Saturday, November 30, 2019

Watching Our Healthcare Hindenburg Burn

Just before Thanksgiving, 15 physicians were notified they will be replaced by less-experienced and cheaper nurse practitioners at the nearly $1 billion Edwards-Elmhurst healthcare system here in Chicago. Doctors, the article says, were "broadsided," perhaps because they were naive to events that occurred in Springfield, IL earlier this year. Thanks to aggressive lobbying, recent legislation was unanimously passed in both the House and Senate Illinois legislature allowing nurse practitioners to practice independently of physicians in any capacity except surgery. Working doctors likely missed this since they don't populate legislative halls - they populate clinics and hospitals caring for patients - or at least most did.

This trend of using more and more nurse practitioners in lieu of physicians appears to be accelerating nationwide as large hospital systems or consolidated primary care clinics with bloated numbers of midlevel administrators look to cut costs. Nurse practitioners are everywhere now: staffing ICUs, Emergency Rooms, and yes, primary care clinics. Some nurse practitioners are used to preferentially fill lucrative surgical pipelines armed with little other knowledge than what a routine case for surgery requires. And while advanced practice nurse practitioners do treat common ailments like earaches and sore throats, often quite well, how many can recognize the warning signs of a case of epiglottitis? What happens to patients then?

Is compromising years of physician training and care experience for cost efficiency really about patient care or cost savings or a facility's bottom line? Is the inevitable pitting of nurses against doctors in the patient's best interest or the institution's? Who sees the costs supposedly saved by hiring cheaper advanced practice nurses?  Will Edward-Elmhurst Healthsystem suddenly stop spending millions on collection agents who served as second-largest contractor for Edward-Elmhurst Healthsystem in Fiscal Year 2018?

Working physicians aren't without some blame either. Where were the physicians on the Medical Executive Committee of Edward-Elmhurst Healthsystem with this announcement? Did they approve  replacing 15 physician-colleagues for lesser-trained nurse practitioners or fearful of losing their jobs if they didn't "align" themselves with this administrative move? Who is advocating for patients at Edward-Elmhurst Healthsystem (or any other large non-physician run hospital system) now? Anyone?

Can Dr. Google and inexperienced physician posers safely replace the highly trained, experienced physician? No one really knows. This latest move is little more than a grand experiment promoted by healthcare consultants with patients' lives on the line.  Which leads us to ask: is touting a shortage of US physicians really a concern of the Association of American Medical Colleges or just a ploy by other member organizations of Accreditation Council for Graduate Medical Education (like the American Hospital Association) to justify these physician firings so hospitals can pad their bottom line?

Our Healthcare Hindenburg is burning: a bubble of excessive prices, high middleman salaries, a rapidly accelerating physician shortage, competition of healthsystems and patients increasingly unable to pay even basic co-pays for healthcare, medications, and procedures, as they are left to take the financial hit to maintain the health care industrial complex's status quo.

In healthcare, it's "Winner Takes All" with the likes of PriceWaterHouseCooper, McKinsey, and the Advisory Board at the helm.  The competition is fierce.

Patients (and their better-trained frontline physicians) be damned.


Sunday, November 24, 2019

The AMA and ABMS Member Boards: Banking on the Promise of Private Equity

Recently, I was sent a prospectus for a medical device company that caught the eye of a local Venture Capital funding group. On that prospectus was this paragraph for a "vision" of future of a "clinical decision support system:"
Collects data from the electronic medical record, medical literature, regulatory warnings and other internet-based public information. Provides analysis of intra-procedural progress that integrates this data with procedural imaging and patient status. Includes predictive analytics with the use of cognitive computing to support optimal clinical decision making."
This pitch was little more than a marketed promise of artificial intelligence, of instant processing of black-box algorithms, of equity funding to solve healthcare's less-than optimal patient outcomes using the internet, numbers, cut-copy-and-paste data entry, physician testing scores, in one big algorithmic, dehumanized, robotic mess.

