Wednesday, December 06, 2017

On the December 4 Meeting of the Untouchables

From the invitation-only December 4, 2017 meeting on Maintenance of Certification (MOC®) practicing physicians were not allowed to attend, came this synopsis from Ohio:
Fellow Council members,

The following are my thoughts following the long-anticipated MOC® meeting in Chicago. An official report that will be distributed to the general membership will follow.

The meeting was hosted by the American Society of Anesthesiologists in Schaumburg, IL. The auditorium designed to hold 150 people, was filled to standing room only.

A bit of background, this meeting was the brainchild of Donald Palmisano, Jr., CEO Medical Society of Georgia, and Hal Lawrence III, MD (Executive Vice President and CEO) ACOG. (Editor's note: The American College of Obstetrics and Gynnecology (ABOG) are subcontractors for "Test Development" with the ABMS.) During the interim and annual meetings at the AMA, the state and specialty societies meet. It was during this meeting in Chicago that the idea for today's meeting was formed.

Dr. Lois Nora, current President and CEO of the American Board of Medical Specialties spoke first. In her 20-min remarks, she acknowledged each of the points raised in the letter penned by the state and specialty societies. Dr. Nora's term ends on December 30, 2017. Her successor is Richard E. Hawkins MD, who is leaving his position as Vice-President of Medical Education at the AMA to take this position.

Her Key Points:
  1. Committed to improving continuing certification
  2. Add state society representation to the Committee on Continuing Certification
  3. Admits that the current MOC® process is problematic
  4. MOC® should not be used as the only criteria for state licensure, credentialing, or employment
  5. Agrees that professional self-regulation is valuable
  6. Asked that the states not support anti-MOC® legislation (citing possible unintended consequences)
Summary of the comments from state and specialty society representatives:


  1. Physicians insist on trust, input, transparency, and improved communication from the boards
  2. Create a process that is developed with us not forced upon us
  3. Process should not be punitive. Use the carrot and not the stick
  4. MOC is an irrevocably tarnished brand
  5. Following initial certification, the high stakes exam should be only one of several options
  6. Create a process that is fair to physicians holding more than one certification
  7. Several specialties have already implemented processes that offer ongoing demonstrations of competency as an alternative to the high stakes exam.
  8. Two specialty societies (Family Medicine and Psychiatry) stated that they were considering up thir own boards as a solution
  9. Anesthesia was the only specialty that admitted that reducing the burden on physicians had a negative effect on their bottom line
  10. Multiple states vowed to continue legislative efforts until tangible efforts in the MOC® process can be seen
  11. Need for dur process for physicians whose ability to work has been adversely affected by inappropriate use of MOC®
  12. The hospitals (AHA) and insurers (AHIP) should be invited to the discussion as they are the entities most likely to use MOC® inappropriately.

Please note that I spoke personally to the organizers of this meeting to request that Ohio be included in future discussions regarding MOC.

Respectfully submitted,

RF Chatman MD, MPH
President, Ohio State Medical Association
It appears the thrust of this "meeting" was to try and get states to NOT pass anti-MOC legislation. It didn't take long for an analysis of the Ohio synopsis to appear in my inbox from one observant physician (printed here with permission):
It seems to me as though this debate has now been quietly and cleverly re-framed in terms of retaining and "improving" (compulsory) MOC®.

Remember, it is only made "compulsory" through collusive "enforcement" by those twin paragons of virtue, the insurance and hospital corporations.

"No more high stakes exams we promise" they cried. The implied subtext being that the obligatory ABMS MOC parasite will remain Ebola-like, in some mutated and quiescent form, and continue to infect us all.

Debating the "character" of MOC® was four years ago. Pretty please. That didn't work. Now the issue is not MOC® but the utter and complete repudiation of ABMS lock, stock, and barrel. (Editor's note: Recall the AMA House of Delegates already voted to do so in June, 2016. We now see the AMA's answer to that resolution: to place physician puppets in position of power at the ABMS to assure their lucrative international medical data mining project grows ever stronger and more valuable.)

