Sunday, May 31, 2015

ABIM Fails to Disclose Lobbying Efforts


The public wasn't supposed to know.

Neither was the Internal Revenue Service (IRS).

According to the American Board of Internal Medicine's (ABIM) most recent tax forms, they never participated in lobbying, nor spent money to do so.

Yet, according to public record, it appears the ABIM most certainly did lobby Congress as a 501(c)(3) organization and has repeatedly failed to disclose this reality to the IRS.

The ABIM's Lobbying Disclosures

Here's the information the ABIM filed with the IRS on their most recent "audited" 2013 Form 990 which includes expenses paid from 1 July 2013 to 30 June 2014 as a 501(c)(3) organization:

ABIM 2013 Form 990 Lobbying Disclosure
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ABIM 2013 Form 990 Itemized Lobbying Expenses
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The ABIM's History of Lobbying

But searching, a website dedicated to transparent government spending, it seems the ABIM spent quite handsomely on lobbying during its fiscal year 2014:

ABIM Lobbying Expenditures for 2014 Election Cycle
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In fact, the ABIM has been lobbying for years (and continues to do so):

ABIM's History of Lobbying since at least 2009

When we delve into who the ABIM paid for these lobbying efforts, we find even more interesting information.  In 2014, the lobbying firm used was Mehlman Vogel Castegnetti, Inc. (Vogel later spun off in 2014 to create his own lobbying firm and the new firm is now called Mehlman Castegnatti Rosen Bingel and Thomas) and used the following list of lobbyists:

ABIM Lobbying Firm in 2014
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Of these lobbyists, five have current or former ties to the insurance industry (Bingel, Castagnetti, Gupta, Rosen and Zook) and one (Thomas) to the Federal Trade Commission and one (Eastman) to the Ways and Means Committee in the House of Representatives.  Needless to say, 13 of the 14 have "revolving door" relationships with one or more government offices.

These revelations are important. Recall that the American Board of Medical Specialties (of which the ABIM is but one of 24 "member boards") was magically inserted into Social Security Act 1848 (k)(4)  that deals with physician payment with passage of the Affordable Care Act in 2010. More recently in January of 2014 changes made to the ABIM's Maintenance of Certification (MOC) program that force doctors to pay them to remain "board certified" in good standing so they can remain credentialed to practice medicine with their employing hospital system and to receive insurance payments.
On January 1, 2014, the Organization revised the nature of the MOC program. The MOC program is now a continuous program based on a calendar year. Upon entering the MOC program, a diplomate must actively maintain their certification by completing certain requirements. These requirements are expected to be completed every two, five and ten years. Candidates choose to pay annually or to prepay for ten years for access to the program.
At the same time, CMS offered a payment incentive to physicians for participation in MOC.  Given the lobbying efforts uncovered here, no longer is the collusion between the ABIM 's MOC program and influential government personnel or agencies just a theory, it now appears (based on public record) to be a very real possibility. The ABIM's long-standing unreported lobbying history raises the very real possibility that the more recent leadership of the ABIM has been more concerned about creating a financial monopoly for itself (and trying to hide it) rather than truly improving patient care.

Further Questions Regarding the ABIM's Auditor

The auditing firm  McGladrey, LLC, appears to have audited he most recent financials for the ABIM. Their "responsibility statement" in the ABIM's financials states:
Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free from material misstatement.
Now I'm just a practicing cardiac electrophysiologist here in the United States, not an auditor and I have no idea what "opinion" was actually "expressed" to the ABIM board members by McGladrey's auditors. But if I can find these financial and tax filing discrepancies (among others) thanks to the wonders of the internet, I think the ABIM and the ABIM Foundation needs a new auditor...

… like maybe the IRS or the Office of the Inspector General of the Department of Health and Human Services.


Addendum: On 6/30/2015, a Lobbying Report was filed by the ABIM in accordance with the Lobbying Disclosure Act of 1995 (Section 5) terminating the ABIM's relationship with their lobbying firm Mehlman Castagnetti Rosen Bingel & Thomas, Inc.

Saturday, May 23, 2015

The ABIM, Its Finances, and the Great Collusion

Yesterday, Newsweek Pulitzer-prize finalist and reporter Kurt Eichenwald pulled back the curtain on the Great and Powerful Oz of medical credentialing, the American Board of Internal Medicine (ABIM) when he meticulously dissected the organization's most recent financials. In his piece, Eichenwald laid bare the "trickery," cronyism, and greed that has come to define the ABIM that has been led by a few self-selected "Untouchables" of our profession.  The details are outrageous for a non-profit espousing "medical professionalism:" $1,712,846 million to the outgoing President and CEO Christine Cassel, MD, an estimated $860,926 to the current Present and CEO Richard Baron, MD, lack of disclosure of lobbying efforts, tax filing discrepancies, to name a few. The story is so disturbing on so many levels, yet so important, that I encourage all to read it.

