ABIM Statement in Response to April 7 Newsweek Opinion Column
Philadelphia, PA, April 8, 2015 – On April 7, 2015, Newsweek posted an opinion column containing incorrect information about the American Board of
Internal Medicine (ABIM).
ABIM Accounting Information
The opinion column inaccurately suggests that ABIM's decision to offer a new program with new payment options in 2014 was driven by financial
considerations and also mischaracterizes ABIM's financial position. ABIM has always maintained a sufficient cash balance to meet the future
commitments made to more than 90,000 diplomates who have paid “up front” and enrolled in its program for 10 years, and ABIM's accounting
accurately reflects these future obligations.
ABIM's financial information is independently audited each year by one of the nation's most-respected accounting firms. The most recent report,
available on ABIM's website, resulted in an “unqualified opinion.” According to Generally Accepted Accounting Principles, the auditor “has
the responsibility to evaluate whether there is substantial doubt about the entity's ability to continue as a going concern for a reasonable period of time”
– if such doubt existed, they could not issue an unqualified opinion.
Efforts to Reduce Duplicative Reporting
In furtherance of its tax exempt purposes, ABIM is proud of its efforts to ensure that physicians meet high quality standards while simultaneously
minimizing overly burdensome and duplicative reporting requirements. ABIM has been very supportive of public policies that enable physicians who
participate in Maintenance of Certification (MOC) to fulfill other reporting requirements. ABIM has been transparent about these efforts and complies
with the Internal Revenue Code and Internal Revenue Service rules applicable to organizations that are exempt from tax under Internal Revenue Code
Section 501(c)(3), including the rules regarding lobbying activities by such organizations.
Moving Forward
On February 3, 2015, ABIM announced changes in its MOC program and a commitment to actively engage with the internal medicine community.
Together, we will seek the best ways to fulfill our shared responsibility to be prepared to meet our patients' needs in a rapidly changing environment.
We are in the early stages of those conversations and look forward to continued dialogue with the community we serve to create meaningful programs.
For media inquiries, contact press@abim.org.
About ABIM
For more than 75 years, certification by the American Board of Internal Medicine (ABIM) has stood for the highest standard in internal medicine and its
20 subspecialties and has meant that internists have demonstrated – to their peers and to the public – that they have the clinical judgment, skills and
attitudes essential for the delivery of excellent patient care. ABIM is not a membership society, but a non-profit, independent evaluation organization.
Our accountability is both to the profession of medicine and to the public. ABIM is a member of the American Board of Medical Specialties. For
additional updates, follow ABIM on Facebook and Twitter.
MOC Watch: ABMS President Rebuts
Critics
Though MOC needs improvement, it remains
valuable to physicians.
•
•
by Shara Yurkiewicz MD
Staff Writer, MedPage Today
Criticism against maintenance of certification (MOC) has been mounting since the American Board
of Internal Medicine (ABIM) adopted the new requirements in early 2014.
Though the ABIM promised major changes earlier this year, the organization -- as well as its parent
organization, the American Board of Medical Specialties (ABMS) -- has continued to come under fire
by physicians.
Physicians have called the MOC process burdensome and irrelevant, and some have questioned
the financial motives of the certifying boards.
In January of this year, opponents of the ABMS program established the National Board of
Physicians and Surgeons (NBPAS) to offer an alternative route for recertification in various
specialties.
Meanwhile, how is the ABMS responding to the criticism? MedPage Today talked to Lois Nora, MD,
JD, MBA, president and chief executive officer of ABMS.
"We are committed to improving MOC while underscoring its importance," Nora told MedPage Today
during a phone call monitored by a communications officer from ABMS.
Nora responded to criticisms leveled against ABMS, discussed steps the board is taking to address
them, and explained why she so strongly believes in the importance of MOC.
MedPage Today: Critics of MOC have argued that there are no independent studies (those
that aren't board-funded) that show its effectiveness. What would you say to that?
Nora: I'd say three things. First, board certification itself has been well demonstrated to be a quality
indicator by a variety of research.
Second, it's important to underscore that research done by the Boards on MOC is actually part of our
quality improvement. While I understand people want to see research in addition to that, it's
exceptionally important that we do our own quality investigation and report it publicly. So I am proud
of the specialty board research that has been done on MOC.
Third, with regard to outside research on MOC, it's important first of all to understand that the
structure of the MOC program is constructed and based on research that has been done in quality
science, adult learning, and assessment. So it is an evidence-based program in terms of how it is
constructed.
Because it is a young program, there is still less research than all of us would like to have on MOC.
But there is emerging research ... that has demonstrated that MOC makes a difference in terms of
patient outcome. Much of that research is related to the quality improvement activities that
physicians do as part of their MOC, but there is developing research underscoring value of MOC in
terms of patient care.
MPT: Another criticism that people have mentioned is that the MOC exams aren't always
relevant to everyday practice. The example often used is that of anesthesiologists who care
for adult patients -- why would they need to memorize pediatric dosing?
Also with regard to relevance, critics have said that some of the quality improvement [QI]
projects aren't always clinically relevant or useful.