MOC® should be in reality just another innocuous and palatable Continuing Medical Education (CME) option, but has become a forced and toxic one. A most profitable and poisonous bubbling brew concocted and fed to us by our "peers in leadership positions." The ABMS have become the very caricature of witches on MacBeth's "blasted heath."
The ABMS and their 24 specialty lackeys should now go off and hawk their wares like any tawdry CME street vendor in the chaotic for-profit "medical education" bazaar. Through their grotesque avarice the ABMS have irreparably tarnished their brand. No physician will ever respect them again. Ever. They are done.

Why on earth does anyone even stoop to converse with the ABMS anymore? It is too late for that. As Texas Medical Association President Carlos J. Cardenas, MD said "Physicians in Texas and across the country... do not see the certifying boards as 'self.' They are, instead, profit-driven organizations beholden to their own financial interests. In fact, they are now one of the outsiders intruding into the practice of medicine."

States should pass their anti-MOC laws, the ABMS and its apologists should be disregarded, and we all should move on.

Why did the state medical societies, which (with very few exceptions) also lack any standing amongst rank and file doctors, even bother to meet with the ABMS?

It is a total charade, a Jersey boardwalk puppet show populated by unrepresentative and self-aggrandizing narcissists lobbying each other. What on earth were they doing, imploring the ABMS on a bended knee to change their wicked ways?

"My" state medical society (sadly not one of the exceptional ones and one having less than 5% of state physicians as members) has no right to negotiate the character of MOC® on my behalf. It is too late for that. The state medical societies have become little more than the mini me's of the hated and corrupt AMA.

The single demand going forward should be to break up the ABMS monopoly and open up the market to competing boards like the NBPAS, recently delineated in an article by an FTC member. Let the physician marketplace decide which boards truly represent their interests. Period.

The hospital and insurer enforcers should be met head on now. Forget the disgraced ABMS. The MOC® debacle has catalyzed the onset of a transformative phase in medicine, one we physicians must be the first to recognize and guide.
Somehow, I didn't think I could improve on this cogent analysis.

-Wes

Sunday, December 03, 2017

When Medical Subspecialty Societies Do Harm

Pediatrician Meg Edison, MD gives her take on her "MOC failure:"
I am a diplomate of the American Board of Pediatrics against my will. I find it morally reprehensible to financially support an organization that harms fellow physicians. I find it demoralizing to know my money supports their lobbying efforts against our state MOC legislation. Yet I paid in order to see my patients. I paid so I could still be a doctor. The American Board of Pediatrics could ask for another $1500 next year, and I’d have to pay again. There is no choice.

Is it possible I was targeted for being so outspoken on MOC? Possibly. My initial letter to the ABP has over 100,000 views. My medical society has used me on the cover of their magazine and their website dedicated to fighting forced MOC. The ABMS Senior Vice President knows me by sight, and has watched me testify against forced MOC in our state capitol on multiple occasions.

But I’ve been contacted by countless quiet Michigan physicians threatened and decredentialed for simply refusing to pay for MOC. It doesn’t matter who you are, an outspoken physician with a state medical society behind you…or a solo practitioner quietly trying to stay afloat…you must comply.

I don’t know the solution to this problem. It seems like every legal, logical, and ethical boundary that should prevent a certifying company from gaining such absolute unchecked power has been ignored, and every professional organization that should help us is impotent.

My state medical society has held clear policy opposing board certification, let alone MOC, for insurance plan participation for 20 years. They’ve been negotiating for 20 years, yet aggressive MOC discrimination continues. The AMA has strong policy opposing MOC abuse, but refuses to do anything. The FTC should see this monopoly as a clear anti-trust violation. They are waking up, but still not acting. I am baffled the IRS doesn’t question the million dollar salaries raked in by these “non-profit” organizations. It seems like this would be a slam-dunk class action lawsuit for some smart law firm, but no one is interested in the case. State legislation is likely our best bet, but the lobbying power of insurers, hospitals, the billion dollar ABMS certification industry and their codependent specialty societies is nearly impossible to fight.

If nothing is done, ABMS will win, because their entire coercive business model relies upon our professionalism. As physicians, we take an Oath to “Do No Harm”. We promise this to our patients.

My first emotion when I heard my patients were forced to receive care in the ER was not anger at ABMS. It was gut-wrenching guilt. I dared to speak. I dared to fight. I underestimated their power. I was stupid enough to think MOC was a physician issue. It never crossed my mind that my patients would be harmed. I know better now. The next time they ask for another check, I will comply, and they know that. I just hope something is done before then. Primum non nicer.
Read the whole thing.

