Saturday, December 17, 2016

Physician Burnout and MOC: Treating the Cause, Not the Symptoms

This brilliant essay appeared in Practical Neurology Nov/Dec 2016 issue by Paul G. Mathew, MD, FAAN, FAHS. Dr. Mathew is on staff in the Department of Neurology and is Director of Continuing Medical Education at the Brigham and Women’s Hospital, John R. Graham Headache Center, and staff neurologist at Harvard Vanguard Medical Associates and the Cambridge Health Alliance. He  also serves as the neurology representative on the volunteer advisory board of the National Board of Physicians and Surgeons. 

Here's a brief example:

WHAT DO PRIVATE PAYERS GAIN FROM REQUIRING MOC?

As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements.

Read the whole thing.

Dr. Mathew will be giving Neurology Grand Rounds at Michigan State University/Sparrow entitled "Maintenance of Certification: Reform or Reboot?" on 13 Jan 2017 from 07:30-08:30 AM EST. All are welcome to attend.

-Wes

Friday, December 16, 2016

Philadelphia Medicine Magazine's ABIM Issue



An entire issue of Philadelphia Medicine magazine devoted to the American Board of Internal Medicine (ABIM), (pdf  here) and the ABIM wouldn't respond other than to say:
"We do not feel that this format appropriately presents the variety of viewpoints about MOC."

The magazine attempted to invite Richard Baron, MD to give the ABIM's side of the story but he declined. This speaks volumes.

-Wes

Wednesday, December 14, 2016

ABMS/ABIM MOC Controversy: 2016 Year-in-Review

It's hard to believe that another year has come and gone since my 2015 update on the ABMS/ABIM Maintenanence of Certification controversy. I thought it would be important to maintain this chronological annual review of the ABIM and their conspiring organizations to keep physicians and the public apprised of the situation unfolding. Here is the timeline of the major developments regarding the ABIM MOC controversy for the past year so far:*

  • 12 Jan 2016 - All ABIM archived webpages published after 1 Jan 2014 are removed from the internet archive Wayback Machine at http://www.archive.org

  • 13 Jan 2016 - More evidence for improper research practices used at ABIM surface on the ABIM website as physicians are asked to "update their profile" so the ABIM can research ways to "improve health care." ABIM diplomates are not informed on the research being conducted nor have they been given informed consent about the research activities being conducted.

  • 21 Jan 2016 - ABIM Foundation publicly discloses for the first time $56 million in transfers (unverified) from ABIM since 1990.

  • 26 January 2016 - Robert Wachter, MD, former Chairman of the Board of the ABIM and its Foundation, publishes a New York Times opinion piece entitled "How Measurement Fails Doctors and Teachers" and suggests "the secret of quality is love." With the article, Wachter  fails to disclose his own conflicts with the "measurement industry" at the ABIM and ABIM Foundation and the stock earnings he received from IPC Hospitalist Company (later acquired by TeamHealth) that is under federal investigation for overbilling Medicare.

  • 16 Feb 2016 - The website DoctorsJustice.com goes live to support the legal defense and countersuit of Jamie Salas-Rushford, MD, a Puerto Rican physician sanctioned and then sued by the ABIM in 2012 for allegedly disclosing ABIM test questions to Rajender Arora, MD, the creator of the now defunct ACGME-accreditied Arora Board Review courses as he studied for his certification examination. Numerous sanction letters and court documents against Dr. Salas Rushford appear online.

  • 8 March 2016 - The peer-reviewed journal article, "Medical Specialty Certification in the US - A False Idol?" is published.

  • 11 March 2016 - Like the practicing physicians' anti-MOC activities underway, medical students push back against another unneccessary and expensive testing requirement: the National Board of Medical Examiners' Step 2 CS requirement.

  • 12 March 2016 - The sworn testimony of Rajender Arora, MD of the ABIM's raid on his home by Federal Marshals appears online and offers remarkable details of the operation ABIM used to gain access to hundreds of review course attendees' personal information and email accounts.

  • 1 April 2016 - Robert Wachter's industry-sponsored blog, Wachter's World, disappears from the internet. Recall that Wachter's company, IPC The Hospitalist Company, for which he served as director and received 3,995 shares of stock valued between $50.68 and $58.50 per share, was sued by the Department of Justice for was overbilling federal insurance providers. The company was later acquired by TeamHealth 23 Nov 2015 for $80.25 a share, netting him and his University, the University of California, San Francisco (with whom he had a sharing agreement with), a comfortable profit.

  • 26 April 2016 - Oklahoma passes comprehensive anti-ABMS MOC legislation and ABMS responds.

  • 10 May 2016 - More changes to the ABIM MOC program to be implemented 1 Jan 2018 that includes more frequent testing are announced.

  • 12 May 2016 - Public disclosure of American College of Physician's Executive Vice President Steven E. Weinberger, MD's upcoming retirement appears.

  • 13 May 2016 - ABIM posts June 30, 2015 Form 990s. ABIM Foundation reports correct year and state of incorporation after six years of inaccurate reporting.

  • 20 May 2016 - The ABIM Foundation moves $6.5 million of diplomate testing fees offshore to the Cayman Islands in fiscal year 2015.

  • 9 June 2016 - The dark story of ABIM's felonious "Director of Investigations" and the strongman tactics used by the organization against economically vulnerable physicians is reported.

  • 14 June 2016 - Scott Shapiro, MD, Bonnie Weiner, MD, Charles Cutler, MD, myself, and Mr. Charles P. Kroll appear before the AMA House of Delegates meeting in Chicago to deliver our evidence supporting financial and professional mismanagement at the ABIM that culminated in the Pennsylvania Medical Society issuing a formal "vote of no confidence" against the ABIM.

  • 16 June 2016 - The AMA membership presses for an immediate end to MOC.

  • 2 July 2016 - Expanding investigations of other member boards of the American Board of Pediatrics reveals retired President and CEO of the American Board of Pediatrics, James A. Stockman, III, MD earned $793,438 working just eight hours a work-week as an "advisor."

  • 10 July 2016 - ABIM Foundation sells its controversial luxury downtown Philaelphia condominium at an estimated $1.2 million loss.

  • 21 July 2016 - The untold story of three ABIM-sanctioned physicians appears that chronicals the humiliation, ethics course requirements, and a $5000 check one of them had to pay ABIM to reinstate their certification.

  • 2 August 2016 - Several doctors of osteopathy file a class action lawsuit against the American Osteopathic Association seeking to recover millions of dollars in annual membership fees that the doctors allege they have been forced to pay for years to the organization to maintain their certification.

  • 4 August 2016 - ABIM Foundation shifts from defining and promoting "medical professionalism" to "co-creating" health care.

  • 5 August 2016 - Medical Economics publishes MOC promotional piece by Richard Baron, MD, President and CEO of the ABIM, then asks for a physician rebuttal via its Twitter feed. After writing the rebuttal at their request, Medical Economics refuses to publish it. The rebuttal is published on these pages and received over 10,000 page views within 48 hours.

  • 24 September 2016 - Retirement plan and change in audit firm disclosed publicly for the first time: value of ABIM's 100% employer funded Retirement Plan now exceeds combined value of ABIM and Foundation accumulated since 1936 (ABIM) and 1989 (Foundation).

  • 28 September 2016 - My 22-minute talk on "Why MOC is Broken and How to Fix It,  delivered at the AAPS meeting in Oklahoma City, appears (video).

  • 16 October 2016 - How the major medical journals, including JAMA and the New England Journal of Medicine, shield ABMS authors' conflicts of interest via IRS Form 990 tax filings and do not report these conflicts (and their own conflicts with the program) in their journals.

  • 16 October 2016 - The California Medial Society holds a debate between Lois Margaret Nora, MD, JD, CEO of the American Board of Medical Specialties and Paul Teirstein, MD, the unpaid President and CEO of the National Board of Physician and Surgeons. Attempts to shorten Teirstein's talk by the moderators are shouted down and Teirstein delivers his 14-minute talk and then receives a standing ovation (video).

  • 27 October 2016 - Press release announcing the retirement of ABMS President and CEO, Margaret Lois Nora, MD, JD appears.

  • 28 October 2016 - Mayo Clinic Proceedings publishes a survey on MOC with editorial commentary by James C. Puffer, MD, the President of the American Board of Family Medicine (ABFM), yet fails to disclose the ABFM's financial conflicts with MOC that includes running ABFM Realty, LLC, a firm that manages a $4.2 million office building purchased with ABFM diplomate testing fees in 2012.

  • 11 November 2016 - ABIM certification scoring methods that changed pass rate cut-offs are disclosed.

  • 14 November 2016 - Resolution 607 re: request for independent ABIM audit, passes in AMA House of Delegates.

  • 21 November 2016 - Letter from the American Board of Anesthesia threatening to report a physicians' certification status as "Not Participating in MOCA" if he does not pay for and complete their MOCA-Minute program by 21 December 2016 appears. (The impact on the physicians' ability to receive payment from insurers if this occurs is not mentioned).