Nora: Sure. I'll talk about MOC as a whole and then specifically about the exam and then the QI
projects.
MOC is an integrated program of multiple elements. It's important that it cover breadth of the
specialty as well as the specifics in which a physician is engaged.
A good example is that many pediatricians in this country have never seen a case of measles. Very
few pediatricians in fact will see a case of measles. But with the changes in immunization rates that
we are seeing -- for example, in California -- it's important that pediatricians recognize and
understand that particular illness.
So elements of the integrated MOC program have to cover things that are both common and
uncommon.
In terms of the examinations: the examinations are developed not by a small group of people but
actually by substantially large groups of people in the specialty. They make determinations of what is
most appropriate on that exam. A number of the boards are moving towards more modular exams.
So if someone has their practice focused in a specific area of a specialty, more of the exam will be
focused on those topics.
We're seeing that movement. But it's important to recognize that MOC as a whole integrates both the
common and the uncommon, and the exam is increasingly becoming more modular and specific. But
each board determines the appropriate balance.
The QI projects in particular are where the new standards are making a substantial difference in a
part of MOC that has some people pretty exercised.
The QI projects are related to our part of MOC that is called Improvement in Medical Practice. The
new standards state ... that the physician diplomate should be engaged in quality improvement
activities either in his or her practice or in the health system in which that person practices.
We think most physicians are, in this day and age, engaged in these quality improvement activities,
oftentimes very explicitly and knowingly. Most physicians do this within their practice anyway. When
MOC began, there was a lot less attention to quality improvement activities; they were less
prevalent. I believe early in MOC there was the development of practice improvement modules, but
there were not enough to cover the breadth of specialties. A number of physicians felt that they were
being asked to do something that was not relevant to their everyday practice.
The new standards recognize the current situation with many more quality improvement projects
available through health systems, hospitals, and specialty societies and to physicians in smaller
practices -- there are many more things available. And boards are recognizing and giving credit for
those activities more now than they have done in the past.
So it's the new standards that are enabling and encouraging the transition. I do believe that some
physicians were frustrated by not finding the required modules relevant and recognizing that they
were doing QI themselves in their health systems. MOC will better recognize the quality
improvement activities that physicians are doing.
MPT: Critics have argued that the ABIM [American Board of Internal Medicine] pass rates are
declining. The ABIM has rebutted that claim. With regard to specialty boards, what are the
pass rates like? Are they declining? And if so, is there a reason you think is behind it?
Nora: I can give you the broad view across specialties. In general, pass rates for both initial
certifications and for maintenance of certification examinations do have some change from year to
year, but overall they remain constant.
In addition, perhaps not surprisingly, pass rates for the maintenance of certification examinations
tend to be higher than the pass rate on the initial board certification examinations.
MPT: Another complaint is that the financial burden of MOC is too high. That includes exams,
study materials, taking time away from practicing.
Nora: Physicians spend time on continuing education as a matter of course. For example, many of
us go to specialty society meetings, have continuing education courses that we pay for, and the like.
Many of those things, if not all, tend to count for maintenance of certification, as well. So I am not
sure of the specific additive costs that people are talking about when referring to continuing
education.
I think where price sometimes becomes an issue is around the exam. I just took my exam in
February. I tried to keep track of this for myself, and I think I probably did one or two more continuing
education projects last year than I would have normally. That ups the cost by about $150. I did take
an online exam prep course. That was another $1,000. These costs are spread over 10 years, and
I'm not sure that is much of a burden.
One of the things that many people find burdensome can be going away from home to take a course
or going away to a test center. So we're hoping that more and more things are online.Various boards
are working on ways to help make the exam a less stressful experience.
Certainly, we also have to recognize that just taking an exam is a stressful experience in itself. I
experienced that stress. I think part of what we're trying to do is first ask the question of what real
additive burdens there are and then, secondly, to try and address any of those burdens in ways that
we can to help make it less burdensome.
Several of our boards are experimenting with remote proctoring that will save people a trip to an
examination center.
MPT: You've started to mention some ways in which the ABMS is responding to criticism
from individuals and societies. What other ways are you doing so?
Nora: I think very thoughtfully. Board certification and maintaining certification is an extremely
important part of our professional self-regulation. When we reviewed maintenance of certification
standards over a 2-year period, we solicited input from specialty societies, organized medical
organizations (the AAMC, the AMA), and others that represent tens of thousands of physicians. We
had an open comment place on our website, and we heard from hundreds of physicians about this.
And we took that feedback very, very seriously.
We want to make sure, out of a responsibility to the role of certification, professional self-regulation,
and our responsibility to the public, that we have a continuing rigorous process. But we also want it
to be meaningful and relevant for physicians. So we are listening carefully. Changes have been
made. For example, many boards have always welcomed specialty relevant accredited continuing
education activities from many providers. Some of our boards have been more restrictive about that,
and those boards are becoming more flexible.
Looking at the examination and ways that the examination can become a tool for physicians not only
to assess the learning that they've done but to help them learn better, with better feedback to
diplomates about how they did. And then looking at some ways to make the exam less stressful.