-Wes

Tuesday, November 28, 2017

Despite Known Conflicts, ACC/HRS Endorse MOC

The Heart Rhythm Society (HRS) and American College of Cardiology (ACC), two organizations who stand to gain handsomely from their NCDR procedural registries, published a carefully-worded combined statement on "Lifelong Learning Requirements for Clinical Cardiac Electrophysiology (CCEP) Specialists" in their respective journals this week.

In a glaring ommision, the publication concerned itself with how Relationships With Industry (RWI's) were handled by the authors, but failed to address the many known RWI's of the bodies that "approved" their statement, including the ACCME, ABMS and ABIM. These relationships include the known collusion of the ABIM with CECity, Inc (held by Premier, Inc, the largest hospital purchasing consortium), the Massachusetts Medical Society and its NEJM Group, the multibillion dollar Netherlands publisher and owner of UptoDate, Wolters Kluwer, PearsonVue, and the myriad of test security companies who benefit from the unproven MOC mandate.

These are not minor conflicts.  They strike to the very core of the integrity of our profession and physicians who must place the interests of our patients before all else. Setting the "rules" for lifelong learning is not required, integrity and honesty in dealing with patients is what is needed instead. Those internal principles cannot be simply articulated in the form of a published "guideline."

This blog has carefully articulated the many civil liberties violations and ethical breaches perfomed by the ABIM (all sanctioned by the ABMS and perpetuated by the AMA) for the past four years. Financial cover-ups, tax fraud, HIPAA Business Associate Agreements that are not optional, and the use of a team comprised of a felonious "Director of Investigation", ABIM staff members, and members of the ABIM legal team to obtain physician emails covertly, so they could use that information to discredit and intimidate physicians, are our reality.  Yet the ACC and HRS have decided to turn a blind eye to the corruption because it might disturb their business model.

Using hugely conflicted certifying bodies to certify a professional position statement document is a problem the ACC and HRS have chosen to ignore to their detriment and the detriment of our professional integrity.

-Wes

Monday, November 27, 2017

Thanksgiving 2017 and the Grooming of Physicians

"Fun, flexible, and refreshing way to earn your credit! Take a break from the bird and have your hand at a few."

So said the American Board of Pediatrics' (ABP) Thanksgiving 2017 tweet seen here (now deleted).

As if family time and the true meaning of Thanksgiving mean nothing to the American Board of Pediatrics (ABP). Rather, David G. Nichols, MD, the President and CEO of the ABP, must need to assure his Christmas bonus.

Boasting that "20,000 physicians enrolled in Question of the Week" (QOW), as if there was another option for pediatricians caught in the regulatory capture vice-grip of MOC®, speaks volumes about the motivation of this organization. In fact, the real world reality is that not signing up and paying for "QOW" risks a practicing pediatrician's ability to participate in insurance panels or to maintain their hospital privileges.

The Thanksgiving message from Richard Baron, MD, President and CEO of the American Board of
Internal Medicine, was equally troublesome given the reglatory capture realities of the ABIM's MOC® program, too:
"Thank you for all you do every day."
You're welcome, Rich.

Now tell us, given the spending, financial shenanigans, and legal fees incurred by the ABIM and ABIM Foundation lately, are the ABIM and ABIM Foundation insolvent as at least one accountant suggests?

Given the realities of the ABMS MOC® program that both organizations promote, placating physicians with such messages at Thanksgiving is akin to a child molester grooming his victims to earn their trust; it's about as ethically moribund as it gets.

-Wes

American Academy of Pediatrics "Sets Sail" to Track All US Children

The American Academy of Pediatrics, (aka, "Big Brother") wants to track your children. Physicians who support the program can earn MOC® credits, too:
The Academy has set sail to be the first entity to collect, store and analyze health data on all U.S. children. The board agreed to commit $583,000 in resources from the Tomorrow’s Children Endowment to begin development of a child health clinical data registry, which is expected to unfold over five years. This unprecedented initiative, called Clinical Health Information and Longitudinal Data Registry (CHILD), is the outgrowth of two strategic plan objectives:

Use data and metrics to develop and priori­tize areas of need for child health policies. Provide state-of-the-art pediatric practice information in the context of a changing industry and professional landscape. Data would be captured through electronic health records, integrated health care systems, payers and existing pediatric disease registries. Data elements would include well-child and sick visits, chronic disease diagnosis and management, specialty care, and developmental and behavioral care. The registry also would include a patient portal to allow parents and patients to input data, while alleviating complications surrounding privacy laws.

