order, a consent order last night, and a pre-anesthetic note this morning.  All keyed in, all according to protocol.

Then a nurse appeared with a note.

"If you call this number, hit "3" on the menu selection, and enter this case number, you can do a peer-to-peer."

"A what?"

"Peer-to-peer approval.  You talk to a medical director and they might be able to expedite the approval for the pacemaker."

I looked for a moment at the "800" number, sighed, and called.

The woman who eventually answered after I heard "all attendants are busy" was pleasant enough, full of "good morning, doctor" and "what can I do for you."  I explained the situation and wanted the ordering physician's name.  I spelled my name to her. Keyboards were heard in the background.

"I see that his is for a CPT code 33208, correct?"  She must have known that I knew my codes.  But I knew that was wrong.  He was not getting a dual chamber pacemaker, he just needed a single chamber, VVIR pacemaker.

"No, that's not correct.  It should be 33207," I replied.

"Oh."

I heard more clicking.

"I'm sorry but I've tried to change that code under this case number and it seems I don't have authorization to do that.  Can I put you on hold while I speak with the medical director to see if he can make the change?"

"Sure," I said.  What choice did I have?

So I waited, listening to some nondescript melody in the background as I was placed on hold.  A few minutes later, the same voice returned.

"Doctor?"

"Yes?"

"It seems the medical director couldn't change the information on this case number either, but I'm going to try to make a new number based on the CPT code you gave me, then I'll have the right information to give to the medical director, okay?"

So we proceeded to build a new case number.  Lots of clicks interspersed with silence, then more clicks in the background, a few more statements like, "Sorry, I'm new to this" and "could you spell your name again," then finally:

"There.  I think I've done it.  Let me transfer you to our medical director...."

A click, some music, then a pleasant official-sounding woman's voice.  "This is Doctor Frigamafrats.  I'm sorry about the delay, I hope you didn't have to wait too long..."

A conversation ensued.  I explained the rationale for the pacemaker, then finally was granted approval.  Case number 2342343240 and approval number A321232451, or something like that.  I notified the staff and handed the numbers to our clerk, knowing full well that pre-approval does not guarantee payment.  Forty minutes rather than 120.

It's the game we play now.  A new game.  The Game of Numbers.  Of money.  Clinical doctors as agents for others who call themselves a "doctor" yet are unfamiliar with the patient and unexposed while they make the call.

As I adjusted my headlamp before scrubbing, I thought about those new interns and residents on our wards upstairs, eager, willing, able.  Bustling about, yearning to make a difference, waiting for their first chance...

... yet all being groomed to play the game.

-Wes

How Much Physician Anti-MOC Sentiment Is There?

This chart says it all:

(Click to enlarge*)

Now that this is firmly established, the question becomes, what are are we going to do about this?  Create legislation altering the Affordable Care Act?  Develop a separate testing authority to compete head to head with the ABIM's process?  Mass non-compliance?  Suit?

This challenge is a good representation of Nancy Pelosi's famous line: "But we have to pass the bill so that you can find out what is in it away from the fog of the controversy."

Well, now that our new health care law has been enacted with the ABMS's MOC program firmly in place, change will not come easily.  This is a great example of how difficult it will be to change any part of our new health care law that is problematic.

I encourage readers to post their suggestions regarding how they might consider changing the ABMS MOC program requirement contained in our new law in the comment section of this blog.

-Wes


*Reference:  ACC Member Survey

Addendum 22 July 2014:  Welcome WSJ Readers!

Here's some other important posts on this issue of physician's "maintaining" their board certification:
The Effects of Maintenance of Certification and Crony Capitalism
The Business of Testing Physicians
When We Reward Regulators More Than Doctors

Examining Maintenance of Certification Failure Rates

The American Board of Medical Specialties' (ABMS)  Maintenance of Certification® (MOC) program is marketed as "an ongoing process of education and assessment for certified physicians to improve practice performance."  After reviewing the recent failure rates of this program over the past five years, I worry the process is not about assuring physician quality, patient outcomes, or practice improvement, but rather as a means to ration the number of doctors eligible to earn Center for Medicare and Medicaid Services (CMS) payment incentives.

Background

As I've previously reviewed, the ABMS MOC program and the physician registry it creates has been written into our new health care law. To date, the MOC program serves as the sole measure of physician "quality" for the upcoming CMS value-based physician payment model that is to replace the current fee-for-service model in 2015.  To create an incentive for physicians to participate in the MOC program, CMS offered a 0.5% payment incentive to the Physician Quality Reporting System for physicians participating in the MOC program in 2014.  While this does not sound like much money, if we consider that physicians were paid $77 billion from CMS in 2012, this 0.5% represents approximately  $385 million dollars paid to doctors (or their employers).  Imagine the cost savings to the government if physicians were not eligible for such a payment.

Methods

I decided to evaluate the failures of "first time" MOC certification for all board certifications issued by the American Board of Internal Medicine from the pass rate data published online by the ABIM.  The number of failing physicians was calculated by subtracting the total number of doctors taking each examination from the number of doctors passing the test to arrive at the number who failed.  Non-integer values were rounded.  Next, I added up the total number of doctors who took the various ABIM MOC examinations each year and the total number who failed each year to generate an annual MOC percentage failure rate.  I calculated these values for 2009, 2010, 2011, 2012, and 2013.  I then applied a linear regression line comparing the total test takers and the total number of doctors failing the examination by year.  I then calculated the number of "certified" physicians each year as a "difference" of the total and failed physicians each year and applied a 2-period moving average trend line to these values.

Results

Here are the raw data assembled in a chart for your review: 

Year	2009	2010	2011	2012	2013
Total Test Takers (n)	8744	9574	10889	11524	12201
Number Failed (n)	861	1030	1357	1610	2138
Percent Failed	9.85%	10.76%	12.86%	13.97%	17.52%
Difference (n)	7883	8544	9532	9914	10063

Plotting these data shows the following trends:

MOC Failure Rate Trends (click to enlarge)

Discussion 

While the number of first-time MOC test takers grew each year studied, the failure rate also grew significantly. Is this because physicians were significantly less intelligent in 2013 than 2009?  Does this mean that board review courses run by each of our professional specialty societies are less relevant now than they were  despite their growing price?  Or might such a failure rate really be a way to "bend the cost curve" for health care delivery by covertly rationing the monies CMS pays physicians?  Each of these are fair questions that need to be answered honestly by CMS, the ABMS, the ABIM, and our professional specialty societies that collude with the ABMS as they run their various MOC board review courses. 

