Enough is Enough

It is 8:30PM CST on the 23rd of May, 2018.

The American Board of Internal Medicine (ABIM) has still not posted their financials from fiscal year 2017, due May 15th, 2018 after an extension is granted by the Internal Revenue Service, on their website. I wouldn't be surprised if they're insolvent, or close to it.

Maintenance of certification (MOC™) is expensive, costing physicians over $23,000 every 10 years in fees, travel, and time from work. Doctors are sick and tired of being manipulated and coerced into playing the continuous certification game created by the non-profit ABIM that has never been independently proven to improve patient safety, care quality, or patient outcomes after a doctor's initial board certification. Doctors are especially sick and tired of these unaccountable member boards of the American Board of Medical Specialties (ABMS) mandating busy work that, if not performed, would limit our ability to maintain our hospital credentials, receive insurance payments, or even obtain state licensure.

We are also sick and tired of being ethnographic research subjects and "HIPAA Business Associates" for the member boards of the ABMS so our data can be bought and sold while board members and officers of the ABMS member boards enjoy their multi-million dollar condominiums with chauffeur-driven BMW town cars, office buildings, first class and spousal air travel, Cayman Island retirement funds, and health club memberships all on our hard-earned nickel.

The conflicts of interest created by MOC spread far and wide: BCBS, CECity/Premier, PearsonVue, ABMS Solutions, LLC, IPC The Hospitalist Group, National Committee on Quality Assurance, American College of Physicians, Wolters Kluwer, Reed Elsevier, UCSF, Massachusetts Medical Society, the AMA, AHA, CMSS, among others.

The financial orgy within the bureaucratic halls of the ACGME has been going on for years at the expense of hard-working doctors. MOC fees alone have mushroomed 244% from 2000-2014 to fund these shenanigans. Numerous doctors are burning out, or quitting altogether, to avoid the ruse. It must come to an end. The integrity of our profession demands nothing less.

Please join me in this GoFundMe crowdfunding drive by Practicing Physicians of America to end MOC™ nationwide for all subspecialties. The specifics of the campaign's purpose are outlined in the campaign's "story" on the GoFundMe page. Please give generously.

It's time to stand up for what's right.

Enough is enough.

-Wes

Earning MOC™ Points: A Self-Paid Advertorial

As a follow-up of my earlier post on the American Board of Medical Specialties' (ABMS) Maintenance of Certification™(MOC™) program's tax on medical education, I was sent the "approved" responses of two different physicians that were required to answer questions to "earn" ABMS MOC™credits from the Heart Rhythm Society (HRS) Scientific Sessions after the meeting. These responses were "approved" by an HRS "reviewer" so the doctors could apply these points to remain "Board certified" and employed with their hospital systems. Each doctor had to write between 50 and 100 words (no more, no less) in response to questions posed by the ABIM. Despite their different responses, each received the exact same "feedback" that included links to various Heart Rhythm Society, American College of Cardiology, AMA, ABMS and non-governmental organizations' policies and web pages.

(See Physician 1's responses here and Physician 2's responses here.)

Given these canned responses to these physicians feedback, how is this time-consuming, costly, and meaningless "feedback" exercise for "earning" MOC™ points anything but a self-paid advertorial for the HRS, ACC, AMA, ABMS, and other non-governmental organizations?

It is a sad commentary that our own subspecialty societies legitimize this corrupt process despite all that we know about it today.

-Wes

ABIM Remains Tonedeaf to Physician Concerns

Recently, Richard Baron MD, the President and CEO of the ABIM, circulated the following email request to a select group of physicians:

(Click to enlarge)

Like a resuscitation attempt that has continued for over an hour, the ABIM appears to want to flog its dying MOC program a few more times, hoping physicians haven't noticed.

But we have.

And they are wasting our time. Despite physicians calling for an end to MOC, the ABIM wants to maintain it. Without it, you see, they'll be bankrupt. Note also that the ABIM wants to offer physicians who participate in their "research" for less than $50/hour. (No compensation is given from travel to and from the testing center). Ironically, UpToDate already makes the need to participate in the ABIM/ABMS MOC program obsolete. Third, most physicians at large hospital settings have access to UpToDate already. Fourth, 20 MOC points seems like bribery when your program is increasingly required for hospital credentialing and insurance company panel participation.

Finally, I wrote the ABIM leadership over a month ago about my concerns of their MOC program in response to a "blueprint survey" request they circulated earlier. I still have not heard from anyone within the organization. This is disappointing. The ABIM needs to respond to its most fervent critics honestly and transparently. But this does not appear to be their modus operandi.  As a participating diplomat in the ABIM, I would expect a response from the organization well within that timeframe if they were serious about improving their credibility. This is a recurrent theme under the helm of Dr. Baron.  In fact, even Dr. Baron has never offered a credible explanation for the tax filing and webpage reporting discrepancies of the ABIM Foundation creation date and domicile location. These communication lapses are inexcusable from a professional organization that pretends to offer public trust in its services.

The ABIM and the ABMS have serious financial conflicts of interest and have demonstrated highly irregular behavior for a tax-funded non-profit organization. It is not proper for a 501(c)(3) organization to have deceptive tax filings and public sanctioning of physicians after home raids to protect their monopoly on re-certification. Their testing subcontractor, PearsonVue, also uses testing "spy" firms that casts wide and unaccountable security nets as well, making the risk for physician participation in such a punative program very real. Until each of these issues are investigated, I could encourage my colleagues to carefully consider the ramifications of participating in this latest ABIM MOC research project that promises to potentiate this expensive and corrupt re-credentialing program that has never shown benefit to patient care.

-Wes

Concerning Conflicts of Interest at the ABIM, ABMS and NQF

By now various medical societies are telling the American Board of Internal Medicine (ABIM) their ship has sailed. The ABIM's worn mantra that the "public" demands their program is simply not supported by evidence. The tales of misguided incentives and corruption within the organization grow daily. The blatant avoidance of the egregious financial dealings and conflicts of interest outlined in this blog's pages and elsewhere simply cannot be ignored by the ABIM - yet they continue to do so.

Why?

Because there are millions upon millions of dollars at stake in areas of physician assessment and measurement.

When Christine Cassel, MD left the ABIM and began her work at the National Quality Forum (NQF), physicians learned of some of her conflicts of interest with other organizations, namely Premier, Inc and the Kaiser Foundation Health Plans and Hospitals. Dr. Cassel labeled these conflicts as "distractions" as she resigned her board seats with those organizations. What we do not know (and this is important) is did Dr. Cassel receive any stock or stock options from the organizations she was so cozy with as part of her compensation package? Given the usual and customary way of compensating corporate board members, I would not be surprised if she did. (Update 19:15 PM: h/t to Mr. Charles P Kroll for confirming that Dr. Cassel owns 3,704 shares of  Premier, Inc stock)

Recently, a Premier, Inc press release announced its plans to purchase a company called CECity, Inc. I suspect most practicing physicians did not notice this announcement. After all, why would practicing physicians be interested in a press release touting a new business opportunity for Premier as it expands its "performance improvement capabilities across the healthcare continuum?"

But practicing physicians need to be VERY wary if our fellow physician-bureaucrats (especially those from the ABIM) when they consider their prior conflicts of interest as "distractions." That word is a flag that everyone should look deeper at these conflicts first reported by ProPublica.

When we do, we find more concerning revelations about the ABIM and the American Board of Medical Specialties (ABMS)'s motives.

According to the press release, CECity, Inc is worth about $400 million (or more) to Premier, Inc. and who do we find has been using CECity as its consultant?

Yep. You got it: the ABIM.

In fact, the relationship with the ABIM has been nearly continuous since 2010. According to CECity, they are a CMS qualified registry that provides physician "quality reporting data" to CMS:

As a CMS qualified registry for the Physician Quality Reporting System (PQRS, ePrescribing, MOC-PQRS) and as the service provider for many physician certifying boards (e.g. ABIM, ABO, AOA) CECity is uniquely positioned to align professional and financial incentives with CQI to deliver ‘game-changing’ quality initiatives that have proven and measureable results.

