Thursday, August 03, 2017

Direct Adverse Effects of MOC® on Patients

The American Board of Medical Specialties (ABMS) successfully lobbied to have their proprietary Maintenance of Certification® (MOC®) program included in the new Merit-Based Incentive Payment Program of the new Center for Medicare and Medicaid Services (CMS) "quality payment program" within Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation. Hospitals and insurers continue to demand MOC® recertification of their physicians without asking a most important question: has MOC® been harmful to patients or their physicians?

Here are real life examples of how the ABMS MOC® program has been harmful to patients:

Example #1, Dr. J.E. of New Jersey

From antitrust legislation before the Northern District of Illinois Federal District Court, Case 1:14-cv-02705:
Association of American Physicians & Surgeons, Inc. v. American Board of Medical Specialties
Assigned to: Honorable Andrea R. Wood
Case in other court: New Jersey, 3:13-cv-02609
Cause: 15:1 Antitrust Litigation

Exclusion of an AAPS Member from Somerset Medical Center (SMC)

29. Defendant ABMS’s foregoing agreements and actions resulted in the unjustified exclusion of a physician member of Plaintiff AAPS (“J.E.”) from the medical staff at SMC, a hospital located in Somerville, New Jersey.
30. Physician J.E. had been on the SMC medical staff to treat patients there for twenty-nine (29) years.
31. J.E. had been board certified by The American Board of Family Practice, which subsequently changed its name to The American Board of Family Medicine (“ABFM”).
32. In 2011, SMC refused to allow J.E. to remain on its medical staff unless he complied with an extremely burdensome and impractical recertification procedure under the ABMS MOC®.
33. ABFM is one of the 24 corporations identified above that has agreed with Defendant ABMS to implement ABMS MOC®.
34. Although J.E. had been fully certified in good standing with the predecessor to ABFM, Defendant’s agreement with ABFM required imposing the following extremely burdensome requirements for recertification under ABMS MOC®:
  • Completion of fifty (50) MC-FP points (acquired by doing modules)
  • Minimum of 1 Part II Module (SAM)
  • Minimum of 1 Part IV Module (PPM or approved alternative)
  • One (1) additional module of [his] choice (Part II or Part IV)
  • Completion of one hundred fifty (150) credits of acceptable CME (minimum 50% Division I), acquired in last three (3) years
  • Compliance with ABFM Guidelines for Professionalism, Licensure, and Personal Conduct which includes holding a currently valid, full and unrestricted license to practice medicine in the United States or Canada
  • Submission of three (3) MC-FP Process Payments; one (1) payment at the start of each module
  • Submission of application and accompanying full examination fee for the MC-FP Examination
  • Successful completion of the MC-FP Examination (Viewed April 23, 2013)
35. The foregoing requirements demand far in excess of 100 hours for a typical physician, with the possibility of an unjustified rejection of recertification for reasons having no proven connection with patient care.
36. The foregoing requirements further impose many thousands of dollars in fees and travel expenses.
37. The foregoing requirements take physicians away from providing care for patients.
38. In addition, the ABMS has entered into agreements with many of the above-referenced 24 specialty organizations to require even more expenditures of time and money by physicians. According to an email sent to physicians by the American Board of Internal Medicine (ABIM) on or about April 6, 2013, Defendant “ABMS is requiring more frequent participation in MOC of all board certified physicians.”
39. Like many other AAPS physician members, J.E. spends a substantial percentage of his time providing charity care to patients who would not otherwise have access to medical care.
40. J.E. manages and works in a standalone medical charity clinic for a substantial part of each week.
41. Requiring J.E. to spend hundreds of hours on requirements for recertification under ABMS MOC® would result in an hour-for-hour reduction in his availability to provide medical care to his many charity patients, who recently surpassed 30,000 patient visits in total number.
42. Patients of J.E. typically lack any alternate means of obtaining comparable medical care.
43. J.E. continued to serve his charity patients rather than comply with the foregoing burdens of recertification demanded by Defendant’s agreement with ABFM to implement ABMS MOC®.