Another major response we are taking that we talked about earlier in the conversation: looking at
improvement in medical practice. We recognize that many things physicians are already doing are
consistent with the standards, such as being involved in meaningful, relevant quality assessment
and improvement activities in their practice and health system. These activities should be recognized
and given appropriate credit.
MPT: Are there any other changes to MOC in the near future that you can foresee?
Nora: We viewed 2014 as an implementation year, and the 2015 standards have only been in place
for a few months. Our boards are looking at all areas of improvement to make sure that board
certification continues to be as meaningful to the public as it needs to be while being as relevant and
valuable to physicians as it can be.
MPT: Switching to two recent developments: first off, the establishment of an alternate
certifying organization, the NBPAS [National Board of Physicians and Surgeons]. Would you
like to comment?
Nora: Alternative boards and the like have come up periodically over the years. I will note that the
NBPAS actually underscores the value of board certification by an ABMS board in that it makes it a
requirement.
I'm more interested in talking about why our MOC program, while it needs to improve, still is the
most appropriate way to recognize board certification and maintenance of certification. I believe that
the ABMS member boards and [the NBPAS] board are fundamentally different organizations.
MPT: There was also the second article written by Kurt Eichenwald in Newsweek about ABIM
[specifically its financial practices]. Do you have any comments or response?
Nora: It's an opinion piece. I don't share Mr. Eichenwald's opinion. You mentioned that it was very
ABIM-focused, and so I think that is the organization to respond.
MPT: Do you want to have the last word on anything?
Nora: I will just share with you something that I'm not sure we've actually talked about as much as I
think we need to. And that's how MOC can be of even more value to physicians during a time in
which physicians are under tremendous stress.
There are many things that make medical practice difficult right now: new regulations, the perceived
loss of autonomy, and other things. I believe that maintenance of certification as a framework for
demonstrating what physicians are doing is important for the public.
A recent RAND study ... talked about satisfiers and dissatisfiers in physicians' practices. One of the
satisfiers is when physicians feel enabled and empowered to improve the activities within their health
system and within their practice. So from my perspective, that underscores the importance of
improvement in medical activities that physicians do and that is recognized in MOC.
Finally, in an era when we know that physicians are being employed to a larger degree, keeping
board certification as an extraordinarily strong part of professional self-regulation and a meaningful
and relevant credential is important.
We are committed to improving MOC while underscoring its importance.
A vocal group of doctors is thumping mad. Is your doctor one of them?
Here's the backstory. If you live in Colorado, Indiana, Montana, New York or South Dakota,
your doctor could be practicing for 30 years and never be required to keep up-to-date as a
condition of renewing his or her medical license every few years. Just fill out a form and send a
check.
It's not much better if you live elsewhere. Other states require licensed doctors to do as little as
20 hours of self-study a year.
To raise the standard in a high-stakes profession, most doctors choose to become certified by a
board of their peers in their specialty, say family medicine or surgery.
Maintaining this certification requires passing a knowledge exam every 10 years and
demonstrating continuous learning and improvement in the care provided to patients.
A group of doctors has circulated a petition to do away with independent examinations of
doctors' medical knowledge and requirements to improve their practice, saying it is too
burdensome and not relevant to what they do every day.
Their solution? Continuing medical education, shorthand for no independent determination of
whether a physician is keeping up-to-date.
Taking a page from Hillary Clinton's "Trust me" attitude in deciding which emails should be
made public from her private account while Secretary of State, the doctors' stance is a "Trust me"
too.
It doesn't fly. Here's why. First, the public wants to trust their doctor but also wants independent
verification that their doctor meets a higher standard: "Trust, but verify."
Second, if the certification process is not well-tailored to physician practice and too costly, don't
throw it out, fix it. Make it relevant. Make it better. Test competence as well as knowledge.
Here's an example. A University of Michigan study of physicians who perform bariatric surgery
were videotaped while performing surgery. Their surgical skill was independently assessed by
their peers who were unaware of who was performing the procedure. Not surprising, patients
whose surgeons had better skills fared better. Independent assessment pinpoints where a
physician's competence can be improved.
Most people probably think this type of testing is already being done. It isn't. It should be. Raise
the bar. Don't lower the floor.
Third, the public expects that doctors stay abreast of emerging health threats such as antibioticresistant superbugs and how to diagnose and treat them.
A gentleman I know in the Washington, D.C. area who had surgery noticed that the wound had
become red and swollen. His doctor did not follow the standard protocol developed by
physicians that has reduced these infections. The result? Months of painful and costly treatment
of an antibiotic-resistant infection.
Doctors are like the rest of us. We don't know what we don't know. Fully free choice of
continuing education is not a solution.
Take patient safety. Most doctors never learned patient safety in medical school. It was never
taught, although that it beginning to change. Fortunately, future doctors in training are expected
to learn how to identify common medical errors and unsafe situations, and how to reduce the
chance of patient harm.