According to the ABIM's Form 990's, they have already paid CECity the following: $600,000 in fiscal year (FY) 2010, $1,217,800 in FY 2011, $1,112,600 in FY 2012, $1,378,138 in FY 2013, and $1,260,000 in FY 2014 (an example of these payments can be found on page 8 of the ABIM's most recent published Form 990 - provided they do not change their Form 990 after this report).

That's right: $5,568,538 of physician testing fees to CECity from practicing US physicians over five years - all of it (so far) on Dr. Cassel's watch.

If Dr. Cassel holds stock in Premier, Inc. from her prior board position there, I wonder how much money she stands to make when this cozy deal with Premier, Inc. closes? Should the U.S. Securities and Exchange Commission investigate this transaction? We don't know, but even the apparent conflict of interest with Dr. Cassel, the president and CEO of an organization responsible for "quality" programs in our nation's hospitals, is very disturbing, indeed.

This is not a minor revelation as physicians continue their difficult task of managing patients in such an overbearing regulatory environment while our specialty societies continue to support the financially conflicted ABMS MOC program. I believe allowing independent and unaccountable third-party organizations (like the ABMS and ABIM) to collect and distribute physician and de-identified patient-related data without written consent of those who could have their ability to practice medicine or collect payment from insurance companies revoked if they don't participate in MOC is a clear violation of Department of Health and Human Services Protection of Human Subject statutes. It also remains to be determined if this violates the Sherman (antitrust) Act.

After all, it is now clear the MOC program is not a "quality assurance" exercise performed for "public's" benefit.

This is profiteering and financially conflicted research on physician subjects in its most fundamental form.

-Wes

Part I: Why Washington?

When I lived in Washington DC years ago, there was a saying my wife and I heard on occasion from our friends who worked on the Hill:

"In New York, it's about finance;
In Boston, it's about power;
In Washington (DC), it's about access."

* * *

The invitation came in a regular envelope. An invitation to go to Washington DC.  Who asked me? What was this for? Was it real?

I studied the invitation: a "personal" invite from Congressman Pete Sessions (R-TX), dinner the first night (dutch treat), then meetings started the next day at 08:30 am in the Rayburn Building, presentations, other Senators and Congressman to be invited (names to be decided). New plans. Need input, discussion, dinner afterward.

I showed the invitation to my wife: "Do you think this is the real thing? Why would they ask me?"

"Looks real. Call them," she said. "Find out who's going.  Maybe there's someone you know."(My wife, unphased, used to testify on the Hill when I was a young staff doctor at the National Naval Hospital in Bethesda, MD many years ago).

I waited a few days, then called. "Well, fifty-five doctors have already RSVP'd so far," said the exasperated voice on the end of the line." Ugh, I thought. "We'll be sending out a revised agenda with a list of the attendees when the date gets closer."

Would it be worth it? Fifty-five doctors? Were doctors being asked to come to Washington at their own expense just so it would look like we were "at the table" when, in fact, we were "on the menu?"  Given health care's recent history and how things got to where we are now, it was very hard to suppress my cynicism. Who funds Representative Sessions, I wondered? I checked. Got it. Then I really pondered: why me?

My wife looked at me like I was an idiot. "You have to go," she said. "You can't go through all of these hours of investigation, research, fire, and brimstone, and not go to Washington. Make some appointments.  Maybe you could stay with our old friends Jack and Jill  (not their real names) while you're there."

"But the time from work... it's so expensive..."

"You decide," she said. "But if it was me, I'd make it worth every minute. Look, Washington is really kind of, well, government. Think DMV. Big hallways. Linoleum floors. Fluorescent lighting. All puffed up, but not that glamorous when you think about it, it's no big deal." My wife sure knows how to sell things...

That night, I stared at the computer screen on my desk. "How much does it cost to fly to Washington?" I searched Orbitz. I'd have to cancel a clinic day, maybe two. Maybe I could swing this if I only missed an extra half a day of my clinic. Folks at work won't like this. Oh heck, she's right. I'd never forgive myself if I didn't go.

After weighing things, I booked the flight, then rearranged and blocked my clinic schedule the next day, though I still wasn't sure. Will it be worth it?

A few weeks later a more finalized agenda came with the names of who would be attending. I googled everyone (this seemed to take forever). I made a list. 18 states. Most were practicing doctors. Most of those orthopedic physicians, (Huh?) a few AMA representatives (young and semi-retired), a few older retired doctors, a few lawyers, an economist, a doctor who ran an ICD-10 coding company, a person who owned a medical collection company, some physician advocacy group representatives, a lobbyist.

Sheesh.

"Mouth of the lion," I thought. "How am I going to get a word in edgewise?" Fifty-five people had grown to sixty.  "It'll be a waste of time," I thought.  The next day I finished my overbooked clinic, then returned home to tell my wife what I had decided. I told her I probably won't go to Washington after all.

"You have to go," she reinforced.

"It's all about access."

Maintenance of Certification's Real Problem: The Four Deceptions

By now, most specialty boards in medicine appear to have "heard" practicing doctors over their displeasure over the American Board of Medical Specialties' (ABMS) proprietary MOC® program.  They understand.  They agree with us.  They want to play nice.  Really.  They know how much we really don't like that secure examination every ten years that makes sure about 10-15% of experienced physicians fail because, well, someone has to fail. They understand that the busywork created by the ABMS MOC® program is time-consuming, duplicitous, expensive and meaningless for assuring quality care. A few of them even acknowledged, by golly, that they got it wrong and promise to make things better by setting up new "design principles" for further MOC® development.

But our ABMS Specialty Boards really don't seem to get the big problem: fraud.

Instead, some keep asking doctors to cough up $2100 for "new and improved" exercises that excludes the old MOC® secure examination and replaces them with annual "mini-assessments."

Fortunately, there's a small group of specialty societies that want change, but appear a bit too nervous about ridding themselves of the term "MOC®."  They include the American Gastroenterological Association, the American Association of Clinical Endocrinologists, the American College of Rheumatology, and (maybe) the Heart Rhythm Society (although this statement is a greatly toned down version of an earlier one).

But these Specialty Boards and professional organizations are relatively small fry compared to the much larger and richer specialty boards like the American College of Cardiology and the American College of Physicians who remain surprisingly quiet on the controversy.

"It's complicated," I'm told.

No, it's not.

***

The American Board of Medical Specialties (ABMS) has a problem.  A big problem.

Their credibility bloom with practicing physicians is off the rose. Once an icon for assuring ethical, quality specialty medical education, the ABMS and their fellow member boards of the ACGME needed more.  Much more. So they over-reached. They paid themselves handsomely despite the origins of the Specialty Boards being frugal.  Almost without exception, the leadership of every ABMS specialty board has Presidents and CEOs that make far more income than their contemporary practicing colleagues - way more. They fly first class (or have until 2000), commonly have expensive dinners at the finest five-star hotels, some of which even overlook the Pacific Ocean, travel overseas to spread their regulatory gospel, all because they can. After all, they are special and they are unregulated.  Meanwhile, residents and fellows making $50,000 a year are wondering where they'll come up with the $3000 or so it takes to become "certified" by the ABMS in their specialty.

The result? Practicing doctors don't trust our ABMS specialty boards any longer. Worse still, the more recent transgressions have prompted a look back at history, and history has shown the ABMS non-clinical specialty board leadership stumping for corporate interests for personal gain instead of stumping for patients' best interests. Is this what the Boards call "professionalism?" The ABMS member boards also continue to allow their Presidents and CEOs to lead their organizations far past the usual maximum one-, two- or three-year term limits of the original boards, all while these executives earn lavish salaries and benefits as they appoint new "Chairs" and "Directors" to make each organization seem "fresh."

The ABMS's largest member board also happens to be the American Board of Internal Medicine (ABIM).

The ABIM still has the sizable problem of their ABIM Foundation that no one wants to mention: that "secret society" without a credible public mission other than "to support the ABIM" when it was created in 1989. The only logical reason for its creation was to accumulate money from the pockets of practicing physicians to fund an investment portfolio created by the now defunct 1838 Investment Advisors (which were paid handsomely each year to do so). The ABIM leadership did very well using practicing physicians' money for this purpose, accumulating a bankroll of over $59 million without concern of IRS intervention. They also lied about their government lobbying activity that likely helped cement the ABMS MOC® program in the Affordable Care Act. Then, in what can only be considered (at best) an incredible lapse of judgment, they bought their infamous luxury condominium (complete with chauffeur) with some of their colleagues' testing fees they "granted" to the Foundation.