In response, Richard Baron, MD sent an emotional  e-mail to all ABIM diplomats yesterday that was in large part a rehash of his disagreements with Mr. Eichenwald's reporting.  He also attempted to dispute two of the allegations made by the most recent Newsweek story:
First, we have never made any effort to obfuscate, hide or delay ABIM's financial information. It's publicly available on our website. Second, no one is trying to hide salaries. I earned $688,000 in compensation in 2014 and $55,000 in deferred compensation (payment of which is contingent upon completion of my five-year contract). That is more than I ever made in 30 years of independent community practice of internal medicine and geriatrics, but it is set by my Board to be comparable to what CEOs of similar-sized health-related organizations earn.
By now it is almost silly for Dr Baron to claim they "never made any effort to obfuscate, hide, or delay ABIM's financial information." No where does the ABIM website discuss its transfer of $30.66 million of physician testing fees to the suspect ABIM Foundation from 1998-2007, the purchase of a $2.3 million condominium complete with a chauffeur-driven Mercedes S class town car in December 2007, the continued contradiction in the ABIM Foundation's creation date (1999) that  conflicts with public record (1989), why the condominium's depreciation was lumped in with "condo expenses" and classified under "program service expenses", nor that the "rent" that the ABIM pays the Foundation for the condo's use does not show up on tax forms as such. I asked him to explain these issues in December of 2014 and only received world class obfuscation of the facts. (Update: And then there was the stunt where they tried to withhold six key schedules from their consolidated financials with Foundation, only to publish them after public ridicule). Was he aware of his actions? Given what we've repeatedly observed regarding his inability to address ABIM diplomats financial concerns regarding the ABIM, it's hard to think otherwise.

More telling was Dr. Baron's pitiful disclosure of his salary and "deferred benefits." It is clear that Dr. Baron is so far removed from the realities of patient care today that he has no concept how entitled he sounds, especially for someone running a non-profit organization that has crushed 139 physicians' professional lives with the past Arora test-preparation scandal to protect their monopoly while they enjoy their lavish salaries and creature comforts all provided with tax exempt status.

Mr. Eichenwald learned of Dr. Baron's follow-up e-mail to ABIM members and broadcast his rebuttal via Twitter. In that thread he gave details on his interaction with the ABIM and their avoidance of the issues. (Details can be read on Jay Schloss's Storify of the tweets.) I'd like to think Baron will accept and offer to be interviewed by Eichenwald, but I know it will never happen - the ABIM's lawyers won't let him.

It's Not Just the ABIM

As twisted, deceptive, corrupt and disappointing the financial story of the ABIM and its Foundation has become, it's only the tip of the iceberg. We should recall that the American Board of Medical Specialties (ABMS - a separate 501(c)(6) non-profit) owns the trademarked Maintenance of Certification® program which the ABIM as one such member board helps administer. The ABMS serves effectively as a "business league" for its 24 member boards, much like the NFL lobbies for its football franchises (in fact, the NFL has the same tax-exempt designation). The ABMS lobbied Congress about the self-proclaimed merits of their branded MOC® program while paying their director,  Lois Nora, MD, JD $779,487 to earn government contracts and to assure the ABMS (with the ABIM as a testing entity) remained in the Affordable Care Act as a physician quality registry (see Social Security Act 1848, Section (k)(4)). The monopoly power of the ABMS regarding physician credentials prompted a pending suit alleging possible anti-trust violations. The fact that the ABMS or the ABIM has never studied the socioeconomic, psychological or physical toll upon physicians (and their patients) who fail the trademarked MOC® re-certification examination is telling and speaks to the blatant disregard of those tested.

(Click to enlarge)

The interconnected relationships of Christine Cassel, MD, Richard Baron, MD, the National Quality Forum, the ironically named "Seamless Care Models Group" in the Center for Medicare and Medicaid Innovation, a component of the Centers for Medicare and Medicaid Services (CMS), reeks of a sophisticated kickback scheme using doctors and their requirement to pay MOC® fees every two years to the ABIM (and other member boards of ABMS) that assures their largess and perpetual cozy employment opportunities. Why else are doctors increasingly required to  participate in MOC® to remain credentialed with their hospital employer? Might this have been the reason the ABIM board felt Dr. Cassel warranted her $1.7 million take from the ABIM for working just a thirty-five hour work week and serving as a consultant to Premier, Inc and Kaiser Foundation Health Plans and Hospitals?

Because of the revolving door between the members of ABIM, the American College of Physicians (ACP), the Accreditation Council for Graduate Medical Education (ACGME), Joint Commission on Accreditation of Hospital Organizations (JCAHO), ABMS, and the American Medical Association (AMA), (with the exception of ABIM, all of these organizations are located in downtown Chicago) is it any wonder that program directors in hospitals must participate in MOC?  Likewise, is it any surprise that our most vulnerable newly minted physicians must enroll in the unproven and heavily marketed  Maintenance of Certification® program before they are even "board certified" for the first time?

Mr. Eichenwald is correct when suggesting that it is time for the "Federal Trade Commission and the Justice Department to investigate whether the ABIM is engaged in a restraint of trade by driving doctors out of business if they don’t pay up. It is time for the IRS to investigate whether the ABIM is a nonprofit or a business." I would add that the ABMS and ABIM should be investigated by the OIG of the Department of Health and Human Services to determine if the MOC program is a carefully contrived pay-to-play scheme using the US government as imprimatur.

Irrespective of the legal plays that are now likely to take place,  US physicians must immediately stop paying for MOC® and insist their local medical executive committees remove MOC® as a condition for hospital credentialing or, at the very least, make enrollment in an alternative to the corrupt ABMS MOC® credential. Otherwise, practicing physicians will be working to potentiate the existence of this very broken program.


Saturday, May 16, 2015

The American Board of Internal Medicine's Land of Make Believe

Hi boys and girls!  My name is Christine Casell, MD.  I was once the President and CEO of the American Board of Internal Medicine, the ABIM Foundation, and the Institute of Clinical Evaluation.  Now I'm President and CEO of the National Quality Forum in charge of setting quality standards for every hospital in the United States. I'd like to tell you about a special place I know called The Land of Make Believe because I want you to sleep better tonight.