Physicians in 2015 should not practice cardiology or surgery as if it were the 1990s. Nor should
they practice as if it were the 1990s when it comes to safety.
A cadre of dedicated physicians have been learning and applying safety science in patient care -on top of their heavy workloads -- with promising results.
To bring more practicing doctors up to speed, the certification process has given greater
emphasis to patient safety. Remarkably, opponents of certification have characterized patient
safety as "busy work" in an article in the well-known New England Journal of Medicine.
There is a saying among professionals who go to work every day to ensure public safety whether
on airplanes, in space flight, in nuclear power plants, on America's highways or in the doctor's
office or hospital: anyone who is not trained to see how mistakes can happen, nor equipped to
avoid them, is the most dangerous person in the room.
The public has the biggest stake in the outcome of whether physicians should be expected to
have independent assessment of their knowledge and performance in practice. We have been left
out of the debate.
The media should invite the public into the dialogue. Hopefully it will be without some of the
vitriol that has surfaced. Perhaps it is indicative of physician burnout, fueled by unrealistic
demands by their employers and insurance companies to see too many patients in too little time
in a system filled with opportunities for error. Whatever the etiology, a constructive tone would
be consistent with the professionalism the public expects.
In the interest of full disclosure, three years ago I agreed to be an unpaid, independent public
member of the public policy committee of the American Board of Medical Specialties. It works
in collaboration with the 24 specialty boards that offer certification to physicians. My purpose
has been to encourage patient safety as an integral part of ongoing assessment of physicians, an
interest sparked 15 years ago while writing Wall of Silence, the first book to tell the human story
behind the Institute of Medicine report, To Err is Human.
Recent estimates suggest that more than 400,000 Americans die from preventable health care
harm annually. All hands on deck are needed to stem the mayhem. The patient on the gurney is
counting on it. "Trust me" doesn't work.
Rosemary Gibson is the author of Wall of Silence and is the 2014 recipient of the American
Medical Writers Association award for her writing on health care in the public interest. She is a
founding member of the Consumers Union Safe Patient Network and is senior advisor at The
Hastings Center. www.rosemarygibson.org
Follow Rosemary Gibson on Twitter: www.twitter.com
Updated | Are physicians in the United States getting dumber?
That is what one of the most powerful medical boards is
suggesting, according to its critics. And, depending on the answer,
tens of millions of dollars funneled annually to this non-profit
organization are at stake.
The provocative question is a rhetorical weapon in a bizarre war,
one that could transform medicine for years. On one side is the
American Board of Internal Medicine (ABIM), which certifies
that doctors have met nationally recognized standards, and has
been advocating for more testing of physicians. On the other side
are tens of thousands of internists, cardiologists, kidney specialists
and the like who say the ABIM has forced them to do busywork
that serves no purpose other than to fatten the board’s bloated
coffers.
“We don’t want to do meaningless work and we don’t want to pay
fees that are unreasonable and we don’t want to line the pockets of
administrators,’’ says Dr. Paul Teirstein, a nationally prominent
physician who is chief of cardiology at Scripps Clinic and who is
now leading the doctor revolt.
Try Newsweek for only $1.25 per week
The physicians lining up with Teirstein are not a bunch of
stumblebums afraid of a few tests. They include some of this
nation’s best-known medical practitioners and academicians, from
institutions like the Mayo Clinic, Harvard Medical School,
Columbia Medical School and other powerhouses in the field.
This spat is hardly academic, though. Some doctors are leaving
medicine because they believe the ABIM is abusing its monopoly
for money, forcing physicians to unnecessarily sacrifice time with
their patients and time for their personal lives.
A little history: For decades, doctors took one exam, usually just
after finishing training, to prove they had absorbed enough
medical knowledge to treat patients. Internists—best known as
primary care physicians—would take one test while those who
chose subspecialties of internal medicine—cardiovascular disease,
critical care, infectious disease, rheumatology—sat for additional
exams. Doctors maintained their certification status by
participating in programs known as “continuing medical
education,” which, when done right, keep physicians up on
developments in their field.
The value to a doctor of being certified can scarcely be overstated.
Many organizations will not hire uncertified doctors. And, without
that stamp of approval, even doctors who open their own practices
rarely receive permission from hospital boards to treat their
patients in hospitals. It was a sensible way to make sure doctors
stayed on top of their game and weed out incompetent clinicians.
Someone, of course, had to pay for the testing and continuing
education, and it was usually the doctors. So physicians shelled
out money to the ABIM to take the tests, and then ponied up more
cash to attend conferences and other programs for continuing
medical education. Few objected—it was worth the money to keep
up the profession’s standards.
But then ABIM decided that rather than just having doctors take
one certification test, maybe they should take two. Or three. Or
more. Under this new rule adopted in the early 1990s, internists
and subspecialists recertify every 10 years with new tests. In other
words, a doctor certified at the age of 30 could look forward to
taking an ABIM exam at least three more times before retirement.
This was not cheap—doctors spend thousands of dollars not only
for the tests, but for review sessions, for time away from their
practices. And with each new test, the ABIM made more money.
