Friday, February 25, 2022

What Entity or Person Serves As ABIM's "Restricted" Contributors?

 In late 2018 through 2020, The American Board of Internal Medicine (ABIM) was involved in a class action antitrust lawsuit for claims of illegal creation and maintenance of their monopoly power in the market for maintenance of certification (MOC). Even though there was an outpouring of physician support for the lawsuit from working physicians, the case did not survive massive legal efforts to kill the case on technical grounds before it went to trial.

Now, physicians are left with little choice but to cough up more money to pay the exorbitant salaries of the non-clinical academic elite who run the organization or risk losing their jobs.  It is the tie that binds ABIM's their proprietary MOC continuing education product to physicians' initial subspecialty board certification that allows ABIM to raise their costs without any oversight because physicians require their initial board certification credential to maintain their hospital privileges or place on insurance companies' rosters.

It is particularly concerning that ABIM decided to raise their MOC fees 25% in 2022 when their own assets mushroomed 18% in 2021 alone to more than $168 million:


 

ABIM has constantly billed itself as a "physician-led" non-profit 501(c)(3) organization. From their About ABIM webpage:

"ABIM is a physician-led, non-profit, independent evaluation organization driven by doctors who want to achieve higher standards for better care in a rapidly changing world."

But are they really? Who is really pulling the strings at ABIM?

We have already seen that the former CEO and President of ABIM, Christine Cassel, MD was serving as a board member of one of the largest Group Purchase Organizations, Premier, Inc, and serving on the Board of Kaisier Hospital and Health Systems while also serving as President and CEO of the ABIM - conflict that was never disclosed to physician-diplomates of the ABIM.

But now we see another concerning potential conflict that needs explanation, especially with the rate hike in fees physician must endure. Who are ABIM's "RESTRICTED" contributor(s) found buried on their latest IRS Form 990?

Might it be George Soros (since ABIM contributed to his Institute for Medical Professionalism in 2003 and 2008)?

Or might it be other members of the Accreditation Council of Graduate Medical Education (ACGME), like the American Medical Association (AMA) or American Hospital Association (AHA)? Who stands to profit from the control of physicians this way?

Physicians have a right to know what the heck is going on at ABIM and why are fees have gone up 25% in 2022 at a time when ABIM is more than flush with cash. We also deserve to know who their contributors are that are supporting his racket. 

Unless, of course, the US is running the physician regulatory system like the mob.

-Wes


PS: For those interested in staying abreast of our ongoing investigation, consider joining Practicing Physicians of America (it's free and allows us to know who wants further work in this arena).



Monday, February 14, 2022

Can There Ever Be a "Kinder and Gentler" MOC?

It has been a long time since I have written anything concerning the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) board re-certification program. But when I read pieces in the media, like the one recently published in Medscape that spin the soothing narrative that MOC can become "kinder and gentler," I feel the need to speak out.

Like a child bring groomed by serial molester, the media miss the seriousness of the harms imposed to physicians and patients by the industry-levied Maintenance of Certification mandate begun in 1990, largely because patients and the public really don't understand US physician board certification and the conflicts of interest with industry that exist. The public knows they want a "board certified" physician (thanks to the marking muscle and self-generated congratulatory "research" articles generated over the years by these multimillion-dollar organizations), but they fail to realize that board certification, once little more than a voluntary lifetime marketing accolade before 1990, became time-limited, mandatory, and an economic necessity for physicians to work, have hospital privileges, or be included in insurance panels since then. 

This change from a lifetime accolade to a time-limited necessity for physicians was unilaterally imposed on (only) US physicians by the highly conflicted and highly political ABMS and their member boards in conjunction with their parent organizations (where the ABMS is also a "member organization") from the Accreditation Council of Graduate Medical Education (ACGME), including the American Medical Association (AMA), American Hospital Association (AHA) and the Association of American Medical Colleges (AAMC). Thanks in large part to the nuances of often-delayed non-profit tax filings, all of these organizations enjoy their tax-exempt status and multi-million dollar budgets on the backs of working US physicians who are the major source of their funding.

The seemingly impenetrable nature of medical journal pay-walls has served to perpetuate the ruse of the scientific validity of time-limited US board certification. There is simply no scientifically valid proof that "longitudinal assessment" questions pushed to physician cell phones or taking day-long tests every 10 years improves patient care. Could it be these actions distract from patient care just to keep the money flowing?