The Land of Make Believe is a magical place.  It has amazing superpowers and can do things no one else can.  For instance, it can telepathically transport from Iowa to Pennsylvania in the blink of an eye and without an explanation to the IRS.  And even more amazing, The Land of Make Believe has a time tunnel that can transport itself from 1989 to 1999 even though there was an IRS Ruling in 1990 without anyone knowing! That's because tax fraud doesn't exist in The Land of Make Believe.

By Choosing Wisely, The Land of Make Believe was able to use their amazing superpowers to use other people's money (like $30.6 million from practicing internal medicine doctors) to amass a pot of gold that has swollen to $79,409,497 with a fancy condo thrown in for everyone's benefit.

But the most amazing part?  In 2004 The Land of Make Believe merged with the mysterious Institute for Clinical Evaluation that was created in 1997 before The Land of Make Believe even existed!

Confused?  Don't be!  It's The Land of Make Believe!

The Land of Make Believe represents nothing but quality! That's because they don't have to worry about where money comes from or how much exists there.  Sweet-smelling smoke and mirrors are everywhere.  And those mirrors can teach you a lot about yourself. I discovered that I was so important  that I could pay myself (with the help of my many friends there) an annual salary and benefits worth $1,234,893 while also working the crowds at Kaiser Foundation Health Plans and Premier, Inc. 

"Let them eat cake!" I say. I'm from the Land of Make Believe!

But the best part, boys and girls, is The Land of Make Believe is REAL! No doubt the quality I gave to the The Land of Make Believe is why I'm in charge of the quality for every hospital in the United States!

See why you can feel safe?

Now get to bed.


Thursday, May 14, 2015

Maintenance of Certification Controversy Dominates Day One of the 2015 Heart Rhythm Society Scientific Sessions

"… This debate addresses whether ABIM's Maintenance of Certification (MOC) program contributes meaningfully to the practice of quality EP. I will discuss the importance of MOC as it relates to the practice of quality EP and argue that it should be endorsed by HRS (Heart Rhythm Society). I will NOT discuss other issues such as ABIM finances, fees, salaries, investments, etc."
- Douglas Zipes, MD, Pro-MOC position
Debate on Maintenance of Certification
2015 Heart Rhythm Society Scientific Sessions

To the credit of the leadership of the Heart Rhythm Society (HRS), the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program controversy dominated the first day of the 2015 Heart Rhythm Society Scientific Sessions in Boston, MA. The day began with a "debate" on whether HRS should endorse MOC between Douglas Zipes, MD (protagonist) and Fred Kusumoto, MD (antagonist). The debate was then followed at noon with a one-hour "leadership luncheon" devoted almost entirely to a question and answer period from members concerning MOC. (It was also mentioned that ABIM wants to "explore" removing the requirement that electrophysiologists have to be re-certified every 10 years in both cardiovascular diseases and cardiac electrophysiology and just re-certify in electrophysiology, a welcome development.) While the luncheon meeting was a packed, standing-room-only affair that had no positive comments made to the HRS leadership, the morning "debate" was not well attended, probably because many had not yet arrived or registered in time to attend. But it was at the morning debate where comments were made attacking the efforts of this blog to transparently disclose the financial practices of the ABIM and their Foundation.  I feel those comments warrant further discussion, especially since questions were not solicited from those of us who attended the session.

It was clear from the beginning of the morning debate on MOC that Dr. Zipes didn't like debates. He mentioned that he has only agreed to participate in three debates in his illustrious career, this being one, but he agreed to participate because he believes in the ABIM and the re-certification process they manage. It was also clear he was furious that I had pointed out on this blog his failure to disclose his prior role at the ABIM as Chair, Chair-elect and Director of the ABIM approximately 10 years ago on the his online HRS disclosures, feeling that these conflicts didn't need to be disclosed because he left his role with the organization long ago. (Perhaps he was justified in this criticism, but because the financial issues at the ABIM that led to this debate occurred in that time frame mentioned, I felt this conflict should have been disclosed and my blog post explains why.) To his credit, Dr. Zipes' opening statement listed his many accomplishments in the field of cardiac electrophysiology, past and present leadership positions held, full disclosure of his financial and leadership positions held while serving the ABIM, and even poked fun at the fact that he was a U.S. citizen with a US birth certificate and therefore was eligible to run for President of the United States. The audience laughed accordingly.

His defense of the program began with a review the ABIM's origin, mission, it's history as a "standard setting" organization that produced a "publicly recognizable" credential. He emphasized that it is a physician-led organization that "has roots with membership organizations but must be insulated from them without being isolated. Therefore its an independent organization led by physicians." He then referenced an ABIM-commissioned 2003 Gallop poll and a 2010 MSNBC poll as evidence of the public's "demand" for MOC. He also repeated the ABIM's canard that physician "skills and knowledge decline with time" without offering supporting evidence to support this claim other than he finds it harder to remember things at the age of 76. Dr. Zipes then said:
What evidence presently exists that MOC, as it is constructed, has value? There's where we have problems. (emphasis mine) The paper published in JAMA 2014 showed that MOC was not associated in the difference in mbulatory care–sensitive hospitalizations, but was associated with a small reduction in cost per cohort of Medicare beneficiaries. (Editor's note: there was no mention that the article was written by ABIM authors). In another study among internists that provided primary care at four VA medical centers, no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures.
Dr. Zipes then discussed "the environment" of MOC today:
What is the environment of MOC today? Anger? Frustration? Concern? Questions raised by the physician community regarding MOC dealing with many of the things that I just mentioned. The ABIM when it heard from physicians agreed that it got it wrong and that changes to the MOC program were needed. And the ABIM leadership, Rich Baron, decided an apology, along with meaningful action, was necessary. They did this and have been meeting with various organizations, as well as soliciting outside input to try to get it right.
Dr. Zipes never mentioned that this blog revealed the potentially corrupt financial dealings of the ABIM in December 2014, well before the ABIM's "apology" published in February, 2015 nor acknowledged that perhaps this blog's investigative reporting on those dealings was part of the reason an "apology" from the ABIM occurred in the first place.  Instead, he went on the attack:
Incitement by irresponsible press articles and blogs is destructive rather than helpful. An article in Newsweek published by Mr. Kurt Eichenwald: "Tens of thousands of internists, cardiologists, kidney specialists and the like say the ABIM forced them to do busy work. There is no purpose rather than to fatten the boards' bloated coffers. … ABIM went from being a genial organization (and I spent fourteen years with the ABIM and never thought of it as a 'genial organization') celebrated by the medical profession to something more akin to a protection racket." (Editor's note: Dr. Zipes failed to mention the follow-up article by Mr. Eichenwald that  delved into the ABIM's finances further and addressed conflict of interest disclosure criticisms made by the ABIM from his original article.)