It goes without saying that test scoring methods and the raw responses of questions performed as part of the MOC process are shrouded in secrecy and serve no retrospective educational learning opportunity for doctors taking these examinations.  Doctors who take the MOC testing must also sign a statement that they understand that  divulging content in the examination will be met with harsh penalties including, but not limited to, possible revocation of hospital privileges or reporting to state medical licensing boards.  In return for this promise of secrecy, the ABMS and ABIM appears to operate in an environment that violates the trust of the public and those they test.  They do not explain their consistently higher failure rates seen year over year.  They do not mention the relationship they have to physician payments from government sources when physicians enroll in their MOC program.  Instead, they describe their process as "voluntary."  They espouse  the ethic of  "the need for public accountability and transparency," yet deliver none of these things themselves.  As such, it is clear that physician quality assurance or practice improvement is not the ABMS or ABIM's real mission for public good.

Rather, it appears from the MOC program failure trends above that the real reason for the ABMS MOC program is not only for self-enrichment, but to provide government cost savings without regard to the professional consequences to the many physicians they test and the patients ultimately affected by the loss of eligible care providers from their insurance panels. 


-Wes

New CMS National Coverage Decision for Pacemakers Begins Today

A new CMS National Coverage Decision for pacemakers begins today.  Here are the specifics.

If your patient is getting a pacemaker for atrial fibrillation or other "ineffective atrial contractions" with symptomatic bradycardia, be very sure to document the "non-reversible" nature of the symptomatic bradycardia in your note and have your billing staff consider adding a "KX" modifier to the claim line(s).

Remember, most regulators look at codes, not notes.

Just sayin' -

-Wes

The Effects of Maintenance of Certification and Crony Capitalism

This note was recently posted on Sermo (login required) Friday:

"I just got results from recent ABIM 10 yr recert and I failed. I over prepared for this exam, studied daily for months, Harvard review course, analyzed over 1000 board type questions the week before, teach medical students daily. I have never come close to failing any previous board exams."

After a panicked e-mail was sent to the American Board of Internal Medicine (ABIM) inquiring if there might be an error in the scoring of the examination, this email was received:

Dear Dr. B:

Thank you for your recent e-mail to the American Board of Internal Medicine (ABIM).

ABIM is entirely satisfied that there was no error in scoring your examination. The scoring process is a meticulous one. A rigorous set of quality control steps are carried out on every examination. Before final scores are approved, the reliability, validity, and fairness of the examinations are verified by the ABIM. ABIM will not release results until it is satisfied that a reliable instrument has been administered and data are accurate. Additional information about the way ABIM develops and scores its examinations is at ABIM's website at www.abim.org/about/examInfo/developed.aspx.

If you would like to have your examination rescored, please put your request in writing. All requests must be received within six months of the results' mailing date. Include your name, candidate identification number, the examination to be rescored, and a check for $250.00 payable to the American Board of Internal Medicine. Send to:

Rescore Request
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106-3699

Results of the rescore will be mailed to you within eight weeks of receiving your request.

If you need further assistance, you may reply to this e-mail or call us at 1-(800)-441-ABIM (2246) Monday through Friday, 8:30 a.m. to 8:00 p.m., and Saturday, 9:00 a.m. to 12:00 p.m. EST.

Respectfully,

Ethan Lambert
Customer Service Representative
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106
Phone: 1-800-441-ABIM
215-446-3500
Fax: 215-446-3590
www.abim.org

This scenario could happen to any US physician undergoing the American Board of Medical Specialties (ABMS) proprietary Maintenance of Certification program today. The hundreds of hours of preparation, survey collection, and timed test, all wasted. And since hospital credentials, legal credibility, and inclusion on insurance panels are increasingly requiring a favorable certification "status," the potential consequences to U.S. physicians are very serious indeed.

This threat to U.S. physicians' ability to practice medicine comes at a time when insured patient populations have swollen. So why would such a "Maintenance of Certification" program be beneficial for American's? Is such a program really about assuring some definition of quality physician? Or might it be about something very different?

While the realities of this situation are sure to raise physician emotions (and maybe the concerns of patients, too), there are several important facts that all physicians and interested patients should understand regarding the American board of Medical Specialties' (ABMS) Maintenance of Certification process that is administered by the American Board of Internal Medicine (ABIM):

1. The Patient Protection and Affordable Care Act (Affordable Care Act)¹ modified sections of Social Security Law² to require Maintenance of Certification of physicians as a condition of receiving payments from Centers for Medicare and Medicaid Services (CMS).³
2. While other organizations may create a "qualified Maintenance of Certification program," the only program specifically authorized  in the Affordable Care Act is the Maintenance of Certification program from the American Board of Medical Specialties (ABMS).³
3. "Qualified Maintenance of Certification" programs must contain surveys as part of their criteria⁴ despite their lack of scientific rigor.
4. According to law, the Maintenance of Certification program will be operated by a "specialty body" of the American Board of Medical Specialties" that meets the criteria for a registry or physician quality and efficiency measurement" for physician payment. It is now clear this "specialty body" is the American Board of Internal Medicine (ABIM).³
5. CMS will receive a portion of $5 million dollars in 2014 from the Federal Hospital Insurance Trust Fund and $15 million from the Federal Supplementary Medical Insurance Trust Fund for the first 6 months of 2015. The National Quality Forum also receives a potion of these funds⁵
6. The Administrator of the CMS shall through contracts develop quality and efficiency measures (as determined appropriate by the Administrator) (editor's note: along with "multi-stakeholder group input into selection of quality and efficiency measures")⁶
7. The current President and CEO of the American Board of Internal Medicine, Richard J. Baron, MD served as Chair of the ABIM Board of Directors in 2008 and as Treasurer of the Board in 2007 and later as a Trustee for the ABIM Foundation while also serving as the Group Director, Seamless Care Models, at the Innovation Center at CMS.
8. The former President and CEO of the American Board of Internal Medicine, Christine Cassels, MD, left the ABIM to join the National Quality Forum, another "consensus-based entity," and also had significant conflicts of interest with the group purchasing and performance improvement firm Premier, Inc and Kaiser Foundation Health Plans and Hospitals which she later relinquished. Despite these conflicts, she retains her current position.
9. An unfinished public webpage (Here's a backup screenshot in case this webpage disappears) raises speculation that current ABIM President and CEO, Richard J. Baron, MD might be slated to sit (or may currently sit) on the National Quality Forum's Board.

