Wednesday, March 27, 2019

Physician's Week

William Osler

"When schemes are laid in advance, it is surprising how often the circumstances fit in with them."

"To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all."

"The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow."

"Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education."

- William Osler
"Physicians Week" has begun but you might not have known it. I suspect most physicians were busy seeing patients and many didn't stop for lunch, or ate what they brought to work while staring into a computer screen, trying to catch up on patient and staff messages, wiping a bleary-eyed tear from the corner of their post-call eyes, and clicking on hundreds of electronic orders placed by others on their behalf. Such is medicine now: an isolating, mind-numbing, depersonalizing series of clicks. It's hard to get excited about a week devoted to you when you can't get all the finger work done. How far we have traveled from the days of Osler's teachings!

Officially, March 30th marks "National Doctor’s Day" in the United States. National Doctor’s Day was started by Eudora Brown Almond in 1933. The date was chosen to mark the date that Dr. Crawford Long, in 1842, first used ether to anesthetize a patient and painlessly excised a tumor from his neck. Mrs. Almond, the wife of a doctor, wanted to create a day to recognize physicians. She did so by mailing greeting cards to doctors and placing flowers on the graves of deceased doctors. The day was later expanded to "Physicians Week" in March 2017 by Drs. Marion Mass, Kimberly Jackson, and Christina Lang who applied to officially have "Doctor's Day" changed to "Physicians Week."

Healthcare today is more complex than ever before. Our role as working physicians is critical to families, individuals, and their loved ones. It is an incredible privilege and responsibility. Yet, we are faced with new and growing challenges, many caused by greed and "the foolishness of yesterday." Much of the last five years of mine has been spent educating other physicians about this issue on this blog's pages.

Despite these efforts, the American Board of Medical Specialties (ABMS) Maintenance of certification (“MOC™”) requirements and costs continue to grow. They sap our time and resources, making us less available to our patients as we increasingly must "study books without patients." Meanwhile, the organizations behind MOC™ and their substantial resources remain unchecked.

The American Board of Internal Medicine (ABIM), the largest ABMS member board, has recently filed a motion to dismiss the case challenging MOC™ and similar motions are expected in the cases against the American Board of Radiology (ABR) and the American Board of Psychiatry and Neurology (ABPN) in the next month or two. The boards have legions of attorneys lined up to defend their conduct and millions of dollars with which to pay them. Your contributions, thus, remain critical in our fight.

So take a moment and really reflect on Osler's words above.

In honor of National Physicians Week (and National Doctor's Day), I ask you to help me by donating now to get us to the next stage of the lawsuits against MOC™. If you have already given, please consider giving again, as I have done. And please promote our cause to your friends and colleagues. If each one of us can invite just two or three new donors to read about our fight and contribute, we could reach our latest goal, which is to have 1,000 new donors contribute $200 each. These contributions will go directly to continuing our legal fight against MOC™. 100% of your contribution goes toward funding the lawsuits (less third-party credit card processing fees).

Many have had concerns of repercussions to themselves should they contribute. If you wish to keep your participation private, you can designate your contribution as anonymous too. As before, you also have the option to add a “tip” to help GoFundMe maintain its platform. Any “tip” is entirely voluntary, goes directly to GoFundMe, and will not be applied to our goal.

For those wanting to send a check in lieu of using the GoFundMe page, please earmark your check for "Legal Fund" and send it to:

Practicing Physicians of America, Inc.
876 Loop 337, Building 101
New Braunfels, TX 78130

We could not have reached this point without you, and I hope you will continue to help in the fight to take down MOC™ -- for your own benefit and the benefit of your patients.


(aka, Westby G. Fisher, MD
Member, Executive Board
Practicing Physicians of America, Inc.)

Sunday, March 24, 2019

Suddenly, Some Specialty Societies Might Be Listening

From the American College of Radiology blog:
"In response to a recent request from the American Board of Medical Specialties (ABMS), the (American College of Radiology) ACR created a work group to comment on a report on the status of (Maintenance of Certification) MOC® across all specialties. That group worked tirelessly over the winter holidays to prepare a detailed comment letter (ed. note: a portion of which is highlighted here):"

(Click to enlarge)
The blog post continues:
"The ACR also signed on to a letter from the Council of Medical Subspecialty Societies (CMSS), which represents approximately 800,000 physicians from 43 medical subspecialty societies.