And this blog that was just published recently: "No where in his current disclosures does Dr. Zipes mention his long relationship with ABIM as a paid 'Director,' 'Chair-Elect,' and 'Chair' of the organization. … No doubt Dr. Zipes has good friends at the ABIM and will find it easy to take the protagonist role in the debate." (Editor's note: Yes, my name appeared on the slide.)
If Dr. Zipes felt I was "irresponsible" and "destructive" because I mentioned his lack of disclosure or  because I spent countless hours investigating and reporting the publicly-available documents of the ABIM and their Foundation, I am sorry. He certainly was always welcome to place a comment on this blog. I found it interesting that Dr. Zipes mentioned at the outset of the debate (quote above) that he would not discuss the financial matters of the ABIM but seemed more than willing to attack those of us who brought to light the use of $30.6 million dollars of our testing fees to support the financially questionable activities of the ABIM and their Foundation. It is important to note that the ABIM has still yet to publicly address the allegations made by this blog or Newsweek with the exception of their statement to Mr. Eichewald's original Newsweek story. They also have not released their 2014 Form 990's for the ABIM or ABIM Foundation for the public's review because they filed an "extension."

Dr. Zipes should recall that it was the ABIM, not myself, who created their ABIM Foundation to market their self-determined definition of "professionalism" that included a "social justice" imperative. It was the ABIM (and its accountants) who appear to have misrepresented their creation date and domicile of their Foundation on tax forms.  It was the ABIM that chose to allow their directors to fly first class (before 2000) to their meetings to write test questions at posh places like the Ritz-Carlton Laguna Niguel. It was the ABIM who helped fund their Foundation's ironically named "Choosing Wisely" campaign, in part, on the back of repeated multi-million dollar "grants" from physician testing fees. It was the ABIM that decided to purchase a $2.3 million dollar luxury condominium complete with a chauffeur-driven Mercedes S-class town car. It was the ABIM who paid their President and CEO over $8 million for the 10 years she directed the organization while the balance sheet went from -$10 million to -$43 million. To attack me for disclosing public record of the ABIM's actions is misdirected. If this blog is "destructive" to the ABIM because it reported these facts, then so be it. However, if this blog was destructive to Dr. Zipes' reputation because I made an unwarranted disclosure regarding his involvement with the organization at the time these actions occurred, I apologize.

Moving Forward

The Heart Rhythm Society is at a critical juncture. They can elect to side with practicing US cardiac electrophysiologists or side with a non-accountable non-profit organization whose leadership is comprised of non-practicing physicians who serve the government and US hospital's interests. This is one heck of a dilemma. Is there a way to make everyone happy? How might they choose to go forward?

I met briefly with Richard Fogel, MD (current President of HRS) and John Day, MD (current President-elect of HRS) after the leadership luncheon to discuss the situation and offer a suggestion.  My idea was remarkably simple and I believe would satisfy many of the concerns of the various monetary "stake holders" in this debate.  Importantly, it does not use MOC.  The ABIM publicly claims  that physician competency erodes over time.  I disagree.  What erodes one's skills is when they stop seeing patients.  (This is re-certification after all, NOT initial certification!)  After all, patients who come to my clinic don't ask me if I'm "board certified," they ask me "How many of these procedures have you done?"

I believe we could use the Medicare payments database, recently made available to all, paired with conventional CME records managed by our state licensure boards, as evidence that physicians are keeping up to date and remain competent in their field of practice. The Medicare payments database reports every procedure and payment made to US physicians for that procedure. This number should be made public for each procedure a doctor performs in an easily retrievable format and the Heart Rhythm Society could do just that. If outcomes of those procedures can be generated, all the better. Cumulative data of physician volumes and practice settings could be created.  There would be no more irrelevant computer tests. No more life-long payments into a broken, unaccountable organization. Online courses with content created by HRS could compete in an open forum for CME credit. No more getting rich on the backs of working colleagues. Let our actions speak louder than meaningless pieces of paper, paid and highly-conflicted journal citations, and propaganda. Use our state licensure boards to document our continuing medical education credits and accept that the legal community can do their job if doctors step out of line. Proving a doctor can continue to do his or her job after initial certification should be as simple as that and not require an alternative board.

Practicing physicians (and I do not make that distinction lightly) have to put their reputation, skill, education, and legal liability on the line every day when we care for our patients. To suggest, even for a moment, that this commitment to our patients and our desire to do them benefit aren't critical, real, or valuable for clinical assessment is ridiculous. Just because the ABIM can't decide if they are about assuring physician (1) excellence to enter their medical profession or  (2) adequacy to maintain their ability to practice (two very different things) shouldn't be held against working physicians as it has.