  • 1 December 2016 - New England Journal of Medicine publishes "Knowing What We Don't Know - Improving Maintenance of Certification" by Richard Baron, MD and Clarence H. Braddock, III, MD, MPH, both employees of the American Board of Internal Medicine, and fails to allow comments or rebuttal, and (once again) fails to disclose the Journal's conflict of interest with the program.

  • 2 Deceember 2016 - The American College of Cardiology sends an email to all of its members announcing their collaboration with Part IV of MOC program and their approval as a Portfolio Program Sponsor by ABMS.

  • 16 Deceember 2016 - Philadelphia Medicine magazine publishes issue dedicated to ABIM. ABIM declines to contribute, stating "We do not feel that this format appropriately presents the variety of viewpoints about MOC." (PDF of entire issue available here.)

-Wes

*Additional updates to this timeline with be made for the remainder of December as needed or if other newsworthy events were missed.

Saturday, December 03, 2016

Chicago's Cold December Game Plan

In June 2016, "Chicago" had a problem. A small renegade group of doctors had uncovered some dirty secrets about the Chicago-based American Medical Association's (AMA) subordinate organizations, the Philadelphia-based American Board of Internal Medicine (ABIM) and its Chicago-based mothership, the American Board of Medical Specialties (ABMS). Action was needed. It would have to be invisible to the lay public. It would take a slick, well-coordinated game plan. It would also take some money. People don't mess with The Chicago Machine.

The major players assembled in the room to get some background on the problem. They'd have to understand the depth and breadth of what was known before they could structure a counter-offensive using every option at their disposal: ties to leadership at medical journals, public relations groups, finely-tuned email lists, and buy-in from like-minded medical societies who needed the AMA's political clout on Capital Hill - the works.

There they were, all the major players in one room, looking less than happy to be there to hear me (of all people) and my colleagues who were rattled to our core at what had transpired in the bureaucratic House of Medicine for all these years.


The room took a while to fill at first, but as time for the presentations approached, they were standing room only. The early attendees looked a bit worried. Those arriving later appeared less concerned for time and money were on their side. Many of the dignitaries were introduced to me by Charles Cutler, MD, from the Pennsylvania Medical Society who had invited a few of us to attend: the President of the Board of the American Medical Association (AMA), the Executive Vice President of the American College of Physicians (ACP), members of some of the medical national medical societies. All in one room to hear me and Mr. Charles Kroll, a certified public account, give our little talks (seen here and here).

They listened intently. They asked no questions. They needed to think. Poor Lois Margaret Nora, MD tried to come to the microphone to defend her actions feebly. It was clear to them she was a liability. More senior veterans at this game would have to step in.

It was a time to marshall the considerable resources of Chicago's medical establishment's senior spin experts: the American Medical Association and their collaborators at the Accreditation Council of Graduate Medical Education. They knew they could do this. After all, it had been done before when Thomas Brem, MD testified before Congress 30 April 1969 after he was paid from "Special Account No. 4" maintained by tobacco lobbyists. (See US District Court for the District of Columbia, United States of America v. Phillip Morris USA, Inc, et al., Case 1:99-cv-02496-GK Filed 8/17/06. Page 174 of 1683. Available at: https://www.gpo.gov/fdsys/pkg/USCOURTS-dcd-1_99-cv-02496/pdf/USCOURTS-dcd-1_99-cv-02496-4.pdf ) We are beginning to see telltale signs of a similar well-coordinated plan to forward a separate, non-patient care agenda against the practicing physicians who had grown restless.

First, the leadership recognized that change was needed. Dr. Steve Weinberger, Executive Vice President of the PhiladelphiaChicago-based ACP had heard enough and wisely wanted out. He could see the writing on the wall and had given plenty of time, energy and effort to the ACP. He announced his retirement. Lois Margaret Nora, MD, JD wanted to stay on but knew she couldn't. She, too, announced her retirement but was asked to stay on until the end of 2017 to help "smooth" the transition. Or to be a fall guy. (This is Chicago, remember.)

Second, a "go live" date had to be set. 1 December 2016, just before the new US President took office, would be perfect.

Third, an article would have to appear in the New England Journal of Medicine without an accompanying rebuttal article reaffirming the importance of MOC and how hard the ABIM are working to modify it. This article would serve as the "starting gun" for all that was to occur next. In turn, Richard Baron, MD would serve, once again, as sacrificial lamb and receive a "special fee" above and beyond $800,000-a-year ABIM salary in return for "publishing" the article (see the article's disclosures). Perhaps this was because Dr. Baron and Braddock didn't write a substantial part of the it, we can't be sure. Practicing physicians would be appalled by the piece containing many non-scientific assertions. It didn't matter. They liked the use of the example where anyone can become an ordained minister online to justify ABIM's unproven maintenance of certification program as a "solid," and "valuable" standard. No one would dare comment that the ABIM's secret, black-box antiquated questions (held secret behind a thin veil of threats of prosecution for leaking those "secrets") were any more "solid" or "valuable" than those "internet based" ministry credentials. Especially if the New England Journal of Medicine didn't allow comments. Furthermore, Baron and Braddock's must make board certification sound as though it was "always" supposed to be time-limited. No one must know that Walter Bierring, MD, the unpaid organizer and first officer of the ABIM never intended the test to become a mark of adequacy to practice medicine rather than an optional sign of excellence. (See: Bierring WL. The American Board of Internal Medicine. Ann Intern Med 1937 10(12):1746-1751.) Denis M. O’Day, MD and Mary R. Ladden, BA's peer-reviewed article on the history of board certification, published the criteria of the American Board of Medical Specialties member boards that stated their voluntary nature and the requirement their tests and programs NOT be tied to the ability of a physician to practice. And practicing physicians certainly should not know about the first recertification test, taken by internists on 26 October 1974,  recommended that "no one should lose their primary certification as a result of the examination."(Meskaukas JA and Webster JD, The American Board of Internal Medicine Recertification Examination: Process and Results. Ann Intern Med 1975 82: 577-581). To provide cover to these facts, Drs. Baron and Braddock must use ABIM's usual strongman tactics and threaten "escalating consequences for unsatisfactory performance over time" in their piece. And so it was.

Fourth, that evening after the New England Journal of Medicine article appears and people have a chance to digest it, a mass email must be sent to all members of the American College of Physicians announcing their "new pilot MOC program" in coordination with the American College of Cardiology (ACC) and the ABIM that promised to "ease the burden and increase the relevance" of the ABIM MOC process. Specific details like time frame, cost, and methods must not be disclosed, however.

Fifth, more pressure must be applied. The AMA and the Committee of Medical Subspecialty Societies (based in Chicago) will coordinate with the American College of Cardiology to use the ACC's considerable financial and political clout to re-introduce the previously-suspended Part IV "Practice Improvement and Safety Modules" via an email to its members the following day. After all, it took a lot of lobbying to assure Part IV of the ABIM MOC program was woven into the new physician "value-based" payment scheme called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For their help, the ACC should be granted "Program Sponsor" status of the ABMS Multi-Specialty Portfolio Approval Program. The message to lowly physicians MUST be: "Participate in MOC or don't get paid, sucker!"

It all seemed like such a good idea at the time. Those pitiful physicians wouldn't stand a chance. The Chicago Machine was in charge. It would be easy to roll over those quiet, unassuming doctors with this plan once and for all!

And then the unimaginable happened. An unanticipated Presidential candidate won the election. Like BREXIT, the medical political establishment were caught completely off guard. None of them could imagine it happening. And even though larger and larger numbers of doctors weren't buying the propaganda of the Affordable Care Act (ACA) and MOC any longer, the AMA, heavily invested in the ACA construct, stuck to their plan to strong-arm physicians with these MOC "modifications" anyway.

Practicing doctors and their patients have been waking up to what the medical establishment have done to the middle class and the practice of medicine in America. We've been slow to catch on thanks to the realities and time required for this thing called patient care, but the reality is profound.

Thanks to Maintenance of Certification, practicing doctors are not so easily fooled any longer and with a new sheriff in town, the Machine might just have to go to an alternate Plan B in January 2017 or face some serious consequences.

-Wes

Thursday, December 01, 2016

Knowing What We Don't Know

This week, Richard Baron, MD and Clarence H. Braddock, III, MD, MPH, both paid staff of the independent and unaccountable American Board of Internal Medicine (ABIM), received more (free?) advertising space in the New England Journal of Medicine to publish their perspective piece entitled "Knowing What We Don't Know - Improving Maintenance of Certification." While my readers are welcome to read the piece, rest assured there is nothing new there except more unsubstantiated excuses to prop up this expensive, wasteful, and corrupt enterprise.

I believe these authors should be very clear that physicians are quite aware of "Knowing What They Don't Know" about Maintenance of Certification (MOC), the ABIM, their collaborators at the American Board of Medical Specialties.