Physicians sheepishly went along with the process, assuming their
good old pal the ABIM was working hard to make sure medical
practitioners were fully qualified.
Then, something strange happened, doctors say. The tests started
including questions about problems that had nothing to do with
how doctors did their jobs. For example, endocrinologists who
worked exclusively with adults said they were forced to answer
questions about endocrinology for children, even though the
pediatric information was irrelevant to their practices. Heart
specialists who do not perform transplants – and even those at
hospitals with no heart transplant programs – said they had to
study techniques for reading transplant tissue slides and how best
to evaluate these patients so they could answer questions on the
tests. But that knowledge was unrelated to the care they provide to
their real patients, they said, and took time that they could have
spent learning the latest medical findings about the cardiology
work they actually perform.Videos and study sessions sold to help
doctors prepare for re-certification exams often featured
instructors saying physicians would never see a particular
condition or use a certain diagnostic technique, but they needed to
review it because it would be on the test. “Exam questions often
are not relevant to physicians’ practice,” Teirstein says. “The
questions are often out-dated. Most of the studying is done to
learn the best answer for the test, which is very often not the
current best practice.”
The result? According to the ABIM’S figures, the percentage of
doctors passing the recertification test started dropping steadily. In
2010, some 88 percent of internists taking the maintenance of
certification exams passed; by 2014, that had fallen to 80 percent.
Hematologists dropped from 91 percnet to 82 percent.
Interventional cardiologists went from 94 percent to 88 percent.
Kidney specialists, 95 percent to 84 percent. Lung experts, 90
percent to 79 percent.
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Wow. Was it Obamacare? Ebola? A sign of the end times? What
was turning so many American doctors so stupid all of sudden?
Not to worry, the ABIM declares—the board could help doctors
keep their certification. All they had to do was pay to take the tests
again. Making doctors appear ignorant became big business,
worth millions of dollars, and the ABIM went from being a genial
organization celebrated by the medical profession to something
more akin to a protection racket.
The ABIM disputes that characterization. Lorie B. Slass, a
spokesperson for the ABIM, says “there have been and always
will be” fluctuations in test results, since different groups of
doctors are taking the exam each year. But in each of the
categories cited above, there are no statistically significant
fluctuations—the passing rate keeps going down. So the point
remains: Either doctors are getting dumber each year, or the test
that helps determine who gets to practice medicine has less and
less to do with the actual practice of medicine.
Slass says the suggestion that the ABIM is “purposefully failing
candidates on their exams to generate more revenue is flat-out
wrong.” Maybe so, but according to the Form 990s filed with the
Internal Revenue Service, in 2001—just as the earliest round of
new-test standard was kicking in—the ABIM brought in $16
million in revenue. Its total compensation for all of its top officers
and directors was $1.3 million. The highest paid officer received
about $230,000 a year. Two others made about $200,000, and the
starting salary below that was less than $150,000. Printing was its
largest contractor expense. That was followed by legal fees of
$106,000.
Twelve years later? ABIM is showering cash on its top
executives—including some officers earning more than $400,000
a year. In the tax period ending June 2013—the latest data
available—ABIM brought in $55 million in revenue. Its highest
paid officer made more than $800,000 a year from ABIM and
related ventures. The total pay for ABIM’s top officers
quadrupled. Its largest contractor expense went to the same law
firm it was using a decade earlier, but the amounts charged were
20 times more.
And there is another organization called the ABIM Foundation
that does...well, it’s not quite clear what it does. Its website reads
like a lot of mumbo-jumbo. The Foundation conducts surveys on
how “organizational leaders have advanced professionalism
among practicing physicians.” And it is very proud of its
“Choosing Wisely” program, an initiative “to help providers and
patients engage in conversations to reduce overuse of tests and
procedures,” with pamphlets, videos and other means.
Doesn’t sound like much, until you crack open the 990s. This
organization is loaded. In the tax year ended 2013, it brought in
$20 million—not from contributions, not from selling a product,
not for providing a service. No, the foundation earned $20 million
on the $74 million in assets it holds.
The foundation racked up $5.2 million in expenses, which—other
than $245,000 it gave to the ABIM—was divided into two
categories: compensation and “other.” Who is getting all this
compensation? The very same people who are top earners at the
ABIM. Deep in the filings, it says the foundation spends $1.9
million in “program and project expenses,” with no explanation
what the programs and projects are.
There are some expenditures, though, that are easy to understand:
The foundation spends $153,439 a year on at least one
condominium. And it picks up the tab so the spouse of the topofficer can fly along on business trips for free.
The ABIM is not what it was. Its original mission was to make
sure doctors provide patients with the best care. When
condominiums and lavish salaries and free trips and making
money off of physicians failing tests became a priority, the
evidence suggests the organization lost its way.
But that may not matter soon. In January 2014, when the ABIM
issued a series of new requirements for maintaining certification—
that would have generated all new fees—Teirstein and his
colleagues declared “enough.” They recently formed a new
recertification organization called the “National Board of
Physicians and Surgeons.” It will only consider doctors for
recertification who have passed the initial certification exam that
has been required for decades. Doctors must also log a set number
of hours with programs that qualify under guidelines as continuing
medical education. The group’s fees are much, much lower than
those charged by the ABIM. And its board and management—all
top names in medicine—work for free.