More importantly, patients suffer as physicians become burned out or quit. Patients suffer as the boards  sell all the physician data they reap from that testing to Group Purchase Organizations (like Premier, Inc) and hospital organizations (like Kaiser) that increasingly consolidate and limit access in the name of lucrative health care "efficiencies."

The monopoly stranglehold on US board Certification (and specifically time-limited "Maintenance" of Certification, or MOC) and the vast conflicts of interest and millions of dollars it generates, is why the ABMS member boards are being sued right now. Their actions, I (and thousands of others) believe, violate anti-trust and unjust enrichment laws. It is not okay that a physician with years of dedicated service to his or her patients can lose their job or ability to care for their patients based on an unproven testing mandate. Nowhere does a physician's years of experience count to these AMBS member boards; only their money.

This is why I, along with many other men and women, help co-found Practicing Physicians of America, a non-profit 501(c)(6) organization, in part so we can work collectively to attempt to end the monopoly status of the American Board of Medical Specialties and their member boards on US Physician board certification. We hope that justice can be served to the hundreds (and perhaps thousands) of physicians  harmed by this discriminatory mandate imposed on us since 1990.

Physicians wanting to learn more or want to help can e-mail me at wes - at - practicingphysicians dot org. Donations for our work can be made at http://www.gofundme.com/practicing-physicians-of-america or (if you don't want to use GoFundMe, mailed to our organization at the following address:

Practicing Physicians of America
876 Loop 337 Bldg 101
New Braunfels, TX 78130

-Wes

Monday, December 06, 2021

The Danger and Hypocrisy of Physician Censorship

In late July 2021, the Federation of State Medical Boards (FSMB), a non-profit self-selected lobbying organization for US state medical boards, issued a press release threatening suspension or revocation of medical licenses for physicians that “generate and spread COVID-19 vaccine misinformation or disinformation.” The American Board of Internal Medicine, American Board of Pediatrics, and American Board of Family Medicine issued a joint press release in support of the FSMB’s statement and further threatened to revoke a physician’s specialty certification on similar grounds.

While likely well-intentioned and politically favorable on its surface, this policy risks compromising physicians’ due process, free speech, and patient care. Physicians serve on a multitude of research data safety monitoring boards and for the Food and Drug Administration, among others. Is leveling a cudgel against US physicians to control speech really in the best interest of promoting thoughtful scientific discourse? It is chilling to think that any private business can control what medical information constitutes “misinformation.”

Misinformation is common in the midst of any pandemic, especially when so much remains unknown about the coronavirus, its origin and variants, their spread, and potential therapies proposed to combat the disease and its comorbidities. While false information has been spread on social media channels by a tiny handful of physicians, the vast majority of working US physicians support the appropriate use of COVID-19 vaccines.  Giving strong, scientifically credible rebuttals to vaccine skeptics is much more likely to quiet skepticism of the vaccines than idle threats from afar by little known non-profit organizations with little real power to control speech.  

Working physicians are familiar with political propaganda, another form of “misinformation” that has become all too commonplace in US healthcare that is increasingly dependent of government funding. The FSMB is a self-interested private business that is not actively supervised by the state(s) and has a long history of attempting to link Maintenance of Licensure for physicians to the lucrative Maintenance of Certification physician educational product promoted by the member boards of the American Board of Medical Specialties, including the American Board of Internal Medicine, American Board of Pediatrics, and American Board of Family Medicine. In 2018 the FSMB also supported legislation that tried to circumvent the 2015 Supreme Court decision that held unsupervised professional boards could not make decisions that potentially violated antitrust laws and quashed competition.

The American Board of Internal Medicine (ABIM) also engaged in "misinformation" by secretly funneling $80 million of physician test fees from 1989-1999 to create the ABIM Foundation that  magically appeared to the public in 1999. Physician were told the Foundation was created to define “medical professionalism,” the same year the ABIM Foundation purchased a $2.3 million 2-bedroom condominium complete with a chauffeur-driven town car. Physicians can only assume that same “medical professionalism” the ABIM promotes extends to their undisclosed offshoring of over $6.5 million dollars to the Cayman Islands in 2015 and labeling their lobbyists in Washington as “consultants” on their tax forms, too. 