Here's what we don't know:

1) Who wants Maintenance of Certification so badly that Drs Baron and Braddock are allowed to publish their promotional piece in the New England Journal of Medicine after US physicians have overwhelmingly voted to end MOC immediately in the June 2016 AMA House of Delegates meeting? We can hypothesize many possibilities:

  • The New England Journal of Medicine itself, who stands to profit from their Knowledge+ educational product for MOC preparation.

  • The ACGME and its many members like the ABMS member boards, the AMA, the American Hospital Association (AHA), and Association of American Medical Colleges (AAMC) who stand to profit directly from the program and or by the anticompetitive practices it creates.

  • The multibillion dollar physician testing industry (Pearson, Prometric, etc.)

  • The major players in the US medical insurance industry (Blue Cross Blue Shield, Unitedhealthcare, Aetna, Cigna, etc.) who want to reduce their costs for expensive experienced physicians in lieu of physicians extenders, using the "National Committee on Quality Assurance" as their scapegoat?

  • Or perhaps, it's all of the above?

2) Why did the ABIM feel it could funnel $55 million of diplomate testing fees from 1989 to 1999 to fund its secretly-created (and undisclosed until 1999) ABIM Foundation?

3) Why has the IRS not investigated the repeated ABIM Foundation Form 990 tax fraud regarding the date and state of its Foundation's origin and the non-disclosed lobbying activities?

4) Why has the ABIM Foundation moved over $6.5 million of diplomate test fees offshore to the Cayman Islands in 2014?

5) Why were lawyers from ABIM's legal team, Ballard Spahr, and Ariel Benjamin Mannes (their two-time convicted felonious "Director of Investigations") allowed to accompany Federal Marshals during a home raid of two physicians homes that had developed an ACGME-accredited board review course? What agreement (monetary or otherwise) exists between the Dr. Rajender Arora (the director of the course) and the ABIM?

6) Why has the antitrust case filed by the Association of American Physicians and Surgeons against the ABIM, originally filed in New Jersey and then moved to the United States District Court for the Northern District of Illinois (Docket No. 1:14-CV-2705) on 4/23/2013, languished unaddressed in the Northern Illinois court docket since 7 Jan 2015?


These are just a few of the things practicing US physicians "Know What We Don't Know."

Rest assured, we won't rest until we find out and bring the corrupt MOC program to an end.

-Wes

Tuesday, November 29, 2016

On Pediatricians' Golden Pond

Satellite view of the
American Board of Pediatrics' 2.8-acre Pond
Pediatricians in the United States can thank the American Board of Pediatrics (ABP) and their time-limited "Maintenance of Certification" (MOC) program for the purchase of their very own "Golden Pond."

Surely, US pediatricians need a 2.8 acre pond. Where else would they be able to sit and contemplate their past careers as academics as the sun sets slowly over the horizon? Everyone knows that when properly maintained, ponds provide a peaceful venue for a leisurely stroll or for the opportunity to toss a hook and bobber in search of a bluegill or large-mouth bass. No doubt these activities are critical pediatric health care quality and safety skills.  Thanks to the leadership and "medical professionalism" portrayed by the ABP leadership over the past 30 years or so, all US pediatricians can feel proud to know that every bit of their $1200 "continuous MOC" fee is going to the support of this worthy landmark.

Surely pediatricians worldwide know about the pond they purchased, don't they?

Perhaps not.

Ponds, you see, don't typically make the internet websites of the American Board of Medical Specialties member boards or IRS Form 990 tax forms (except as "land and buildings"). Few would think of lands and buildings as including a pond, but for the American Board of Pediatrics, it does. In fact, their pond (picture) rests on a consortium of properties adjacent to 111 Silver Cedar Ct, Chapel Hill, NC that span over 9.3 acres and comprises two separate buildings (201 Silver Cedar Ct is also owned by the ABP). Unfortunately, it's hard to imagine how a pond adds to the safety or quality of pediatric care in the United States. Instead, we can only surmise that a pond is an important asset to the American Board of Pediatrics because it improves their property value and provides important tax revenues and political influence to the state of North Carolina and beyond.

And who better to pay for that pond and annual taxes than unsuspecting US pediatricians increasingly forced to comply with Maintenance of Certification?

No one was supposed to know that the first recorded deed of these properties coincided in time with the creation of Maintenance of Certification, 1986, according to North Carolina real estate records. No one was supposed to know that as President and Advisor to the American Board of Pediatrics, James A. Stockman, III, MD, earned $1,307,415 in Fiscal year 2012 before his retirement package of another $2.4 million kicked in the next year, either.

And let's not forget the many cars that pediatric diplomates helped Dr. Stockman purchase during his tenure at the ABP.

Here are Dr. Stockman's own words, published in Pediatric Annals:
Dr. Shulman: If you had not chosen medicine, which field would you have chosen?

Dr. Stockman: I’d be a car salesman.

Dr. Shulman: I suppose that’s not a surprise. You are quite the collector of classic cars. Your wife once told me that during a 5-year period in Chicago you bought and sold 40 or 50 separate autos. And that was before eBay!

Dr. Stockman: Yes, my collection is very diverse. Among them are a ’56 Cadillac, a Sting Ray, a Triumph, and a twin turbo engine Porsche 911. I love driving them on all the country back roads here in North Carolina. There is life beyond academe!…
Life beyond academe indeed.

Especially when one considers that Maintenance of Certification (MOC) was Stockman's "most far-reaching  achievement" of his 20-year career with the American Board of Pediatrics (according to the well-funded Illinois-based American Academy of Pediatrics that has an extensive lobbying presence on Capitol Hill).

-Wes

Monday, November 28, 2016

Staying Prepared at Christmas

Good Samaritan cardiologists never know when they (or someone else) might need 81 mg of aspirin  this holiday season.  Here are some fancy cufflinks (seen in clinic today) that every cardiologist should consider:





-Wes

PS: I have no commercial interest in this gift idea. :)

Monday, November 21, 2016

Nickle and Dimed

The American Board of Anesthesia's heavily-promoted "MOCA Minute" had some not-too-flattering details exposed recently.

First, was this letter sent to a diplomate who had not purchased their MOC offering:



Second, was the cost and the requirement to renewed requirement for physicians to participate in previously-suspended Part IV of the ABMS MOC program:



Here's the math: $210 per anesthesia diplomate annually x 20,000 anesthesiology diplomates = $4.2 million EVERY YEAR.

That's $42 Million every 10 years.

That's $42 million to the ABA for a program that threatens to compromise an anesthesiologist's ability to practice.

That's $42 million to the ABA for a program that threatens an anesthesiologist's ability to earn revenues from insurance companies.

It doesn't matter if doctors pay one lump sum every 10 years (as internists can do), or break their fees into bits. Forcing them to pay to keep practicing is the problem. Such a program in the egalitarian United States will never fly. Why, then, do the American specialty boards continue to insist that physicians participate when there are simply no proof it adds value to patient care or safety?

Because we're letting them get away with this.

It's time for all practicing physicians to stop supporting the ABMS MOC program, especially when there's at least one better option.

-Wes

Friday, November 11, 2016

More Insights to ABIM Board Certification Tests and Scoring

From a recent early-career physician who failed their certification board examination and is trying to understand why:*

Dr. Fisher,

I contacted ABIM today asking many questions about the initial certification exam and the scoring. 

As I've seen you mention, they claim to use the (modified) Angoff Method to set the cut score for passing. It involves a bunch of "experts" reading questions and estimating what percentage of "minimally competent" test-takers would answer correctly. They then average all experts' percentages for each question, and average the percentage for all questions, to achieve the minimum passing score. Apparently. No info on who the experts are. Also no definition of what a "minimally competent" test taker is.

That's a weird system, but it wasn't what I found most egregious. Without going into too much detail, there are 240 questions on test. By my answer report, based on number of missed questions, I got 74% correct. They have interviews with their president and examples online stating you need to get about 65% correct to pass. I blew that away and still failed. So, I called them. To start, they told me that at least 35 questions are "test questions" that end up being thrown out and neither count for or against you. So we are paying to be research subjects. And paying handsomely. Even if you throw out 35 questions, I still got 70% correct, so I asked how I could've failed if I was still well above the 65% threshold. They told me that not all tests are equivalent and essentially I may have had an easier version and needed to get more correct. So apparently someone could've missed more than I did but still passed if their test was arbitrarily deemed more difficult? 

I asked many questions about how this could even be considered an equitable way to grade a high stakes test, but got little response. They did offer to have a psychometric statistician call me. In 7-14 days.

Thanks for your time and for reading. What an arbitrary process. Also, they will not let me see my test or answers, nor can they show me what questions were thrown out. This being clouded in such secrecy just adds to the mistrust from physicians. How can we trust a test that's so arbitrary? Also, if I continue to fail (or am failed, depending on how you look at it), is the ABIM going to pay off my student loans? I've proven competence in residency and now fellowship training. I would argue I've proven competence on this very test too.
A few notes about this physician's observations.