Both the ACR and CMSS letters call for an immediate moratorium on MOC® until many programmatic deficiencies are corrected.
. . .

These important ACR member issues have recently been amplified by the backdrop of various ABMS member boards coming under intense scrutiny and even legal actions for financial practices, lack of transparency, non-democratically elected leadership, high-stakes non-validated psychometric testing and concerns about monopolistic behavior. The American Board of Radiology (ABR) was named as a defendant in one class action suit and a “co-conspirator” in another.

Our Task Force is studying these issues and preparing to make recommendations to the BOC and CSC at both the ACR 2019 and ACR 2020 annual meetings."
Mind you, these cases have not been brought before the court yet, but there now appears to be a serious level of introspection and concern at the highest level of some specialty societies as to what transpired to get us where we are with "continuous" ABMS Board certification.

Colleagues, now is not the time to back off our funding campaign to support the litigants in this anti-trust battle. In fact, we need more physicians from ALL specialties frustrated with the current MOC® status quo to join us to keep the pressure on ALL of the ABMS member boards.


Thursday, March 21, 2019

The Astronomical 10-year Cost of ACC's Continuous Maintenance Pathway

Since the inception of Maintenance of Certification (MOC®) by the American Board of Internal Medicine (ABIM) tied to our initial board certification credential in 1990, the costs of "maintaining" initial certification through "continuous certification" have steadily climbed by way of the threat of invalidating our initial certification credential.

Nothing is different with the new "Continuous Maintenance Pathway" proposed 15 Mar 2019 by the American College of Cardiology (ACC). In fact, the monetary demands are an order of magnitude greater for working heart specialists and cloaked in smooth propaganda published in the Journal of the American College of Cardiology.

To compare apples to apples, it is important to compare 10-year out-of-pocket costs required from physicians participating in MOC®. By way of background, the cost for "Maintenance of Certification" from the ABIM in 2000 was $795 every 10 years.

Here is a breakdown of the costs cardiologists and cardiac electrophysiologists will incur by participating in the "Continuous Maintenance Pathway" proposed by the ACC and the ABIM:

(Click to enlarge)

If you are an ACC member, you get to pay even more to the ACC, despite what their website says.

Here's the breakdown for ACC members:
  • $795 initial ACC membership fee + $150 admin fee x 10 years LESS $400 credit on CMP program every 5 years x 2 = $1495
  • PLUS $1500 every 5 years to ACC for CMP x 2 = $3000
  • PLUS $160 per year to ABIM x 10 years = $1600
  • GRAND TOTAL = $6095 every 10 years of MOC/CMP (or $609.50 / year)
And let's not forget this VERY important adhesion condition for these fees:
(Click to enlarge)
In summary, the ACC's new Continuous Maintenance Pathway is one of the most shameful money grabs from US cardiologists and cardiac electrophysiologists imaginable and represents a remarkable 654% increase in fee payments for MOC® since 2000 for non-ACC members and an incredible $766% increase in fees for ACC members for MOC® since 2000. More importantly, the ACC leverages (ties) CMP to the threat to a physician's ABIM board certification status (and therefore their right to work) and I believe represents a restriction of trade and is in violation of US anti-trust and racketeering laws.

It is truly unbelievable that the ACC and the Heart Rhythm Society would do this to their own membership, but then again, given their prolific financial balance sheets, maybe it's not so unbelievable after all.


PS: Please help support the federal antitrust class action lawsuit against the American Board of Internal Medicine by contributing here.

Wednesday, March 20, 2019

ABIM Gives First Public Legal Response to Lawsuit

On 18 March 2019, the American Board of Internal Medicine responded for the first time in opposition to the federal class action lawsuit filed against it by four internists in early December 2018. The 39-page memorandum accompanying their proposed motion to dismiss is re-published here without comment for physicians to read themselves.

Physicians wishing to contribute to the support of the four internists involved in this case are encouraged to donate to this GoFundMe page.


