Sunday, August 23, 2015

American Gastroenterological Association Takes Important First Step to Oppose ABMS MOC® Program

One by one, Internal Medicine subspecialties are fleeing the sinking American Board of Internal Medicine (ABIM) Maintenance of Certification® ship and creating new, non-punitive learning pathways in lieu of "recertification."

Especially important in this proposal is the permanent rejection of the need for additional "Performance Improvement" and "Patient Voice" modules AND the rejection of the high stakes secure examination after initial certification.

Here's why.

Here are the gastroenterology ABIM Maintenance of Certification secure examination first-time pass rate results for the past 15 years:

(Click to enlarge)
Note the linear regression line of the published first-time pass rates of the ABIM gastroenterology Maintenance of Certification® secure examination has declined steadily by a remarkable 0.5% per year since 2000. The pass rate also changes year to year, suggesting a lack of precision of this testing metric. As more and more gastroenterologists have had to participate in MOC®, this declining pass rate of the secure examination results in a progressively higher number of gastroenterologists that must take time away from caring for patients to retake their MOC® secure examination (and pay for more review courses) to ultimately pass. Yet there are simply no data that taking the MOC® secure examination after a gastroenterologist has practiced a minimum of six years makes them a better or safer gastroenterologist. More importantly, because participation of the American Board of Medical Specialties'  (ABMS) MOC® program is increasingly tied to a physician's hospital credentials (likely thanks to the fact that the ABMS and the American Hospital Association are both member boards of the ACGME), clinical gastroenterologists now realize they could lose their ability to practice in a hospital setting without cause if they fail this unproven secure examination metric (see this reference).

Look for other medical and surgical subspecialty organizations to quickly follow suit.

The ABMS's lucrative continuing medical education monopoly over practicing physicians will slowly but surely come to an end.

The next question will be: how will this new paradigm affect the new CMS physician payment scheme?


Saturday, August 15, 2015

The ABIM Foundation: Increasing Transparency or More Cover-up?

It is one thing to have a financial scandal.

It's a whole new thing when you try to cover it up.

But it appears this is what we should expect from an organization that has exhaustively defined their version of the term "medical professionalism" using testing fees of practicing physicians worldwide.

The American Board of Internal Medicine (ABIM), a non-profit 501(c)(3) corporation, has been under pressure since the story broke about its Foundation purchasing a $2.3 luxury condominium complete with a chauffeur-driven Mercedes S-class town car in December of 2007. The bizarre tale of a physician testing organization creating a separate non-profit charitable "Foundation" funded by physician testing fees while its own balance sheet dwindled to a $48 million deficit was unimaginable at first. But as the story grew and gained media notoriety in Newsweek, it appears the ABIM will still stop at nothing in an attempt to hide the truth. 

Given the money involved, this was predictable.

Here is the ABIM Foundation's "About Us" web page I captured as late as June 13, 2015.  

Here is the ABIM Foundation's "About Us" page today. (In case the ABIM changes the page again, I have it copied here).

Note the difference in the dates of creation of the ABIM Foundation on the two web pages - the first claiming the ABIM Foundation was started in 1999, the second stating the Foundation was started in 1989. 

Let's examine what is said on the new web page more carefully.

First the new Foundation About Us web page says: 
"How was the ABIM Foundation established?

ABIM created the ABIM Foundation in 1989. Through an extensive strategic planning process, in 1999, the ABIM Board of Directors established a separate Board of Trustees to govern the ABIM Foundation."
Note that the ABIM now admits the ABIM Foundation was indeed created in 1989 as this blog uncovered in December 2014. This does not explain why the ABIM Foundation was established and why they hid its existence before 1999 on their website previously. In fact, the US Internal Revenue Service should be VERY interested in why the Foundation still lists its creation date as 1999 on its most recent tax filing made this year.

It is interesting that the ABIM suggests there was "an extensive strategic planning process" to create a separate "Board of Trustees to govern the ABIM Foundation." This still does not explain the ABIM Foundation origination date discrepancy nor does it relieve the organization of its responsibility to disclose to the public the existence of the Foundation before 1999. In 1998 the ABIM did change its bylaws, however. At that time, the new ABIM bylaws made the ABIM Foundation the "sole voting member of the Board as a corporate entity" effective 1 January 2002.

How is the ABIM Foundation funded?

ABIM initially transferred $5 million to the Foundation in 1990. Over nearly 20 years (between 1990 and 2008), approximately $56 million was transferred by ABIM to the ABIM Foundation. There have been no transfers since 2008.

According to the above statement, the ABIM Foundation claimed they received "approximately" $56 million of physician testing fees to their Foundation for their own use. We should note that the ABIM Foundation already had $59,618,428 million in assets by 30 Jun 1999.  It appears the Foundation is using a very loose definition of "approximate" because the amount transferred was much more. In fact, an additional $20,660,000 were transferred to the Foundation from 2000-2007 for a grand total amount of accumulated assets courtesy of US physicians of $80,278,428. (Links to the itemized transfer amounts are included here for your review: In 2000: $3,300,000; in 2001: $1,600,000; in 2002: $1,000,000; in 2003: $1,760,000; in 2006: $7,000,000, and in 2007: $6,000,000.)

And what does the ABIM Foundation do with all that money?
What kind of work does the ABIM Foundation do?

The ABIM Foundation is an operating charity, and as such develops and implements projects in support of its mission.