ABIM has published several "abstracts" on their webpage about methods of psychometric testing. The first abstract, published in February 2011 an co-authored with a representative from the computerized testing firm PearsonVue, discusses "transitioning the board from linear computer-based test to an adaptive, multistage testlet-based examination" and their "experience 'selling' this change to leadership." In other words, it appears the method of scoring ABIM examinations made a change before February 2011 to IRT scoring. Secondly, it appears a member of PearsonVue and an ABIM non-physician helped "convince" the ABIM leadership why they should change methods. (On a side note for those interested, here's a not-so-"simple guide" to Item Response Theory.) The second abstract, published in April 2011, discusses a "transition from classical test theory (CTT) to item response theory (IRT) scoring." What prompted the change in scoring technique is uncertain, but it appears the method for scoring examinations for ABIM board examinations changed before early 2011. Importantly with this new technique, the pass rate cut-off appears to be determined AFTER the test is taken and may vary from individual to individual, as the doctor suggests in the email above.

For those interested, the 2005-2015 pass rates for initial ABIM board certification were as follows: 92% (2005), 91% (2006), 94% (2007), 91% (2008), 88% (2009), 87% (2010), 84% (2011), 85% (2012), 86% (2013), 87% (2014), 89% (2015). (source: the Internet archive and ABIM websites).

Was this change in examination methods responsible for the declining pass rates of physicians taking the ABIM certification examination noticed by program directors across the country in 2013? Or was this the way PearsonVue required the test be scored if PearsonVue's computerized test centers from  were used for scoring (making it a "win-win" for both organizations)? We are left to wonder. The  falling pass rate hypotheses considered even included the possibility that study methods of millennial physicians were less rigorous.  The New England Journal of Medicine's summary of the controversy tried to quell the outcry from millennials who were quick to respond. Even the American Board of Family Medicine's leadership felt compelled to explain their falling pass rates about the same time.

Isn't it interesting that no one ever entertained the possibility that a change in scoring method at the ABIM had occurred that might have caused the drop in pass rates? If true, the process of passing a physician's initial board certification is inconsistent between test takers since tests contain questions that are "weighted" differently for each diplomat and the process of determining pass rate cut-offs remain shrouded in secrecy.

It's time for the ABIM to stop hiding their "secret sauce" of test development, changes in test scoring, and test "security" processes and address this young physician's questions directly and honestly. Test scoring and the setting of pass rate cut-offs should be transparent and reproducible for any high stakes examination administered to US physicians, especially when this self-proclaimed "voluntary" testing and re-testing now affects all US physicians' ability to gain (and retain) employment.

Or is that too much to ask of folks that use physicians as research subjects without their consent, engage in illegal lobbying of Congress and "stakeholders" for their benefit, and delight in moving our testing fees offshore to the Caymans for their own benefit?

-Wes

* Portions of the letter were edited to protect the physician's anonymity.

Friday, November 04, 2016

Teirstein vs. Nora

Lois Margaret Nora, MD, JD of the American Board of Medical Specialties vs. Paul Teirstein, MD of the National Board of Medical Specialties debate at the California Medical Association meeting 16 October 2016:

Nora was given  20 minutes to speak.

Teirstein was given 10 minutes (but California Medical Association members booed until he got another 5 minutes).

Definitely worth a 14-minute viewing for it shows the revolving door of non-profit interests that maintain the MOC monopoly as only Paul Teirstein, MD can:


-Wes

Dr. Teirstein's slides can be downloaded here or a a pdf of his slides can be viewed here.

Friday, October 28, 2016

The Canary in the American Board of Family Medicine's MOC Gold Mine

In an editorial in the Mayo Clinic Proceedings this month entitled "The Evolution of Physician Certification and the Canary in the Coal Mine," James C. Puffer, MD, President and CEO of the American Board of Family Medicine (ABFM), reviewed a recently published survey on Physician Attitudes About Maintenance of Certification (MOC) by Cook, et al. that appears in the same issue. To his credit,  he acknowledged the following:
"Physicians today are overburdened with the vagaries of their electronic health records, endless reporting requirements, and the demands of multiple payors. The amount of time that they are spending with patients continues to dwindle, and the last thing that they want to do is spend additional time, meeting yet another set of requirements that they find burdensome.
Unfortunately, Dr. Puffer couldn't bring himself to admit that the costs for MOC are excessive, both in fees paid and the time required to perform this unproven exercise, and he failed to call for an complete moratorium on the unnecessary MOC requirement for the many family medicine diplomates his organization certifies.  Instead, he glowingly reviews the survey's "methodological approach," "meticulous design" and "rigorous analysis of the data," despite the survey being designed by an American Board of Medical Specialties (ABMS) employee and reviewed by a mysterious "anonymous external reviewer" (see Acknowledgements). As a result of the survey findings, he calls on "modifications" to MOC because the results of the survey represent the "canary in the coal mine" of how physicians will accept the current iteration of the MOC physician re-certification "quality" metric going forward.

But by merely disclosing that he is an employee of the American Board of Family Medicine (ABFM) in the Mayo Clinic Proceedings editorial, Dr. Puffer carries his own canary into the hallowed financial walls of the ABFM's MOC gold mine. It should come as no surprise for readers of this blog that MOC has opened all sorts of wondrous financial opportunities for the ABFM (and all of the member boards of the ABMS) at practicing physicians' expense.

For instance, while the public only has access to the ABFM's tax forms to disclose the financial dealings of the organization, we quickly see that MOC continues to be a windfall for the ABFM. In fact, in 2014 MC-FM fees (the ABFM's MOC program equivalent) contributed 46.4% ($12,776,905) of their $27,525,430 annual haul from ABFM diplomates. These fees helped support Dr. Puffer's $803,687 annual compensation and the organizations' $3,521,629 "donations" made to their "ABFM Foundation" and "Pisacano Leadership Foundation."  (In 2012 and 2013 these "donations" were even larger: $6,147,376 and $7,878,535 respectively). MOC also helped fund the ABFM Executive's first class and companion air travel and their Directors' first class air travel and a  $1,449,525 retirement package with $435,000 in post-retirement medical benefits. No wonder MOC is such a great deal and needs to continue!

The ABFM is a tax-exempt 501(c)(6) tax-exempt organization that has accumulated a remarkable $130,082,516 in assets on the backs of working physicians that is offset by "liabilities" that fund the salaries of 75 people and other "projects" in the amount of $45,838,832 yeilding a net asset balance of $84,243,684 at the end of 2014. Rather than offset the fees that diplomates have to pay the ABFM for MOC, these fund transfers show the ABFM would rather continue to plow this money into itself (rather than defraying costs to its members) by growing its supporting "Foundations."

But careful review of the ABFM Foundation's tax forms shows it carries many similarities to the infamous ABIM Foundation that gained considerable notoriety after its condominium purchase (complete with a chaueffer-driven town car) was disclosed on these pages and elsewhere.

According to the ABFM Foundation's most recent IRS Form 990, it exists for the "Fostering of Education and Scholarly Analysis or Research in Family Medicine." Like the ABIM Foundation, it seems that "scholarly analysis and research in family medicine" actually involves (in part) managing potentially lucrative real estate investments for themselves.

The ABFM Foundation is the controlling entity of ABFM Realty LLC (created in 2010) and ABFM International LLC (created in 2013), both based at the ABFM's office in Lexington, KY and lead by Dr. Puffer.

According to tax records, ABFM Realty LLC purchased a 22,793 square-foot office building (pictured here and whose location relative to the ABFM corporate headquarters is pictured here) at 1500 Aristides Blvd in Lexington, KY for $4,245,074 on June 26, 2012 from the $6,147,376 (page 11, Line 24a) of  diplomate fees "donated" by the ABFM to its Foundation that year. It appears this transaction happened about the time a large law firm, Bingham McCutchen planned to move hundreds of its employees to Lexington, KY the same year. The deal was consumated by a promise of $6.5 million in tax breaks from the Kentucky governor and anticipated revenues of $22.5 million over 10 years in rent and building improvements. Unfortunately, it seems Bingham was struggling financially and was "absorbed" just two years later by Philadelphia's Morgan Lewis and Bockius LLP law firm. Google's street view still shows Bingham's Global Services Center sign outside the ABFM's building as late as December, 2015. What this loss meant to the ABFM (and its many diplomates) is unclear, in part because to the best of my knowledge and belief this transaction was never been disclosed to ABFM's practicing physicians. Roger Bean, the Chief operating officer for ABFM at the time, "couldn't be reached for comment" either.

Here we are in late 2016 and the 2015 tax forms for the ABFM and the ABFM Foundation still have yet to be disclosed publicly.  Perhaps their recent real estate snafu explains why these forms aren't available and why the ABMS still feels compelled to continue the highly conflicted ABMS MOC program publicly in the Mayo Clinic Proceedings.

Or maybe Dr. Puffer is positioning himself as the heir apparent to the ABMS now that Lois Margaret Nora, MD JD has announced the end of her tenure at the organization.

