Thursday, April 27, 2023

ABMS Maintenance of Certification – Its Origins, Realities, and Implications for Medicine – Part I

This piece first appeared on Sensible Med on 4/26/2023.

If you’re a board-certified internist, you’re probably quite familiar with the controversy surrounding the American Board of Internal Medicine (ABIM) that began when lifelong board certification mysteriously became time-limited in 1990.

Physicians were told the justification for this change was that doctors needed to keep up with ever-changing medical innovations and that their skills and intellect atrophied with age. Never mind that the physicians who insisted on this change exempted themselves from the process and a system was already in place that addressed continuing professional development (CPD) of physicians using ACCME-accredited Continuing Medical Education (CME).

The annual market for physician CPD products in the US is massive: about $3 billion per year. Faced with the limited income stream of initial board certification of physicians in their specialty, CPD products were an attractive target for the American Medical Association and their subsidiary organizations, the ABIM and the ABMS (American Board of Medical Specialties). With the stroke of a pen, and with the help of medical societies and clever politics, the era of board “re-certification” and lifelong “Maintenance of Certification” (MOC) was born.

To assure physicians participated in board re-certification, the “Task Force on Recertification” threatened “uncertain circumstances” if physicians failed to “maintain” their board certification through repeated testing. As physicians confronted increasing regulations to practice medicine independently, more of them became employed. Thanks to their hospitals insisting that their staff physicians be ABMS board-certified to garner admitting privileges, doctors could no longer buy the CPD products of their choosing, but rather had to purchase CPD products that offered “MOC points” if they wanted to practice medicine.

MOC soon grew to include not only testing of physicians but added requirements for “practice improvement modules” and “Patient Voice” modules (whatever those were). A “Director of Test Security” was appointed to catch physicians who might share test content with their colleagues and compromise the money-gathering process. That individual was well-suited to the task, holding felony and misdemeanor convictions for impersonating a police officer and carrying an unregistered firearm in Washington DC after he was fired from the Washington DC police force for targeting a journalist.

Through political lobbying disguised as “consultant” work on tax forms and with the help of medical “stakeholders,” MOC was quietly added to the Affordable Care Act (ACA) as a “quality registry.” No one ever mentioned to physician diplomates of the ABIM that the President and CEO of their organization also sat on the boards of Kaiser Health Plans and Hospitals and Premier, Inc, the largest Group Purchase Organization for hospitals and nursing homes at the time the Affordable Care Act was being passed in Congress.

A close look at MOC enrollment shows physicians must agree to an adhesion contract that makes them a “business associate” with ABIM. MOC is not about physicians “keeping up” any more, it’s about diverting CPD funds to the ABMS member boards and selling the data the ABMS member boards collect on physicians via the for-profit ABMS subsidiary, ABMS Solutions, LLC at our expense.

Might the ABIM’s press release that was leaked to the Wall Street Journal about doctors cheating been timed for the passing of the ACA law later in 2010? Since the former President and CEO of the ABIM was a member of the President’s Council of Advisors on Science and Technology and soon began serving as the director of the National Quality Forum, the timing of these events is remarkably coincidental.

As I face the prospect of board certifying in cardiology and cardiac electrophysiology for the FOURTH time (I am “grandfathered” in Internal Medicine), I can’t believe this program has been allowed to continue. But as I hold my nose and reach deep into my bank account to pay nearly $3600 dollars for study materials worth one-fifth of my re-certification bill, I now completely understand.

Ten years ago on this blog, I began looking into the activities of the ABIM and other member boards of the ABMS, especially since the side effect of their policies on US physicians (and their legality) have never been studied. I reviewed 75 of their “studies” they published, many behind firewalls, to justify their extortion of working physicians. Most were written by ABIM officers themselves, some by members of Washington think tanks, and at least one included a veterinarian as author.

With the help of a forensic accountant, I began investigating the ABIM’s finances in 2013. In December 2014, I published my investigation on the ABIM Foundation, the Choosing Wisely campaign, and their undisclosed $2.3 million 2-bedroom condominium purchase using our test fees. Later in 2017, with the help of a diverse set of physicians and doctors of osteopathy, I co-founded Practicing Physicians of America, (PPA) a non-profit 501c6 organization with free membership, to continue our work fighting MOC and supporting working physicians.