The profession of medicine and scientific inquiry are never perfect but demand constant vigilance to ensure its integrity. Just as any medical treatment demands careful weighing of its risk and benefits to our patients, the self-interested private entities that comprise the US medical regulatory system should carefully weigh the adverse effects of their edicts before they are unilaterally imposed on practicing US physicians.

Caveat emptor. Primum non nocere.

-Wes

Monday, March 01, 2021

The Courts Speak: Internists to Be Boarded to Death

It is with great sadness and a heavy heart that I must announce that on Thursday this past week, the United States 3rd Circuit Court of Appeals ruled in favor of the American Board of Internal Medicine (ABIM) and upheld the earlier District Court dismissal of the antitrust, racketeering and unjust enrichment lawsuit filed by four internists in December 2018. An attorney for the physician-Plaintiffs issued this statement following the ruling:
"The Plaintiffs are disappointed by the Court’s opinion but not discouraged. They remain committed to bringing an end to Maintenance of Certification (MOC). The ruling was based on a narrow and technical principle of antitrust law: whether ABIM Certification and MOC should be viewed together as a single product. The decision was specifically classified by the Judges as “Not Precedential” – meaning it should not be cited as precedent in other cases.

“It is important to understand that the ruling cannot be viewed as an endorsement of MOC or ABIM’s conduct. Contrary to ABIM’s litigation position, Certification and MOC are not voluntary. As admitted by its own leadership, they are an economic necessity for a successful medical practice.

“Significantly, the decision does not take issue with the many studies documenting the complete absence of any evidence of a causal connection between MOC and improved patient care. There simply is no reason for MOC to exist other than the hundreds of millions of dollars in fees it generates for the ABMS Boards and their management.

“Plaintiffs would also like to take the opportunity to thank the thousands of doctors across all specialties that have joined with them in this struggle. The emails and phone calls of support have been inspirational and demonstrate how deeply unpopular MOC and the ABMS Boards are with rank and file doctors, physicians who actually practice medicine and treat patients outside the corporate medical establishment.

“All remaining options are being considered, including the possibility of seeking a rehearing by the full Third Circuit Court of Appeals.”
The fight against MOC and in support of practicing physicians continues. The wellspring of our inspiration for supporting the Plaintiffs has been the Oath that we both earned and then gave when we became doctors. It might be stifled but it will never be extinguished.

-Wes

Thursday, February 18, 2021

ABIM and Its Washington Lobbyists

The American Board of Internal Medicine (ABIM) is a 501(c)(3) non-profit organization that certifies "internists and (medical) subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care." According to the IRS, "In general, no organization may qualify for section 501(c)(3) status if a substantial part of its activities is attempting to influence legislation (commonly known as lobbying). A 501(c)(3) organization may engage in some lobbying, but too much lobbying activity risks loss of tax-exempt status."

In April of 2015, Kurt Eichenwald wrote an opinion piece in Newsweek that exposed the ABIM's tax-reporting discrepencies concerning its lobbying activities:
Start with ABIM's Form 990. This is the document a nonprofit organization has to file with the Internal Revenue Service to disclose its activities and prove it deserves tax-free status. In Part IV, which appears on Page 3 of the document, the government asks a simple question on line 4: "Did the organization engage in lobbying activities?" And year after year, ABIM has answered "no."

Unfortunately, the real world answer is "yes." According to the Center for Responsive Politics, from 2009 through 2014, ABIM paid $390,000 to Mehlman Vogel Castagnetti, a lobbying firm. Asked about this, an ABIM representative says it complied with all rules governing IRS filings. Maybe. Yet according to Independent Sector, a prominent organization for nonprofits, the words "lobbying activities" in line 4 includes elements as miniscule as holding strategy meetings to coordinate lobbying with others and time spent preparing arguments to be advanced to government officials. Unless ABIM just wrote a check and never spoke to its lobbyists, it's hard to see how it complied with those standards. (Side note: A random check of seven 501(c)(3)s that paid less than ABIM to lobbying firms showed all of them answered with a "yes" on line 4.)

So what did ABIM spend all this lobbying money on? According to Mehlman Vogel's filings with the government, ABIM's lobbyists provided "strategic advice" on issues related to Obamacare, including "physician quality reporting requirements." And if you haven't guessed yet, what does the ABIM consider "physician quality reporting requirements"? Maintenance of certification (MOC), the program that so many doctors say is worthless—and that ABIM refuses to show has any impact on "physician quality" with independent research or other science-y stuff.