Crony capitalism is pervasive in Washington, DC and nowhere is this more evident than the American Board of Medical Specialties and the American Board of Internal Medicine incorporation into our new health care law. The conflicts of interest contained within the Affordable Care Act's requirement of Maintenance of Certification as a basis to assess physician quality are increasingly harmful to physicians.  Given the conflicts of interest between the American Board of Internal Medicine, National Quality Forum, and the Center for Medicare and Medicaid Services, paired with the growing Maintenance of Certification failure rates of physicians without a clear explanation, the specter of cost control at the expense of patient care must be considered.

Only by understanding the environment of government cronyism and regulatory entrapment created by our new health care law can  physicians begin to address these very real concerns for patient care.

-Wes

References:
 ¹ Full text of Affordable Care Act: (pdf 2.1 MBytes)  
 ²  42 U.S. Code § 1395w–4 - Payment for physicians’ services
 ³ ACA law pdf above, page 247 (124 STAT. 365)
 ⁴ ACA law pdf above, page 845 (124 STAT. 963)
 ⁵ 42 U.S. Code § 1395aaa - Contract with a consensus-based entity regarding performance measurement
 ⁶ 42 U.S. Code § 1395aaa-1 - Quality and efficiency measurement

The Quiet

With the advent of social media and seconds-long news cycles, the internet noise grows louder.  Everyone is listening these days: new organizations, stock holders, businesses, special interest groups, and yes, the government.    There are even websites devoted to "secure" areas where the noise can permeate.

The Internet, you see, is it.

Yet what about The Quiet? 

The Quiet is the silent majority.  The Quiet smiles and seems happy.  The Quiet appears unaffected by policy changes and mandates.  The Quiet doesn't mind typing.  The Quiet follows rules. 

At least for a while.  The great cameleon.

So it comes as no surprise to The Quiet that the largest medical device company in the United States recently "purchased" another to avoid some taxes and improve its clout. 

A Quiet move.

And what about the National Quality Forum (here) or the Institute of Medicine's (here)  little conflicts of interest lapses?  And those electronic medical record  or insurance problems?

Shhhh.  Say nothing.  Smile.  No big deal, remember?

Dinner conversations with sons and daughters.  It's different now.  Consulting, enginnering, finance, or maybe nursing. Why be trapped by debt and a dwindling supply of paid residency positions?  There are other ways to help people.  Explore them.  See what you think.  You're young, remember?

The Quiet is marking time, working hard, advising.

Quietly. 

-Wes

Medicine's Great Disruption

"Disruptive innovation is competitive strategy for an age seized by terror."

- Jill Lepore, author of
"The Disruption Machine: What the Theory of Innovation Gets Wrong"

"What do you want me to do with all the stuff in this box?" my wife asked this weekend.

I looked inside and saw my former self: one of BNC and pin connectors, wires, a notebook with sin, cos, theta, and a host of other equations - a project I worked on but never grew - it came from a time of creativity and endless possibilities for me in medicine.  Engineering and computers were how I entered this field - the hope of solving problems, doing things a little better, safer, and maybe faster.  A chance to innovate and collaborate.  A chance to make a difference.

But the world of medicine has changed from one that promotes discovery and creativity to one that promotes productivity and the lock-step over the past several years.  See more.  Do more.  Don't sway.  Follow the guidelines.  Stay between the lines.  Want to try something new?  The message to doctors is loud and clear now: don't you dare!

Every month another set of guidelines and rubrics, as if the guidelines are how we want doctors to think, or rather, recite.  Medicine is rapidly becoming a staid world of group-think, as we are forced to use the latest "disruptive technology" to change our medical world.  Bit by endless meaningless bit.  The "value-added" ideas never end.  There is little ownership now.  Little personal investment.  Punch the clock.  Get 'er done.  Do what those grey suits say.

It's the era of the creative destruction of creativity. 

What kind of doctor we are breeding in medicine now?  The American Medical Association (AMA) and Accreditation Council of Graduate Medical Education (ACGME) want to shorten studies and push medical students through school based on competencies and "not based merely on a traditional time-based system."  Time with patients can no longer be trusted it seems.  In the place of time: competencies gained from simulators. Plastics superseding flesh. As though doctors should become technocrats that make a cameo appearance at the patient's bedside with their smart phone in hand.

Is the hurry-up push toward technology and Big Data really needed or what we're being sold?   Enter your note, doctor, click another box, you're being scored now.  Do as you're told.  What's that? A little software glitch?  Don't rock the boat.  Just work around it.  The fix will be here in September. We must do more with less.  Oh, and forget the staff, they're expensive. Hurry up.  Perfect data, remember?  Your pay depends on it.

Oh, and that idea you wanted to work on?  Sorry, no time or money.  Really doctor, we're on a time line. Could you move it along?  My kids have a play date.

The Disruption Machine is moving, alright.

But will we be better for it?

-Wes

Damage Control

When you shine light on cockroaches, they scatter.

But we should not think for a minute that the cockroaches are eradicated.

That takes an exterminator.  And sadly, there are very few exterminators who deal in the shady cracks and crevices of the multi-billion dollar non-profit organizational world these people have created for themselves.  There are very few ways to hold individuals who hide behind this altruistic-sounding corporate facades that have been erected by the American Medical Association/American Board of Medical Specialty mothership and their flotilla of member organizations accountable.

But we should acknowledge the tremendous efforts put forth by these "key stakeholders:"

Internationally regarded leaders in medical education discussed data on the value of knowledge examinations. Members of multiple ABMS member boards presented proposed and in-place innovations that will impact these examinations. These innovations included use of evaluations taken at home, short segment continuous evaluation strategies and multiple strategies that provide important formative feedback to physicians as they mature in their careers while also providing the necessary summative data to meet their professional requirements of monitoring and ensuring the public good. 