One thing's for sure: with his editorial Dr. Puffer's own canary in the ABFM's MOC gold mine just died and many more US family physicians are now officially on notice.

-Wes


Tuesday, October 25, 2016

Are Hospitals Hurting Their Physicians?

It's becoming a near daily event for my email in-basket: receipt of another real-life story describing how the American Board of Medical Specialties (ABMS) and US hospitals are joining forces against capable doctors:
I am trying to find physicians in FL who have unfairly lost ABMS certification and as a result have been unable to find reasonable positions in Medicine.

I am a radiologist certified by ABR in 2002, the first year to require 10th year (re)certification. I lost my contract with a hospital in 2010 and took locums positions as I could find them after that. I have passed the recertification exam, for which I paid $2000, but because of short term locum positions, was not able to complete PQI requirements and consequently lost my certification. Now, unless I sign a promise to never sue the board (emphasis mine), I cannot even sign into my page on the ABR website to see my status. Since losing the certification the only work I have been able to find is a bottom-feeding imaging center where I earn less in a year than the MRI and CT technicians, while working 55-hour work week with no more than 3 unpaid weeks of vacation per year.

I am certified by the National Board of Physicians and Surgeons thru March of 2017 but this is not recognized by most locations. I was turned away at the door when I drove to NC after being invited to interview for a position. The reason -- the certification I had was not recognized except for by a handful of places.
What is going on?

It appears the ABMS Maintenance of Certification (MOC) recertification requirement is creating the situation where capable, experienced physicians are losing their job on the basis of this unproven "quality" metric.

I am sure similar stories are occurring elsewhere. There are only about 809,845 US physicians active in patient care nationwide. Many of these board-certified physicians, formerly a lifetime credential, are now receiving letters from their hospital credential committees insisting they recertify thanks to a unilateral rule change implemented in 1990 by the ABIM strictly for their financial benefit.

Why would hospitals (who need physicians to staff their hospitals) do this?

As usual, I believe it's about the money.

Many physicians are employed by hospitals that help train medical school graduates in their specialty. To do so, their post-graduate training program must be accredited and approved by the Accreditation Council on Graduate Medical Education (ACGME). Hospitals that are not ACGME "approved" cannot receive additional Medicare revenue for training these residents in medicine. The ACGME (and Joint Commission) accreditation process requires program directors to be ABMS board certified. And wouldn't you know: both the ABMS and JCAHO are member boards of the ACGME.

Appropriately experienced and trained physicians should have the right to work without having to pay into a corrupt system that funnels their money toward non-clinical executives' lavish salaries, luxury condos with chauffeurs, first class airfare, health club fees, and other delightful creature comforts, including world travel. I believe hospitals would be wise to side with their practicing physician staff on this issue. Don't hospitals need these experienced physicians to staff their clinics and to do the necessary work of training residents and caring for patients? Or do they just plan to hire less experienced (but cheaper) program directors instead? What would such a move mean to tomorrow's caliber of physicians?

How long before the growing frustration of residency training program directors swells to the point that they refuse to participate or just retire early?

I would hope that the leadership in the American Hospital Association (AHA - another member board of the ACGME) is considering these issues. Physicians unjustly targeted should come forward and join the AAPS anti-trust suit already filed against the ABMS. And currently employed physicians who have not yet had to endure this hassle should work with their Medical Executive Committees to incorporate alternatives to the ABMS MOC program in their hospital bylaws now.

-Wes


Friday, October 21, 2016

It Just Takes One

A physician pushes for reform in Maryland to make ABMS Maintenance of Certification (MOC) voluntary:
I have just got off the phone with Mary Beth Carozza, my State Delegate. Following in the wake of legal actions against MOC in OK, MI, Florida, and others, I expressed to her that I wish to have her champion legislation ending compulsory MOC in Maryland. The bill I’d offer basically says, if you wish to participate in Maintenance of Certification efforts, you are welcome to, if you do NOT, no employer, payer, etc. can use your board certification status to hire, fire, pay, not pay, promote, demote, etc. you. It makes MOC voluntary.

If you love MOC, truly believe that it’s improved the quality of your patient care, made you a better doctor, and that it’s completely worth the time, effort, and $$ you’ve invested, and you care not one bit how your board has used that tremendous surge in their income, then I apologize for having bothered you with this, feel free to delete without reading further.

If you disagree with the essentially obligatory nature of MOC, then the time has come for you to do something. ...
Read the rest here.

Each state can do this, and it just takes one dedicated physician at a time to move the needle. Kudos to Dr. Fernley.

-Wes

Sunday, October 16, 2016

ABMS IRS Form 990's and the Art of Dodging Disclosures

For years physicians, hospitals, the insurance industry, and "the public" have endured the American Board of Medical Specialties' (ABMS) and the American Board of Internal Medicine's (ABIM) breathless calls for repeated physician "re-certification" under the trademarked Maintenance of Certification (MOC) banner. What is uniformly never mentioned in the myriad of press releases or articles that support the ABMS MOC program are the multitude of financial incentives to market this program to physicians and the public.

It was with that as a background that I wrote my post on these web pages entitled "How the ABMS MOC Program Threatens Major Medical Journal Integrity" on September 5, 2016. I was concerned that the ABMS President and CEO, Lois Margaret Nora, MD, JD and her colleague Thomas Norris, MD had failed to disclose financial conflicts of interest in a letter that they had published in the New England Journal of Medicine (NEJM). I felt it was also clear that Dr. Nora had a similar lapse of failing to disclose financial conflicts in her pro-MOC article that she was invited to pen for the NEJM and in another promotional article published in the Journal of the American Medical Association (JAMA) in August of 2015.

Specifically, I felt Dr. Nora disclosure as an employee of the American Board of Medical Specialties was insufficient as it relates to collecting third-party revenues from it's separate for-profit Georgia-based corporation, ABMS Solutions, LLC. The revenues received by ABMS from ABMS Solutions, LLC are above and beyond fees paid by physicians who participate in ABMS MOC re-certification. Also, no mention of lobbying activities the organization engages in for the corporation's financial benefit was made in either journal as well.

Because of these concerns, I sent an email to the editors of JAMA and the NEJM, asking them to investigate the failure of Dr. Nora (and in one case Dr. Norris) to disclose the conflicts and to consider retraction or a correction for the failure to disclose these conflicts.

Both journal editors were responsive to my concern, but in different ways.

Journal of the American Medical Association

The Editor in Chief for JAMA, Howard Bauchner, MD responded felt that Dr. Nora's financial disclosure as President and CEO of ABMS was adequate because "professional societies and organizations, medical societies, medical schools, hospitals, and industry stakeholders in healthcare employ lobbyists on their behalf. We suspect our readers are aware of this and we do not expect authors to separately declare that their employers engage in lobbying efforts." No mention of my specific concerns regarding the money received by the for-profit subsidiary, ABMS Solutions, LLC, was made, but he did copy his email to me to the journal's editorial counsel, Mr. Joseph Thornton. When I inquired why the issue ABMS Solutions, LLC was not addressed in a subsequent email, I received no reply.

New England Journal of Medicine

The editors of the New England Journal of Medicine forwarded by communications to Dr. Nora and Dr. Norris of the ABMS.  Here is a copy of the short email I received from Mary Beth Hamel, MD, MPH, the Executive Deputy Editor of the New England Journal of Medicine in response:

(Click to enlarge)
The New England Journal of Medicine editor sided with Dr. Nora that her financial disclosure was adequate after reviewing this letter they received from Dr. Nora. In her letter, Dr. Nora stated my concerns of failure to report financial conflicts were "incorrect" for the following reasons:
"The operations, activities, and finances of ABMS Solutions, LLC and the other subsidiaries of the ABMS are consolidated for accounting purposes with those of the ABMS. Likewise, the operations, activities, and finances of ABMS, ABMS Solutions, LLC, and all other subsidiaries are consolidated for tax purposes and publicly reported on a combined basis on the IRS Form 990 for the ABMS. The references in our disclosure to ABMS refer to the consolidated entity, as publicly reported, and as such our disclosures were full and complete."
The problem is, when physicians or the public go to the ABMS website, you will notice that their Form 990 and "consolidated financials" are nowhere to be seen. Instead, it appears the NEJM expects its readers to check financial dealings themselves.

So I did.

Thanks to my familiarity with reviewing IRS Form 990's, I knew to go to Guidestar.org to look up the ABMS's latest-available 2014 ABMS Form 990 (pdf). From that, I found the following publicly reported just as Dr. Nora suggested:
ABMS Solutions, LLC earned ABMS $3,469,401 in 2014 (see page 44). Also note that ABMS claims ABMS Solutions, LLC is domiciled in Illinois (it is not, it is domiciled in Georgia). (We've seen this misreporting of the state of domicile of affiliated corporations on IRS forms dealing with the ABIM Foundation, too.)