What a deal.

But it's hard to shelter that a profit motive for a non-profit from the IRS unless you have a plan, and who is smarter than the folks and lawyers at the ABIM?

First, for Deception #1, you have to file a request for tax-exempt status for your newly-created "American Board of Internal Medicine Foundation" with the IRS. Note that this was a very different name from the "ABIM Foundation" that was filed with the state of Pennsylvania in 1989.  That way, the "American Board of Internal Medicine Foundation" never had too many dollars in its coffers to be tracked by the Internal Revenue Service (IRS).

Next, to avoid the tax consequences of accumulating a lot of money in a non-profit, you have to deflect.  Unfortunately for the ABIM, changes in the IRS Form 990 made in 2008 required them to start reporting a "state of domicile." Deception #2: tell the IRS and the public (repeatedly until this year) on their Form 990 that the ABIM Foundation was domiciled in Iowa where no financial audit is required.

Then, when you realize your Foundation (that's supposed to be supporting the ABIM) has made a lot of cash covertly from the wallets of ABIM diplomats and investments, you magically perform Deception #3: ask the IRS to change the name of your "American Board of Internal Medicine Foundation" to the "ABIM Foundation" yet keep it 'domiciled' in Iowa. Oh, and be sure the "computer-generated notices" are "changed" and a new non-profit determination letter is re-issued in the new name because, gosh, they got it wrong when they first applied.

And guess what happens? The new ABIM Foundation magically has a boat-load of physician-supplied cash to give back to the ABIM (or their many cash-hungry friends who promise to spread the gospel of "Choose Wisely®") without an easily traceable trail because (as the ABIM Foundation website and their tax forms claimed) the ABIM Foundation really didn't exist (in the public or the IRS's eyes) before 1999!

Finally, it is very important to perform Deception #4: Make up a reason the ABIM Foundation was "created" in 1999 and delete the web page the stated the ABIM Foundation was "restructured" in 1999 as an operating Foundation to 'complement' the ABIM." Then be sure the reason for the "new" Foundation sounds really sincere - like "to advance the core values of medical professionalism to promote excellence in health care." (Forget to mention you created your own definition of "medical professionalism") Who could argue with such a "mission?" Also, make sure to create a Physician Charter of all your best bureaucratic and academic friends so they can join you at really nice venues to talk about things. Then make sure doctors "Choose Wisely®" treatments that they must forego in the name of "social justice."  Once you've done all of these things, no one will ever know (or have time to suspect) where all that ABIM Foundation money came from.

It's a clever way to hide the money trail to the ABIM, it's officers and membership fees paid by the ABIM to the ABMS, don't you think?

(No wonder "it's complicated.")

Now, let's end the ABMS MOC® program entirely - every last bit of it - shall we?

That would be the truly professional thing to do and every ABMS specialty board today knows it.

-Wes

American College of Cardiology and the MOC Crisis

This week's issue of the Journal of the American College of Cardiology (JACC) contains an editorial from Robert Shor, MD, Chair of the American College of Cardiology (ACC) Board of Governors entitled "Addressing the Maintenance of Certification Crisis Calls for Working Together." The editorial touches on the relationship of the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) and that "ACC-sponsored polls have shown that the vast majority of cardiologists have concerns about the validity, relevance, utility and associated financial and opportunity costs of meeting these revised (MOC) requirements."

Importantly, the editorial also mentioned several other well-known facts: that new 2014 MOC rules established by the ABIM that "required newly graduated fellows who have successfully completed their initial certifying examination to also sign up for ABIM MOC or be listed as "not certified." 

Fortunately for our most vulnerable new cardiologists, the ACC is pressuring the ABIM to revise this policy that financially benefits the ABIM exclusively. It seems the ABIM will stop at nothing to monopolize the recertification market for themselves.

While the ACC Leadership under Dr. Shor 's direction seems sincere, his letter ignores the financial cover-up at the ABIM, specifically the fees that were funneled from the ABIM to the ABIM Foundation from 1989 to 1999, the lavish salaries of the officers and staff there, and the fact the ABIM remains has a balance sheet that is over $47 million in the red. Instead, the chooses to "be cautious because we realize the complexity of the situation." Dr. Shor continues with a half-truth, saying: "In the interim, all of us have alternatives. These include joining a new board, waiting to see the final ABIM proposal, and waiting to see if an alternative ACC board is feasible and/or needed."

Because of the regulatory capture created by the ABMS and their demand for "recertification," contrary to Dr. Shor's statement practicing physicians do NOT have a choice avoid ABIM recertification. Practicing physicians cannot "wait." Practicing physicians MUST continue on their ABIM recertification pathway lest they lose their hospital privileges or aren't allowed to participate  on insurance panels to receive payment for services.

We should note that after revealing ABIM lobbying efforts that were not disclosed the ABIM's tax forms on 31 May 2015, the ABIM terminated their relationship with their lobbying firm on 30 June 2015.

It is increasingly clear that the ABIM and the ABMS have constructed a lucrative money stream for themselves thanks to "recertification" at the expense of practicing physicians.  Recertification after initial certification still has no Level A evidence that it improves patient outcome or care. Instead, as clearly documented on this blog and elsewhere, recertification has been proven to be a corrupt and potentially illegal process that demands thorough investigation by the IRS, Iowa and/or Pennsylvania Attorney Generals, and the US Attorney General or the Inspector General of the Department of Health and Human Services.

This is where the ACC should insist on action. It is simply not in keeping with the highest standards of medical ethics and integrity to collude with organizations that have shown themselves to be working in their own interests over those of practicing physicians and their patients everywhere.

-Wes

Why Electrophysiologists Need to Flood the MOC "Debate" at HRS2015

Anti-MOC Buttons
Click image to order yours

On 13 May 2015 at 8 am in Room 162A of the Boston Convention Center, a session called "Controversies in Public Policy"will occur at the 2015 Heart Rhythm Society Scientific Sessions. As part of that session, a "debate" on Maintenance of Certification (MOC) entitled "Maintenance of Certification is Important for the Practice of Quality EP and Should be Endorsed by HRS" will occur at approximately 10 AM.  Every cardiac electrophysiologist should attend. (Yes, the Atrial Fibrillation Summit can wait a bit).

Doug Zipes, MD will serve as the protagonist of the "debate" and Fred Kusumoto, MD will serve as the antagonist.  I am sure the so-called "debate" will be cordial.  Both speakers are class acts and I'm sure each will do their best to up-end the other.

But I have many concerns about this "debate," some of which I articulated earlier. Now after reviewing the program format and disclosures for the "debate," I have more concerns.

First of all, the limited time for the debate does not allow time for input from the audience.  This is a shame.  HRS needs to hear concerns from ALL of their membership. Granted no one wants a shouting fest, but polite and pointed discourse should be encouraged at meetings, not squelched.

Secondly, let's look at the disclosures for this debate, because I think this is important.

Dr. Zipes lists his disclosures for the  MOC "debate" as follows:

Douglas P. Zipes, MD, FHRS. Krannert Institute of Cardiology, Indianapolis, IN

Disclosures
  D.P. Zipes: E - Royalty Income; 3; Elsevier. I - Research Grants; 1; Medtronic, Inc.
Abstract
  There is no abstract associated with this presentation.

No where in his current disclosures does Dr. Zipes mention his long relationship with ABIM as a paid "Director," "Chair-Elect," and "Chair" of the organization. Here is what Dr. Zipes earned from the ABIM between July 1, 1998-Jun 30, 2003:

FY 2003 $31,133 as "Chair"
FY 2002 $17,469 as "Chair-Elect"
FY 2001 $13,907 as "Director"
FY 2000 $20,996 as "Director"
FY 1999 $30,484 as "Director"

No doubt Dr. Zipes has good friends at the ABIM and will find it easy to take the "protagonist" role in the "debate," but is he the right person for a non-biased recommendation for endorsement of the  ABIM's MOC program by the Heart Rhythm Society?