Note how there are no attempts to rid doctors of this menace. And the conversations must have been remarkably short, since there are few objective data to support their tactics.  Instead, we see self-aggrandizing platitudes like "internationally regarded leaders."  We see fervent efforts being made to rearrange the deck chairs on the Titanic.   Bullying doctors and making them less available for patient care is not insuring the public good.  Making my profession more untenable is not for the public good.  Suggesting that organizational sycophants (payees) are the only ones who are concerned about physician quality and physician education is hubris and surely not ensuring the public good.

A real general does not turn around and open fire on his groups.

What these "stakeholders" don't realize is that US physicians are already doing their overwrought busywork at home.  Doctors are already performing "short-segment continuous evaluation strategies" called knowledge assessment "modules" and "practice improvement modules" that take months to complete on top of an already overwhelming clinical load.  And because eyes must remain on a computer screen as a means of providing  "important formative feedback," we see the hopium for effective clinical teaching perpetuated.   We also see how deeply these individuals have permeated the halls of Congress as the Physician Quality Reporting System incentive payments with CMS are still tied to this unproven and potentially destructive program to physician retention and morale.

It is one thing to sit inside a self-proclaimed ivory tower and preach.

It is another thing entirely to lead.

-Wes

ABIM's New Research on Physicians

"A systematic, intensive study intended to increase knowledge or understanding of the subject studied, a systematic study specifically directed toward applying new knowledge to meet a recognized need, or a systematic application of knowledge to the production of useful materials, devices, and systems or methods, including design, development, and improvement of prototypes and new processes to meet specific requirements"

 - Definition of "Research" - National Institute of Health

It's one thing to ask a doctor to stay current on his knowledge, it's quite another to insist he survey his patients for a private enterprise, especially if that survey represents unvetted independent research.

Recently, a colleague of mine was attempting to maintain his "board certification" credential with the American Board of Internal Medicine (ABIM) and signed up for the ABIM's requirement for a "practice improvement module" worth a required "20 points" of 100 total required before he could sit for his specialty board re-certification examination.  For his module, he optimistically chose to offer a survey created by the ABIM to his patients, receive feedback on how he did on the survey, then repeat the survey to a later set of patients to show "improvement" of care.  In return for his considerable efforts, he would be granted his required "points" from the ABIM so he could qualify to sit for his specialty re-certification examination.

Here is an exact copy of the survey (pdf - 3.52 MBytes) my colleague was sent in its entirety.   He received a packet of 70 of these surveys from the ABIM, neatly shrink-wrapped, to distribute to his patients.

What could go wrong?

First, imagine the time and work involved to distribute these surveys. Whether he provided the survey to his patients himself or he tasked others to do so, what lab result was not reviewed or phone call not answered as a result?  We can only speculate.

Second, informed consent about the true nature of this survey was not obtained from patients nor my colleague.  Rather, my colleague was coerced into purchasing the survey because he might not be able to continue practicing medicine unless he complies with this requirement.  Informed consent would suggest that the doctor and his patients are informed of potential harms or risks involved with the collection of such survey data.    For the patient: what might their responses mean for their doctor's ability to practice medicine?  How might the working relationship with their doctor be degraded or the trust he has in them be compromised?  For the doctor: how are the data collected on the non-secure website protected, how will they be used against him? Will the data be used for future health care policy development or sold to third parties?

I have no doubt that many will see this survey collection as a benign attempt to truly improve a physician's practice or as an opportunity to empower patients with an means of changing physician behavior.  But I suspect these same people never consider the potential negative consequences of such a survey.  The very idea that this survey is a destructive intrusion into the doctor-patient relationship is a foreign concept to its designers.  We can only imagine the moral outrage and disavowal that will arise in the halls of ABIM with such an assessment.  Yet like a bull in a china shop, the collection of anonymous survey data completely disrupts one of the most tenuous and vulnerable relationships in medicine.  It ignores the vulnerable, highly-charged and often emotional circumstances that accompany any visit to a doctor's office while rendering valid concerns a patient might have about their experience into the muddied waters of anonymous data aggregation.  

Also, this unscientific research survey contains a host of dependent variables like age, race and self-assessments of general health status and mental illness.  Self-assessments make a mockery of non-biased data collection, yet the destructive assumptions made throughout the survey are clear: doctors should have unlimited time, provide unlimited access, and perfect manners toward patients without regard to forces (such as this ABIM survey) that increasingly pull them from what they yearn to do: care for their fellow man, woman or child.   This lack of concern with scientific validity and objectivity  leaves the end game of any particular individual or group "findings" only left to the imagination.  If we are going to investigate whether an individual doctor's behavior reflects an age/education/gender/race bias toward their patients (see questions 42 through 46), this is a serious question, deserving of the doctor's consent, and requiring scientific validity far past that of correlational survey data on an n of 70 patients. The possible "end result" or accusation is far too damning.  Or haven't the ABIM committee members thought of that? But we shouldn't worry - patient bias/irrationality/emotionalism is controlled for by question 41 - where the patient provides us with an assessment of his overall mental health.

If doctor's are subjecting themselves to this kind of scrutiny, shouldn't they (and their patients) know how it will be used? Whether aggregated or individual data, this kind of helter-skelter approach is surely designed to lead to progressive "quality" initiatives to adjust doctor's behavior whether findings are valid or not. We are participating in the first step of yet another new initiative in micro-managing and control of the already besieged doctor.

The intrusion of this survey into the sanctity of the doctor-patient relationship by an independent and non-accountable non-profit organization that ignores sound research and ethical principles should be stopped.  It's negative consequences far outweigh any benefit to patients.   In a recent survey of their membership of over 4000 cardiologists nationwide, the American College of Cardiology found that nearly a third of their respondents indicated that the changes imposed by the ABIM's subversive "re-certification" process (that includes these patient surveys as one tool) will affect their future career plans and will likely accelerate their decisions, such as early retirement, part-time work, or transition to non-clinical work.  Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement is a likely outcome.  Exactly how will such a survey help patients already struggling to access care?  Is ABIM responsible for the repercussions of their physician bullying?

