Tuesday, July 16, 2013

Spousal Travel Fees and the Cost of Medical Board Certification

Recently, I have been enduring my "Maintenance Of Certification" (MOC) training so I can continue to call myself  "Board Certified" in Cardiovascular Diseases and Cardiac Electrophysiology.  Later this year, I will sit for my re-certification examinations.  But I was also recently reminded just how expensive this process has become for doctors. 

Yesterday, I received a $775 bill for my "additional examination fee" from the American Board of Internal Medicine (ABIM) in the mail.  I was surprised and had to ask myself, "Why?"  Especially since this rate is more expensive than staying at a five-star hotel room in Chicago for a day.

In total, the out-of-pocket expenses for Maintenance of Certification in both of my subspecialties above have been as follows:

Enrollment Fee: Maintenance of Certification:  $1840 (this includes only one exam fee)
Additional Examination Fee:     $775.00

ACC Self-Assessment Program (ACCSAP 8): $620
Heart Rhythm Society Board Review Course and ABIM Recertification Module $1440

So far, that's: $4675 just to "maintain" my certification this time around.  (Per annum: about $500 per year).  (Note that this cost does not count the lost revenue I sustain from leaving my workplace to attend the Board Review Course, to study , or take the tests.)
And to think I get to do this every ten years!

But when we learn of the salaries of the leadership of the ABIM, it becomes clear why these fees are so high.   According to the publically-available IRS Form 990 from 2012 (the last available), ABIM Executive Christine K Cassel received salary and benefits of $786,751 in 2011, plus payments for spousal travel. (At that salary, why are testing physicians picking up travel expenses for Dr. Cassel's husband?)

Equally outrageous has been the ABIM's recent requirement for re-certifying physicians to complete a "Practice Improvement Module" as part of their re-certification requirements.  For those unfamiliar, doctors have to find something to improve in their practice, measure how its going, make a change, then measure the effect of that strategy in hopes it will improve patient care.  On the surface this requirement seems so, well, nifty!  How could anyone argue with the intent of such a requirement?  But imagine the time it takes to conceive and execute such a project.  How much patient care suffers as a result?  So doctors who are already stretched for time look for ways around this requirement and luckily, they find it is easily gamed.   So they talk to their hospital's quality coordinator, get some useful data, enter it into the MOC website, then answer questions that ask "what-did-you-learn-as-a-result-of-completing-this-module?" and, presto!  Their module is done!

Really, is this useful?  Maybe we should include handwashing exercises, too.  Or is this more about the ABIM maintaining their leadership's benefits and political favor?  As I performed this painful part of my re-certification requirement, I couldn't help but hear echo's of Don Berwick's Institute for Healthcare Improvement's educational curriculum that helped pave the way for the life-long healthcare guartantee he received for himself and his family for life.  Could the leadership of the ABIM have similar aspirations for a similar golden parachute?

I can't help but wonder.

As I wrote my additional exam fee check, I also reflected on what the "value" of this re-certification process is for physicians like myself that have been previously certified.

Will doctors get more income for having this certification? No, especially in the current payer climate that seeks to continue to limit physician payments.

Will doctors get more prestige for having this certification?   Not really, especially when nurse practitioners  at Walgreens can call themselves "board certified," too.  (It is interesting to note that their certification only costs $395 - 8.4% of the cost for medical re-certification.  Maybe doctors  should take their test instead?) What responsibility does the ABIM have to protect the value of the term "board certification" for physicians who invest in this process?  Given the ongoing board "certificate" fraud perpetuated by others directly under the nose of the ABIM, we are left to wonder if they have any authority to protect physicians' investment in this process.

Is the time required to re-certify worth it for doctors and patients?  Will doctors be smarter for having this certification?  I think the ABIM does try to make the knowledge assessment modules relevant to new knowledge in the medical field.  (Actually, I found these almost fun to take).  But I already stay up to date with current innovations and studies in my field thanks to my teaching responsibilities, ongoing state licensure requirements for continuing medical education credits, and my rather healthy social media presence.  Do these costly re-certification tests improve my knowledge significantly enough to affect my patient's outcomes?  I honestly don't think I've ever felt so.