We should recall that Christine Cassel, MD was the acting President and CEO of the ABIM and the ABIM Foundation during the time Dr. Zipes' had his appointments there.  Dr. Cassel now is President and CEO of the National Quality Forum (NQF), a non-profit organization called a "consensus-based entity" that sets quality metrics that soon will influence how physicians are paid.  The NQF has close ties to the ABIM and derives most of its revenue from the Center for Medicare and Medicaid Services (CMS) by way of government grants. Recall that the current President and CEO of the ABIM, Richard Baron, MD worked for the National Quality Forum before coming to the ABIM and may have been slated for a leadership role there as evidenced by a screen shot I captured from the National Quality Forum's website in July 5, 2014 (the web page is no longer present).  Also realize that the National Quality Forum continues to employ Ms. Cassel who was responsible for (1) the repeated piecemeal funneling of $30.6 million of our physician testing fees to the ABIM Foundation (and that purchase of the now infamous $2.3 million luxury condominium), (2) the creation and write-off of $3 million dollars for the now defunct "Institute of Clinical Evaluation" created by the Foundation, and (3) the non-disclosure of grants the ABIM Foundation received from the Josiah Macy Jr. Foundation and the "Institute of Medicine as a Profession," a non-profit created by George Soros and his Open Society Institute.  Needless to say, Dr. Zipes' conflicts are very significant in light of this interplay of money and politically-connected individuals and organizations.

Let's now look at Dr. Kusumoto's published conflicts of interest for this "debate:"

Fred M. Kusumoto, MD, FHRS. Mayo Clinic, Jacksonville, FL

Disclosures
F.M. Kusumoto: None.
Abstract
There is no abstract associated with this presentation.

(I did not see Dr. Kusumoto's name on any of the ABIM's Form 990 tax disclosure forms either. )

The Heart Rhythm Society must make a clear choice after the upcoming scientific sessions. They can side with the working community of cardiac electrophysiologists or they can side with continuing their support of government grants, cronyism, and an increasingly political agenda that promises cash flow from the government.  Which will they choose?

So let's show up with a sea of buttons and other bling and make it clear that the HRS's endorsement of MOC must go.  All of it.

To promote the anti-MOC movement, I have created a section of my MedTees.com website specifically to purchase anti-MOC bling. All proceeds I receive (about 1-5% of the prices) will go to the ABIM's competitor, NBPAS.org instead. The rest of the costs go to the manufacturer of the bling, Cafepress.com, including the high shipping prices (sorry, out of my control).

If you'd like to get a FREE 2.25" Anti-MOC button from me before the "debate" session at HRS2015, I will have a hundred of them to distribute(limit one per doctor - I paid for them myself), so get there early.

I look forward to seeing everyone at the meeting.

-Wes

On the Value of Losing

“There is no teacher more discriminating or transforming than loss.”
        ― Pat Conroy, My Losing Season: A Memoir

On April Fools Day I received an email notifying me that I was one of 14 finalists for the National Institute for Health Care Management (NIHCM) Foundation's Digital Media Award for my work exposing the financial practices of the American Board of Internal Medicine (ABIM) and its Foundation on this blog.  Hard to believe, really.  Especially when I looked at the other individuals who were also selected as finalists, many of whom are veteran and highly decorated digital health care media journalists who do amazing work day in and day out.  If you have a few minutes, be sure to read (or watch) each of the works nominated for this award.

Several days ago I learned that I was not selected to receive the grand prize. While I can't deny that an infusion of cash into my bank account after tax day would have been nice, just being nominated and recognized as a finalist with such other distinguished writers in this space is reward enough.  (In fact, I still marvel that I was chosen as a finalist for this award in light of the fact that many of the largest insurance company executives sit on the board of the NIHCM.)

I can recall my reluctance to publish this work. The prospect of publicly labeling a national accreditation organization responsible for "certifying" one quarter of US physicians as potentially corrupt was risky. I ran the piece by other trusted colleagues before publishing who gave me phenomenal edits and suggestions. I had several lawyer friends review the piece as well. After all, I am not a person who enjoys criticizing others or exposing my family to legal risks. I also knew that there was a better-than-even chance that some senior leadership at my institution would not be pleased with the report.

Celebrated syndicated columnist David Brooks once noted that there are things we do as "resumé builders" and other things we do as "eulogy builders." Writing in medical journals builds resumés. Sadly, writing on a blog does not. While I have no doubt that winning the grand prize for this Digital Media Award would have been quite a "resumé builder" for a second chapter after medicine, that was never my motivation for this work. As a working physicians who has now endured the increasingly onerous ABMS Maintenance of Certification® (MOC®) process three times, I have seen it morph from a personal marketing tool to a mandatory and ridiculously onerous biannual money stream for a group of unknown non-clinical physicians hiding behind the thin veil of non-profit leadership hubris and avarice. Then, seeing my residents and fellows shell out large sums of money to pre-register for for MOC® before they were allowed to register for their initial certification added more concerns. Finally, the long history of money transfers between the ABIM and its Foundation, the highly conflicted evidence base with shoddy or colluding peer review that the ABIM promotes, and the subspecialty organization political funding machine that occurs as a result, led me to conclude that MOC® was always been about the money, nothing more.

So thanks to the NIHCM. Thanks to everyone who have supported me and given guidance in this endeavor. (You know who you are.) Thanks (especially) to Charles Cutler, MD whose independent yet highly professional 28-minute critique of the ABIM helped blaze the way for my essay's publication.

It will be interesting to see where this all goes.

-Wes

Money for Nothing

Imagine paying $4,675 for a piece of paper. It would make the days of $436 military hammers look pretty cheap, wouldn't it?

Now imagine that piece of paper comes with a promise of having to pay more for your own good and where time spent acquiring that paper meant nothing.  Most rational people would have visions of Bernie Madoff or some other Ponzi scheme.

Yet this is the reality of the American Board of Medical Specialties' Maintenance of Certification (MOC) program for practicing US physicians.

I recently went throughout the Maintenance of Certification process in 2013.  I sat for both by Cardiovascular Diseases Certification (that expired in 2013) and Clinical Cardiac Electrophysiology recertification (that expired in 2014) secure examinations in October of 2013.  Here's what I got for my cardiovascular recertification fees:

ABIM Cardiovascular Disease Certificate 2013 - Click to enlarge

Note that because the cardiovascular certificate was renewed in 2013, it now was extended from 2013 through 2023.  The cover letter that came with the new Cardiovascular Disease certificate was also notable for the three references its cited as "proof" of the value of these certificates. The three references were (1) Arch Intern Med 2010; 170(16): 1442-9, (2) Arch Intern Med 2009 (sic - Editor's note: actually 2008) 168: 1396-1403 and (3) JAMA 2005 294(4): 473-81.

Reference (1) concludes that "Publically available characteristics of individual physicians are poor proxies for performance on clinical quality measures." Reference (3) is a cross-sectional retrospective analysis of data on US physician respondents to the 2000-2001 Community Tracking Study linked to Medicare beneficiaries they treated in 2001 that only generated the hypothesis that "profiling practices may help develop tailored interventions that can be directed to sites where the opportunities for quality improvement are greatest."

But the worst reference was Reference (2).  This reference is notable in part because of the glaring and inexcusable conflict of interests of every author on the manuscript. Each author was either a paid member of ABIM or an employee of Qualidigm of Middletown, CT, a data analytics firm that does the following according to its website:

Collecting relevant data, turning that data into information, and that information into action, drives almost every Qualidigm initiative and contract.

Qualidigm analysts have the qualitative and quantitative knowledge, skills and experience to provide a wide range of services including but not limited to:

• the analysis of claims data from a single source or aggregating claims data from multiple sources;
• the collection, integration and analysis of claims data, administrative data and medical records data;
• the geographic analysis of various types of databases, e.g., claims, medical records;

So it appears that Qualidigm's authors (and the purpose of these certificates and entire MOC program) was manufactured not only for the money it creates for these boards, but for insurance company claim denials.