I know this is a time of multiple instances of moral outrage and demoralization for physicians.  But I would ask that you take that outrage and forward this survey to colleagues.  I would also ask that you contact your local professional subspecialty organizations, state licensure boards, and appropriate members of Congress to insist on an immediate moratorium to the American Board of Medical Specialties/American Board of Internal Medicine Maintenance of Certification process as it currently exists.

Believe me, this discussion is ongoing and far from over.

-Wes

On Mentoring

Recently, I had one of those "proud Daddy" moments: watching my son play in the Chicago Civic Orchestra's last concert of their 95th season.  (For those unfamiliar, the Civic Orchestra is the training orchestra of the Chicago Symphony Orchestra.) They played Prokofiev's Symphony No. 5 under the direction of Jaap van Zweden - one of the most amazing conductors I have ever seen (and I later learned, one of my son's favorites).   Afterward, we were invited to a reception and I had a chance to meet YoYo Ma who served as an inspiration, role model, and mentor for my son for the past year in his role as creative consultant with the orchestra.  What a wonderful guy.  He was fun, energetic, complimentary and thoughtful.

Later that night, my encounter with these artists got me thinking about my role as a mentor to young physicians.  I teach residents.  I teach EP fellows.  What are they thinking?  Am I doing all I can for them?

So it came as a surprise that I had just been offered to speak at a fellows conference later this year.  The conference was sponsored by a major medical device manufacturer in a lovely US city.  100 fellows would be there along with 40 industry personnel.  I would be paid well for my travel and speaking time.  I'd connect with other contemporaries of mine whom I admire that would also serve as speakers.  My topic involved an aspect of social media for physicians.

How could I resist?

And yet, here I am talking about the Health Care Industrial Complex and the Iron Triangle of comprised of Congress, special interests, bureaucracy and how doctors are swept up in their wake.  I thought about being a mentor, a teacher, a doctor.  I wondered how it might ever change.  I wondered if doctors would ever have the courage to push back against the seductive powers of ego and money.  Then I realized: probably not.  It's how we're groomed for this from the beginning.  We're human.  So  I have no doubt another doctor will be more than happy to serve as my replacement.

And so it goes.

But perhaps I could do what I love again, I could teach for the joy of watching young doctors get excited again, not because I needed to make a buck.  Perhaps I could teach those same doctors that we do what we do because it's not about the corporate boondoggle, but about the patient.  I could mentor.

So I declined the offer.

After all, I've got other priorities now.

-Wes

Why Do Hospitals Side With Maintenance of Certification?

With the recent 22% percent failure rate of the most recent Maintenance of Certification (MOC) testing offered by the American Board of Medical Specialties/American Board of Internal Medicine, I was puzzled as to why any hospital systems would want to support the proposed Maintenance of Certification changes imposed 1 January 2014.  After all, wouldn't hospitals risk of looking like they have substandard physicians on on their staff if they failed to pass their MOC exam? Do hospitals really really side with the ABIM's leadership that MOC testing is for public good?  Or might there another motive why hospitals support the MOC process?

To reach an understanding of this issue, I asked a senior member of our staff who has served many policy roles within the leadership of the American College of Physicians, the Illinois Chapter of the American College of Cardiology, and served as a founding fellow of the Society of Cardiovascular Angiography and Interventions (SCAI), Joseph V. Messer, MD, MACC.  Joe is widely respected in the cardiovascular policy circles and has worked extensively on such things as "Appropriateness Use Criteria" and performance measures for cardiology. He carries a unique understanding of the challenges inherent to bureaucratic methods to measure quality care and (importantly) the limitations of creating such systems.  Joe is a luminary in many respects and thought hard about the question I posed him.  His response was both eloquent and insightful.  With his permission, I am publishing his response to me so others might enjoy Joe's perspective on why hospital systems want to "align" with the MOC process. Here is what he wrote:

Wes, your question yesterday at our Cath Conference started me thinking. Since I have decided not to go the MOC route, haven't given it much thought. Here are my ideas:

Both the Feds and the Hospital Systems prefer a single payer system. Several years ago at an ACC conference, the CMS representative told me their goal was to pour all the money into a single funnel and let healthcare systems worry about the distribution, providing a significant source of "handling" fees for the systems.

CMS and hospital systems seek alignment. The "funnel" analogy is one example. Further, CMS has very limited authority to define and require demonstration of quality from providers. They will encourage the hospital systems to handle this role, and will provide the $$ for same - thus more revenue for hospital systems, not unlike current support for residence and fellow training programs.

As we move toward a single payer system, hospital systems will continue their effort to control physicians - the most important of the distribution recipients in healthcare other than the systems themselves. By ultimate controlling MD's they can take a larger piece of the pie for themselves. Increasingly impotent physicians will have little recourse, since the public consumer now values convenience and low cost over quality.

Supporting MOC assists the hospital systems in controlling MD's. Systems will use public opinion, in part, as a tool in this effort. Hospital systems will vigorously claim that MOC assures higher quality. By requiring and advertising that all system employed MD's are MOC certified the systems will have another weapon against the "private practice" MD, many of whom will not pursue the MOC course, many of whom will be "concierge MD's" and the most vocal opponents of hospital systems.

Ultimately, I believe the hospital systems want to control the certification process. By supporting the MOC initiative they will likely destroy the ABIM as it loses its physician support because of MOC. The specialty societies are lukewarm at best about MOC's and I hear increasing criticism of ABIM for its ulterior financial motivations. Some specialty societies are receiving similar criticism for the fees they charge for educational materials crafted to meet MOC requirements. Thus, ACC and others may well suffer with the ABIM for not vigorously opposed MOC in its current form.

Marginalizing the special societies has already begun. It is very clear that employed cardiologists find less interest in the ACC. The largest grant the ACC has ever received just went to two Chapters - Wisconsin and Florida - to test local, grassroot proposals for health care financing. ($15.8 million over 3 years). National ACC supported this project for a while, but then fell away when the leadership lost interest. My concern here is that the ACC/AHA/STS/HRS/SCAI remain key supporters of quality, appropriate use and performance measurement. If they are significantly weakened by all of these issues - MOC, physician employment, decreased specialty influence in CMS and Congress, the hospital systems will surely move into the vacuum to control education and quality definition to their advantage.