This new board is not just about breaking the ABIM monopoly,
Teirstein says, but is also part of an effort to put the right people
in charge of the profession’s future. Medicine has been
“controlled by individuals who are not involved with the day to
day care of patients,” he says. “It is time for practicing physicians
to take back the leadership.”
Correction: An earlier version of this story incorrectly suggested
that ABIM also certifies anesthesiologists. Anesthesiologists are
certified by the Board of Anesthesiology.
A Certified Medical Controversy
BY KURT EICHENWALD 4/7/15
My wife is an internist. My brother is a pediatrician at a major academic institution. So was my
father. My best friend is a surgeon. I regularly see an internist for my medical care, and I like her
very much. I also should mention that this article is an opinion column.
And it is my opinion that the American Board of Internal Medicine (ABIM) has hidden managerial
incompetence for years while its officers showered themselves with cash despite their financial
ineptitude and the untold damage they have inflicted on the health care system.
That unnecessary first paragraph is necessary because ABIM apparently considers itself the enemy
of doctors, since it believes a journalist with ties to physicians (me) must be biased against the
organization. I found that out when I recently wrote about a group of nationally renowned
physicians who revolted against the ABIM, which certifies doctors as meeting certain medical
standards. The roots of the uprising trace to January 2014, when ABIM attempted to expand its
program for recertifying doctors, adding boatloads of requirements and fees to be paid by
physicians. As a result, the prominent group of doctors formed a competing certification
organization, while condemning ABIM’s recertification program as an expensive waste of time that
hasn’t been shown to improve medical knowledge or the quality of health care.
In response, ABIM attacked me—claiming that since my wife is a doctor, I have a conflict of interest
in reporting about an uprising by physicians—then defended itself with a series of misrepresentations
and absurdities. Topping it off, they condemned Newsweek for allowing me to express an opinion in
an opinion column.
That told me either ABIM uses the same public relations firm employed by Scientology, or its
officials have a lot more to hide. So I decided to dig deeper.
The answer? Whoo-boy, does ABIM have a lot to hide.
First, one clarifying preamble: While ABIM certifies about one out of every four doctors in America,
it is not alone. Doctors with specialties unrelated to internal medicine are certified by other
organizations—most of which are part of a larger body called the American Board of Medical
Specialties (ABMS). While there is anger brewing among these specialists, who also feel abused and
cheated, they aren’t fomenting a revolt like the one playing out with ABIM. So while there is plenty
to say about the other certification boards, let’s stick with the group that has doctors attempting to
organize a coup and why they are so unhappy.
What I found suggests that the primary reason ABIM attempted to expand its recertification
process—which set off the uprising—is that the organization has been crippled by accounting games
and needs a lot more revenue, fast, to avoid a fiscal train wreck. I also found misleading or false
statements in government filings, attempts to withhold public information, damage inflicted on
federal science programs and more. ABIM now even appears to be trying to trick Congress into
passing laws that would force doctors to cough up cash to cover the organization’s financial follies. It
even benefited from something slipped into Obamacare that seems to have been written by ABIM or
its lobbyists.
The last sentence says “seems” because, other than saying it complied with the rules on filings with
the government, ABIM ignored every question I asked it before writing this column. It wouldn’t even
say “no comment.” Even though it’s supposed to be public information, ABIM also refused to
provide the 2014 salary it paid ABIM President and CEO Rich Baron, perhaps the most Dickensian
name since Dickens. (By the way, from what I’ve learned, Baron received $568,000 plus $135,000 in
deferred compensation last year. ABIM will have to officially reveal those numbers in a filing to the
government sometime in May.)
Start with ABIM’s Form 990. This is the document a nonprofit organization has to file with the
Internal Revenue Service to disclose its activities and prove it deserves tax-free status. In Part IV,
which appears on Page 3 of the document, the government asks a simple question on line 4: “Did the
organization engage in lobbying activities?” And year after year, ABIM has answered “no.”
Unfortunately, the real world answer is “yes.” According to the Center for Responsive Politics, from
2009 through 2014, ABIM paid $390,000 to Mehlman Vogel Castagnetti, a lobbying firm. Asked
about this, an ABIM representative says it complied with all rules governing IRS filings. Maybe. Yet
according to Independent Sector, a prominent organization for nonprofits, the words “lobbying
activities” in line 4 includes elements as miniscule as holding strategy meetings to coordinate
lobbying with others and time spent preparing arguments to be advanced to government officials.
Unless ABIM just wrote a check and never spoke to its lobbyists, it’s hard to see how it complied
with those standards. (Side note: A random check of seven 501(c)(3)s that paid less than ABIM to
lobbying firms showed all of them answered with a “yes” on line 4.)