Surely the public wants to know their doctors are quality doctors.  But what is more important, years of direct medical care experience or just having their doctor pass an expensive test every 10 years?  With the expected avalanche of patients entering our health care system, does the public want to pay for irrelevant bureaucracy that just feeds the system rather than improving physician availability?.  I suspect that the public would rather have their doctors engaged in their care rather than being distracted by unproven testing exercises. 

But it seems bureaucrats must endlessly continue the money flow that assures their spousal travel fees, so maintenance of certification will likely soon be tied to the granting of hospital credentials or state licensure. We should ask ourselves if we really want this.  In 2011, the ABIM received $44 million in fees from doctors sitting for  board certification and maintenance of certification.  That's a hefty chunk of change.  So much so that at least one doctor has recently sued the ABIM over concerns of monopolizing the process.

Doctors need to speak up, especially when others stand to enrich themselves on the labors of their colleagues.  If doctors can't get use a pen from a pharmaceutical rep, they sure as heck shouldn't being using their own colleagues' hard-earned funds for their spouse's travel.

Please think of these things when you cash my latest $775 check, ABIM, will you?



Anonymous said...

"Practice Improvement Module" May I suggest a better grade of coffee in the waiting room and magazines from the current decade.

Anonymous said...

i do not believe the questions on the examinations reflect information that the average practitioner needs in their daily practice. studying for the exam (imo) only takes time away from reading things that might actually improve the care the patients each physician sees might receive.
especially as we continue to sub specialize, the boards may consider whether the time spent preparing for things never encountered in actual practice is time well spent, or whether more modular practice specific testing can be performed. or whether any testing at all is necessary after the first certification. perhaps the moc can be performed with just the reading units ala cme.

Anonymous said...

Dr. Wes

Everyone agrees with you, but since we are all to go down the corporate hospital maw shortly which requires board certification to design quality rating ads for the public, how can you dare to criticize board committees. If any consequences follow from your questioning of the bureaucracy,I will write to you in Canada as the execs usher you across the border.

Anonymous said...

Good point

We should all be required to include nurse practitioner certification in our qualifications. Maybe even EMT as well.

Robert W Donnell said...

I posted about a controversy involving ABIM just the other day:


DrWes said...

Dr. Donnell -

Everyone should read your post.

Excellent discussion. Thanks for sharing.

Keith said...

Another example of how a presumed non profit established to do a given task (test compentenc of residents completing training) morphs into a profit driven entity with a handsomely paid CEO at the helm. Does any of this sound familiar (hint-your friendly hsopital CEO?)

I, fortunately, am grandfathered in to avoiding this costly and time consuming testing. But if I were not, I would be attempting to organize a boycott by physicians to taking these boards. Eventually, there would be no board recertified physician left and only us incompetent grandfathered docs left.

Keep on blogging about this injustice for which no other professional entity has similar requirements. Better yet, maybe ABIM can just extend their reach and start recertifying lawyers, judges, accountants, plumbers, hairdressers, etc. every 10 years!

Anonymous said...

Great post and agree with most of the comments. However, how about putting some practice into the preaching by refusuing to take the board.
Or at least, removing the "board qualified" label with your name and personal description? It surely does not matter that your blog readers know if you are board certified or not!

Dr. Eskridge said...

Its easy to say, just don't take the boards, but then most hospitals require certification to maintain privileges, as do insurance companies. I have no idea why it is so costly but it wouldn't be so bad if the exam actually improved competency. Rather I felt the exam (at least for Internal Medicine)just rehashed a bunch of specialty board questions which if I were truly presented with some of these intensely complex scenarios I would do what we all normally do, call my specialist colleagues. Internal medicine is a specialty of connecting the dots, seeing the big picture and taking non medical aspects of patient care into account. Doing a practice improvement module is not so difficult and can be fun if you are honest about the fact that no practice is perfect, but most docs are so busy and overburdened that they just see this as another burden. The cost of course is outrageous but the last thing most people want to hear is a bunch of doctors complaining about the cost of something!! If you really want to make a difference, volunteer, go abroad, teach, get your hands and feet dirty and see how most people in the world live and then you might gain a little more perspective. If you are just upset about someone getting travel expenses paid, then you really don't have much to complain about. I say this as I embark on a plane tomorrow to Malawi to visit several medical settings, help bring morphine to a country where it is chronically in short supply, and teach a family practice resident and a premed student who are joining me. (and yes, I am paying my own way, bringing my own supplies and taking my own vacation time for this). You can't necessarily change the board review process but you are the master of your own perspective and how you want to give back to a profession that is an amazing privilege!