But, when all is said and done, I doubt that the incoming crop of physicians care. In a recent survey (2-3 years ago) the primary motivation of medical school applicants was "job security".

Ugh.  Depressing.  Sadly, I think he's correct.

Thanks for your insights, Joe - 

-Wes

On the ACC's Response to ABIM’s MOC Requirements

The American College of Cardiology (ACC) recently issued a response to the American Board of Medical Specialties (ABMS) and American Board of Internal Medicine's (ABIM) recent change to their Maintenance of Certification (MOC) requirements. The ACC's response was based in part on the results of a completed member survey that was distributed through their state chapters in the spring of 2014. The survey was completed within four weeks by over 4,400 members (12 percent of the total solicited). Nearly 90 percent of respondents opposed the changes to the American Board of Medical Specialty (ABMS)/American Board of Internal Medicine (ABIM)'s new Maintenance of Certification (MOC) requirements, citing, among multiple concerns, higher than expected costs. Nearly a third of respondents indicated that the changes will affect their future career plans and will likely accelerate career decisions such as early retirement, part-time work, or transition to non-clinical work. Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement was a probable outcome.

If true, the implication of this change to MOC has significant implications for patients everywhere.

This must have prompted the leadership of the ACC to throw their considerable weight into the discussion with the ABIM. In their statement, the ACC promised to:

• Have "ongoing discussions" with ABIM leadership, in partnership with other cardiovascular professional organizations whose members are similarly affected, to review these issues and to explore changes in MOC requirements that will result in more meaningful outcomes and less onerous burdens for ACC members (Editor's note: To date, MOC has never been shown to alter outcomes, so we are left to wonder what this statement really means.)
• Request for ACC representation at ABIM to participate in discussions involving MOC, including its educational and financial aspects (Editor's note: What financial aspects might they mean? Does the ACC want in on this cash cow, too? Or might they want to strike a deal offset some of the fees since they want to keep their educational MOC-preparation income stream coming?
• Review of the evidence base underlying current recommendations (Editor's note: Let me help: there are none. Any positive articles are likely authored by those standing to profit from the endeavor or research paid for by the ABMS. Negative articles are also suppressed from publications sympathetic to the regulatory world. And we should recognize that we have never developed a definition of the "quality" physician. Quality to whom? Is "quality" following rubrics and care pathways? Or might "quality" be something very different, like empathy, listening skills, interpretative skills, or surgical skill? The reality is, if you can't agree on what defines quality, you can't define how to measure it.)
• Investigation of impact of MOC changes on non-ABIM certified members (Editor's note: I strongly agree with this - it is unethical to impose MOC mandates of any kind without first understanding how they negatively affect doctors, especially if a doctor should not pass and is unable to practice their vocation on the basis of a 180-question timed test)
• In the interim, ACC will support its membership by:
  • Free provision of web-based MOC modules and navigation tools to ACC members
  • Expansion of Part IV MOC modules through ACC programs such as the NCDR’s inpatient registries and the PINNACLE Registry
  • Creation of mechanisms for ACC members by which patient safety and patient survey requirements can be efficiently fulfilled
  • Bidirectional communication with and engagement of membership through Chapters, Sections and Councils.
  (Editor's note: It's okay to make MORE MOC modules available to us? Is that what doctors want? How many more hours must we spend on this drill and for how much time in lost revenue? "Free" is in the eye of the ACC, not those who have to endure these processes.)

The good news (if there is any with the ACC's announcement), is that front-line doctors are starting to be heard. While the ACC's actions might be a step in the right direction (one can hope), it is disappointing that their statement still sides with the ABIM's requirements for the unproven MOC process in the first place, the busy-work requirement for "Practice Improvement Modules" (especially when quality measures are already required by hospitals), and for permitting a private organization to monopolize the ability of physicians to practice their trade. Furthermore, the ACC's statement does nothing to insist upon changes to the ABIM's non-transparent and self-serving Conflict of Interest policies that keeps conflicts confidential except to certain chosen individuals within the ABIM.

Unless the ACC can convince the ABMS and ABIM to come clean on these important issues, significant physician resistance to this process will remain. Furthermore, the lack of involvement by other subspecialty boards in resisting the ABMS/ABIM's MOC process is concerning. Hopefully, other subspecialty boards will be encouraged by the ACC's example.

After all, cardiologists aren't the only ones frustrated by this change in MOC policy.

-Wes

Clicks Unchecked

"Where did that menu item come from?" I recently thought.  "Come to think of it, where did the Allergy field go? What's that?  I have to enter an 'Order' for a consent now?  Whatever happened to speaking with the patient?"

Such are the myriad of thoughts the EMR engenders lately.  So ridiculous.  So time-consuming.  Death my a hundred thousand clicks.  It's like my fingertips are on high continuous suction. Pretty soon I'll have to click the "Excuse Me" or "Pause" button so I can use the bathroom.

Seriously.  In medicine, everything is entered on the computer now.  Everything.  Not just notes and orders, but schedules, message boards, meeting notifications, billing check-boxes that must be paired with diagnosis check boxes.  If it isn't clicked, it didn't happen.  Every time a new "idea" for process improvement that springs forth is codified for the computer.   And guess who's the data entry clerk?

It's gotten so bad we now must scroll to display all the menu options. Even filtering the notes to ones you wrote is dreadfully slow.  Unfiltering them worse still.  Precious seconds of patient care time are repeatedly wasted.

It was bad before, but it's getting worse.  The foxes are minding the hen house of patient safety and doctor overload.  Not that computers aren't wonderful at some things - they are - but to suggest, even for a moment, that they can fix what ails health care in America is ludicrous; to suggest they aren't silently inflicting their own patient care comprise even crazier.

Yet the drumbeat of unending support for computers, simulation, data manipulation continues.  Profit does this.

The data clerks are growing weary.

And patients are noticing.