44. Effective June 24, 2011, SMC excluded J.E. from its medical staff, as a result of Defendant ABMS’s agreements with other entities to require the ABMS MOC® program.
45. Patients are now denied the benefit of being evaluated and treated by J.E. when taken by emergency to SMC.
46. There is no value to patients in the completion of the above litany of onerous recertification requirements.
47. The lack of any genuine value of ABMS MOC® as a measure of professional skill or competence is demonstrated (viewed March 4, 2013) by how ABMS itself selected and appointed as its new President/CEO in 2012 someone who was “Not Meeting MOC Requirements,” but had an exemption not available to younger physicians.
48. J.E. is unquestionably a first-rate physician who continues to practice in good standing in New Jersey.
49. Whether J.E. purchases and complies with ABMS MOC®, as implemented by the ABFM, has no bearing on his medical skills as a physician.
50. Like J.E., other members of AAPS face imminent injury from Defendant’s agreements to impose ABMS MOC®, and Defendant’s concerted actions to require physicians to purchase and comply with its proprietary product.
51. Defendant’s agreements and concerted actions limit the supply of physicians available to hospitalized patients, thereby denying patients care by their choice of physicians."
Example #2 Megan Edison, MD of Michigan
"Regarding opting out (from MOC®), I can demonstrate harm to my patients. As you know, I did not pay the $1300 to the ABP. I have no educational requirements due until 2023. Within weeks of not paying, Blue Cross/Blue Shield of Michigan (BCBSM) sent me a letter dated 19 January 2017 (and received by my office 28 Feb 2017) telling me to pay by 20 March, 2017 or I would be kicked off their panel. I mailed my appeal letter 1 March 2017.  When I did not pay, BCBSM did not contact me to initiate the appeal process detailed in my contract ( which involves two peer-to-peer hearings where I can explain by case). Instead, they sent letters directly to my patients telling them I was no longer a qualified in-network physician and they would be reassigned to another doctor. I was not allowed to see my patients without having another physician in the room with me. Even if my patients decided to pay cash to see me, any prescriptions or studies ordered would not be covered by BCBSM. On March 10, 2017, I received notice that my appeal hearing was granted for 5 April 2017.

They refused to stop sending the letters pending my active appeal case. They said they would continue sending letters until I complied, or my appeal was done, whichever happened first. Obviously, this caused extreme distress for my patients and my staff.  I contacted a lawyer with the Michigan State Medical Society, who told me to pay the money. I did.

Within seconds I had my board certificate in hand. Within hours BCBS re-instated me and never sent out another letter. Of course, they never sent letters to the hundreds of patients letting them know of their error. I am not the only one this has happened to, it happens all the time. To opt out of MOC®, docs are hiring NPs to see their BCBS patients because they will credential a NP...but not a MD opting out of MOC®. It's madness that MOC® is now more important than a MD."
As seen in these examples above, the American Board of Medical Specialties' MOC® program is not a benign recurrent educational exercise for physicians. Rather, MOC® is a means of assuring a continuous cash flow to ABMS member boards using threats and intimidation by unaccountable ABMS member board members and insurers that adversely affects patients as well.

- Wes


  1. I am dumbfounded by these examples of the chill placed on physician and patient rights by the ABMS and their affiliated corporations. Why can't you get this out to the major news wires?
    Stories like these show the absolute harm of ABMS MOC summoning within us both tears and outrage.

  2. With all the ABMS MOC docs are mandated to do today, and all the continuous demand for fees, one can plainly see certification is now all about the money and the power it brings to the ABMS and their executives.

    Quite often that means politicization of an NGO and lobbying such as we've seen with the hiring of politicians, thugs and Wall Street bankers to fill executive positions.

  3. It is fair to say that physicians today are no longer certified for life;
    Docs are now "certi-feed" and "tested to death" for life by ABMS MOC!

    It is not about lifelong learning, mutual trust and respect;
    it is all about control and money!

  4. Thanks for all that you are doing, Wes, and the strong grassroots and lobbying efforts of the AAPS for decades. The ABMS is certainly destroying the fabric of life and medicine in America. It is not about human values, but has turned into a monstrous corporate machine.

    Special thanks to Megan for sharing her personal heart-wrenching stories. Just think of it, an insurer bulling her like that and telling her kids that they no longer have an "in system" doctor. To me that good, hard-working honest pediatrician is what America is all about at its finest.