In short, this is what health care market investors see now: a vision where fewer staff, more data entry, and less humanity and human touch are sold as better health care. Worse still, working physicians who remain are being grown and matured in a muzzled petri dish where dissent is openly discouraged by employers and "certifying" bodies.

This data-driven model didn't work out so well for Boeing.

And it won't work so well for health care either.

But don't tell that to the American Medical Association. Because to the AMA, working physicians in the US are little more than data entry ports "Moving Medicine" toward the AMA's latest vision for a business-oriented private equity-driven health care model for tomorrow.


Friday, November 15, 2019

Timeline for Justice: ABIM v Salas Rushford

A young resident physician, Jaime Salas Rushford MD, came to New Jersey from Puerto Rico to study for his initial American Board of Internal Medicine (ABIM) board certification examination with an ACGME-approved Arora "Unusual Board Review" course. He later took his examination and passed, making him officially board certified on 8/20/2009.

Over three years later, he received a letter from Ms. Lynn O. Langdon, Chief Operating Office of the ABIM at the time, that his board certification was suddenly, indefinitely revoked because of claims he "collected and compiled hundred of ABIM examination questions from multiple sources" and that he "sent hundreds of ABIM examination questions" from his email to Arora Board Review. The letter implied he did "not maintain moral, ethical, or professional behavior satisfactory to the Board," engaged in "misconduct adversely affecting " his integrity, and engaged in "behavior that subverts the examination process."

Because the ABIM felt he violated their "Pledge of Honesty," the Board elected to "indefinitely revoke" his certification and "notify the Medical Board in every jurisdiction" that he was licensed.

He had 10 days to appeal that decision through a never-disclosed ABIM "three-stage appeal process" that lasted two years. Following this, he later discovered the ABIM had filed a copyright infringement lawsuit against him.

He describes the ordeal in detail here. In that description, he notes the additional reprimanding of some "2700 physicians," the use of a "spy" sent to the board review course he attended, the secret funneling of millions of dollars of ABIM Diplomate testing fees to create the ABIM Foundation, the raid using federal Marshals of Dr. Arora's home to copy computer files and secure physician's email addresses, and the undisclosed conflicts of interest of Christine Cassel, MD, former President and CEO of the ABIM, none of which were known to Diplomates of the ABIM at the time.

Instead, the ABIM issued a press release that was picked up by the Wall Street Journal and shocked the medical community on June 9, 2010, detailing the sanctioning of 139 physicians for claims of "cheating:"
"Any high-school kid knows that cheating is unfair," said Dr. Christine Cassel, president and chief executive of the ABIM, who called the sanctions "a message and a deterrent."

The ABIM's move springs from a case involving test-prep firm Arora Board Review, which it sued last year. The ABIM's suit alleged that Arora instructors told class members the review questions were from the actual exam and solicited them to supply the company with additional questions they remembered after taking certification exams.

The ABIM and an attorney for Livingston, N.J.-based Arora both said they are in settlement talks. Arora's website says it has "put [its] business on hold until a settlement is reached in the near future."

Materials seized from Arora in December as part of the case included 2,000 emails and audio and other communications from physicians disclosing exam questions, according to the ABIM.

Based on these materials, the ABIM sued Monica Mukherjee of Washington, D.C.; Anastassia Todor of Aurora, Colo.; Pedram Salehi of Los Angeles; Sarah Von Muller of Tulsa, Okla.; and Frederick Oni of Warner Robins, Ga.

Dr. Mukherjee couldn't be reached for comment. Dr. Todor and Dr. Salehi had no comment. Dr. Oni said he didn't know the questions he purchased were from previous tests.

Dr. Von Muller said courses like Arora's are necessary for busy physicians attempting to get their optional board certification.

Dr. Cassel said she doesn't believe sharing or selling actual questions is common. "We have a great deal of confidence that most people don't cheat on this exam," she said, adding that there are "legitimate board-review programs that continue to function." (The ABIM doesn't offer its own review courses.)