ABMS International, LLC, a "holding company" for the ABMS, earned $5,034,433 in 2014. (see Page 44. While it not itemized in their form 990 or "consolidated financials,"  practicing physicians should note that employees of the ABMS attend posh conferences in Qatar (video) and Venice, Italy to promote their credentialing program to other groups outside of the United States. ABMS International LLC is the "Direct Controlling Entity" of ABMS Singapore, LLC that earned $0 in 2014 for ABMS in 2014. Dr. Eric Holmboe, the ABIM's former medical director (before he moved on to the Accreditation Council on Graduate Medical Education) can be seen promoting (video) the ABMS/ABIM MOC program with Singapore physicians here for an undisclosed sum).

Dr. Nora earned a remarkable $763,005 from ABMS in 2014 (and at least 11 other officers of the organization earned over $200,000) - a sum that eclipses the vast majority of practicing physicians in the United States.

These ABMS "related" organizations' revenues represented 47 percent of the ABMS total Program Service Revnue (of $18,128, 145) in 2014 - certainly not a "de minimus" amount. Why are U.S. physician fees supporting overseas marketing of this program to other countries?

But there's more.

ABMS is also the controlling entity of  the American Board of Medical Specialties Research and Education Foundation, whose principle officer is also Lois Margaret Nora, MD JD and has it's own separate IRS Form 990.  That Form 990 claims the ABMS Research and Education Foundation's mission "shall be to support the scientific, scholarly, and public education purposes of the American Board of Medical Specialties (1) by encouraging and conducting research to improve the capacity to measure, assess, and evaluate the educational scientific, clinical, and professional qualifications and performance of physicians engaged in the practice of medical specialties and (2) by conducting educational programs and disseminating information to the public to assist its recognition, evaluation, and underdstanding of the significance and importance of initial certification, of subcertification and of maintenance of certification of physicians engaged in the practice of medical specialties (3) by fostering national and international cooperation and the exchange of information related to initial certification and maintenance of certification."

Items (2) and (3) appear to represent little more than a marketing mission for ABMS certification and MOC propaganda. Item (3) further supports the the promotion of ABMS Solutions, LLC sale of physician credentialing status as well.

The finances of the ABMS Research and Education Foundation demonstrate it has a deficit of $573,644.  In FY 2014, the ABMS issued $2,115,569 grant to this "education and research" Foundation (Page 46 of the ABMS Form 990) to cover their loss.

ABMS is also the controlling entity for Multi-Specialty Portfolio Approval Program whose finances are under a separate Form 990 (website here), the first of which appears to have been created in 2014. In FY 2014, the ABMS issued $217, 548 to this organization as a "gift, grant, or capital contribution" (for "promoting physician participation and competency") (Page 46 of the ABMS Form 990). 
What does the Multi-Specialty Portfolio Approval Program do?

It seems it loses money. After all, the organization is still $181, 423 in debt after the ABMS granted it $217,548 that same year).

And what what THAT money transfered for?  The "mission" of the Multi-Specialty Portfolio Approval Program is "To promote physician participation and competency in quality improvement efforts by granting maintenance of certification credit for quality improvement efforts in local enviroments that improve quality care." Closer inspection of its website seems to hint at promoting the suspended "Part IV" of the old MOC program that Dr. Baron halted when the controversy and physician frustration with MOC began. In reality, it appears the mission of this 'Portfolio Program' is to issue funds to other "exempt non-charible related organizations" (line 49a of its own Form 990)."

I wonder who decides which "local environments" should receive that money and how it is distributed?  Really, this seems like a slick way to pay money to others that support institutions that the ABMS deems worthy of their support.
In summary, it took reviewing three Form 990's (one from ABMS and two from "related" organizations) to uncover the "disclosed" conflicts of Dr. Nora's.  As we can now see with the travel of ABMS members, "consolidation" of financials has a funny way of disclosing details.

Still, there they are. I suppose I should apologize to Dr. Nora for the fact that I was unaware of this network of spending using our re-certification fees for the benefit of ABMS and I appreciate her openness for "disclosure" in her publications and engaging with this discussion.

As an aside, it was telling that the editors of the New England Journal of Medicine never mentioned their own financial conflicts with the ABMS MOC program. (I brought this to Dr. Hamel's attention but never received a reply.)

Live and learn, colleagues.

-Wes


Addendum: On 10/17/2016 after sharing this blog post privately with the editors a week before it was published and receiving no response, the same day the post was published I received an email from Lauren Lindenfelser, Manager of Editorial Administration at the New England Journal of Medicine  that stated "Thank you for your email. Your comments were received and shareed with the editor. We have no further comment at this time."

Wednesday, October 12, 2016

MOC and DINOs Limit Patient Care in Michigan

Marc Keshishian, MD
BCBS - Michigan
Meet Marc Keshishian, MD.  He's a DINO - a Doctor in Name Only - who is the Medical Director of Blue Cross, Blue Sheild, Michigan.

Marc (aka "Dr. Keshishian") believes in the ABMS Maintenance of Certification (MOC).  At least in principle. You see, Marc does not participate in MOC himself.  Instead, after a two-step "careful review," he just decides that those who do not participate in MOC are not worthy of his blessing to participate as a BCBS-Michigan provider, even if they have 10 years experience and are a minority physician provider.

Here are the letters from that physician who refused to participate in the ABMS MOC program in Michigan and instead credentialed with the National Board of Physicians and Surgeons (NBPAS.org):

Initial notification of revocation of insurance panel participation by Blue Cross Blue Shield of Michigan
(Click to enlarge)

Second Appeal Letter from Dr. Keshishian dated 8 Sep 2016

Michigan patients should be furious. After all, these corporate DINOs are limiting patient access to physicians because credible physicians who refuse to participate in the unproven, costly, and corrupt ABMS MOC re-certification process. Because MOC has been documented to be more interested in its political and financial agenda than patient care, the AMA House of Delegates resolved to immediately end MOC. It is clear that corporate DINOs at Blue Cross Blue Shield Michigan don't care.

As we can now clearly see, MOC helps preserve the DINOs income and the company's bottom line by restricting access to hard-working (yet expensive) patient-care physicians.

-Wes


PS: Remember, while it is unsaid in his letter, there may be other conflicted DINOs responsible for Blue Cross Blue Shield's policy of requiring MOC for insurance panel participation.

Wednesday, September 28, 2016

Take Twenty-two Minutes to Learn About the ABIM

My talk given to the American Association of Physicians and Surgeons (AAPS):

For those who have been following this blog closely, much of this information won't be new. But to those who want the entire depth and breath of the corruption of the ABIM/ABMS MOC program summarized in 22 short minutes, this is a "must see." Learn, also, what can be done to disrupt the MOC re-certification cartel in medicine. The video was nicely produced and incorporates my slides into the video.

Tell your colleagues who might not know this story to watch.

Tell your local news reporters to watch.

Tell your state legislators and health care regulators to watch.

Then ask your friends at the IRS, FTC, and DOJ to watch.

After all, it's one amazing story that touches much of the bureaucratic house of medicine.

Thanks-

-Wes

Monday, September 26, 2016

Just Dues

She reached into her large canvas bag and handed it to me. “I read about your award, Dr. Fisher, and wanted you to have this to remember it by.”

I was stunned (and a bit embarrassed). “Thank you, Ms. Smith (not her real name).” There in my hands was a beautifully engraved replica of the front-page story in “The Journal,” the local National Naval Medical Center bulletin describing the Young Investigator Award I received from the North American Society of Pacing and Electrophysiology (NASPE) in 1992. Looking back, it was one of my proudest achievements in my young medical career that I can remember. That experience taught me how to do credible research, speak at a scientific session, support my work in a public forum, and write a scientific paper. Ultimately, the award opened important doors for me, like obtaining a fellowship slot at the University of California, San Francisco, one of the most academically productive electrophysiology programs in the country at the time. This plaque still hangs in my office today.

NASPE has since morphed to the Heart Rhythm Society (HRS) to better reflect the organization's more global mission to raise awareness and foster innovation in cardiac rhythm research and management. Cardiac electrophysiologists from around the world attend their annual scientific sessions to learn the latest and greatest innovations in our field. In 2015, HRS had $17M in revenues ($6.6M in registration fees (from Scientific Sessions and board review courses, I assume), $3M from grants, $2.7M from annual meeting exhibits, and $2M from membership dues, representing the largest source of revenues. These revenues were offset by $20M in expenses in FY 2015, somewhat larger than usual due to dissolution of the HRS Foundation which had accumulated a little more than $2M in losses due to lingering administrative overhead expenses. While it touts practicing physician officers, to each of their credit, none of them earned any revenue from their service to HRS in 2015. The CEO of HRS, Mr. James Youngblood, did enjoy a salary of $682,193 for his administrative services in 2015, however. So from what I can gather, MOC educational programs remain important to HRS’s bottom line. No wonder they are reluctant to lose those revenues for the organization! But supporting an illegitimate program that could damage a physician's career just for the revenue stream is wrong.