-Wes

Maintenance of Certification and Licensure: Regulatory Capture of Medicine

An important article by Paul Martin Kempen, MD, PhD that critically reviews the American Board of Internal Medicine (ABIM) and American Board of Medical Specialty's (ABMS) Maintenance of Certification (MOC) process recently appeared in the Journal of Anesthesia and Analgesia.  Unfortunately, the article resides behind a pay wall.  As such, I can only publish a small sampling of the article for discussion here, but I think the points raised are important ones to bring to the public's attention for discussion ( I have also included the appropriate references at the end of the excerpt):

MOC: RESEARCH VERSUS MARKETING

The ABMS emphatically stresses that multiple articles support MOC. A quick review of these proffered ABMS articles readily identifies the authors as overwhelmingly ABMS paid executives and/or hired paid consultants.(4,c)

These corporate authorships mitigate scientific validity and introduce significant bias into these retrospective data-base interpretations, as would occur for any proprietary medical device or drug.(5) At best, they can statistically substantiate only associations and not causality. Negative studies may never be published. Publication further occurs in journals owned, edited, managed or supported by organizations strongly influenced by ABMS senior staff or national societies, otherwise exhibiting significant financial interests in proprietary and endorsed products associated with recertification programs.(4,c) Executive members of ABMS boards are frequently found to serve as executives of all national medical societies, associated journal editorial boards, and many academic departments. Corporately sponsored/authored publications of both FSMB and ABMS affiliates, financed with the $374 million in ABMS’ gross annual receipts, repeatedly support a significant corporate advertising campaign, without significant opportunity for opposing views from practicing physicians.(6,7)

In 2002, the ABMS unsuccessfully attempted to validate board certification itself, via meta-analysis coauthored by 2 ABMS (executive and associate) vice presidents documenting, “Few published studies (5%) used research methods appropriate for the research question,” and “Perhaps one lesson to be learned from this review is the need to thoughtfully examine this recertification process to document its value.”(8) Cochrane Collective Database Review (another quality indicator) also fails to support MOC or board certification validity. The only ABMS-funded prospective randomized study found in the Cochrane database (yet missing from ABMS listing), however, did document “no benefit regarding primary outcome” from the specifically studied practice improvement module.9 These facts together emphasize significant scientific limitations supporting validation of the ABMS program, despite ABMS insistence to the contrary.

PRACTICE IMPROVEMENT MODULES—BREACHING ETHICAL RESEARCH STANDARDS?

MOC practice improvement modules require physicians to define subset populations in their practice, where patient care might be improved. A plan is introduced for selected

patients, and changes in care are introduced. Data are collected to specifically demonstrate quality improvements in one’s own practice to the ABMS to enable recertification. This practice improvement modules method is initiated to facilitate the individual physician’s personal certification, that is, personal gain.

Practice improvement modules constitute an experiment: changing practice to demonstrate a positive result. This experimentation occurs without any institutional review or written informed consent. Patients unknowingly assume the costs and risks of the practitioner’s experiment. Without IRB oversight, review, and approval, practice improvement modules violate the Nuremberg Code of 1947(d) (safeguarding humans from experimentation) and the Declaration of Helsinki.(e) This represents a significant moral concern. No individual rigorous review of methods, adverse outcomes, risks, or costs is mandated or occurs.

As a physician working for an internationally recognized center of medical excellence, I should not be allowed to tamper with proven protocols merely to meet ABMS requirements for my very personal recertification needs. For example, perhaps I want to change my practice to improve (reduce) hemoglobin A1c levels. Thus, I become more aggressive with insulin management to achieve this worthy goal. However, we know that tight control of insulin can be extremely dangerous and the burden of treatment associated with therapeutic complexity and risk of harms increases with lower targets.(11,12) Such experimentation with changing insulin management to meet personal recertification needs may result in fatalities. Is such tinkering with standard practice worthwhile, ethical, or even likely to improve quality?

REGULATORY CAPTURE OF PHYSICIANS

Recent attempts by the testing/regulatory corporation, the FSMB Inc., to legally mandate MOC nationally with testing every 5 years exemplify regulatory capture: monopolies or special interest groups co-opting policymakers, or political bodies (e.g., regulatory agencies), to further their own ends.(13,14) While current board certification is generally a prerequisite for hospital privileges and applicant hiring, informed physicians are now proactively pushing to prohibit bylaws that require recertification compliance as documented by resolutions passed at the 2013 annual meeting of the American Medical Association (AMA) in Chicago, IL. Passage of anti–MOC-MOL resolutions in New York, New Jersey, Iowa, Michigan, North Carolina, Oklahoma, and recently Florida followed Ohio’s State Medical Society’s lead in recent years. These are specific examples of the rising concern among working physicians that unproven certification restrictions and costs are becoming mandated by private and corporate interest groups. These efforts strive to place time-limited certificate holders on equal ground with grandfathered lifelong certified physicians. Nationally, the Association of American Physicians and Surgeons and Doctors for Patient Care have led the opposition, followed by AMA actions at the annual meeting in Chicago, IL, in 2013. Examples of physicians losing hospital privileges and/or the ability to participate with insurance programs including Medicare over recertification have been noted. This led the Association of American Physicians and Surgeons to file a lawsuit on behalf of the national membership against the ABMS in April of 2013 seeking redress on multiple issues regarding conspiracy and restraint of trade (see United States District Court for the District of New Jersey Docket No.  3:13-cv-2609-PGS-LHG). While the FSMB’s MOL program (linking participation to the ability to practice) goes further than the ABMS currently voluntary certification proposals, neither protects against lawsuits nor insures competence, while both limit competition from noncertified physicians and intimidate physician compliance with ABMS programs.(15) The ABA has now expanded testing, which requires mandatory passage of their part 1 test before allowing completion of any residency training program. This undermines any appearance of voluntary participation and provides a clear trend for the future.