Monday, March 18, 2019

The Big Easy: The ACC, HRS, and the ABIM

This weekend, at the American College of Cardiology (ACC) Scientific Sessions in New Orleans, the ACC and the Heart Rhythm Society (HRS) announced their commitment to the American Board of Internal Medicine's (ABIM) continuous certification financial shakedown of US cardiologists and cardiac electrophysiologists. Taking a playbook from the American Medical Association, their leadership has realized the financial milk and honey for their business rests squarely alongside the business interests of US hospitals and the powerful device industry, not the physicians for whom they pretend to advocate.

So they have reached out to their academic colleagues, many of whom are medicine's leading industry thought leaders, teachers, and spokespersons, to create yet another Maintenance of Certification (MOC) testing "pathway" (called the "Continuous Maintenance Pathway" (CMP)). This "pathway" requires purchase of the ACC Self-Assessment Program (ACCSAP) to extract cash from their own colleagues and more vulnerable, younger cardiologists. As always, failure to participate some way with "continuous certification" will always be met with the threat of pulling a cardiologist's credentials to practice medicine if they don't comply. The CMP will only be valid if physicians continuously purchase the ACCSAP study materials. How much will that cost? Well, the ACCSAP used to cost a cool $400 per year and the 2019/2020 prices have yet to be announced, but was promised to be "less than $500 annually").

And why not?

With its Harry Houdini-like balance sheet where over $25 million in assets exactly matches its expenses, we see the value of numbers to the ACC. We also see, like the ABIM, the "value" of a Foundation.

The ACC Foundation has $113,934,622 revenue (and $231,442,569 in assets), over one third of which funds the organization's salaries. The ACC Foundation has also created the ACC Political Action Committee (the ACC-PAC) under the umbrella of the Foundation, "as part of a multi-pronged approach to expand its advocacy program to support incumbent and prospective candidates who are supportive of patient access to care and promotion of quality cardiovascular care."

You are reading that correctly. Leveraged MOC dollars and the fees paid for physician education materials will now be used, in part, for the ACC's support of political candidates.

But if that's not enough, there's this little gem.
In 2018, the Accreditation Council on Graduate Medical Education (ACGME) published a revision of program requirements for accredited internal medicine residency programs. At the same time, the Internal Medicine Board had decided to revisit the procedural requirements for graduating residents, presenting a timely opportunity to make changes to these requirements.
With the announcement yesterday of the CMP physicians will be required to perform two tests, one given by ACC and one given by ABIM EVERY YEAR and much of it for their political gain.

If this new collaboration between the ACC , HRS, and the ABIM sounds problematic to you, you might want to join our effort to end this shakedown of your dollars for political purposes.


Saturday, March 16, 2019

ABMS Board of Directors Accepts ABMS Vision Commission's Recommendations

ABMS Board of Directors Accepts "Independent"
ABMS-funded ABMS Vision Commission's Recommendations
Enough said. 


P.S.: Please donate.

Wednesday, March 06, 2019

MOC Legal Battle Broadens to ABPN

Today in the Federal District Court of Northern Illinois, another class action lawsuit on behalf of over 25,000 psychiatrists and neurologists was filed against the American Board of Psychiatry and Neurology (ABPN) by two psychiatrists.

In a script we have seen before, the Plaintiffs brought the action pursuant to the Clayton Antitrust Act, 15 U.S.C. §§ 15 and 26 to recover treble damages, injunctive relief, costs of the suit, and reasonable attorney’s fees arising from violations of Sections 1 and 2 of the Sherman Act (28 U.S.C. §§ 1 and 2). The suit alleges that there is illegal tying of the ABIM’s initial board certification product to its maintenance of certification® (MOC®) product in violation of Section 1 of the Sherman Act and illegal monopolization and monopoly maintenance in violation of Section 2 of the Sherman Act. In addition, the suit alleges that ABPN's conduct has caused it be be unjustly enriched at the expense of the Plaintiffs and the other Class members.