Did the lobbying work? Yup. Under Obamacare, physicians who participated in MOC through 2014 qualified for an incentive payment. The description of MOC is so specific in the law that ABIM and similar groups in ABMS were the only organizations that met the definitions. In other words, in the first few years of Obamacare, the government was paying doctors to pay ABIM and related certification organizations to participate in a program that has never been proven to do squat.
So it should come as no surprise to working physicians that lobbyists have come to the rescue of the ABIM by filing Amicus briefs in support of the ABIM in the lawsuit failed against them by four working internists. One of these lobbying groups is a seasoned veteran of the Washington scene while the other two are relaively new, formed in large part to fight the national physician pushback against Maintenance of Certification (MOC): the American Society Association Executives (1575 I St. NW, Washington, DC), the Institute for Credentialing Excellence (2001 K Street, Washington DC). and the Professional Certification Coalition (formed "to address efforts to enact state legislation that would undermine the activities or recognition of certifications developed or offered by non-governmental, private certification organizations" and actively promoting their work in support of ABIM on their website).

Think there's money in continuous re-certification and lifelong testing of physicians?

You bet.

Will the public ever learn of the extent of lobbying that the ABIM performs to advance their political and economic agendas?

Never.

Unless, of course, the current lawsuit against the ABIM wins its appeal and the case goes to discovery.

-Wes

Wednesday, January 27, 2021

Is ABIM Ending Its "Knowledge Check-In" MOC® Pathway?

The following (redacted) email was received from Morgan Allen, Customer Relationship Advocate at the American Board of Internal Medicine (ABIM), in response to an ABIM diplomate that was unable register online for their every-two year Knowledge Check-In "continuous" Maintenance of Certification (MOC®) product.

According to this email, it seems the ABIM has decided to end its Knowledge Check-In recertification pathway and only permit its every-10-year high-stakes recertification examination for physicians to remain ABIM Board Certified.

At the time of this writing, I could find no public notification of this policy change on ABIM's website. Once again, working physicians are irresponsibly left uncertain of the latest requirements to remain ABIM Board Certified in good standing.

ABIM has a long history of changing the rules for the names and requirements for physician board recertification/maintenance of certification/continuous certification. But despite the many name and rule changes of this racket, each rebranding becomes more expensive and serves to perpetuate the discrimination against younger physicians and physicians of color from senior "grandfathered" physicians who are not required to purchase these products to retain their ABIM Board Certified status. The Knowledge Check-In recertification pathway was no different from its predecessors in this respect. But the Knowledge Check-In pathway also suffered from a plethora of technical, security, and (undisclosed) privacy issues for physicians. (See my earlier video that critically reviewed this recertification pathway and the people who created it.)

One thing is a constant, however. Ever since the ABIM changed Board certification from a lifetime to time-limited physician marketing accolade, this unproven repeated testing of working physicians remains a career-long psychological and economic stressor that distracts from what matters most: patient care.

-Wes

Monday, December 07, 2020

ABIM and Its Appellate Court Arguments

The unofficial transcribed 3rd Circuit Appellate Court arguments held 23 Oct 2020 between Mr. Philip Curley (lead attorney representing the physician Plaintiffs) and Ms. Leslie John (representing the American Board of Internal Medicine (ABIM)) are now available for US physician review. The appeal was filed after the 3rd Circuit District Court dismissed the Plaintiffs complaints before discovery because, as Mr. Curley states in those arguments:

"And that's what the district court did here that was incorrect; it concluded that as a matter of law, there could only be one product, and it shouldn't have arrived at that or any other conclusion in our judgment. It arrogated to itself a determination of the ultimate fact issue which is out of the separate products. It was indifferent to our allegations. It improperly weighed evidence. It explicitly made findings. It used those words, and had accepted ABIM's affirmative defenses that are outside of the Complaint. All those are in violation of the proper standards in ruling on a 12(b)(6) motion to dismiss. And we respectfully point out to the Court that this is not a motion where only conclusory recitations of law are pleaded or claims rote elements are simply recited. This is a highly detailed and factual Complaint, and we are entitled to discovery and the right to prove our claim. So we respectfully ask that the district court be reversed."

While I made some earlier observations when only the audio file of the arguments became available, there are a number of other observations that I believe are important from those arguments.