These past several weeks I received emails requesting renewal of my annual membership fees to HRS, fees I proudly paid every year since I won that NASPE Young Investigator Award. Usually, my administrative assistant would pay the annual fee automatically from my $2500 expense fund I receive from my hospital system. This year, after two years of struggling to have an impact on the MOC debacle and after having an internal debate with myself, I asked her to not pay my dues to both HRS and American College of Cardiology (ACC).

I do not make this decision lightly. I realize that many of my colleagues will think I’m being silly, rigid, or just plain dumb. After all, I won't be able to sit on steering committees for my profession without that membership or the opportunity to chair a scientific session. But most of them also know how strongly I feel about supporting the ABMS MOC program that was born from nothing more than a desire for our cash and is paid to an organization that has participated in blatant tax fraud, accounting irregularities, and strongman tactics that have threatened and intimidated too many unsuspecting and vulnerable physicians without just cause.

This is not to say I do not appreciate the earlier efforts the Heart Rhythm Society to change the MOC system for the better. Efforts like removing the double jeopardy requirement for cardiac electrophysiologists to have to certify in cardiology as a pre-condition to being granted recertification in cardiac electrophysiology, even though you passed the test, for instance, were influenced by their efforts. I also appreciated when they tried to hold sessions at their annual Scientific Sessions debating the need for MOC. But the session held with Dr. Douglas Zipes as MOC protagonist and Dr. Fred Kusumoto as MOC antagonist, allowed the protagonist to dictate the rules, insisting that no discussion of the finances of the ABIM and MOC program would occur, immediately stifling any real debate. Since that time, both the HRS (and their big brothers at the ACC) have increasingly shied away from their original public rebuke of the MOC program. It appears they have acquiesced to MOC's perpetuation, albeit in some as yet undisclosed “modified” form and with a new "blueprint." For this reason, I no longer find myself able to support any organization that allies itself with this scientifically and morally corrupt program.

The MOC re-certification cartel has become a $5.7 billion business enterprise annually in the US alone. It is incredibly divisive to our profession, dividing the bureaucratic in our ranks from those on the front line of patient care. Because this unproven and unwarranted program also threatens physicians’ ability to practice their trade and care for patients, I believe it causes significant harm to our patients by crushing the morale of too many physicians without legitimate cause just so the ABIM, the ABMS, and our own specialty societies can wallow in the MOC program's revenues. Many senior practicing physicians are leaving medicine because of this MOC requirement because they know it's just about the money. The fact that the adverse effects of this program to physicians and their patients have never been independently studied speaks volumes why this MOC program should end immediately.

I have no idea if withholding my dues will make a difference in the fight against MOC.  Certainly if HRS and ACC change their mind and work to end the MOC program entirely, I’ll be the first to reinstate my dues. But what else can I do in the short term? Keep paying? While I'll lose my subscriptions to the Heart Rhythm Journal and the Journal of the American College of Cardiology, I can search our library for articles I need. Still, I suspect I could lose some of the camaraderie that I have enjoyed in my relationship with HRS over the years, and that will be missed, but it seems like a relatively small price to pay.

My years-long investigation of the ABIM has taken me to places I never fathomed I'd have to go to get to the bottom of this story. It is strange the effect this story has had on me. On one hand, I feel greater connection to more of my peers than ever, yet on the other, I feel a quiet discontent from the House of Medicine's leadership that stands to lose the support of their rank and file as the story unfolds. I suppose I should not be surprised, especially since the MOC program has secretly funded so many for so long. But the stakes appear to be getting higher for all involved.* I just hope that exposing all of the corruption against practicing physicians by those in our own ranks ultimately brings the practice of medicine to a better place.

To offset this ennui, it would be great to have an opporuntity to meet those who might join me in my efforts to stop this program by refusing to pay their society dues. Perhaps we could arrange a trip to Chicago in May, 2017 to hoist a beer together in the epicenter of the ACGME MOC bureaucratic Machine together. It would seem quite apropos and I'd look forward to hosting that event. Let's call it "Lemonade out of MOC lemons."

We need to bring back the integrity of our profession ourselves, one dues payment at a time. It is clearer than ever that no one else will do this for us.  It would be quite remarkable if this movement gained steam, but I'm really not holding my breath.

But if it did, it would be nice to at my patient's thoughtful plaque and feel pride in what it means to be a member of a subspecialty medical society again.

-Wes

* I would have posted a picture of my award to accompany this post, but it appears my server may have been hacked. I'll know more in 48 hours as technicians are working to resolve the problem.

Sunday, September 18, 2016

Who Makes Insurance Companies Require MOC?

One of the largest reason physicians must participate in the ABMS Maintenance of Certification (MOC) program is because insurance companies demand it.

At least this is what the NCQA would like us to believe.

Those "evil-doer" insurance companies!

But it is the National Committee for Quality Assurance (NCQA), heavily marketed (video) by the likes of Atul Gwande, MD, that set the rules about which credentialing bodies US insurers can accept. Not surprisingly, the "Department of Health and Human Services (HHS) selected NCQA as an accrediting entity for Qualified Health Plan issuers participating in the Health Insurance Exchange Marketplace."

Who comprises the leadership ranks of the NCQA? Lots of good folks from the ABIM Foundation, the National Quality Forum, American College of Physicians (ACP), the Association of American Medical Colleges, and the insurance industry are members of its board of directors and its leadership team, who else?

And there you have it: a perfectly legal way to monopolize the credentialing process of US physicians, particularly one the ABMS, ACP, and ABIM stand to profit from.

And how much "quality" does the NCQA really require of insurance companies?

Not much:
(Click image to enlarge)
Sheesh. What an incredible waste of tax dollars.

If this is the hypocritical "quality" that the NCQA assures, we're all in trouble.

Time for the NCQA to add the National Board of Physicians and Surgeons (NBPAS.org) to that list of accepted credentialing bodies for insurance companies to utilize nationwide. Otherwise, given the number of suits being filed against the AOA (a.k.a., the "American Osteopathic Information Organization" as circled in the letter above) and the ABMS and its member boards these days, the NCQA board members might need an alternative, legitimate credentialing body to add to their list of acceptable credentialing boards in order to keep their jobs.

Just saying'-

-Wes

Sunday, September 11, 2016

I'm Thinking Vasodepressor Syncope

Hillary Clinton leaving the 9-11 memorial service:
There she was, standing in one place for quite a while while feeling poorly, being supported by one or more colleagues (? secret service agents?), when she tries to "walk" and stumbles toward the ground.

This just doesn't smack of an abrupt cardiac arrhythmia (usually there's no warning there), but rather hypotension. Perhaps a simple faint. Perhaps a side effect of medications. Whatever it was, there wasn't enough blood pressure to remain vertical unassisted.

Other thoughts? (Please be respectful).

-Wes

Thursday, September 08, 2016

A Rebuttal to ABIM President and CEO's Defense of MOC

In August, Medical Economics published an interview with Richard Baron, MD entitled: "The Man Behind MOC Defends the Program Against Critics." Medical Economics then solicited practicing physicians to write a rebuttal. I accepted, but with a warning:
After exchanging a series of Twitter direct messages and e-mails with the staff at Medical Economics, much to my surprise they seemed agreeable to publish my piece  and promised to move forward with the rebuttal for both print and online versions of Medical Economics.  So I signed a "Contributor License Agreement" with UBM LLC, a nearly $2.8 billion owner of Medical Economics (among lots of other throw-away publications) and proceeded to spend the better part of an evening composing my rebuttal and submitted it a few days later.

That was August 12, 2016.

I reached out to Medical Economics yesterday to inquire where things stood on the rebuttal and received a phone call a short time later from a more senior editor that they would be unable to publish my work, especially the part that dealt with the ABIM, but would be willing to write about modifications I might suggest for the MOC program. I thanked them for their review but saw no utility in promoting "modifications" to MOC over ending the program entirely. We parted company politely.

Needless to say, I'm frustrated, but this isn't the first time this has happened. (Welcome to the realities of the Medical Industrial Complex!).

*sigh*

But one of the beauties of social media and the disruptive force of the Internet is that anyone can be their own publisher. Glenn Reynolds famously coined our ability to compete with larger publishing firms "An Army of Davids."

And so, thanks to the wonders of technology, I present my rebuttal to Dr. Baron below.

* * *

Richard Baron, MD, President and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, was recently interviewed by Jeff Bendix of Medical Economics and once again attempted to defend the ABIM's Maintenance of Certification (MOC) program by rehashing his usual talking points. Dr. Baron argues that because there is an explosion of medical information out there, doctors should use ABIM recertification metric to prove to themselves, patients, and institutions that they are staying current in medicine. Dr. Baron also seems to believe that taking computerized tests assembled from a database of rehashed test questions every ten years is superior to gaining 10 years of direct patient care experience.

Unfortunately, Dr. Baron and his bureaucratic colleagues at the ABIM seem to have forgotten that practicing physicians are committed to caring for patients, not to supporting Dr. Baron’s retirement fund.