At the end of the debate, I think both Drs. Zipes and Kusumoto agreed that the concept of physician re-certification (especially, the American Board of Medical Specialty's trademarked "Maintenance of Certification" program as it currently exists) is seriously flawed on many levels. It will take brave, honest, and transparent action to correct this reality for our patients' benefit.  Hopefully we can move on to a new paradigm (with the Heart Rhythm Society "taking the stick") that creates a mechanism for competency assessment for physicians, patients and payers alike that is measurable, simple, cost-effective and meaningful.  This isn't rocket science.

It's called, measuring clinical experience.


Tuesday, May 12, 2015

Today in JAMA: ABIM MOC Program's Evidence Base Gets Destroyed

Paul Tierstein, MD and Eric Topol, MD critically review the evidence base for the American Board of Internal Medicine's Maintenance of Certification program in the Journal of the American Medical Association (JAMA) and the results aren't pretty:
In this context, perhaps one of the most overreaching assertions by the American Board of Internal Medicine (ABIM) is that MOC is “evidence based,” even though recent reports provide no convincing evidence that MOC has improved quality of care. For instance, a recent literature review promoted as evidence supporting the value of physician certification and MOC concluded: “In general, physicians who are board certified provide better patient care, albeit the results have modest effect sizes and are not unequivocal.” However, that article was written by ABIM employees and published in a special journal supplement that was supported by the American Board of Medical Specialties (ABMS). In an observational study (supported by the ABIM and conducted by ABIM employees) of physicians who provided care for Medicare beneficiaries, imposition of the MOC requirement was not associated with a difference in the increase in ambulatory care–sensitive hospitalizations, but was associated with a small reduction in the increase in differences of cost of care, although the small difference in cost was only discernable after significant statistical adjustment (propensity matching followed by a multivariate analysis). In another observational study among internists who provided primary care at 4 Veterans Affairs medical centers in which an electronic health record was used with embedded reminders, there were no significant differences between physicians with time-limited ABIM certification (and required recertification) and those with time-unlimited ABIM certification on achieving 10 primary care performance measures.
Read the whole thing.

We should note that this entire new issue of JAMA is devoted to licensure, professionalism, and regulatory issues. Interestingly, no one wants to talk about the money. That would be too politically incorrect. (I guess that explains why I was not asked to be an author).

So let me refresh all of these authors' minds with a few of my former works:

The ABIM Foundation, Choosing Wisely, and the $2.3 Million Condominium

As ABIM Struggles to Find Itself, Doctors are Moving On

Why the ABIM Wants Us to Ignore 1997

ABIM Pleads for Mercy

Board Review: Sixteen Little Questions 

What Happens To Physicians Who Fail Their Maintenance of Certification Examination?

The MOC Money Flow 

I invite them to spend time reading these pieces, then ask yourself if we really need any form of "Maintenance of Certification" at all when Continuing Medical Education has been effective throughout the history of medicine. And I also want to know why the latest ABIM and ABIM Foundation Form 990s have not been released to the public by now.  Are they still cooking the books?

This whole lucrative regulatory capture of physicians needs legal review of these self-serving and unaccountable programs to the public at large, not a meaningless issue full of propaganda in JAMA.


EP Lab Activism

Getting ready for the 2015 Heart Rhythm Society Meetings in Boston later this week.

Looking forward to seeing everyone there!


Friday, May 08, 2015

What Happens to Doctors Who Fail Their Maintenance of Certification Examination?

What is it like for physicians to fail their ABMS Maintenance of Certification® (MOC) program examination? How does the largest member board of the ABMS, the American Board of Internal Medicine (ABIM), respond to doctors who fail their secure examination?

As I continue to confidentially collect information from physicians who have failed their MOC examination, I thought it would be important to publish an example of a physician letter I received. The psychological, social, and financial consequences of failure of Maintenance of Certification are real yet have never been studied by the ABMS and their member boards, including the ABIM. To me, this is both highly unethical and inexcusable. This lack of concern for the negative ramifications of the high-stakes ABMS MOC examination that is increasingly tied to a physician's ability to practice medicine is alarming, especially when judgment is rendered by an unaccountable organization led by non-practicing physicians and scientists that benefit so handsomely from this program.  It is also very concerning in light of the high suicide rate among physicians.

I have also included an example of how the ABIM finally responded. The lack of timely response, transparency, and obfuscation of methodology and facts reflects very poorly on the ethics, scientific credibility, and legitimacy of the MOC program.

(While some physicians have granted me permission to use their name, I have elected to redact their personal information for this post.)

My name is *******. I practice Internal Medicine in ******. I've been in private practice for 10 years.

I was devastated when I opened an e-mail from ABIM on Monday June 30, 2014. I knew it was the strangest, most difficult test I had ever taken, but I had no idea that I would be failed. I wanted to curl up in a ball and cry, but I knew I had to be strong for all the patients that needed me that busy Monday. I was in a state of functional depression for weeks. Crying whenever I was alone. The thought of studying all over again for a crapshoot exam was more than I could stand. Fortunately, I connected on Sermo and learned what was going on and that I was not alone.

I wrote to ABIM 4 different times, once a week for 4 weeks. I want clear answers about the delivery of the test questions and scoring. I have not yet received a reply.

I spent many, many, lost, precious hours away from my husband, children and grandchildren on weekends and evenings studying for my exam. I started studying hard several months prior to the exam.

Cost: Loss of time with my family - Priceless, MKSAP books, ?$650, Test $750, MOC module $1600, Loss of revenue $ 3000+.