So what did ABIM spend all this lobbying money on? According to Mehlman Vogel’s filings with
the government, ABIM’s lobbyists provided “strategic advice” on issues related to Obamacare,
including “physician quality reporting requirements.” And if you haven’t guessed yet, what does the
ABIM consider “physician quality reporting requirements”? Maintenance of certification (MOC), the
program that so many doctors say is worthless—and that ABIM refuses to show has any impact on
“physician quality” with independent research or other science-y stuff.
Did the lobbying work? Yup. Under Obamacare, physicians who participated in MOC through 2014
qualified for an incentive payment. The description of MOC is so specific in the law that ABIM and
similar groups in ABMS were the only organizations that met the definitions. In other words, in the
first few years of Obamacare, the government was paying doctors to pay ABIM and related
certification organizations to participate in a program that has never been proven to do squat.
And now it looks like the government may have been lobbied to create more pressure on physicians
to shell out cash to ABIM and its brethren. This time, it’s through a bill just passed by the House
called the Medicare Access and CHIP Reauthorization Act. Among its provisions is one where
doctors would qualify for a new incentive pay system in Medicare by meeting quality standards
established by the government in consultation with certification boards like ABIM. Unless these
groups finally acknowledge that MOC programs have not been independently demonstrated to
improve patient care, doctors could be subjected to federal coercion to participate in them—and pay
the boards more fees—whether they want to or not.
Unfortunately, there are bigger problems with MOC programs than forcing doctors to spend time and
money on something that has never been proven to have any value. Instead, they are harming
medicine. A recent report by the National Institutes of Health concluded that, with subspecialty board
recertifications becoming more time-consuming, many physician-scientists are refusing to go through
the process, choosing instead to drop their hospital privileges and end their work in clinics. The
report concluded that this “can have a profound effect on the quality of care delivered by large
numbers of more general subspecialty physicians who seek their advice and refer patients for
consultation.” In other words, not only have certification organizations failed to prove MOC provides
any benefit, but scientific experts also say it is damaging the quality of care.
To understand why ABIM is pushing so hard on the MOC you need only look at its accounting.
Those numbers say ABIM is in danger of becoming a financial corpse.
“It is just shocking,’’ Charles P. Kroll, a certified public accountant who specializes in health care,
says of the consolidated financial statements of ABIM and a related entity, the American Board of
Internal Medicine Foundation. “I have never seen anything like it in my 35 years of accounting and
auditing experience.”
Kroll says he has no vested interest in his ongoing investigation of ABIM’s finances and has taken on
the organization largely out of outrage at what he considers to be its accounting abuses. ABIM made
it quite difficult to obtain its audited financials, he says, but the group eventually posted one year’s
version on its website. By then, however, Kroll had obtained copies elsewhere and found that ABIM,
in that posting, left out many pages without revealing it had done so, a move that hid plenty of its
expenses—including salaries—from prying eyes. Kroll disclosed the ruse online and ABIM quietly
reposted the document, this time in full.
What it showed were accounting techniques that would make the illusionists at Enron blush. ABIM
and the ABIM Foundation lost $39.8 million on program services in the five years ended 2013—a
nonprofit indeed. Yet during that same time, the organizations paid $125.7 million to its senior
officers and staff.
How does any organization with year after year of massive losses continue paying huge salaries? By
relying on an accounting maneuver called “deferred revenue.” Until January 2014, ABIM maintained
a 10-year MOC program, in which doctors coughed up a series of fees. But the payments came
before the doctors went through the decade-long process of recertifying, so ABIM counted the
money as a liability—revenue it had received for services not yet provided. In other words, in
extremely simplistic terms, ABIM was taking advances from doctors for a board recertification owed
sometime in the future. And that deferred revenue grew to the point where it reached $94 million as
of June 30, 2014. The huge sums of cash were only recognized as revenue when the various
services—like a test—were provided.
And there is the bookkeeping magic trick. ABIM is collecting a lot of money up front that it is not
recognizing on its income statement and then using the cash to fund the massive losses from the
program itself. “Deferred revenue has kept them afloat,’’ Kroll says. “They are in a financial free
fall. I have never seen anything so reckless.”
What throws the financial train off the track, unsurprisingly, is lavish spending. Millions have been
paid out to senior officers of ABIM, with additional amounts stuffed away in an obscure line in its
990s for “deferred compensation.” Meanwhile, ABIM’s net assets minus liabilities
were negative$47.9 million on June 30, 2014; staff expenses for the fiscal year ended that same day
climbed 13 percent, or $3.5 million, to $30.7 million. There were forehead-slapping losses too:
ABIM purchased $3.6 million in computer equipment in fiscal 2013, then wrote it all off in 2014,
proclaiming in a footnote in its financials that the technologies were “no longer suitable for their
intended use.”
Which brings us back to the beginning: ABIM’s announcement in January 2014 that it was changing
the MOC process into something so onerous and expensive that it set off a doctor rebellion.
Footnotes in the audited financials make one thing clear: The MOC revision, which ABIM says it
will abandon and revise in the face of the uproar, had nothing to do with improving medical
education. It was all about trying to fix the fiscal mess at ABIM by compelling doctors to deliver
more cash faster.