The "hundreds" of allegedly infringing questions used by the course were removed from the pool of questions used on the computerized tests starting in 2009. Doctors who took the Arora course but weren't sanctioned or sued will get letters of reprimand, the ABIM said.
The ABIM subsequently lost the copyright infringement lawsuit against Salas Rushford, but his counterclaim lawsuit filed against the ABIM goes on after being recently moved to Puerto Rico Federal District Court.

On 7 Nov 2019, the case management order for this lawsuit was published by the federal judge Francisco A. Besosa with the following timeline:

  • 29 Nov 2019 - Objections to Case Management Deadlines and all outstanding pleadings due.

  • 3 Dec 2019 - Motions to amend the pleadings or add parties to be filed.

  • 31 Jan 2020 - initial Case Management and Settlement Conference

  • 29 May 2020 - Motions to Dismiss must be filed

  • 30 Dec 2020 - All discovery must be completed

  • 9 Apr 2021 - Pretrial and Settlement Conference

  • 19 Apr 2021 - Trial Shall Begin (09:00AM)

The wheels of justice might turn slowly, but they are turning. The number of lawsuits currently underway against the ABIM is mounting and while it appears they will stop at nothing to maintain their monopoly, the activities that took place in the case of these physicians need investigation and explanation.

Perhaps now light will shine on the inner dealings of the so-called "voluntary" US Physician Board Certification process that has harmed practicing physicians without accountability or means of due process for years.


Tuesday, November 12, 2019

Is CMS's Value-Based Healthcare System Already Being Gamed?

Take a look at the address of the American Board of Medical Specialties (ABMS) that owns the Maintenance of Certification (MOC®) trademark that is the subject of at least six anti-trust lawsuits (see here, here, and here for instance) underway because MOC binds physicians to their hospital privileges and insurance payments to made to hospitals on behalf of their employed physicians:

Now look at the address of the American Medical Association (AMA)-sponsored PCPI Foundation with board members from UnitedHealthcare, Premier, the American College of Cardiology, the American College of Physicians, several trustees of the AMA, and others:

Recall that the AMA maintains a monopoly on the procedure codes (CPT® codes) for every medical procedure performed in the United States and sells the rights to use that database to insurers and electronic medical record companies. Each of the AMA codes, then, have particular "value" to hospitals and insurers.

The AMA also determines the "relative value system" used by the government coding for weighting physician compensation that strongly incentivizes physician behavior. Some procedures, then, have more "value" to physicians than others. Hospitals know this, too.

Gee, I wonder, with all these codes and friends that stand to profit on the backs of working physicians and our patients, is the Affordable Care Act's value-based healthcare already being gamed?


Saturday, November 09, 2019

MOC®: It's All About Physician Data

The Facebook–Cambridge Analytica data scandal was a major political scandal in early 2018 when it was revealed that Cambridge Analytica had harvested the personal data of millions of peoples' Facebook profiles without their consent and used it for political advertising purposes. The scandal, first exposed by The Guardian in 2015, revealed that Cambridge Analytica had managed to obtain data on millions of Facebook users in the UK, US, and beyond, made possible through "improper sharing" practices conducted between the "This Is Your Digital Life" Facebook app developer and the company. By giving this third-party app permission to acquire their data, back in 2015, this also gave the app access to information on the user's friends network; this resulted in the data of about 87 million users, the majority of whom had not explicitly given Cambridge Analytica permission to access their data, being collected.