While endlessly promoting their Maintenance of Certification (MOC) program to the public, the truth is that the potential adverse effects of ABIM re-certification on physicians and their patients have never been studied, nor has the American Board of Medical Specialties (ABMS) MOC program ever been shown to improve the quality or safety of patient care (See here, here, and here), especially as it pertains to a physician's specific practice environment. Their form of assessment is, in effect, a one-size-fits-all assessment of a physician's ability to retain facts and take a test, little more. Despite these facts and thanks to heavy lobbying to the medical community by those who stand to profit from the program, practicing physicians certified after 1990 must perform this ritual every 10 years to retain their hospital privileges or be allowed to be providers for many large insurance plans while physicians certified before 1990 do not - a discriminatory practice against younger, more economically vulnerable physicians.

As a triple "Board-certified" physician in good standing who has experienced the transition of the ABIM "Board certification" credential from a voluntary once-in-lifetime designation to a time-limited one, I have experienced first-hand the irrational and humiliating process of re-certification that makes a mockery of the entire health care accreditation process. After spending nearly $10,000 to "maintain" my certifications in cardiovascular diseases and cardiac electrophysiology in 2013 for the third time and having to be scanned, searched, and videotaped to assure my integrity in a PearsonVue testing center, I decided to study the finances, practices, and financial conflicts of interest that have come to define the ABIM and (as I have since learned) much of our physician credentialing system in the United States. Some of my earlier work has already been published. In the financial analysis of the ABIM, I was joined in my effort by Mr. Charles Kroll, a certified public forensic accountant specializing in health care non-profit organization accounting who has donated over 1500 hours of uncompensated time to this review. As our analysis has continued, other physicians have quietly come forward with additional information and personal stories of the impact of an ABIM sanction when the organization targets practicing physicians they feel are cheating while attempting to study for their unproven quality metric. I have reviewed the ABIM's federal Forms 990 from 1997 to the present and other sources including the internet archive (archive.org), IRS Form 1023, Guidestar.org, Brightscope.com, Pacer.gov, and called and emailed Dr. Baron to understand why my fees were so high and better understand why Dr. Baron is able to pay himself $812,000 per year (nearly four times the typical US internist salary) while the ABIM is $50,642,980 in debt according to its most recent Form 990 (line 22, "net assets and fund balances").

By expanding my review to the ABIM Foundation and other member boards of the American Board of Medical Specialties (ABMS) (of which the ABIM has the most physician diplomats), it became obvious that the problems I found at the ABIM were endemic to most of the United States physician credentialing system under the direction of the American Board of Medical Specialties (ABMS). For instance, the American Board of Pediatrics paid a $2.4 million golden parachute to their retiring 20-year veteran President and CEO, James A Stockman, III in 2012, yet still employed him two years later for $793,438 for working just eight hours a work-week: an almost incomprehensible $2066.24 per hour. Worse still, to the best of my knowledge and belief, all of these transgressions appear to have been conveniently ignored by the leadership of US medicine’s associated member organizations of the Accreditation Council of Graduate Medical Education (ACGME), including the American Medical Association, the Association of American Medical Colleges (AAMC), and the Council of Medical Subspecialty Societies (CMSS). The House of Medicine has become deeply divided between the bureaucratic elite of these organizations and those who struggle every day to do the real work of hands-on patient care.

After writing about by re-credentialing experience in 2013 on my blog, Dr. Wes (http://drwes.blogspot.com), my dive into the corrupt finances of the ABIM began in earnest 16 Dec 2014 with my article entitled "The ABIM Foundation, Choosing Wisely®, and the $2.3 Million Condominium." Since that time, a partial list of my ongoing investigation has uncovered the following:
  • The ABIM Foundation, which was flush with over $47 million in cash when it was supposedly "created" in Iowa in 1999 (as disclosed on its tax forms from 2008 through 2013), was actually secretly created on October 17, 1989, in Pennsylvania. It has since been determined (and later acknowledged by the ABIM on their revised website) that the organization was funded by making multiple (undisclosed) transfers of ABIM diplomat fees from the ABIM (IRS Form 990's for the Foundation are unavailable for review because the ABIM had the IRS remove available tax forms after it changed the name of their Foundation from the "American Board of Internal Medicine Foundation" to the ABIM Foundation in 1999). Additional revenues were transferred from the ABIM from 1999 through 2007, culminating in the purchase of a $2.3 million luxury condominium complete with a chauffeur-driven Mercedes S-class town car in December of 2007. It remains unclear why a 501(c)(3) non-profit testing agency would purchase a condominium as an "investment" or for housing ABIM staff and directors when other cheaper options for housing exist in the Philadelphia area. The list of names of those who actually used the ABIM Foundation's condominium has never been publicly disclosed.

  • One independent peer reviewed cost analysis of Maintenance of Certification has demonstrated the average cost for an internist to re-certify is $23,607 (95% CI, $5,380 to $66,383) and cost US physicians $5.7 billion in 2015. Despite all of these facts, the ABIM and ABMS managed to lobby Congress to have MOC included in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as a physician quality measure even though 501(c)(3) organizations like the ABIM should have lost their tax-exempt status when they covertly participated in this activity, according to federal law.

  • ABIM's own published Maintenance of Certification pass rates from 2000-2014 have demonstrated 13.2% of physician first-time test-takers failed their examination with large and inconsistent year-to-year pass rate volatility raising significant concerns of how the pass rate cut-off point is determined each year and the ABIM's motives for testing.

  • Christine Cassel, MD, the former President and CEO of the ABIM and its Foundation from 2004-2014 earned over $8.9 million dollars over 11 years she worked at the ABIM for 35 hours per week and never disclosed her financial conflicts of interest while she simultaneously served on the boards of Premier, Inc., and Kaiser Hospital Health Plans until these relationships were disclosed after she left the ABIM to serve at the National Quality Forum. Despite these ethical lapses, Dr. Cassel still describes herself as a medical ethics "expert" and still serves as a consultant to the highest office in the land: the U.S. President's Council of Advisors on Science and Technology (PCAST) without Maintaining her own Certification status.

  • The ABIM showers their executives with lavish perks on the backs of their physician diplomat fees. For instance, ABIM paid for spousal travel fees for Dr. Cassel for the ten-year duration of her term, even as residents and fellows struggle with the high fees for their certification while having record medical education debt.

  • The ABIM website registration requirements and registration agreement used for their MOC program, ABIM and the ABIM Foundation routinely conduct "research" on physicians and their practices without a research protocol, Investigational Review Board review, or informed consent in violation of FDA and Health and Human Services Protection of Human Subject statutes. Note that the enrollment agreement (no longer found on the current ABIM website) stated: "I understand that the ABIM may use my examination performance, training program evaluations, self-evaluations of knowledge and practice performance, and other information for research purposes, including collaboration with other research investigators and scientific publications." There is no mistaking the ABIM was (and still is) conducting "research" on their diplomats for their benefit.

  • Robert Wachter, MD, former President of the ABIM Foundation, earned stock options from the IPC Hospitalist Company while serving at the ABIM Foundation. While it is unclear what role Dr. Wachter played at IPC Hospitalist Company, the company remains under federal investigation for Medicare fraud.

  • From 2010-2014, the ABIM paid a little-known company to the practicing physician community, CECity, $5,568,538 for their services. Just before leaving ABIM, Dr. Christine Cassel received $130,000 in cash and $100,000 in stock from Premier, Inc, that then announced its purchase of CECity for $400 million a short time later on August 4, 2015.

  • The ABMS plans to sell physician certification data to a multitude of parties at ABMSSolutions.com and offer subscriptions to its CertiFACTS Online product (video). Funny how Dr. Baron and his colleagues at the ABMS fail to disclose this fact to major medical journals and Medical Economics when they are interviewed or publish their articles promoting the need for physician re-certification.

  • Since 1 January 2014, to facilitate the coverup of its operations and to limit transparency, the ABIM no longer permits archived webpages to be stored on a regular basis on the Wayback Machine at archive.org as seen by the absence of archived webpages after that date.

These are just a small sampling of the serious problems that have been uncovered by careful review of the ABIM's actions, ongoing cover-ups, and propaganda inherent to the ABMS MOC program that Dr. Baron supports. Legal fees (all paid by ABIM diplomats) are mounting against the ABIM and the ABMS member boards as they attempt to defend an antitrust lawsuit brought against them, attempt to sanction even more physicians, and have more threats legal action from the Pennsylvania Medical Society’s recent announcement of a vote of no confidence against the organization at the AMA House of Delegates Meeting in June of this year.

Practicing US physicians don't need any more propaganda from Dr. Baron in Medical Economics promoting the ABIM's Maintenance of Certification program, we need a careful independent audit of their finances and a thorough investigation of the ABIM and their collaborating organizations by appropriate authorities to end this unjustified, highly corrupt, and conflicted ABMS MOC program nationwide.

Westby G. Fisher, MD
Director, Cardiac Electrophysiology,
NorthShore University HealthSystem, Evanston, Illinois
Clinical Associate Professor of Medicine
Pritzker School of Medicine
University of Chicago