    I still can't get over her twitter image of the ABMS representative passing Megan his card at the state assembly meetings on anti-MOC legislation in Michigan. Subtle but very strong political and psychological pressure; it still turns my stomach to think of it. It had the reverse effect on everybody, just made the movement to get rid of MOC in every state stronger. Thank you to all.

    By the way, I am a patient who is rooting for you all in this anti-MOC fight, and I will not give out my name, for fear the ABMS will come calling on me; or due to my concerns their insurance buddies might blacklist me from getting insurance or healthcare.

    Also, I really don't like having my records "on the cloud" or electronic databsase for anybody other than my doctor and his people to see. My personal information has been hacked twice already. Now identity thieves have put fraudulent charges on our credit cards.

    Also, here's my sense of EHR and the continuous-click quality assurance syndrome: in my opinion it has turned our healthcare system into one just like the VA, which I have known to be the biggest bottleneck in healthcare ever since they went "live" so many years ago.

    The VA has always been hard to get in. What the government and corporate boys are doing to medicine today has put the whole healthcare system about 5000 clicks away from home. It just does not work anymore as we get more electrified, corporatized, privatized, and cronyized.

  5. Buying a luxury condo with docs over-priced certification fees? More stories about the politicization of the ABIM/ABMS, and the over-billing of physicians to pay for CEOs' lavish political ambitions and lifestyles . . .

    Let's talk about Christine Cassel and Dickey's Dacha; let's talk about unfair trade practices and price-fixing among the ABMS member boards

    With the ABMS/ABIM/ACGME and "other business pals" everything is "fixed", even the NGO executive compensation

    Views from within

    Robert Wachter, of IPC Medicare fraud fame, approved of the entertainment packages and luxury lodgings arranged for prominent and influential people - key folks in helping Christine Cassel with her lifelong political ambitions and agendas. Cassel was hell-bent on achieving by "hook or crook" her partisan and strangely almost neo-conservative healthcare reforms. Cassel and her cronies used both methods - hook and crook - and then some!

    This intense decades-long process for Cassel and her partners in DC, CA, IL, PA and elsewhere took shape from the time Cassel worked closely with Bill and Hillary Clinton on their failed healthcare reform endeavors back in the 1990's.

    With a dedades long political ambition and agenda we can see the 1990's were good years for the ABIM Foundation finacnially - investing physicians' fees, albeit recklessly after transferring about a hundred million in docs surfeit testing fees from the ABIM to the aforementioned "big piggy bank".

    No, Bob, it was not a hundred years of savings from the ABIM. The ABIM was only in its early 50's then and it is a non-profit. Let's not misconstrue the facts.

    $100 million dollars to the big piggy bank. (I am calculating in all the losses they made on those gains during the dotcom bust of the early 2000's when the ABIM executives and board approved of the continuance of highly risky stock jockeying. It was as if they were in the "Triple Crown" - the races of their life in the 90's, with some insider help I'm sure. But sometimes even the insiders can get it very wrong. The jockeys fouled up in the early part of the new millennium and Bush White House as they stock-jockeyed their way to wealth and power but during this fresh decade with profoundly negative consequences.

    The stock markets went sour

    They had to mask about 20-30 million in realized and unrealized losses by selling everything including their home runs. Lots of window dressing by their brokers and ABIM CFO who created the American Board of Internal Medicine Foundation in 1989/ He passed the hot potato on a decade later to the first woman - Chairman Cassel - just before the big bust.

    The ABIM's now defunct stock jockeys went belly up and had to sell all their horses as the "new riders of 1838 Investment Advisors" (formerly of the defunct "racketeering" firm Drexel Burnham Lambert) shuttered its doors after taking on way-too-much risk with clients' money.

    Funny, but 1838 had a specialist just for non-profit investors, like the ABIM, who MUST NOT take such profound risk by the sound rulings/guidelines laid down by the the IRS and SEC.

    Bob Wachter was in on everything with Cassel, Langdon, Holmboe and Baron on setting up the "office of investigations", finding a felon to fill the position of "director of investigations", and even the horrific decision to spy on and persecute competing board review courses - but especially physicians who purchased competing review books such as FrontRunners and who attend non-ACP courses like the ABR.

