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.


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.


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 Baucher, 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.


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.


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.



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.


* 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'-