Because my Cardiac Electrophysiology certificate expired in 2014, doctors should be aware of the changes that have occurred to board certificates.  I recieved this new certificate after passing by secure examination and countless hours collecting survey data, attending board review courses, and reading enough material to put the Encyclopedia Britannica to shame:

ABIM Clinical Cardiac Electrophysiology Certificate 2014 - Click to enlarge

Note the fine print below the words "Clinical Cardiac Electrophysiology:"

"Ongoing certification is contingent upon meeting the requirements of Maintenance of Certification. Please visit www.abim.org to verify certification status."

In essense the new 2014 (and later) "Maintenance of Certification" certificates are nothing more than very expensive hyperlinks to the ABIM.org website.

Sorry, but I will never recertify and participate in this Ponzi scheme again.

Ever.

-Wes

Physician Civil War or Revolution?

Today, Kurt Eichenwald published a report in Newsweek on the American Board of Internal Medicine (ABIM) scandal entitled "The Ugly Civil War in American Medicine." Here's a small exerpt:

Slass says the suggestion that the ABIM is “purposefully failing candidates on their exams to generate more revenue is flat-out wrong.” Maybe so, but according to the Form 990s filed with the Internal Revenue Service, in 2001—just as the earliest round of new-test standard was kicking in, the ABIM brought in $16 million in revenue. Its total compensation for all of its top officers and directors was $1.3 million. The highest paid officer received about $230,000 a year. Two others made about $200,000, and the starting salary below that was less than $150,000. Printing was its largest contractor expense. That was followed by legal fees of $106,000.

Twelve years later? ABIM is showering cash on its top executives—including some officers earning more than $400,000 a year. In the tax period ending June 2013—the latest data available—ABIM brought in $55 million in revenue. Its highest paid officer made more than $800,000 a year from ABIM and related ventures. The total pay for ABIM’s top officers quadrupled. Its largest contractor expense went to the same law firm it was using a decade earlier, but the amounts charged were 20 times more.

And there is another organization called the ABIM Foundation that does...well, it’s not quite clear what it does. Its website reads like a lot of mumbo-jumbo. The Foundation conducts surveys on how “organizational leaders have advanced professionalism among practicing physicians.” And it is very proud of its “Choosing Wisely” program, an initiative “to help providers and patients engage in conversations to reduce overuse of tests and procedures,” with pamphlets, videos and other means.

Doesn’t sound like much, until you crack open the 990s. This organization is loaded. In the tax year ended 2013, it brought in $20 million—not from contributions, not from selling a product, not for providing a service. No, the foundation earned $20 million on the $74 million in assets it holds.

The foundation racked up $5.2 million in expenses, which—other than $245,000 it gave to the ABIM—was divided into two categories: compensation and “other.” Who is getting all this compensation? The very same people who are top earners at the ABIM. Deep in the filings, it says the foundation spends $1.9 million in “program and project expenses,” with no explanation what the programs and projects are.

There are some expenditures, though, that are easy to understand: The foundation spends $153,439 a year on at least one condominium. And it picks up the tab so the spouse of the top-officer can fly along on business trips for free.

Be sure to read the whole thing.

What the American Board of Medical Specialties and their member boards (like the ABIM) don't realize is that America's practicing physicians are sick and tired of funding organizations that serve as little more than job boards for non-practicing physicians looking for their next career.

-Wes

Some Thoughts on the National Board of Physicians and Surgeons

I admire Paul Tierstein, MD's honest attempt to create a greatly simplified alternative to the  ABMS's Maintenance of Certification® (MOC) program called the National Board of Physicians and Surgeons (NBPAS).  I hope he's successful, but I sense there will be large headwinds for the effort ahead.

Here's why.

The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.  Section (k) is the section that defines how a "Quality Reporting System" is to be set up (with subsection (4) requiring the "Use of Registry-based Reporting") and Section (m) defining physician incentive payments physicians might receive if quality reporting occurs properly. (Sadly, those CMS incentive payments do not cover the cost of participating in MOC for most of us.)*

Section (k) was modified by the ACA to include the ABMS MOC program as a "physician registry."  The registry was "defined" as requiring all four parts of the MOC program created by the ABMS, including the much-maligned "practice improvement modules" that have been described by the physician community as overly time-consuming, irrelevant and may even violate federal research statutes regarding the study of physicians, their practices, and patients.

Unfortunately the new NBPAS does not address these requirements of the our new health care law, leaving the creation of the NBPAS to look like a Rand Paul moment all over again with physicians signing up for something that, legislatively, means nothing.

Welcome to the concept of "regulatory capture."

Screenshot of Heart Rhythm Society webpage

Physicians should realize that special interests and their lobbyists (including the US hospital, pharmaceutical, survey companies, and insurance lobbying groups) were highly influential in the creation of our new health care law.  They are also very good at politics.  It is unlikely that these entities want to see MOC go away, irrespective of how corrupt the system has become.  There's just too much money involved.  Even our own specialty societies use the MOC program's educational requirements to coerce physicians to take their educational courses to "earn MOC points" to help pad their bottom lines as physician attendance (and corporate sponsorship) at scientific sessions has dwindled over the past years.

But what's more important to our patients in the long run? Time for their needs or time for test-taking and survey collection?  Is it more important to satisfy government requirements or address the real needs of our patients?  Certainly continuing education of physicians is needed, but irrelevant work for an unaccountable  third-party organization so they can measure us rather than help us is not.

A second Heart Rhythm Society webpage devoted to MOC

Physicians need to take the stick, but we can't do this alone since we care for patients.  So we need to ask this question: will our specialty societies commit to supporting practicing physicians or the  new bureaucratic divide? (They can't do both.)  Will they truly step up to the plate and commit their considerable staff, dollars, pager-less hours, lobbying and legislative efforts to help remove the corrupt MOC program from the Affordable Care Act or allow practicing physicians - their members - to wallow in the corrupt status quo as they are coerced to participate in MOC?

I remain pessimistic that creating another "board" will fix the current deep-seated problems with the ABMS MOC construct with ABMS as the mothership directing a flotilla of 24 member boards.  In my view the only way to truly "change" MOC is to have a coordinated effort from all specialty societies to insist our legislators remove the portion of our new health care law that requires we participate in a "physician registry" that robs not only practicing physicians, but patient care itself.

HRS and ACC, are you on board?

-Wes

*Addendum 2/12/2015: 
It should be noted that the payment incentives offered 2012-2104 from CMS for participation in MOC ended January 1, 2015, but that MOC participation will still be used as a physician quality reporting metric. 

The ABIM Foundation, Choosing Wisely®, and the $2.3 Million Condominium

Is it "medically professional" for a non-profit organization to use physician testing fees to "choose wisely" a $2.3 million luxury condominium complete with a chauffeur-driven BMW 7-series town car? In my view, obviously not. To most people such an action would conjure up images of hypocrisy, waste, and corruption.

Yet, after a review of public and tax records, it appears to me this is exactly what has happened.

Background

In 1999 for reasons that are unclear, the American Board of Internal Medicine (ABIM), itself a tax-exempt 501 (c) (3) independent non-profit physician evaluation organization domiciled in Iowa, created (Editor's note 10/20/2015: referenced web page has since been edited by the ABIM Foundation; the original referenced web page can be viewed here) a second non-profit tax-exempt 501 (c) (3) organization, the ABIM Foundation (Foundation), to first define and later promote the term "medical professionalism." Both the ABIM and the Foundation share a common address in Pennsylvania and common officers:

"The American Board of Internal Medicine (ABIM) is related to the ABIM Foundation (Foundation) in that The Foundation is the sole voting member of the ABIM. As such, the two organizations share a common president, a common CFO, and a common senior vice president whose base salaries are allocated between ABIM and The Foundation based on the time spent by each executive."