Yes, I'm willing to co-author and fight for this cause, and yes my name can be used.

I announced my failure at the quarterly Int Med meeting a few weeks ago at ****** Medical Center where I admit. I'm lucky because they are going to grandfather me in, so I won't lose my privileges.

This is lame I know, but it can't bring myself to tell my parents.

In August, 2014, the physician above finally received this response from Richard Baron, MD, the President and CEO of the ABIM:

Dear Dr. *******:

Thank you for your e-mails to the American Board of Internal Medicine (ABIM). I apologize for our delayed response. I understand your disappointment in learning that you were unsuccessful on the Spring 2014 Internal Medicine Maintenance of Certification (MOC) examination. I appreciate the time you dedicated to prepare for the exam and that you were not expecting this result. I understand your concerns and I’d like to respond to your questions about the examination and how it is scored. I’d also like to let you know of a recent policy change we have made for physicians who, like yourself, were unsuccessful in their first exam attempt.

With regard to your inquiry about the specific questions each examinee sees, though ABIM uses multiple versions of the exam, we take steps to ensure all takers are on a “level playing field.” We do this by constructing equivalent versions of the exam in content and level of difficulty so that, regardless of the version taken, examinees faced the same challenge. In addition, scores for all examinees were converted to a standardized score in the scoring process. The scoring process, along with the use of equivalent examination versions, ensures the comparability of scores regardless of the examination version taken. We follow standard testing industry best practice throughout our processes.

Concerning your question about whether ABIM exams are scored on a curve, the answer is that they are not: ABIM uses an absolute standard – a specific level of performance one must achieve in order to pass our examinations. Rather than scoring on a curve where a fixed percent of physicians will pass and fail, the absolute standard is a more fair and equitable process in that each test taker must meet a threshold of performance that makes their performance totally independent of other test takers. Because of this, the pass rates for an exam can and do fluctuate naturally.

About your question related to pass rates dropping, the differences in the percent of test takers who pass the exam (pass rate) from one administration to another is not due to changes in the exam content or difficulty but to the natural fluctuation that occurs with using a consistent absolute standard with different groups of exam takers who may have different motivation, ability and training.

ABIM has made a recent policy change that I hope will be good news for you– because your Internal Medicine certificate expires this year and you were not successful in this exam attempt, ABIM will grant you an extra year to pass your exam, providing you complete the Self-Evaluation of Practice Assessment requirement by December 31, 2014. During the extra year, you will continue to be reported as “Certified, Meeting MOC Requirements,” provided all your other MOC requirements are being met. You will need to pass your exam by December 31, 2015 and once passed, your next MOC exam will be due 10 years from the last pass.

We hope that you find this information helpful. Again, I completely understand your disappointment and wish you success in your next attempt. 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.


Richard J. Baron, MD, MACP
President and CEO
American Board of Internal Medicine

This letter is important for several reasons.

First, there is no excuse why the ABIM should have had such a "delayed response" to any physician diplomat's inquiry, given the high cost of their "program" and the millions of dollars spent to support this program.

Secondly, we now find doctors who sit for the MOC examination are not all given the same examination, but rather different ones deemed to be "on a level playing field."  How is "equivalency" between examinations determined exactly?  Wouldn't we all like to know?  Might there be bias created by such a process?  And what are "standard testing industry best practices?"  Shouldn't doctors be enlightened on these?

Thirdly, there's the issue of determining an "absolute standard" for physician knowledge.  Who decides this "absolute standard?"  How can an "absolute standard" be determined for a physician when a central authority is completely blind to a physician's scope of practice? Is there some "industry best practice" that doctors don't know about?  Is the "absolute standard" of a quality physician only someone who can cram facts and "pass" a computerized test based on an arbitrarily-determined knowledge base?

The ABIM leadership are masters at skirting these very real concerns of the MOC program.

Finally, the doctor's question regarding the rising failure rates on MOC examinations was not acknowledged nor  answered by Dr. Baron.  Rather, Dr. Baron blames the rising failure rates on experienced physicians' "different motivation, ability, and training." That's right: it seems the higher failure rates are the doctors' fault.

Not surprising, though.

The American Board of Medical Specialties' MOC® program, which has been exhaustively marketed and sold to physicians and legislators as a valid mechanism for assuring quality physicians, appears hopelessly mired in scientific uncertainty and conflicts of interest.  The process is also having profound emotional and psychological consequences to those adversely affected.  This is not a training or teaching exercise, but rather a punitive assessment technique based on an undisclosed set of centrally-predicated and non-transparent benchmarks that appear unevenly distributed.  And sadly, our own professional societies continue to support the program primarily because they profit handsomely from it.

As the veil is lifted on this Draconian process, it is becoming increasingly clear that the ABMS's MOC program is deeply flawed. Yet for reasons that only its well-paid creators understand, the program is no longer a voluntary exercise for physicians, but increasingly tied to government physician payment formulas and credentialing.   

I have no doubt that the members of the ABMS and ABIM feel in their heart of hearts that such a centralized, top-down secretive system of physician testing carries nothing but the most enduring benefit to society.  McCarthyism was hatched from a similar line of reasoning. 

It is clear that the inconsistencies and self-serving nature of the ABMS MOC program is becoming increasingly destructive to our colleagues and profession.  Now we must ask ourselves, what should working physicians do to fix this mess?

At the present time, it seems the only viable alternative is mass non-compliance with the ABIM MOC program or legal action. For not only is the MOC program scientifically indefensible, it is now clear that it is potentially very destructive to many physicians.


PS: Physicians who failed a MOC examination are still encouraged to confidentially submit their stories as I continue my efforts to expose all sides of the Maintenance of Certification debate.