Renowned contemporary medical leaders simply never need MOC to secure their newest or next position, their reputation suffices. Thus, certification is mostly a marketing mechanism for employment, required by industry insiders and overwhelmingly ignored and unappreciated by the general population. Multiple ABMS executives themselves have published statements indicating long-term failure to recertify or participate in MOC, complying only when it has become a recent job requirement as ABMS officers, individual chief executive officers (CEOs) having been paid 6 and 7 figure salaries (Table  1).(16,17) The chairman of the American Board of Pediatrics received $1,241,588.00 as annual income, when, in 2009, the board’s corporate deficit  (expenses-revenues per the 2009 filed Internal Revenue Service 990 forms) was documented at $2,713,406.00.(18)

These salaries pale in comparison to the $374 million yearly expenditure for ABMS certifications. The current 2013 ABMS and FSMB physician CEOs were not enrolled in MOC and have never recertified as of January 2013, as verified by ABMS databanks found at the ABMS and ABIM Web pages to verify a physician’s certification. This strongly undermines any personal statement regarding conviction of certification’s personal value versus corporate profits from ABMS programs. One might argue that these CEOs are no longer practicing medicine. However, why should the many administrative physicians be required to submit to the MOL or MOC protocols and costs to maintain licenses necessary to work in administrative or research positions? On the contrary, executives in the certification industrial complex, along with our academic colleagues pushing for certifications, are typically not those practicing full time and maintaining their clinical skills. This push for certifications by executives in the certification industrial complex may be simply reflecting their myopic prejudice arising from their academic distance from practice, when often treating patients only several hours per day, week, or month, if at all. Those physicians near retirement may be economically and inappropriately forced to retire, rather than to maintain a full license and ABMS certification protocol. With the 10-year certification intervals, retirement may become an economic enticement at 10-year intervals from first certification.

The ABMS has, nonetheless, actively and effectively lobbied Congress to pass Physician Quality Reporting System-MOC (PQRS-MOC) legislation, requiring ABMS MOC compliance for payment. The ABA openly disclosed that the 0.5% initial PQRS-MOC benefits would not cover the costs of MOC, which is soon slated to become a 2% penalty for nonparticipants. (f) Only 9 specialty boards had fulfilled PQRS-MOC requirements to become providers, leaving all other 15 physician specialist groups (ABA included) exposed to reap only PQRS-MOC’s future penalties, because 2013 is the prescribed index year required for such protections.(g) Only recently did the ABA attain provider status despite openly declining to do so in 2010, declaring then “Based on its understanding of the current CMS requirements, the ABA does not believe that the additional requirements for the MOC bonus will have a sufficient impact on patient care, nor will the reimbursement bonus justify the additional time and resource burden on its diplomates.”(f) Many individual ABMS specialty affiliates opposed transitioning to time-limited programs but succumbed to ABMS corporate directives to comply or lose ABMS accreditation and these exclusive franchise rights.

While the ABMS argues that MOC is inexpensive, the ancillary cost of travel, study, time away from patient care, locums coverage, and busywork are quite significant. However, these minor costs are deemed insignificant, if the benefit is a measurable improvement in patient care. The burden of proof for any claim rests with the claimant. If the ABMS believes there is value to offset the costs, then it has the burden of proof to support this claim and this claim remains to be conclusively demonstrated by objective and reproducible means.

If you have the time, be sure to read the whole thing.  I welcome responsible comments and encourage doctors so moved to sign the petition to roll back the MOC process.

-Wes

Addendum 2 JUN 2014: The full article has now been posted online here: http://www.changeboardrecert.com/documents/KempenANesAnalg.pdf

References:

(c ) ABMS Maintenance of Certification® (ABMS MOC®) Updated March 20, 2013 Myths & Facts. Available at:   http://www.abms.org/maintenance_ of_certification/pdfs/ABMS_MOCMythsFacts_3-20-13.pdf . See LISTS 1–5 (Qualidigm, Middletown, CT [Drs. Wang, Meehan, and Ho and Ms. Tate]). Accessed January 16, 2014.

(d) The Nuremberg Code. Available at: http://history.nih.gov/research/down-loads/nuremberg.pdf . Accessed May 28, 2013.

(e) WMA Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. Available at: http://www.wma.net/en/30publications/10policies/b3/index.html . Accessed May 28, 2013.

(f) The American Board Of Anesthesiology, Inc. Maintenance of Certification and Physician Quality Reporting System Requirements. Available at: http://www.theaba.org/pdf/MOC_PQRS.pdf . Accessed February 28, 2013.

(g) Qualified Maintenance of Certification Program Incentive Entities for 2012. Available at:     http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Fully-Qualified-2012-MOC-Posting-Document-Rev-11282012.pdf . Accessed February 28, 2013.

(4) Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician’s commitment to lifelong learning. Ann  Intern Med 2012;157:287–9

(5) Lehman RS. Nullius in verba: don’t take anyone’s word for it. JAMA Intern Med 2013;173:1049–50

(6) Kempen P. Maintenance of licensure. Ann  Intern Med2013;158:219

(7) Chaudhry HJ, Talmage LA, Rhyne JA. Maintenance of  licensure-Reply. Ann Intern Med2013;158:219

(8) Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med 2002;77:534–42

(9) Simpkins J, Divine G, Wang M, Holmboe E, Pladevall M, Williams LK. Improving asthma care through recertification: a cluster randomized trial. Arch Intern Med 2007;167:2240–8

(10) Vollmann J, Winau R. Informed consent in human experimentation before the Nuremberg code. BMJ 1996;313:1445–9

(11) Finfer S, Liu B, Chittock DR, Norton R, Myburgh JA, McArthur C, Mitchell I, Foster D, Dhingra V, Henderson WR, Ronco JJ, Bellomo R, Cook D, McDonald E, Dodek P, Hébert PC, Heyland DK, Robinson BG; NICE-SUGAR Study Investigators. Hypoglycemia and risk of death in critically ill patients. N Engl J Med 2012;367:1108–18

(12) Lipska KJ, Montori VM. Glucose control in older adults with diabetes mellitus–more harm than good? JAMA Intern Med 2013;173:1306–7

(13) Federation of State Medical Boards. Report from the Maintenance of Licensure Implementation Group. Euless, TX: Federation of State Medical Boards, 2011

(14) Dal Bó E. Regulatory capture: a review. Oxf  RevEcon Policy 2006;22:203–25

(15) Wallace DA. Occupational licensing and certification: remedies for denial. William Mary Law Rev 1972;14:46–127. Available at: http://scholarship.law.wm.edu/wmlr/vol14/iss1/3

(16) Johnson DH. Maintenance of certification: confession of a grandfather. J Oncol Pract 2012;8:203–4

(17) Brennan TA. Recertification for internists–one “grandfather’s” experience. N Engl J Med 2005;353:1989–92

(18) American Board of Pediatrics. 2009 IRS 990 form, part VII. http://www.changeboardrecert.com/tax-returns.html . Accessed January 16, 2014