Because patients do not give consent for the use of their data, who better to target for access to sensitive patient-related information than those entrusted with their care? As details come to light about the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) program that has plagued physicians since 1990, many similarities to the Cambridge Analytica data-sharing scandal are appearing. The adhesion contract that forms the basis for MOC and is increasingly tied to physician hospital privileges and insurance reimbursements, assures this data pipeline remains open:
I also understand that ABIM may use my examination performance, training program evaluations, self evaluations of knowledge and practice assessment, and other information for research purposes, including collaboration with other research investigators and scientific publications."
Unbeknownst to most physicians, the ABMS has been involved with the sale and sharing of physicians' demographic and sensitive MOC data with third parties for years. Each clinical physician in the United States may see 2000-3000 patient's each annually. Marrying physician data with their patient's data and targeting patient markets becomes possible with physician-specific MOC information. Procedural and pharmaceutical data allows medical suppliers, pharmaceutical companies, device companies, and others virtually unlimited opportunities to sell their products while optimizing most their bottom lines through increased sales and offering rebates to health care facilities (aka, kickbacks).

Group purchase organizations (GPOs) and Pharmacy Benefit Managers (PBMs) decide what equipment appears on a database for hospitals to purchase. Companies pay those GPOs and PBMs to be on the list. Doctors' equipment choices and pharmaceutical preferences influence that list. Companies want to know what doctors are using and who doctors are seeing. By knowing their patterns and knowing the procedures performed on patients, highly sensitive patient information can be deduced. Registries owned by procedurally-heavy specialty societies (like the American College of Cardiology) are a particularly ripe source of procedural data, particularly when it can be made doctor-specific (where MOC comes in). More data sales occur. Repeated MOC testing and demographic data entries required by physicians assures these physician-specific databases are kept current. Having the President and CEO of the American Board of Internal Medicine on the President's Council of Advisors for Science and Technology assured uninterrupted marketing access to physicians and their patients.

By using physician information and their patient care information for these corporate purposes, the ABMS/ABIM MOC® product looks more like Cambridge Analytica than a physician education tool and affects far more people's health care than the Cambride Analytica ever did.

So how how do all these organizations coordinate and connect their MOC data, registries, and corporate databases?

Through a virtually undisclosed tax-exempt AMA-funded private foundation shamelessly called the Physician Consortium for Performance Improvement (PCPI).

Reportedly formed in 2000 with the help of the AMA, the PCPI Foundation is located just blocks away from the AMA's corporate headquarters in downtown Chicago. The organization describes itself as follows:
The AMA-convened PCPI, in partnership with its members, has developed more than 350 measures, many of which are used in the Physician Quality Reporting System (PQRS) and Meaningful Use, as well as private health plan payment models. (emphasis mine)

In 2011, American Medical Association staff to the PCPI worked with a group of committed volunteer leaders to launch the NQRN®, a national, multi-stakeholder network of clinical registry stewards and others interested in registries. The NQRN has created tools and educational opportunities and increased the visibility and value of clinical registries as reporting and improvement systems. In 2016 NQRN was merged into the PCPI as a key program. In 2013, the AMA-convened PCPI launched the PCPI Quality Improvement Program to support its members improvement needs beyond measurement.

In 2014, the AMA and AMA-convened PCPI leadership undertook an evaluation to determine the optimal governance structure to meet the growing demand for value-based health care. The result of this evaluation was the adoption of new By-Laws in June 2015, which set the course for the PCPI Foundation (PCPI), an independent organization with an expanded membership.
Not surprisingly, it's Board of Directors is lead by John S. McIntyre, MD of the American Psychiatric Association, who has never participated in MOC and is not required to do so:

The remainder of the Board of Directors include:
  • Thomas Granatir, MD, Senior Vice President for Policy and "External Relations" of the ABMS (formerly from Humana)
  • Lewis G. Sandy MD, FACP of the UnitedHealth Group
  • Non-physician Nancy E. Lundebjerg, MPA of the American Geriatric Society (Vice Chair)
  • Non-physician Laura J. Cranston, RPh of the Pharmacy Quality Alliance (Secretary)
  • Non-physician Dianne V. Jewell PT, DPT, PhD, FAPTA of the American Physical Therapy Association (Treasurer)
  • Larry A. Allen, MD, MHS of the American Heart Association
  • Bruce S. Auerbach MD, FAECP of the American College of Emergency Physicians
  • Arlene S. Bierman MD, MS of the Agency for Healthcare Research and Quality
  • Claire Bradley, MD, MPH who oversees "Quality Improvement"
  • Non-physician Carol A Cronin MA, MSW of the Informed Patient Institute
  • Non-physician Melissa Danforth of the Leapfrog Group
  • E. Scott Ferguson, MD - A radiologist on the AMA Board of Trustees and AMA representative to the National Quality Forum but does not appear to participate in MOC.
  • Deeraj Mahajan, MD FACP, CMD, CIC, CHCQM ("Certified Medical Doctor, Certified Infection Control, Certified Health Care Quality Measures") of the Medical Specialty
  • Lawyer Melanie G. Phelps JD of the North Carolina Medical Society who previously worked in the Government Affairs Department of Blue Cross Blue Shield
  • Non-physician Aisha T. Pittman MPH of Premier, Inc, the largest hospital Group Purchase Organization
  • Amir Qaseem MD, PhD, MHA, FACP of the American College of Physicians
  • Martha J. Radford, MD FACC, FAHA of the American College of Cardiology
  • David Shahian MD of the Society of Thoracic Surgeons
  • Computer Scientist Kurt Skifstad, PhD CEO of ArborMetrix, a data analytics company
  • Sandra Adamson Fryhofer, MD MACP from the Board of Trustees of the AMA
  • Richard D. Zorowitz MD, FAAPMR of the American Academy of Physician Medicine and Rehabilitation

Members get to "access the latest tools and insights on performance measurement, clinical registries, and quality improvement" as well as "influence through representation on the PCPI board, committees, advisory and other, as well as expert panels and task forces."

Members of this organization, according to the revolving banner on the PCPI website, include:
AvaMed, FigMD (MOC data collectors), AMA, ACP, ACC, ABMS, Informed Patient Institute, CMSS, Am Society of Clinical Oncology, The American Health Quality Association, Am College of Occupational Medicine, Primaris (A healthcare consulting and data abstraction company), American Academy Foot and Ankle Orthopedics Society, UnitedHealth Group (Market cap: $262B), The Society of Thoracic Surgeons, Pharmacy Quality Alliance, American Gastroenterology Association, Health Care Services Platform, American Optometric Association, Academy of Nutrition and Dietetics, American Heart Association, American College of Radiology, and on, and on...

It's handsomely paid CEO and Executive Director, Kevin Donnelly, is a non-physician, too. Here's their latest 2017 IRS filing that confirms a cool $2.78M contribution from the AMA to the PCPI and contains this explanation why the organization is not a true public "charity" after all:
The organization is filing this 990PF after the extended due date of November 15, 2018 (extension was for Form 990). Upon completion of schedule it was determined that the public support test had not been met for the second year. Research into IRS code and regulations was done to determine the next steps, which took the organization past the due date. The organization did not intentionally disregard the filing requirement, but rather, took time to ensure that that (sic) the appropriate filings were being made. Going forward, now that the requirements are understood, all 990PF filings will be timely. Additionally the organization properly extended the 2018 return as fling a Form 990PF.
I'm sensing some BS here, but I'll leave that to my readers (and the IRS) to decide.

Are UnitedHealth, Humana, Blue Cross Blue Shield, Premier, AvaMed (and all the medical device companies they represent), FigMD, and Primaris really about "quality" or their own bottom line?

Is there any wonder, then, that when a physician points out certain conflicts to medical editors of the Journal of the American Medical Association (JAMA) or the New England Journal of Medicine (owned by the Massachusetts Medical Society), he can't get a straight answer and is referred by the conflicted party to IRS tax filings?

One thing's for sure, to the best of my knowledge and belief, these multiple organizations are colluding with each other for their own best interests ("covert rationing" - a concept coined by the prescient Dr. Richard Fogoros) and using our physician MOC® data to drive their bottom lines while hiding behind non-profit tax law and the ruse of assuring the public it's all in the name of "quality."