Saturday, May 02, 2015

Why Electrophysiologists Need to Flood the MOC "Debate" at HRS2015

Anti-MOC Bling
Anti-MOC Buttons
Click image to order yours
On 13 May 2015 at 8 am in Room 162A of the Boston Convention Center, a session called "Controversies in Public Policy"will occur at the 2015 Heart Rhythm Society Scientific Sessions. As part of that session, a "debate" on Maintenance of Certification (MOC) entitled "Maintenance of Certification is Important for the Practice of Quality EP and Should be Endorsed by HRS" will occur at approximately 10 AM.  Every cardiac electrophysiologist should attend. (Yes, the Atrial Fibrillation Summit can wait a bit).

Doug Zipes, MD will serve as the protagonist of the "debate" and Fred Kusumoto, MD will serve as the antagonist.  I am sure the so-called "debate" will be cordial.  Both speakers are class acts and I'm sure each will do their best to up-end the other.

But I have many concerns about this "debate," some of which I articulated earlier. Now after reviewing the program format and disclosures for the "debate," I have more concerns.

First of all, the limited time for the debate does not allow time for input from the audience.  This is a shame.  HRS needs to hear concerns from ALL of their membership. Granted no one wants a shouting fest, but polite and pointed discourse should be encouraged at meetings, not squelched.

Secondly, let's look at the disclosures for this debate, because I think this is important.

Dr. Zipes lists his disclosures for the  MOC "debate" as follows:
Douglas P. Zipes, MD, FHRS. Krannert Institute of Cardiology, Indianapolis, IN

  D.P. Zipes: E - Royalty Income; 3; Elsevier. I - Research Grants; 1; Medtronic, Inc.
  There is no abstract associated with this presentation.
No where in his current disclosures does Dr. Zipes mention his long relationship with ABIM as a paid "Director," "Chair-Elect," and "Chair" of the organization. Here is what Dr. Zipes earned from the ABIM between July 1, 1998-Jun 30, 2003:

FY 2003 $31,133 as "Chair"
FY 2002 $17,469 as "Chair-Elect"
FY 2001 $13,907 as "Director"
FY 2000 $20,996 as "Director"
FY 1999 $30,484 as "Director"

No doubt Dr. Zipes has good friends at the ABIM and will find it easy to take the "protagonist" role in the "debate," but is he the right person for a non-biased recommendation for endorsement of the  ABIM's MOC program by the Heart Rhythm Society?

We should recall that Christine Cassel, MD was the acting President and CEO of the ABIM and the ABIM Foundation during the time Dr. Zipes' had his appointments there.  Dr. Cassel now is President and CEO of the National Quality Forum (NQF), a non-profit organization called a "consensus-based entity" that sets quality metrics that soon will influence how physicians are paid.  The NQF has close ties to the ABIM and derives most of its revenue from the Center for Medicare and Medicaid Services (CMS) by way of government grants. Recall that the current President and CEO of the ABIM, Richard Baron, MD worked for the National Quality Forum before coming to the ABIM and may have been slated for a leadership role there as evidenced by a screen shot I captured from the National Quality Forum's website in July 5, 2014 (the web page is no longer present).  Also realize that the National Quality Forum continues to employ Ms. Cassel who was responsible for (1) the repeated piecemeal funneling of $30.6 million of our physician testing fees to the ABIM Foundation (and that purchase of the now infamous $2.3 million luxury condominium), (2) the creation and write-off of $3 million dollars for the now defunct "Institute of Clinical Evaluation" created by the Foundation, and (3) the non-disclosure of grants the ABIM Foundation received from the Josiah Macy Jr. Foundation and the "Institute of Medicine as a Profession," a non-profit created by George Soros and his Open Society Institute.  Needless to say, Dr. Zipes' conflicts are very significant in light of this interplay of money and politically-connected individuals and organizations.

Let's now look at Dr. Kusumoto's published conflicts of interest for this "debate:"
Fred M. Kusumoto, MD, FHRS. Mayo Clinic, Jacksonville, FL

F.M. Kusumoto: None.
There is no abstract associated with this presentation.
(I did not see Dr. Kusumoto's name on any of the ABIM's Form 990 tax disclosure forms either. )

The Heart Rhythm Society must make a clear choice after the upcoming scientific sessions. They can side with the working community of cardiac electrophysiologists or they can side with continuing their support of government grants, cronyism, and an increasingly political agenda that promises cash flow from the government.  Which will they choose?

So let's show up with a sea of buttons and other bling and make it clear that the HRS's endorsement of MOC must go.  All of it.

To promote the anti-MOC movement, I have created a section of my website specifically to purchase anti-MOC bling. All proceeds I receive (about 1-5% of the prices) will go to the ABIM's competitor, instead. The rest of the costs go to the manufacturer of the bling,, including the high shipping prices (sorry, out of my control).

If you'd like to get a FREE 2.25" Anti-MOC button from me before the "debate" session at HRS2015, I will have a hundred of them to distribute(limit one per doctor - I paid for them myself), so get there early.

I look forward to seeing everyone at the meeting.


Friday, May 01, 2015

Friday Read: The Not-So-Simple Pacemaker Check

Her breathing had never taken a second thought, except for the past several months.  Slowly, gradually, her breathing became work so she came to our emergency room.

Her life had been an full one: married, kids, grandkids - all of whom brought her incredible joy. But since the loss of her husband and all of the changes that occurred in her life as a result, she felt more alone than ever. Perhaps this was the reason the pacemaker she had received some 14 years before just didn't seem so important any more. Her kids and grandkids were what remained now, and for them she was grateful for they had noted she'd become too short of breath with even the slightest effort, so they brought her in.