To define "medical professionalism," the new Foundation enlisted other members of the non-profit world including the ABIM, the paid "directors" of the Foundation, the Robert Wood Johnson Foundation, the American College of Physicians-American Society of Internal Medicine and the European Federation of Internal Medicine.  The group was chaired by Troy Brennan, MD, JD a paid "Director" of the Foundation who was also President and CEO of Brigham and Women's Physician Organization at the time. (He later became the Chief Medical Officer of Aetna in 2006, and now serves as the Executive Vice President and Chief Medical Officer of CVS Caremark). In 2002 this group published a white paper entitled "Medical Professionalism in the New Millenium: A Physician Charter" without peer review in the Annals of Internal Medicine (here) and The Lancet (here).  At least the Annals editor, Harold C. Sox, MD mustered the courage to express concerns about the manuscript in his introductory remarks to his readers:

"The introduction contains the following premise: Changes in the health care delivery systems in countries throughout the industrialized world threaten the values of professionalism. The document conveys this message with chilling brevity. The authors apparently feel no need to defend this premise, perhaps because they believe that it is a universally held truth. The authors go further, stating that the conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare. These are very strong words. Whether they are strictly true for the profession as a whole is almost beside the point. Each physician must decide if the circumstances of practice are threatening his or her adherence to the values that the medical profession has held dear for many millennia."

The paper centered on three fundamental principles that the authors claimed defined "medical professionalism:" (1) the primacy of patient welfare, (2) patient autonomy, and a new concept, (3) the principle of social justice - that is, "the medical profession must promote justice in the health care system, including the fair distribution of health care resources." With this definition, physicians could no longer just be unwavering patient advocates concerned with the "primacy of their patient's welfare," they had also had to serve the financial needs of The System of medicine lest they be labeled "medically unprofessional."

Ten years later after accumulating some $76 million in assets, the Foundation began their hard-to-disagree-with "Choosing Wisely®" campaign to encourage physicians and providers to question the value of medical testing in an effort to eliminate unnecessary tests and procedures. The campaign has grown to include 70 societies and some non-physician organizations, including Consumer Reports, AARP, SEIU, and Univision among others. As part of the campaign, monetary grants from the Robert Wood Johnson Foundation are awarded to institutions willing to "educate practicing physicians about the recommendations from specialty societies, and building physician communication skills to facilitate conversations with their patients about the care they need."
 
The Money Trail

So how did the ABIM Foundation accumulate all that money? Reviewing public tax records of the ABIM and its Foundation reveals a significant portion of the Foundation's revenues came directly from the ABIM.  Recall that ABIM receives 97% of its annual revenues from physician certification (62%) and re-certification fees (35%), with only 14% of these fees going toward physician examination development.  In 2007 and 2008 alone, cash grants from the ABIM to its Foundation of $7 million and $6 million respectively were issued.  The public records disclosed that $17,360,000 from the ABIM were made to its Foundation in the 7 years ending 6/30/2008. As a three-time participant in the ABIM certification process (candidate #127308), I can attest that to the best of my knowledge physicians were never made aware of this use of the testing fees they paid the ABIM.

The Luxury Condominium

Street View, "The Ayer Buidling," 210 W. Washington Square

So why did the ABIM Foundation need all this cash from physicians? We can't be certain, but the Foundation disclosed in their 2008 Form 990 that a portion of the money they received from the ABIM via physicians fees was used to purchase a 2,579 square foot 3-bedroom luxury condominium (Unit #11NW, in the "Ayer" Building, 210 W. Washington Square, Philadelphia) in December 2007 for $2.3 million. The luxury property borders Washington Square Park of the most historic areas of Philadelphia, across the street from the Tomb of the Unknown Revolutionary War Soldier and the Eternal Flame. The condominium building previously advertised a chauffeur driven Mercedes Benz S-series town car (more pictures here).

Since then, the Foundation has reported "condominium expenses" totaling $850,340 from December 2007 through June 30, 2013 (FY 2008: $42,522, FY 2009: $164,460, FY 2010: 161,957, FY 2011: $165,982, FY 2012: $161,980, FY 2013: $153,439 (most of these reported as "program service expenses")). In my view, these expenses were accrued while the ABIM appears to have been on an inherently unsustainable financial course from 2001 to 2012 with its net asset or fund balances on 6/30/2002 beginning with a negative balance of $10,762,954 and growing to a negative balance of $43,150,390 ending 6/30/2013. Meanwhile, over the same period its shadow organization, the ABIM Foundation, fund balance was $73,841,719 on 6/30/2013.

It should be noted that in the year of the condominium purchase the President and CEO of the ABIM, Christine Cassel, MD, earned $484,883 from the ABIM and $161,627 from the Foundation. Dr. Cassel continues to serve as President and CEO of the National Quality Forum despite a history of other seemingly conflicted financial dealings. Other executives of ABIM that year included F. Daniel Duffy, MD who served as Executive Vice President of the ABIM earning $379,915 from the ABIM, and Cary Sennett, MD, PhD who served as Senior Vice President earning $185,122 from the ABIM and $185,122 from the Foundation and now serves as a Vice President of Anthem, Inc., formerly Wellpoint. That year Dr. Richard Baron, the current President and CEO of the ABIM and Foundation, served as the secretary/treasurer of the ABIM Board earning $59,729 until 7/1/2008 when he became an unpaid Director of the Board. By comparison, according to one reliable source, the median general internal medicine physician salary in the U.S. was $205,441 in 2009.

More Questions

Reviewing the public record on when and where the ABIM Foundation was actually created discloses another discrepancy.  We observe that the Foundation has recorded on their tax returns as being founded in 1999 with its "legal domicile" in Iowa, like the ABIM.  However, a search for the organization in Iowa comes up empty, while a search in Pennsylvania Department of State (screen shot here) shows the Foundation was actually created in Pennsylvania in 1989.  Which is correct?

We should note that non-profits are not required to file financial statements with the state of Iowa, while Pennsylvania requires them. This raises uncomfortable questions. Is the Foundation's Iowa domicile sheltering the sources and uses of its funds? Why does a non-profit promoting "medical professionalism" need to accumulate this much revenue? Is this how the Foundation demonstrates their "medical professionalism" to the public? To whom is the ABIM and Foundation "accountable?" Anyone?

My Call to the ABIM

On 4 December 2014 I contacted the ABIM and requested an explanation regarding the condominium, the ongoing condominium expenses, and the discrepancy of the ABIM Foundation domicile and founding date.  Richard Baron, MD, the current President and CEO of the ABIM returned my call and explained the following:

1. Dr. Baron stated that the condominium was purchased as a "investment property" and part of the investment portfolio of the Foundation.  He mentioned that real estate holdings were not uncommon with other similar non-profits.  The condominium was used for several purposes, including housing ABIM personnel who resided out of state and returned to Philadelphia for meetings, by contractors (for instance, to house an IT team from India), and for off-site retreats and meetings with the Communications Group of the ABIM, for instance. He noted that when ABIM members use the Foundation's condominium, the Foundation is paid $150/night from the ABIM (compared to the "usual" Philadelphia hotel  rate of about $190/night) and there was cash flow to the Foundation from the ABIM for the use of their facility.


2. After revelations of the luxury condominium were disclosed at a 2 Dec 2014 Pennsylvania Medical Society town hall meeting, Dr. Baron mentioned in passing that the ABIM was putting the condominium up for sale. I asked Dr. Baron the name of the listing agent and the price.  He stated he could not comment because "the paperwork was not in order" and the those details had not been finalized because they were advised that the real estate market would be better in the Spring. 


3. When asked about the high ongoing condominium expenses and the discrepancy about the ABIM Foundation's creation date and domicile, Dr. Baron could not immediately respond but sent this follow-up e-mail 4 Dec 2014 at 2:39PM (CST):

   "Hi Dr. Fischer (sic)-
   
   Attached please find the breakdown of the condo expenses. As I explained the depreciation $$ are a required reporting artifact for the condo as a business investment. The other costs are covered by the condo usage fees.
   
   Regarding the 1989/1999 question - In 1999 ABIM Foundation became a separate operating foundation.
   
   Thanks,
   
   Rich
   
   Richard J. Baron, MD
   MACP
   President and Chief Executive Officer
   American Board of Internal Medicine"



4. In closing, Dr. Baron expressed his willingness to be open to further questions.


5. Today I learned that the condominium is now listed with the following description:

   "Extremely Spacious Three Bedroom, 3.5 Bath Home at the Ayer Condominium. Tremendous Entertaining Space. 11’7’’ ceiling heights. Bulthaup b-3 kitchen system, Miele and Subzero Appliances. Huge windows with northwest views. High floor offering stupendous sunsets. Gorgeous stone bathrooms. Abundant closet space. One garage parking space included. Concierge, doormen, valets, gym, chauffeur driven BMW 7-Series." (More details here.)