ABIM Never Answers the Question About Forcing or Monopoly Control of Certification

On Page 27 of the transcript, Judge Chagaras asked Ms. John the following question: 

"Could I just ask a follow-up there about forcing? How do we conclude that internists aren't forced to buy MOC at this stage in the litigation in light of the allegations that internists can't successfully practice without certification; and isn't the feasibility of practicing without certification ultimately a question of fact?"

Rather than answering the question, Ms. John responds:

"I think you can first look to the facts in this case. So, for instance, Doctor Manalo who never -- who did purchase initial certification and never purchased Maintenance of Certification, I think that certainly shows that his purchase of initial certification was not contingent on the later purchase of Maintenance of Certification. So I think that is one way you can look at it."

Recall that in the Amended Complaint, Dr. Manalo has been unable to become employed as a result the fact that he refused to participate in MOC. The judge presses further:
"But, Counsel, what I'm talking about is it may not be so voluntary. If they want to make a living, are they forced to buy your product? You seem to say no, they're not forced to, but is that essentially an issue of fact that's more appropriate for summary judgment?"

And of course, Ms. John forgets the fact that many physicians are grandfathered and don't have to perform MOC, but states:

"I would suggest not because I think when courts look to forcing, they look at what is the situation at the time of the initial purchase, and at the time of the initial purchase here ABIM had a program for certification; and aspects of that program were initially passing your initial Board certification exam, and then that that certification would expire after a set period of time, ten years, without -- unless that diplomate passed subsequent examinations. And so when they up front bought that product, they knew there would be a continuing obligation as part of the certification program that they would have to demonstrate, in fact, that they possess the requisite knowledge to hold themselves out and say, yes, I am ABIM or Board certified. So there is no forcing because there is the knowledge up front at the time of purchase of what certification entails, and that was the periodic demonstration of knowledge."
Unfazed, the judge then asks:
But I suppose that the most basic form of your argument is they don't have to go through ABIM to practice?"
To which Ms. John answers as only a lawyer can:
"Yes, your Honor. So, for instance, if you look at the Amended Complaint, the Amended Complaint is quite clear that Board certification is not required to practice medicine in the United States. That is simply a function of state boards of medicine that license doctors. You only need a license in your state to practice medicine. Board certification is not required. Board certification is more like the stamp of approval that you can hold yourself out to have special qualifications. Some -- some patients and employers look to that; others do not, but it is not a requirement to practice medicine in any state in the United States, which is a fact that is pled in the Amended Complaint."
Fortunately, the judge did not back down, politely recognizing the doublespeak:
"Well, but I mean this does go to your market power. I mean, yeah, it's true you don't need the ABIM certification, but is it really feasible not to have it in reality? And I think that the allegations, don't they say you -- a lot of places won't let you practice. Your malpractice rates are going to go higher. Reimbursement is going to be an issue. So is it really feasible to practice without certification, and is that something that should be a subject of discovery as opposed to, you know, at this juncture with a motion to dismiss to resolve?
We should note that as long ago as 1991, Dr. Benson (the first President of the ABIM) wrote in the Annals of Internal Medicine that certification "is no longer an option for the physician entering the marketplace." A later ABIM President agreed, Dr. Christine Cassel, writing in a climatology journal article in 2008 that "many physicians really feel that board certification is not optional." Finally, the Arthritis Care and Research article from 2019 concluded in no uncertain terms that "Board certification, which started as a voluntary achievement and remains so in theory has become involuntary in practice, making participation in MOC programs mandatory for many if not most physicians in order to maintain employment and clinical privileges, or receive reimbursement." 

We should note, then, that ABIM's own leaders have conceded the issue that it's own attorney in these arguments would not. 

ABIM is Not a Professional Society

And then there was this exchange from Mr. Curley's final rebuttal statement:

So another fact question that arose from your inquiry was professional society. Is ABIM even a professional society? We don't believe it is, but in any event, there certainly is nothing in the Complaint that speaks to that. That's another example of an affirmative defense that ABIM is trying to raise, standards, professional society, internists aren't keeping up, all sorts of things that can only be resolved after discovery.
Given these revelations made from the arguments before the Appellate judges. It is hard for this physician to not be encouraged by what transpired before the Appellant Count judges. I'd love to hear what others think as well.

One thing's for sure: if the Appellate Court refers this case back to the District Court for discovery, Pandora's Box will open for the ABIM and all other member board of the American Board of Medical Specialties.

-Wes