It was with that as a background that I wrote my post on these web pages entitled "How the ABMS MOC Program Threatens Major Medical Journal Integrity" on September 5, 2016. I was concerned that the ABMS President and CEO, Lois Margaret Nora, MD, JD and her colleague Thomas Norris, MD had failed to disclose financial conflicts of interest in a letter that they had published in the New England Journal of Medicine (NEJM). I felt it was also clear that Dr. Nora had a similar lapse of failing to disclose financial conflicts in her pro-MOC article that she was invited to pen for the NEJM and in another promotional article published in the Journal of the American Medical Association (JAMA) in August of 2015.
Specifically, I felt Dr. Nora disclosure as an employee of the American Board of Medical Specialties was insufficient as it relates to collecting third-party revenues from it's separate for-profit Georgia-based corporation, ABMS Solutions, LLC. The revenues received by ABMS from ABMS Solutions, LLC are above and beyond fees paid by physicians who participate in ABMS MOC re-certification. Also, no mention of lobbying activities the organization engages in for the corporation's financial benefit was made in either journal as well.
Because of these concerns, I sent an email to the editors of JAMA and the NEJM, asking them to investigate the failure of Dr. Nora (and in one case Dr. Norris) to disclose the conflicts and to consider retraction or a correction for the failure to disclose these conflicts.
Both journal editors were responsive to my concern, but in different ways.
Journal of the American Medical Association
The Editor in Chief for JAMA, Howard Bauchner, MD responded felt that Dr. Nora's financial disclosure as President and CEO of ABMS was adequate because "professional societies and organizations, medical societies, medical schools, hospitals, and industry stakeholders in healthcare employ lobbyists on their behalf. We suspect our readers are aware of this and we do not expect authors to separately declare that their employers engage in lobbying efforts." No mention of my specific concerns regarding the money received by the for-profit subsidiary, ABMS Solutions, LLC, was made, but he did copy his email to me to the journal's editorial counsel, Mr. Joseph Thornton. When I inquired why the issue ABMS Solutions, LLC was not addressed in a subsequent email, I received no reply.
New England Journal of Medicine
The editors of the New England Journal of Medicine forwarded by communications to Dr. Nora and Dr. Norris of the ABMS. Here is a copy of the short email I received from Mary Beth Hamel, MD, MPH, the Executive Deputy Editor of the New England Journal of Medicine in response:
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"The operations, activities, and finances of ABMS Solutions, LLC and the other subsidiaries of the ABMS are consolidated for accounting purposes with those of the ABMS. Likewise, the operations, activities, and finances of ABMS, ABMS Solutions, LLC, and all other subsidiaries are consolidated for tax purposes and publicly reported on a combined basis on the IRS Form 990 for the ABMS. The references in our disclosure to ABMS refer to the consolidated entity, as publicly reported, and as such our disclosures were full and complete."The problem is, when physicians or the public go to the ABMS website, you will notice that their Form 990 and "consolidated financials" are nowhere to be seen. Instead, it appears the NEJM expects its readers to check financial dealings themselves.
So I did.
Thanks to my familiarity with reviewing IRS Form 990's, I knew to go to Guidestar.org to look up the ABMS's latest-available 2014 ABMS Form 990 (pdf). From that, I found the following publicly reported just as Dr. Nora suggested:
ABMS Solutions, LLC earned ABMS $3,469,401 in 2014 (see page 44). Also note that ABMS claims ABMS Solutions, LLC is domiciled in Illinois (it is not, it is domiciled in Georgia). (We've seen this misreporting of the state of domicile of affiliated corporations on IRS forms dealing with the ABIM Foundation, too.)In summary, it took reviewing three Form 990's (one from ABMS and two from "related" organizations) to uncover the "disclosed" conflicts of Dr. Nora's. As we can now see with the travel of ABMS members, "consolidation" of financials has a funny way of disclosing details.