  6. Let's talk about waste - not so subtle inexcusable outlays of money that were just for political show - such as the hiring of Richard Baron and Lois Nora as the next CEOs of the ABIM and ABMS umbrella.

    ABIM wastes money on a nationwide CEO/President search

    Bob Wachter was the principle involved in the nation-wide search for a new ABIM CEO. What a joke as Baron was already there and appointed before spending over $100K, paid out to an executive search firm - or so we are led to believe. See tax forms under contractors. What was that money really spent on? Or was it just paid out to the account for another use?

    You can search for Bob Wachters own words in print on his commercially-paid-for healthcare industry blog-site sponsored by a "healthcare society" and a media giant.

    The hiring of Lois Nora

    The ABMS about the same time paid out over a $100K to a Massachusetts executive search firm when they already had their next CEO Nora already in hand. The timing of when the expense these things is highly suspect imo and is meant to obscure what it is for lending itself to "malleable interpretation".

    The ABMS spent over 100K, or so it appears from looking at IRS forms, to search for Lois Nora to replace Kevin Weiss. Dr. Nora was already there working the various boards and being groomed with seats on the BOD of medical organizations such as the highly influential Association of American Medical Colleges.

    If this is true, and again just for the outward shoe, what a fraudulent waste of money for these corporate/government shills at the ABMS. It is becoming apparent with stories like Wes Megan and the AAPS have shared with us today, that CEOs and other executives are appointed by the healthcare industry in concert with the quality assurance/testing cartel.

    Why were they going through the motions with an executive search company? Why did they expense the money for it and where did it really go? It may have been for other purposes or personnel. If true this is fraud and the public should be outraged. Such an outward show can never nullify or ameliorate the serious conflict of interests and corruption that we find at the ABMS and ABIM, or within their infamous charade of creating national "search committees".

    With the ABIM and ABMS member boards it is all about repeatedly getting away with in-house clandestine shenanigans. The result is still obfuscation of fiduciary responsibility, "trademarked highly profitable service to the public", and the obvious monetization and politicization of what should be an objective and non-profit neutral body.

    It is time to put the foot down and say, "nor more political and financial shenanigans!"
    That means the ending of the highly controversial mandates associated with ABMS MOC. As we can see today, from our cloudless day, the sunshine tells us the corruption must stop.

  7. The MOC thing is like a Dilbert cartoon for doctors. It's a scheme to extort money via prometric but other industries have been prometric'd and you probably can't really stop it for the following reasons.

    First, some doctors are more focused on hating MOC than treating patients and a few take this out on patients. God listens to the cries of the wounded hearts, and for those screwed over patients, there is a price to pay. God also has mercy on doctors, so it's a balancing act between the two competing interests. Doctor & patient pitted against each other spells problems.

    Second, a lot of doctors are Boomers. This group often undermined and sabotaged GenX as potential competition, but lavished great attention on Millennials who were perceived as the ones who would pay Boomers' retirement. So to encourage Millennials and make sure they were often bribed, rewarded, courted there were constant events that could be used to issue trophies, certificates, awards, etc. So the Millennials got addicted to taking tests so they can get an A, because everyone wins a prize and gets an A. Except there's that 12.1% failure rate built in to keep test revenues going. I'm not sure what Millennials do with that, probably sh1tpost on twitter.

    I'll keep it at three reasons for digestibility. The desire to be progressive or inclusive or whatever they're calling it nowadays opened the door to people going to medical school who actually hate all that patient care crap. That's just not even where the big money is. You get the degree, then you can know just enough to get into a high-paying "leadership" role, and from there you can get super rich--not these small potatoes of maybe $400K annually if you're doing a lot of surgeries and whatnot--the big bucks is in regulating and micromanaging people who are doing all that very intensive work of patient care. Sure, they KNOW more than the DINO but are they truly saavy with money? Of course not, they work too damn hard for money. "Smart" people do the least work possible for the most money--and that's who rules over doctors... the people that progress demanded entry into medical school that they hated, with colleagues that they hated and ultimately filtering down to every patient, which they also hate... Because money is love to these people, these very rich people who at least in one thing view us equitably: they hate us all & only see us as revenue streams.