The Complaint details the alleged harms experienced by the Plaintiffs and the numerous changes to ABPN MOC® the Plaintiffs and Class members endured since its implementation. In addition, the Complaint alleges:
"Between 2004 and 2017, after the advent of ABPN MOC, ABPN’s “Program service revenue” account exceeded its “Program service expenses” account by a yearly average of $8,777,319, as reported in its Forms 990 for those years. During that same period of time, ABPN’s “Net assets or fund balances” account skyrocketed 730%, from $16,508,407 to $120,727,606. In other words, at year-end 2017, as ABPN MOC revenue continued to grow, ABPN net assets (assets less liabilities) more than septupled, which included, according to its 2017 Form 990, almost $102 million in cash, savings, and securities."
The Complaint also details allegations of unjust enrichment by the President and CEO of the ABPN, Larry R. Faulkner, MD:
In 2007, he was paid total compensation of $500,726 as Executive Vice President. Dr. Faulkner became ABPN President and CEO in 2009. In 2017, the last year for which data could be located, his total compensation as President and CEO was $2,872,861, including a bonus of $1,884,920.
This lawsuit follows on the heels of two other class action antitrust lawsuits filed against the American Board of Internal Medicine and the American Board of Radiology.

As I've said before, it is critical working physicians see the legal battle against MOC® for what it is: not a campaign against continuing medical education, but rather a campaign against the massive runaway train of economic exploitation, self-enrichment, and micro-management of our professional lives that are now the hallmark of ABMS and its member boards.

I encourage all working physicians donate to our GoFundMe page to help support the next phase of the litigation as ABIM, ABR, and ABPN prepare their responses to the lawsuits.


Saturday, March 02, 2019

Maryland Board of Physicians Rejects NBPAS

In November 30, 2018, the National Board of Physicians and Surgeons (NBPAS) and the National Board of Osteopathic Physicians and Surgeons (“NBOPAS”) requested the Maryland Board of Physicians ("Board") formally recognize them as a specialty certification board for continuing certification. Armed with a 17-page letter from the DOJ, they were hopeful, but the outcome of their request they just received from the "Board" was almost predictable:
As a policy matter, board certification or re-certification is not a requirement for licensure. Board certification, however, may be a requirement for employment, hospital privileges, insurance carriers, etc. In that regard, the Board does not believe that it is the appropriate entity to evaluate re-certification or continuing certification boards for approval.

The Board believes, consistent with the DOJ opinion letter, that board certification and the approval of a certifying board for recertification is a business decision to be made by hospitals, insurers, and employers. Even if the Board approved the NBPAS or NBOPAS as a continuing certification board, hospitals, employers, and insurance carriers would still be able to make their own determinations about which boards they choose to recognize for purposes of meeting any eligibility requirements.

Given the inconclusive findings of the MHCC workgroup and the lack of data on quality of care, the Board believes that approval of the NBPAS and NBPOS as a certifying board is premature. The Board will continue to monitor the discussions and research projects regarding maintenance of board certification, including the recommendations from the Continuing Board Certification: Vision for the Future Commission, which are expected to be released in a final report sometime this year.
It is a shame this fight has come to this, but it has. Maybe now the leadership of the National Board of Physicians and Surgeons will recommend their diplomates join our nationwide, multi-specialty legal fight to end "Maintenance of Certification."


Addendum: Maybe Maryland joining the Interstate Licensing Compact (with the help of Kaiser Permanente, a fond bedfellow of ABIM's former President and CEO, Christine Cassel, MD), had something to do with this decision.

Why the ACC Threw Cardiologists and EPs Under The MOC® Bus and Why We Let Them

In its latest update with Maintenance of Certification (MOC®), the good ol' boy network of the American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), Heart Rhythm Society (HRS), and Heart Failure Society of America (HFSA), announced their commitment to "continuous certification" and MOC® and all its lucrative trappings for US cardiologists and cardiac electrophysiologists.

It seems the authors of this announcement, all older white men without much to lose, just can't get enough of the money associated with locking their younger, more vulnerable colleagues into continuous participation in their expensive board review courses, scientific sessions, self-assessment programs, and pricey study materials. They convened a "Task Force" (or was it a "Committee?") some time ago to study the revenue lost without MOC® verses the money made with MOC®'s leverage on their programs, and it appears they have decided they just can't let go.