The chest-xray taken when she came to the Emergency Room showed her pacemaker and prompted the ER staff to ask about it. "She hasn't had a pacer check in a while, " the family mentioned. So we were consulted to check the pacemaker's function.

Before we'd done so, we looked at her EKG and weren't surprised at what it showed. After all, we'd seen this scenario before.

So with some confidence I entered her room. There sitting beside her was one of her sons and a granddaughter. She was propped up in bed wearing a green oxygen face mask that covered her mouth and nose but couldn't suppress her kind smile as I entered. After a brief introduction, I explained what her EKG showed and how I thought a good portion of her shortness of breath might be stemming from her pacemaker's low battery.

In our conversation she mentioned that she had been told her pacemaker battery would need to be changed soon. That was before her husband died. After his funeral, the need for a recheck of her pacemaker was quickly forgotten. So she had not anticipated that the pacemaker might be a cause of her symptoms.

We discussed her options. She could leave things well enough alone if she preferred while we arranged to keep her comfortable for her remaining days, or we could change her pacemaker battery. At the time, she didn't want excessive resuscitation measures and had declared herself a "DNR - Do Not Resuscitate" in the event of cardiac arrest.  She thought hard about the choices but wasn't sure...

"Mom, it seems like such a small thing and it might be able to help you feel better! Don't you want to see your grandkids a little longer?" the son pleaded. She listened to him, then looked at me. It was clear she understood the choices and their implications. I suggested she think about it and left the room to give them time to discuss things. Some time later, she asked me to return.

She asked again, "So you think it might help me feel a bit better to have the battery changed?"

I replied, "Honestly, I do, but it's always hard to gauge how much."

So after a few more questions were answered and worried looks shared with her son, she agreed to have her battery replaced. I left the room to document my visit. (After all, nothing happens in medicine any longer unless typing occurs.) Seated next to me was my nurse practitioner, herself transfixed to the computer screen as she returned patient phone calls and made arrangements for procedures to be performed the next day. Next to her was the pacemaker programmer which she wisely brought with her to help check the patient's device. She finished her call and then offered to check the device while I finished my note. I thanked her and continued typing.

It was still relatively early in the afternoon and the eight computer terminals around me were completely occupied by nurses, physical therapists, and residents hammering away and looking stone-faced, somewhat akin to what the New York Times newsroom must look and sound like just before deadline.

Until that sound was shattered by "Call a Code! Code Blue! Get Dr. Fisher!"

Somewhat startled, I looked up to see a sudden shift of the masses. Was that the voice of my nurse practitioner? It couldn't be, could it?

It was.

Poor thing. It seems she placed the wand of the pacemaker programmer over the patient's device, only to see a strange screen on the programmer appear that read something like: "Pacemaker reached ERI 8/13/2013…" followed by a bunch of other text that said something about "Power-on Reset mode" among other things. As she struggled to read the long message and donned a pair of glasses, she noted some twitching in the corner of her eye coming from the patient's direction. She looked up to see a peaceful blank stare on the patient who now laid motionless and unresponsive - a quick glance at the monitor showed it had flat-lined with only a rare agonal ventricular escape rhythm. Realizing what had happened, she was briefly at a loss how to react. This was not supposed to happen. Fleeting thoughts raced through her head like "Seriously?" and "Oh, God, I'm too old for this!" That's when she called out for help.

The poor son and granddaughter sitting in the corner were stunned, not knowing what had just happened. A horde of medical personnel swept in to the room and ushered them out, terrified. I entered the fray and saw my pleasant patient lying there motionless, small puffs of condensation appearing on her face mask and her pupils somewhat dilated. The monitor, too, was devoid of motion, except for an occasional blip seen one the screen. I reached for a pulse. It correlated to the monitor. Not much at all.

"Can we get some atropine and epi?" A asked the code team nervously assembled, not knowing what to do in this "no code" situation. Fortunately, I removed the programmer head from her chest and watched her breathing carefully. Seconds seemed like hours as my poor nurse practitioner stood beside me with her mind scrambling. "Come on guys, we need those meds… What's taking so long?… " she snipped. "Get the pacing patches!" They still were rifling through the drawers of the crash cart when she offered like a pro: "Guys, the purple box!" And within a second, the purple box appeared. The first medication was administered as time seemed to stand still. An occasional blip, then more people in the room. "What can we do?" the anesthesiologist asked.

I looked at the monitor dreading the thought of starting CPR given her wishes, or the what I might say to the stunned family at her bedside if we didn't.

But then, just as unexpectedly as it had begun, a paced rhythm resumed on the monitor! "Hold it!" I said, "I think we have a pulse!" And like a wilted daisy that just received its water, she immediately regained consciousness and wondered what all the fuss was about.

"What happened? Where did all these people come from? Why are they here?"

"It seems your pacemaker battery is a lot lower than anyone expected, Ms. Jones (not her real name). When we checked it, we must have used some of the last energy that pacemaker had. It looks like we need to take you our laboratory and replace that battery right away!"

She smiled and looked up at me with her precious eyes gleaming. Here we were, total strangers just minutes before, now bound together by some unimagineable force. She looked so comfortable lying there, then out of nowhere she reached up to me and grabbed my head, pulling it toward her oxygen mask in an attempt to give me a kiss right through it.

"Thank you," she whispered and smiled, "Thank you."

After reassuring her family and explaining what had happened, we hurried off to the EP lab, our eyes transfixed on her monitor and me still reeling from that beautiful and totally unexpected kiss...

... plastic face mask and all.