I never received a clear answer to my ABIM Foundation domicile discrepancy.

Larger Implications

Sadly, the medical profession has become a house divided.  On one side are many non-clinical physicians who have become far removed from patient care and are firmly embedded in the non-profit, academic, and public policy circles making handsome salaries while seeing little problem with coercing their colleagues to pay fees to support their various economic, policy, or personal agendas.  In the words of my colleague Jordan Grumet, MD: "they talk about 'accountability' as if they are the ones in the ICU having the family meetings. They pray at the altar of 'quality' yet fail to define the specifics of such a term. They resent 'over treatment' but never have suffered the consequences of not doing enough."

On the other side are the physicians buried in the work-a-day world of patient care, busy doing the best they can for their patients in our increasingly complicated health care system, working as "excellent sheep" as they do their difficult job and try not to rock the boat. While such a dichotomy is not unique to medicine (look to education, the public service sector, and politics, for instance), is ignoring this new reality useful to our profession?  Might the unintended consequences of these unaccountable non-profit organizations and revolving-door employment practices with government and business interests be causing unimaginable harm to the integrity and credibility of our profession while simultaneously wasting valuable resources?

It is a shame that most physicians, particularly younger doctors saddled with exorbitant training debt and concerns of job acquisition and job security, are not in a position to protest the actions of the ABIM and its sycophants, particularly since their ability to practice medicine is increasingly tied to these ABIM board certification and their new perpetual maintenance of certification payments.  But this is the point, isn't it?  Regulatory capture.  As these younger doctors gain experience and awaken to the realities of their new health care arena that is increasingly dominated by unaccountable organizations led by non-clinical members of our own profession, we risk creating cynicism in our ranks and physicians who must be more concerned with passing a test than providing direct patient care.  Even worse, we risk promoting ourselves, career or cause over the complicated needs of our patients as the divide grows ever deeper.  As a result, the brittle credibility and hard-earned trust with our patients is squandered beyond repair.  In my opinion, this is what we risk when we have corruption within.

Is this what our profession and the public wants?

I can only hope that practicing US physicians and the public will demand a full accounting of the ABIM and their Foundation's entire financial dealings and non-transparent co-mingling of funds. I hope that Congress decides to investigate the ABIM's role in including their MOC program as a physician quality reporting measure in the Affordable Care Act (see pages 247 and 844-845) to determine its legitimacy in light of these findings.  Furthermore, an investigation into possible violations of federal policy on the protection of human subjects (in this case practicing physicians involved in direct patient care) regarding the American Board of Medical Specialties' requirement for practice and patient survey collection for Part IV of their trademarked Maintenance of Certification® program that the ABIM helps conduct should occur, especially in light of lack of informed consent afforded to physicians regarding how the fees and data they collect are used.

It is time we hold the non-clinical members of our own profession that lead these organizations accountable to all physicians and the public at large. Until this occurs, physician-members of every ABIM subspecialty organization that profits from educational content provided to the ABIM should divest themselves and work to create their own, more credible, simplified and transparent life-long learning pathways.  The American Association of Clinical Endocrinologists has already set a good example. While I understand that refusing to buck the coercion created by the multimillion dollar ABIM and its Foundation will be difficult, our credibility as stewards of our patients' best interests and the preservation of the integrity of our profession demands nothing less.

-Wes

Acknowledgement

I am indebted to Charles P. Kroll, CPA for his invaluable assistance collecting tax records of the ABIM and ABIM Foundation before 2007 and assisting in the understanding of the nuances of not-for-profit accounting methods. Mr. Kroll provided forensic accounting analysis to the Minnesota attorney general's office during the Medica-Allina scandal and testified at the Minnesota Senate hearing on the matter.

My Interview at AHA 2014 on ABIM's Maintenance of Certification Program

Thanks for C. Michael Gibson, MD for hosting an interview with me on my concerns with the American Board of Medical Specialties (ABMS) / American Board of Internal Medicine's Maintenance of Certification Program earlier today on his Clinical Trial Results website. A direct link to the interview is included here (if you're using a mobile phone, click the "Download video" link on the webpage).

As the physician groundswell of opposition to the ABMS's proprietary MOC program grows, physicians (especially younger physicians) must understand the complex forces that are intervening between the doctor and patient. The ABMS/ABIM Maintenance of Certification Program is just one of these forces. I encourage all doctors to educate themselves by reviewing the materials collected about MOC at changeboardrecert.com. It's an excellent resource from a variety of physician voices around the United States. Overseas doctors, too, should be aware that the ABIM is extending its tentacles there as well (video), all without any independently-verified evidence base upon which to impose their program as a physician quality or patient safety measure. Doctors must understand the importance of becoming more involved in preserving our profession by becoming more politically engaged.

It is interesting that the AMA just adopted the following new "Principles for MOC" in their press release of 10 Nov 2014:

The MOC principles will now include:

• MOC should be based on evidence and designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care.
• The MOC process should be evaluated periodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice.
• MOC should be used as a tool for continuous improvement.
• The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.
• Actively practicing physicians should be well-represented on specialty boards developing MOC.
• MOC activities and measurement should be relevant to clinical practice.
• The MOC process should not be cost-prohibitive or present barriers to patient care. The policy encourages specialty boards to investigate alternative approaches to MOC and directs the AMA to report annually on the MOC process.

The American Board of Medical Specialties (ABMS) is the organization responsible for developing the MOC process. ABMS works with its 24 member boards in the ongoing evaluation and certification of physicians.

AMA policy supports physician accountability, life-long learning and self-assessment. The AMA will continue to work with the appropriate organizations to ensure the MOC process does not disrupt physician practice or reduce the capacity of the overall physician workforce. In June, the AMA and ABMS convened stakeholders in Chicago to discuss Part III of the MOC exam, focusing on the value of MOC Part III and innovative concepts that could potentially enhance or replace the current thinking around the secure exam requirement of MOC.

On first blush, this seems so promising. But we should appreciate that the ABMS and ABIM was an earlier spin-off of the AMA, making those of us familiar with these facts suspect.

Similarly, the Pennsylvania Medical Society, just released their "statement of principles" for MOC that sound eerily similar:

The Pennsylvania Medical Society is committed to lifelong learning, cognitive expertise, practice quality improvement, and adherence to the highest standards of medical practice. The Pennsylvania Medical Society supports a process of continuous learning and improvement based on evidence-based guidelines, national standards, and best practices, in combination with customized continuing education.

The Maintenance of Certification (MOC) process should be designed to identify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care.

The Maintenance of Certification (MOC) process should be evaluated periodically to measure physician satisfaction, knowledge uptake and intent to maintain or change practice. Board certificates should have lifetime status, with Maintenance of Certification (MOC) used as a tool for continuous improvement.

The Maintenance of Certification (MOC) program should not be associated with hospital privileges, insurance reimbursements or network participation.

The Maintenance of Certification (MOC) program should not be required for Maintenance of Licensure (MOL).

Specialty boards, which develop Maintenance of Certification (MOC) standards, may approve curriculum, but should be independent from entities designing and delivering that curriculum, and should have no financial interest in the process.

A majority of specialty board members who are involved with the Maintenance of Certification (MOC) program should be actively practicing physicians directly engaged in patient care. Maintenance of Certification (MOC) activities and measurement should be relevant to real world clinical practice.

The Maintenance of Certification (MOC) process should not be cost prohibitive or present barriers to patient care.

While these "principles" from the AMA and the Pennsylvania Medical Society address many of physicians' concerns regarding these programs, both potentiate the concept of Maintenance of Certification (MOC), despite the many problems we've identified with this "program" to date (see here, here, here, and here for starters).
Neither of these "principles" insist on researching the unintended negative consequences of the MOC program on physicians should they fail to re-certify, especially since failure rates of this program is 22%.
So why have these two prominent organizations suddenly produced these two similar documents? Might it be to distance themselves from anti-trust concerns with MOC that continue to weave themselves through the courts? Might it be because they see the ABIM becoming irrelevant as more revelations of the management of these organizations comes to light? Might the AMA still want to perpetuate the loss of physician autonomy to gain favor with large hospital systems that are being created by our new health care law today?