Christoph U. Lehmann, M.D., FAAP, medical director of the AAP Child Health Informatics Center, and professor of pediatrics and biomedical informatics, Department of Medicine, Vanderbilt University School of Medicine, presented project details to the board, including the following primary goals:

Create substantial improvements in child health and well-being. Accelerate advances in child health. Improve outcomes for children using data. Demonstrate the trajectory of child health through adulthood. Among the benefits of this registry, Dr. Lehmann said, are tracking childhood health and illness trends, which would help draw conclusions on a number of areas, including gaps in care, treatment options and regional variations in care. The data also will help inform the creation of AAP guidelines and policies, and provide guidance to payers.

Members could use the data to help create reports for quality improvement projects, as well as for meaningful use and Maintenance of Certification, Dr. Lehmann said.
What could possibly go wrong?

-Wes

Friday, November 10, 2017

The History of the ABIM Art Collection U.S. Physicians Have Never Seen

They were the glory days; a time when the ABIM was still respected; a time before the World Wide Web and moving diplomate testing fees from the ABIM to a secretly-created shadow "Foundation" could occur below the radar.

John A. Benson Jr., MD and Harry R Kimball, MD were the first two Presidents of the ABIM appointed after the bylaws were changed to pay officers salaries. Dr. Benson was the first President of the ABIM from 1975 through 1991 and ran the organization from his home in Portland, OR, leaving his academic and clinical practice for the administrative world of the ABIM save for one long-time physician-patient he kept while serving in that capacity.* Dr. Kimball, his all-too-willing successor from 1991 through 2003, understood the number of doctors being trained was finite and paying executives would be difficult without a new business model. It was Dr. Kimball who conceived of "maintaining" one's board certification through ABIM's Continuing Professional Development (CPD) program to keep the money flowing. But the initially voluntary program flopped as doctors saw the program for what it was: an unnecessary distraction from their busy practices. So CPD would have to become mandatory. His like-minded colleagues at the American College of Physicians (who would also financially benefit) could see to that, and soon money flowed like honey. So much, in fact, that something had to be done with all that money earned by a so-called "non-profit."

It was under Dr. Kimball's direction as ABIM's Chairman of the board from 1989-1990, the ABIM Foundation was secretly created in 1989. Multiple money transfers from the ABIM to the Foundation were made to facilitate lucrative investments with (the now-defunct) 1838 Investment Advisors. For a while, it was a win-win for both corporations. So many trades were made that ABIM paid nearly a quarter of a million dollars annually for their services.

With that money flowing to the ABIM, nearly $90,000 of artwork was purchased for their Walnut Street offices in Philadelphia in 1997 and 1998. We know this because the ABIM offices were later renovated in fiscal year 2003 as the computerized testing age came to Philadelphia. At that time, the value of that art work was disclosed on ABIM's IRS tax forms (see here, here, and here).

In total, it appears $89,874 dollars worth of some kind of art adorns ABIM office walls, thanks to ABIM diplomates. No wonder they "surprised" Dr. Kimball with a black tie event and had the first "Kimball Lecture" in honor of him in August, 2004!

But then 2005 came.

The gravy train ended when 1838 Investment Advisors' fund lost 74% if its value and mysteriously disappeared:
"The silence has been deafening," said one money management executive in the region, who declined to be named. It's as if they "fell off the face of the earth," said a pension consultant, who asked to remain unidentified. One private equity veteran, who declined to be named, said it's unusual for a firm with such a long history to simply disappear. The firm traced its lineage back to Drexel and Co., a banking and investment management firm founded by Francis Drexel in Philadelphia in 1838.
Principles from 1838 Investment Advisors were holdovers from the Drexel Burham Lambert that came under investigation for illegal activities in the junk bond market for stock manipulation. Since that gravy train collapsed, another hopeful investment was made in real estate: a condominum puchase in December 2007.

The ABIM Foundation was never about "medical professionalism" or "Choosing Wisely®." It was a "get-rich-quick" scheme using diplomates' testing fees for the organization's own corporate benefit.

That is, until it wasn't.