One of the Foundation’s most significant contributions has been the publication of Medical Professionalism in the New Millennium: A Physician CharterCo-authored with the ACP Foundation and European Federation of Internal Medicine, the Charter has been endorsed by more than 130 organizations and 100,000 copies have been distributed.
The "mission" here remains undefined. We should recall that the Medical Professionalism in the New Millenium paper wasn't published until 2002 and the team assembled to "define" the term "medical professionalism" didn't start work until 1999.  This leaves a gaping hole in the "mission" of the ABIM Foundation from 1989-1999. In fact, it appears that the ABIM Foundation was little more than an investment vehicle for the ABIM and a way to shelter cash from the ABIM and a means to pay their friends other grants that are undisclosed on their new "About Us" web page. For instance, the ABIM Foundation paid money to the George Soros' group, IMAP, and paid back funds to the ABIM and to the American College of Physicians. In addition, the Foundation has made grants to their own (now defunct) Institute of Clinical Evaluation among others. Is the ABIM Foundation ever going to mention these transfers of physician testing fees to these many institutions? It seems unlikely.

A thorough house cleaning and investigation of the ABIM and its Foundation is long overdue. The recent attempts at "transparency" by the ABIM Foundation are only making things worse.  It is no longer tolerable that our professional organizations who have supplied content to the ABIM for their Maintenance of Certification program permit the ongoing cover-up of the ABIM's financial actions over the past twenty-five years.  The longer these other organizations collude with the ABIM, the more they risk their own credibility with today's practicing physicians.

It's time to stop the madness and for the ABIM and their collaborators to come clean.


Wednesday, August 12, 2015

On the Origins of Note Bloat

"If all clinicians needed to do with our documentation was practice medicine, our notes would be more logical and much less bloated. Laundry lists of irrelevant and inaccurate diagnoses would not populate into every note. Copy and paste would occur a lot less often, and likely could be limited to appropriate uses such as carrying over past medical history (which should always be copy and pasted after verification to reduce errors). Only relevant physical exam findings would be reported, so these would not be lost in a sea of normals. Useful information that is not valued externally, such as personal touches – i.e. patient’s wedding anniversaries, achievements of their children, would have it’s own optimized workflow.

Regulatory compliance and malpractice protection, are responsible for the large majority of the drivel that shows up in our notes. Believe me, we doctors would all love to confine our work to health care delivery, but external forces box us into this uncomfortable place, and this creates junk documentation."
Read the whole thing.


Tuesday, July 28, 2015

An Independent Cost Analysis of the ABIM Maintenance of Certification Program

Today, the first independent cost analysis of the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program was published online before print in the Annals of Internal Medicine from the University of California San Francisco and the Veterans Affairs Palo Alto Health Care System.

The results of the Base-Case Analysis are remarkable: "Internists will incur an average of $23,607 (95% CI, $5,380 to $66,383) in MOC costs over 10 years, ranging from $16,725 for general internists to $40,495 for hematologists-oncologists. Time costs account for 90% of MOC costs. Cumulatively, 2015 MOC will cost $5.7 billion over 10 years, $1.2 billion more than 2013 MOC (emphasis mine). This includes $5.1 billion in time costs (resulting from 32.7 million physician-hours spent on MOC) and $561 million in testing costs."

How much does it cost by specialty over 10 years? Here's a copy of one of the tables from the article included for your review:

Cost to Participate in MOC by Subspecialty (Click to enlarge)

Here's a breakdown of MOC costs for individual physicians from the article based on the number of certificates they maintain with confidence intervals displayed:

MOC Costs for Individual Physicians - (Click to enlarge)

MOC is not an educational program based on evidence of improved patient outcomes or care quality.  Rather, it is an educational program that was created by fear - fear of loss of credentials and fear of loss of insurance panel participation and payments.  As such, it is inherently coercive.

If there ever was a time to stop the wasting of physicians resources and time that has yet to demonstrate any evidence that the program improves patient outcomes or care quality, the time is now.


Alexander T Sandhu ,  R. Adams Dudley, Dhruv S. Kazi. "Cost Analysis of the ABIM Maintenance of Certification Program" Ann Intern Med 28 July 2015,(), doi: 10:7326/M15-1011.

Addendum 29 Jul 2015 @ 12:41PM CST:
Dr. Richard Baron responds to this Cost Analysis on the ABIM blog as "The Cost of Keeping Up." No public comments are taken on the blog any longer, but the ABIM is accepting e-mails.  Baron's response fails to acknowledge that the authors projected ABIM will make more than half a billion dollars in ten years and that this cost estimate is ten times higher than Dr. Baron has mentioned on numerous occassions (see here and here), irrespective of the time required by physicians "to keep up."

Sunday, July 26, 2015

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.


Monday, July 20, 2015

Schloss: Surgeon Scorecard and the Fallacy of Aggregated Administrative Data

Edward J. Schloss, MD reviews the recent controversy over ProPublica's recent sensationalized public reporting of administratively-collected surgical mortality and readmission data:
"Some have argued that it was important to get this data out for public review, despite it’s limitations. I respectfully disagree. I subscribe to the belief that bad data is worse than no data. Certainly the scientific literature is replete with examples that prove this correct.

So is Surgeon Scorecard bad data? Strong words, but I say yes. This analysis was a great idea, but it fails to deliver on its goals. The data and methodology both have significant flaws. I say that from the perspective of a working clinician and clinical researcher with over 20 years experience, but I’d like to see a higher level of review. This project is as much science as it is journalism.  Surgeon Scorecard should be peer reviewed and critically discussed as would any scientific outcomes study. As I suggested to ProPublica, we need to kick the tires."
His analysis is a "must-read" for it speaks to many of the major flaws of using poorly collected and analyzed Big Data to improve medical care.