We must wonder.

These are big issues. For young doctors overwhelmed with the realities of beginning practice, taking another test seems the easier option than confronting these realities. But all of us as treating doctors must not sit idly by as our autonomy is increasingly usurped and corrupted to benefit the system rather protecting the real health care needs of our patients.

-Wes

ABIM Placates Physician Anti-MOC Sentiment with "Commitments"

From the 5 Aug 2014 issue of the Journal of the American College of Cardiology (JACC):

"Note: There is evidence that the ABIM has heard the concerns of its diplomats and is acting responsively. In a July 10, 2014 letter to the internal medicine community, and in a face-to-face meeting in Philadelphia on July 15, 2014, which was attended by 26 internal medicine subspecialty societies including the ACC, the ABIM committed to:

• •Provide a 1-year grace period for those who have attempted but failed to pass the secure examination.
• •Update its governance and financial information on its website.
• •Ensure a broader range of CME options for medical knowledge and skills self-assessment (Part II).
• •Provide more feedback regarding test scores.
• •Evolve the “patient survey” requirement to a “patient voice” requirement and increase the number of ways this requirement can be met.
• •Reduce the data collection requirement for the practice assessment requirement; utilizing performance improvement activities already in place and minimizing the time and complexity of data input.
• •Investigate changes in the secure examination to increase relevance with specific attention to exploring applications for practice focus areas (“modular examinations”) and open-book examinations.

For its part, the ACC has recently:

• •Released a special video that catalogs the suite of ACC resources available to help members meet the MOC Part IV requirements.
• •Determined that free-standing MOC modules will be offered to ACC members at no charge.
• •Posted online (CardioSource.org/MOC) a comprehensive list of ACC MOC Part II offerings. New modules will be added as they become available."

It is concerning that the ACC leadership feels the ABIM is "acting responsively" and continues to market the MOC proess so aggressively.   Let's critically review the list of proposed ABIM "commitments" outlined above:

Provide a 1-year grace period for those who have attempted but failed to pass the secure examination.
We can only imagine what this means.  Does it mean your name won't be posted on the ABMS's Wall of Shame for a year so you can attempt to take the test twice more?   Nowhere is there a concern for the lost revenue, additional hours of study, psychological stress, and damage to a physician's professional reputation created by this unproven process.  While the ABIM acknowledges the increasing failure rate of their examinations in their "letter" to the Internal Medicine community, they provide no evidence of critical self-apprraisal nor a viable rationale for this.  Instead, the spin is that doctors should feel grateful they were granted a 1-year grace period to complete the MOC testing.

Update its governance and financial information on its website.
Updating a website does not mean change in governance will occur at the ABIM.  All ABIM members should be elected by physician peers, not selected by ABIM members themselves.  Is this what they mean?  Of course not.  Do we really think these back-slapping chums will change their self-serving ways? The fact that ABIM members "exercise ultimate fiduciary responsibility and authority" is not acceptable to professionals whose livelihoods are placed at risk by ABIM members who remain unaccountable to those they regulate.  Until physicians have an active voice in the ABIM's "governance," this organization's professional credibility will remain suspect.

Regarding the financial information they will disclose:   How will they justify the high salaries of the executives of the member boards that exceed the salaries of the doctors they pretend to represent by many times? Will they insist on the disclosure of all conflicts of interest and income gained as consultants? So far, the ABIM has failed to list the transfers of funds between organizations like the ABIM and it's separate "ABIM Foundation" publicly. Shouldn't all financial and societal relationships with the ABMS, AMA, ACP, CMS, National Quality Forum, AMA's legal team, academic centers, the American Hospital Association, insurers and other "stakeholders" eager to use the ABIM's data trove be disclosed as well?  Will the ABIM disclose how the survey and test data collected on their server is protected, sold and/or shared?  Why is this unproven MOC process being promoted as a measure of physician "quality?"  Why has it been allowed to continue as a Medicare physician payment incentive?   Given these problems with fiscal transparency, why does our government collude with this private entity?  If the ABIM's "governance and financial information" fails to change sufficiently or mention these specifics, physicians and the public have gained very little from any "commitments" promised by the ABIM.

Ensure a broader range of CME options for medical knowledge and skills self-assessment (Part II).
This is really not a concern, so why it was included as an "action item" for the ABIM is uncertain.  Physicians have always had many ways to earn continuing medical education (CME) credits that do NOT involve the ABIM's MOC process and these MUST be preserved.  Physicians to not want the ABIM to monopolize their ability to gain CME from other sources or methods, especially when the ABIM commands repeated  high payments from physicians for their products.

Provide more feedback regarding test scores.
"Feedback" can come in many ways: statistics, providing answers, or maybe even disclosing a passing level.  But let's be honest.  Why do we care?  Especially when failing still has significant employment, credentialing and social ramifications.  Isn't the point to of life-long-learning to educate?  Isn't the point to learn?  Is forcing doctors to take a computerized test in a secure prison-like environment really beneficial to patients, or just a means of making subordinates of clinical professionals?    Why do we physicians continue to allow such a punitive means for assessment to take hold when there is no independently validated evidence that MOC does anything to improve patient care? 

Evolve the “patient survey” requirement to a “patient voice” requirement and increase the number of ways this requirement can be met.
Oh my goodness.  Really?  A "patient voice" requirement rather than a "patient survey?" The ABIM really has no idea whom they are serving.  They have a Utopian vision for themselves: as one Great Overseer of All Things Perfect and to define for both doctors and "the Public" (whoever they feel that comprises) what "voice" we should all hear.  I can see it now: patient's flying in a horrible thunderstorm with their doctor piloting the plane and the ABIM's answer to improving the safety of the flight?  Make sure the patient's have a "voice" or let's pass out a "survey!"  The reality today is that patients have a voice in their health care: they can go elsewhere, they can sue, they can critique their doctors publicly.  To suggest that patients need a "voice" in assuring physician competency, courtesy of the ABIM's expensive MOC requirement, is not only patronizing, but insulting to both patients and doctors.

Reduce the data collection requirement for the practice assessment requirement; utilizing performance improvement activities already in place and minimizing the time and complexity of data input.
This is nothing new.  It already existed and is exactly what I did recently in my recent recertification process in 2013.

Investigate changes in the secure examination to increase relevance with specific attention to exploring applications for practice focus areas (“modular examinations”) and open-book examinations.
This sounds like a Carte Blanche idea to expand the ABIM's reach and costs without oversight.  Who will fund such an initiative?  Who will regulate the spending of these self-imposed regulators?  How can we control costs of this whole process when the process is continually expanded with such unrealistic and grandiose ideas?   Isn't medicine and real life already an "open book test" for today's physicians?  Why do we need  the pleasure of paying $750 or even more for a another secure exam in a videotaped office building that prides itself on cavity searches? This whole process is already out of hand.  Cut it back and make it manageable, don't expand it.

Why should anyone care about all of this?  Yesterday morning, my good friend John Mandrola, MD sent a prescient tweet my way:

Yet another of Louisville's finest docs sends letter of resignation. Experienced docs are leaving in droves. No one is secure. @doctorwes
— John Mandrola, MD (@drjohnm) August 5, 2014

Senior doctors are getting tired of all the nonsense in medicine these days. And nowhere is there more nonsense that the ABIM's complicated Maintenance of Certification program.  Their continuing education program is far too cumbersome, onerous, and expensive and supplies little to no marginal utility for patients relative to the care that their physicians provide.  As a result, the ABIM's MOC process is causing more harm than good to patient care while also compromising physician retention.    Unless this is horrible mess is greatly simplified or stopped all together, look for more and more doctors to move on to other less hostile work environments or to simply retire.

After all, actions speak louder than words.

-Wes

Addendum: If you've failed a recent Maintenance of Certification examination, I am still confidentially collecting stories from affected physicians.  Please consider contributing yours.