-Wes

* Interview with Dr John A Benson, Jr, MD, conducted April 27, 1999, page 18.

Thursday, November 09, 2017

Combating MOC Abuses

Thanks to the Orlando Medical News for their comprehensive coverage Tuesday on the American Board of Medical Specialties' (ABMS) Maintenance of Certification (MOC) scandal.

Physicians' best approach to collapse the current ABMS monopoly on credentialing standards remains mass non-compliance.

Employed physicians (like myself) are finding noncompliance impossible without jeopardizing their employment, since many hospitals require their physicians to be "board certified" in their specialty. Since ABMS no longer "recognizes" lifetime certification as a valid credential (except for older "grandfathered" physicians who obtained their board certification before 1990), younger (more economically vulnerable) physicians risk the loss of employment if they do not participate in MOC and agree to the ABMS's "HIPAA Business Associate Agreement," becoming little more than data entry clerks for the lucrative insurance, pharmaceutical, and hospital industries.

Is this really what our patient's want?

I don't think so. Most patients I know would like to see their doctor look them in the eye rather than at a computer screen. Most want to be viewed as humans rather than a data profit center. And all of them want to spend more than 8 minutes with their physician.

So how do physicians combat MOC? How do we preserve our ability to work without having to make extortion payments to the ABMS and their member boards just for their political and personal benefit?

The fight against MOC continues on many levels, but it is a long, difficult, and expensive David-vs.-Goliath battle:
  1. The development of an alternate certification board that is affordable and does not require physicians to comply with the ABMS/ABIM HIPAA Business Associate Agreement and comprised of highly-respected unpaid members of the physician community who understad the conflicts of interest inherent to the ABMS member board construct and is gaining acceptance hy hospitals accross the country.

  2. State-by-state legislation efforts outlawing the use of MOC as a condition of insurance panel participation, hospital privileges, or state licensure.

  3. Persuing other legal avenues, including anti-trust and class action suits against members organizations of the Accreditation Council for Graduate Medical Education, among others.

I would encourage employed physicians who are given a professional stipend from their hosptial systems for professional society memberships to seriously consider using some of those fees to join Practicing Physicians of America in lieu of other conflicted professional and subspecialty organizations as we continue to push back against the MOC mandate (an example of to testimony and evidence provided the Ohio Health Committee here). Other areas to contribute include becoming certified by NBPAS or contributing to their advocacy efforts. It costs nothing to join the Facebook group Physicians Working Together, too. That group offers lots of productive ideas on how we can work collectively to restore the integrity of our profession.

It is only through a corrodinated effort from a large portion of the working physician community that our freedom to truly work in our patient's best interest without unnecessary and unproven third party interference can be restored.

-Wes

Wednesday, November 01, 2017

The Hidden Message Coming From the AMA

This morning I received a press release from the American Medical Association (AMA) that said "New AMA Research Finds One in Five Physicians Ready to Reduce Clinical Work Hours." The press release pointed to "new research" (sorry, it's behind a pay wall) that appeared in the Mayo Clinic Proceedings from "experts" from the AMA, Mayo Clinic and Stanford University. The lead author of the research was Christine A. Sinsky, MD of the AMA.

But what Dr. Sinsky fails to disclose in her article in the Mayo Clinic Proceedings, is she is also a Director of the American Board of Internal Medicine (ABIM) and a member of the Board of Trustees of the ABIM Foundation, serving as the Vice Chair. This is not a minor lapse in disclosure, since the ABIM Foundation and the entire national Maintenance of Certification debacle may become one of the largest medical education corruption stories in modern medical history. Funneling over $78 million dollars for ABIM testing fees behind physicians' backs to fund the ABIM Foundation appears of little importance to Dr. Sinsky. She is more concerned about our psychologic well-being rather than the behavior of the Foundation she runs with our Maintenance of Certification (MOC) cash. This corruption renders Dr. Sinsky's arguments why physician burnout is at an all-time high mute moot. Turning a blind eye to the facts only deepens physician frustration with our current bureaucratic leadership.

If Dr. Sinsky is so concerned about physician burnout, why isn't she the leading spokesperson at the AMA insisting the leadership there end MOC as it was resolved by the AMA House of Delegates in 2016?

Perhaps it's because she's too conflicted to understand the problem.

-Wes