At nearly the same time, Paul Teirstein, MD created a recertification board with academic colleagues to compete with the ABMS medical boards’ CPD product called the National Board of Physicians and Surgeons (NBPAS). Unfortunately, for physicians who work at teaching hospitals, the ACGME accreditation requires ABMS-board certified physicians, so NBPAS is not recognized at academic hospitals that wanted to remain ACGME-accredited (The ABMS is a member organization of the ACGME), nor has it been able to penetrate this political firewall as of this writing.

In response to an outpouring of negative feedback from physician diplomates and others, ABIM began amending the MOC process in 2018 to introduce it by another name in 2022—the Longitudinal Knowledge Assessment (LKA). This new program promised more frequent testing and money-gathering pushed to doctors’ cell phones.

Working physicians explored multiple avenues to end maintenance of certification, including the passage of an AMA resolution, having a “vote of no confidence” issued by the PA Medical Society, and a state-by-state effort to pass legislation to end the ABMS member boards stranglehold on physicians. None of these efforts succeeded in ending ABIM’s monopoly on certification.

What options did working physicians have to end the injustices and discrimination that the implementation of MOC created?

Legal action.

Part two of this piece will appear next week and will briefly summarize the outcome and status of lawsuits filed against the boards because of MOC and the consequences of this program to our profession.


Sunday, April 02, 2023

MOC and the Demise of CME

With the ongoing forcing of participation in Maintenance of Certification (MOC) of US physicians by the American Board of Medical Specialties (ABMS)and its 24 member boards, we are seeing the slow demise of physician-selected Continuing Medical Education (CME) in America. Attendance at specialty society meetings is at an all-time low. Doctors, increasingly employed and facing the reality of how to spend their continuous professional development budget, must choose to maintain their board certification or pay for  CME credits at a course of their choosing. Paying even more money to socialize and interact with colleagues, to share ideas, review posters, and participate in group learning sessions is going away. 

Specialty societies have read the tea leaves. Their budgets are tight now too. Is there any wonder then that the largest subspecialty society, the American College of Cardiology (ACC), buddied up with the American Board of Internal Medicine (ABIM) to sell their continuous professional development products like ACCSAP (ACC Self Assessment Product), EchoSAP (Echo Self-Assessment Product), CathSAP, HFSAP (Heart Failure Self-Assessment Product), and (the soon-to be) EP SAP (Electrophysiology Self Assessment Product)? Buy their products for the cool tune of $1500-1900 for "20% review of the field," and doctors get CME and MOC credits "without the stress of having to achieve a passing score" on their Performance Assessment!

The Federation of State Medical Boards (FSMB), a private non-profit, has been working tirelessly to influence state medical boards on the value of MOC, too.  Their Interstate Licensing Pact requires their physicians to (1) pay $700 on top of each state's licensing fee, (2) be fingerprinted with background checks, and (3) requires physicians to be ABMS board certified (and participate in MOC). At least two states, Georgia and Illinois, now accept participation in MOC in lieu of CME requirements for licensure.

Meanwhile, there is no proof MOC makes us better doctors. 


But we sure become wonderful computerized data points.

Consequently, physicians are left isolated from their colleagues. They are no longer valued for their creativity, intellect or social skills, but work productivity. They are data points shared between those of Medical Industrial Complex hospital systems, insurers, drug companies and their pharmacy benefit managers, and medical device companies that pay hefty fees for access to that data.

Physicians are burning out an leaving medicine in droves. Gaslighting of physicians by the member organizations of the Accreditation Council of Graduate Medical Education (read AMA, ABMS, CMSS, AHA, among others) regarding the "importance" of maintaining your certification through MOC (or is it LKA "Longitudinal Knowledge Assessment" now?) is a big reason why.

Yes Virginia, CME is on life support and its prognosis, thanks to MOC, is grim.