    So Wes & others will continue on as the anti MOC Don Quixote's, put more time into it than MOC itself, eventually may just put up with MOC, there will be some restructuring and deregulation, Trump will do some stuff that shocks even people that are used to his personality and voted for him, and in the end Wes will be remembered most of all for his excellently wavy full head of hair.

  8. MOC will end not with a bang, but with a whimper.

    The states should and will ban mandated ABMS MOC with legislation providing physicians and patients with statutory relief. What Wes Fisher and so many others are doing together is important groundbreaking work, that is to say, ending the usury and fraud involving the politicization and monetization of CME at the ABMS.

    The ABMS is broken beyond repair. It is mendaciously corrupt and duplicitous to the point of no return. This is a fact.

    Moreover, the facts indicate a syndicate exists comprised of "organizations of new formation" solely dedicated to crony corruption. This graft involves the gamut of NGOs making up the quality assurance/testing/accreditation cartel. There are a great deal of them working together serving themselves, each other and special interests.

    Most of these "quality assurance organizations" were founded in corruption, have been perpetuated by corruption and they will most assuredly end as hopelessly corrupt entities. They will end in spite of the venal, fraudulent, under-handed leader at their helms trying to sustain their fortunes and legacies. These organizations live in their own specialized self-made swamp. It is a mire of special interests, government revolving door insiders with executive appointments made by the same special interests that benefit from their existence. The public is not benefited, physicians do not benefit. There is only harm for the insouciant patient and frustrated physician.

    Corruption is not new, but this "quality assurance organism" with its blend of corporate propaganda and government disinformation is a fairly new phenomenon in the US, only two or three decades old. I am referring to the creation of the private companies, somehow with tax exempt status creating personas of false authority centered around a collection of NGOs deceptively acting like they are government ministries of regulation.

    The NCQA, NQF, ABMS, ACGME and so many other "watchdogs" created for and by special interests or have been infiltrated to the point of obscuring their real histories with fake ones. This seemingly endless corruption has rendered certification, accreditation, and the incredulous maintenance thereof virtually meaningless. Many of these organizations--in fact, most of them--need to go away.

    The ABMS is one of these redundant corrupt self-dealing private corporations serving themselves and special interests. We have come to the point where there is not choice but to end this now. Today. Trust has been obliterated with exposure of the corruption, negligence and intellectual malpractice. Certification needs to be taken out of the hands of the ABMS' corrupt hands and placed in trustworthy ones.

    There is no other choice than to take a pragmatic and prudent approach giving back to physicians and patients the promise of lifelong certification with true self-regulation and observance of that self-regulation performed by the state medical boards. The redundancy of ABMS involvement in certification or CME makes no sense, and never did. Now to work together with an untrustworthy and corrupt partner would be madness. Pure insanity. Who wants to submit to the ridiculous and absurd. Nobody except the profiteers and special interests.

  9. The end of the end for mandated MOC

    Let's be clear about what needs to happen next. Certifications need to be made less painful and integrated with residency and fellowship providing a suitable, relevant test at the end of each specialization that is granted for life. Lifelong learning has always been a part of that. None of the founders of he certification movement would ever go along with the corruption that we have today.

    Medical education in the form of MOC (and certification, I'm sad to say) have become just one big pyramidal quality assurance scam. A Ponzi scheme.

    CME as regulated by the states is sufficient. Certification needs to be for life again. The ABMS should not be involved in any of this. Too late for them to be reformed. Lifetime certification needs to be achieved and granted prior to one's specialist diplomas(s) and administered by "accredited" GME programs. This can all be paid for with the pools of federal grant moneys that exist already for allotment. I repeat this can be done without any new expenditures and takes the burden off young debt stricken physicians starting their careers and paying off educational loans.

    The ACGME needs to be reformed to accomplish this without politicization and monetization.

    Additionally, to achieve these GME reforms, I call for a full congressional investigation of the corruption that has made work and life unbearable for physicians and patients. These cartels and their crony special interests partners made a mess of healthcare while pocketing billions in excess profits. This cabal of elites has strapped two boots together making it impossible to walk, let alone practice or learn. This corruption is real and we can not allow it to continue to plague our educational and healthcare systems ever again.


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