ABMS International, LLC, a "holding company" for the ABMS, earned $5,034,433 in 2014. (see Page 44. While it not itemized in their form 990 or "consolidated financials," practicing physicians should note that employees of the ABMS attend posh conferences in Qatar (video) and Venice, Italy to promote their credentialing program to other groups outside of the United States. ABMS International LLC is the "Direct Controlling Entity" of ABMS Singapore, LLC that earned $0 in 2014 for ABMS in 2014. Dr. Eric Holmboe, the ABIM's former medical director (before he moved on to the Accreditation Council on Graduate Medical Education) can be seen promoting (video) the ABMS/ABIM MOC program with Singapore physicians here for an undisclosed sum).
Dr. Nora earned a remarkable $763,005 from ABMS in 2014 (and at least 11 other officers of the organization earned over $200,000) - a sum that eclipses the vast majority of practicing physicians in the United States.
These ABMS "related" organizations' revenues represented 47 percent of the ABMS total Program Service Revnue (of $18,128, 145) in 2014 - certainly not a "de minimus" amount. Why are U.S. physician fees supporting overseas marketing of this program to other countries?
But there's more.
ABMS is also the controlling entity of the American Board of Medical Specialties Research and Education Foundation, whose principle officer is also Lois Margaret Nora, MD JD and has it's own separate IRS Form 990. That Form 990 claims the ABMS Research and Education Foundation's mission "shall be to support the scientific, scholarly, and public education purposes of the American Board of Medical Specialties (1) by encouraging and conducting research to improve the capacity to measure, assess, and evaluate the educational scientific, clinical, and professional qualifications and performance of physicians engaged in the practice of medical specialties and (2) by conducting educational programs and disseminating information to the public to assist its recognition, evaluation, and underdstanding of the significance and importance of initial certification, of subcertification and of maintenance of certification of physicians engaged in the practice of medical specialties (3) by fostering national and international cooperation and the exchange of information related to initial certification and maintenance of certification."
Items (2) and (3) appear to represent little more than a marketing mission for ABMS certification and MOC propaganda. Item (3) further supports the the promotion of ABMS Solutions, LLC sale of physician credentialing status as well.
The finances of the ABMS Research and Education Foundation demonstrate it has a deficit of $573,644. In FY 2014, the ABMS issued $2,115,569 grant to this "education and research" Foundation (Page 46 of the ABMS Form 990) to cover their loss.
ABMS is also the controlling entity for Multi-Specialty Portfolio Approval Program whose finances are under a separate Form 990 (website here), the first of which appears to have been created in 2014. In FY 2014, the ABMS issued $217, 548 to this organization as a "gift, grant, or capital contribution" (for "promoting physician participation and competency") (Page 46 of the ABMS Form 990).
What does the Multi-Specialty Portfolio Approval Program do?
It seems it loses money. After all, the organization is still $181, 423 in debt after the ABMS granted it $217,548 that same year).
And what what THAT money transfered for? The "mission" of the Multi-Specialty Portfolio Approval Program is "To promote physician participation and competency in quality improvement efforts by granting maintenance of certification credit for quality improvement efforts in local enviroments that improve quality care." Closer inspection of its website seems to hint at promoting the suspended "Part IV" of the old MOC program that Dr. Baron halted when the controversy and physician frustration with MOC began. In reality, it appears the mission of this 'Portfolio Program' is to issue funds to other "exempt non-charible related organizations" (line 49a of its own Form 990)."
I wonder who decides which "local environments" should receive that money and how it is distributed? Really, this seems like a slick way to pay money to others that support institutions that the ABMS deems worthy of their support.
Still, there they are. I suppose I should apologize to Dr. Nora for the fact that I was unaware of this network of spending using our re-certification fees for the benefit of ABMS and I appreciate her openness for "disclosure" in her publications and engaging with this discussion.
As an aside, it was telling that the editors of the New England Journal of Medicine never mentioned their own financial conflicts with the ABMS MOC program. (I brought this to Dr. Hamel's attention but never received a reply.)
Live and learn, colleagues.
Addendum: On 10/17/2016 after sharing this blog post privately with the editors a week before it was published and receiving no response, the same day the post was published I received an email from Lauren Lindenfelser, Manager of Editorial Administration at the New England Journal of Medicine that stated "Thank you for your email. Your comments were received and shareed with the editor. We have no further comment at this time."