So they have a plan.
  1. First, make a lukewarm statement that is supposed to sound opposed to the ABMS Vision Commission, but really says nothing.

  2. Second, to co-brand their own version of "continuous certification" with the American Board of Internal Medicine (ABIM) and call it another name to assure annual payments continue.

They thought hard - really - and recruited lots of their well-respected academic partners and thought leaders in cardiology and EP - to create their own ABIM MOC® pathway called the "Collaborative Maintenance Pathway." (You can't make this stuff up.)

As if cardiologists are deaf, dumb, and blind.

But cardiologists and electrophysiologists have to be honest: we live with the reality that our skills and intellect are uniquely valuable to hospital and health care systems. Without us, they'd die. And now that 75% of cardiologists are employed by hospitals, hospitals need us just as we need them.

The ACC, tied irrevocably to the good fortunes of the Medical Industrial Complex and the realities of managed care data collection, knows this.

So they sugar-coat their decision to side with "continuous certification" as a "commitment to lifelong learning" instead of what it really is, an adhesion contract with the ABIM and the ACC, SCAI, HRS, and HFSA for their lifelong funding at our expense.

In effect, the ACC is saying "Cardiologists and EP's - get over it - you have no choice but to be the breadwinners for US hospitals and health care systems. We scratch their backs so they can scratch ours, so you have to pay up."

Ooops, I just said the unspeakable.

I can hear it now:

"But we are beneficent, selfless 'care providers' who do the work, take call, and save lives at 3 AM when we're dead tired, not just the funding vehicles for US hospitals! We are the good guys, need to keep up with the latest advances, and deserve what we get! How can you dare say such a thing?!?"

Because, deep down inside, it's the truth.

A growing tension is exacerbated by the ACC siding with the corrupt ABMS MOC® program: cardiologists serving hospitals' best interests verses cardiologists serving their patients' best interests. Certainly no one will argue with the benefit to a patient for stenting an occluded coronary at 3AM - it's the magic of what we do and why we do it. But there is also a growing conflict of interest that develops when we must live in fear of losing our credentials (and our jobs) because we don't participate in MOC® and MOC® is tied to our ability to make a living only at hospitals: that tie makes us beholden to our employer before our patient.

It has been revealing to be a student of MOC®'s evolution over the years. I believe there is are complicated psychological and economic principles at play with MOC® (or "continuous" certification).

First, MOC® forces the doctors to split. Psychologic splitting is commonly used to justify unreasonable behavior. Why else would highly intelligent people put up with the now highly public political, financial, and monopoly-making activities of the ABIM? Perhaps its because by participating in MOC®, we can remain the "good guy" in a guideline-directed decision making world of medicine while the ABIM can remain the "bad guy." No need to consider the realities involved with their conflicts of interests. By continuing to participate in MOC® (or it's latest "continuous" iteration, doctors don't have to worry themselves with the nasty details of the high cost of medicine, the waterfalls in the front lobby, and the big screen TV's in every patient's room. We are "just" the beneficent doctors working within the "guidelines." So we "keep up" with our education and those "guidelines" (thanks to the ACC and their "Collaborative Maintenance Pathway") to impress our patients (and truth-be-known somewhere deep inside, ourselves) by promoting this "board certified" marketing accolade and not dealing with its unpleasant realities.

Secondly, MOC® influences the "behavioral economics" of physicians in perverted ways. As an example, behavioral economics states that even if a doctor wants to lose weight and sets his mind on eating healthy food going forward, his end behavior will be subject to cognitive bias, emotions, and social influences. What is a bigger cognitive bias and social "influencer" than the fear of losing your credentials or ability to receive insurance payments because of lack of participation in MOC®?

So the next time you wonder why the GoFundMe page to fight Maintenance of Certification has been fairly slow to reach its ultimate goal, I believe this is why.

Many doctors are putting up with the MOC® charade because they are afraid of losing their job if they speak out and are not completely honest about the MOC®'s role in maintaining healthcare's costly financial status quo.

Perhaps it's time we be honest with ourselves. Who ultimately loses with MOC®'s perpetuation?

Not just younger, more economically vulnerable physicians, but our patients, too.