Anonymous said...

My goodness, so many complaints. I'll knock off a few of them.

MOC is a great idea. Traditional CME (lectures passively received in dark room from which you duck out early to enjoy the beach or slopes with your family) doesn't work. Doctors don't learn from them, they do not improve practice. The modules in my field are pretty good and they require one to actively read and learn in order to finish. My modules cost $75 per module, 1 per year.

Next, the quality improvement project burdens you? Really? You are too busy doing status quo care to make any improvement? It taxes you too much to improve even one small thing? Quality improvement doesn't take you away from good care, it is part of how one provides good care. Implement a Coumadin protocol. Implement a call-back system for patients post-procedure or post-hospital-discharge, and voila, you've knocked off two projects, good for 6 years worth of demands from my specialty board (one quality improvement project every 3 yrs).

As an interventional cardiologist, how much do you make? Do you really have any basis for complaining about the high cost of MOC? It's a business expense, and a modest one compared to staff, malpractice insurance, and all that. You are not going to garner sympathy about money as a highly paid interventional procedure-performing cardiologist, not from the general public, and not from this lowly small town family physician.

Study for the boards? Why study? I never have. I consider every single day of my practice a board review course. If I read a couple journals, ask questions of my colleagues and consultants, and look stuff up on the occasional tricky patient, I stay quite up to date. I pass my boards with flying colors. I'm sorry yours may be tougher or more esoteric. Get on the committee to write the test questions. I've been offered that opportunity, and I turned it down, too busy, have to tend to family.

Decrying the high salary of the ABIM CEO is a popular rant, and I agree wholeheartedly that executives all over American business are paid WAY too much. But I think that is a distraction from your real distaste for the MOC process. A non-wealthy lawyer friend of mine pointed out that American doctors are the highest paid professional class in the world. I don't think we have too much to complain about financially.

DrWes said...


Traditional CME doesn't work? This would suggest that weekly cath conferences are worthless. Since when? Please don't make assumptions for others.

And you say, "Why study? I never have." So why the need to recertify? Your logic supports my argument: that once you've certified once, there is simply no need to do it again, and again, and again, just to support the corporate ABIM structure.

But then again, it appears you're happy to donate your funds to the ABIM to support their high salaries for unproven patient outcome benefits.

Me? Not so much.

Robert W Donnell said...

I'm struck by the presumption in your statement that traditional CME "doesn't work." For whom? How about some respect for the fact that individual learning needs vary? I for one benefit more from the didactic than other methods.

Besides how would you know what works or doesn't work for others? No offense to those in love with metrics, but reducing (and, IMHO, dumbing down) CME to artificial measurable surrogates will not address the question.

And those quality improvement projects? Great ideas, often aimed to promote evidence based treatments, but when you turn them into performance something unintended happens. The failure of core measures to improve meaningful patient outcomes, demonstrated time after time, should tell us something in that regard.

Anonymous said...

Things will never change until Internists learn one word NO! The process is cumbersome and reminds one of a Rube Goldberg Contraption. It is artificial and overly time consuming. I am grandfathered and have no skin in this charade. The least the ABIM could do would be to offer an extra year for those who do not complete the written exam within the specified time frame.

Anonymous said...

Dr. Keith-

You mention that you were "fortunately grandfathered" You are NOT immune. HA> HA.


Robert B Geller said...

Great comments. As ridiculous as Dr. Cassel's salary appears to be, even more outrageous are the salaries paid to Lynn Langdon ($690,000) as an advisor to the President, and to Rebecca Lipton, an academic biostatistician making over $350,000. Despite the comment about how physicians are a highly paid group of people who should not complain, the last I checked the median salary for internists is around $200,000. Obviously, Ms. Langdon and Dr. Lipton deserve 3.5times, and 2 times, respectively working for the board. Advising the President and crunching numbers is clearly more important and stressful than caring for over 20 pts/day. This has really gotten out of hand.