Rather than a 10-year program, the January 2014 plan declared that MOC would be continuous, with
doctors required to complete new requirements every two, five and 10 years. Doctors could pay their
new fees annually, and ABIM would recognize the money as revenue when it was paid. Money from
doctors who prepaid would be counted as revenue evenly, year after year. In other words, if a
physician prepaid for 10 years, rather than booking revenue when ABIM provided the certification
services, the group would count one tenth of the payment each year.
Had ABIM not been forced to back down on this idea, it was an approach that might have cleaned up
the disaster caused by ABIM’s accounting practices—that is, if the group can accomplish that
without first falling into bankruptcy. Not even the most secretive organization can keep piling up
losses forever while carrying negative asset values on its books. Of course, no one will know what
accounting changes ABIM is using to get out of its self-created crisis until next year, when it files its
new audited financials, or whether it will continue to rely on deferred revenue.
But there are bigger questions ABIM and ABMS have to consider. Why should doctors be forced to
keep ladling out cash and spending time away from their practices studying useless information
simply because the ABIM is managerially incompetent? And when will ABIM finally start telling the
truth to the doctors it supposedly represents?
The New York Times
Board Certification and Fees Anger Doctors
http://well.blogs.nytimes.com/2015/04/13/board-certification-and-fees-anger-doctors/?ref=health
By Joshua A. Krisch, April 13, 2015, 5:36 p.m.
Dr. Jonathan Weiss is tired of passing exams.
A triple-board-certified physician from upstate New York, Dr. Weiss retakes a long written test in
each of his specialties — internal, pulmonary and critical care medicine — every 10 years to
maintain his board certification.
If he opted out, he could still keep his medical license. However, many hospitals would not hire
him, and patients would be less likely to seek his expertise.
Now, in light of recent changes to the board certification process, Dr. Weiss and thousands of
other physicians are rallying against these examinations, which they say are expensive, time
consuming and ultimately irrelevant to patient care.
“I’m an idiot,” Dr. Weiss said in an interview. “Here I am, going through this ridiculous process
that gets harder each cycle, and all the stuff they’re asking me isn’t helping me. I’d argue that it
detracts from my ability to be a good doctor.”
Passions run high when it comes to so-called maintenance of certification. Some doctors
contend that organizations like the American Board of Internal Medicine extort physicians by
charging large exam fees, administering draconian tests that must be retaken if not passed, and
persuading hospitals to blacklist doctors who buck the system. But the internal medicine board
maintains that these exams are voluntary and continually evolving to meet doctors’ needs.
Physicians who take them, the board contends, are demonstrating a superior level of
commitment to the well-being of their patients.
“Knowledge changes really fast and really dramatically,” Dr. Richard Baron, chief executive
and president of the board, said in an interview. “One reason for this framework is to have an
ongoing and evolving professional articulation of what the good doctor looks like, what the good
doctor knows and what the good doctor does.”
Dr. Baron’s organization certifies doctors who specialize in internal medicine — about a quarter
of all physicians in the United States, including cardiologists and other nonsurgical specialists.
Although board certification is not legally tied to state licensure, it is a highly regarded credential
that many hospitals and private practices require.
Board certification was once a lifetime credential. But in 1990, the American Board of
Internal Medicine started requiring physicians to retake certification exams every 10 years. In
January 2014, it overhauled its approach again, requiring regular questionnaires throughout
each 10-year period, culminating in a thorough written exam. Although the board loosened
several of the intermittent requirements in early February, the exams still carry much weight. On
its website, the board has a search function for finding out whether doctors are board certified
and whether they are participating in the periodic assessments.
“We launched the new program and told all 200,000 of our diplomates that the rules were
changing,” Dr. Baron said. “We committed to report publicly whether doctors were engaged in
this program.”
But many doctors railed against the new rules. More than 20,000 cardiologists signed a petition
calling for the board to revert to its pre-1990 requirements.
Individual physicians have vented on blogs and social media.
On Sermo, a closed, anonymous social network for physicians with more than 300,000 active
users, the board certification debate rages across lengthy comment threads. “3 months to learn,
memorize and regurgitate the meaningless, trivial facts that normally I would just look up on
Google,” TedHak wrote in mid-March. “Exactly my experience after almost 30 years of practice
as well,” CyclingDoc replied. “It was my last time. I won’t do M.O.C.,” the user added, referring
to maintenance of certification.
“Thank God I’m ‘old’ and retiring soon!” drzzzzz posted on the same thread.
Opponents of the new recertification regimen see it as an unnecessary addition to schedules
that afford scarcely enough time for patient care and self-guided education. To maintain their
state licenses, most doctors already must complete a number of continuing medical education
courses.
“Continuing medical education and lifelong learning make better doctors, but not maintenance of
certification,” Dr. Wes Fisher, a cardiologist from Illinois who has blogged extensively about the
new requirements, said in an interview. “Medical practice is supposed to be evidence based.
There are no data that the maintenance-of-certification program makes any difference in what
matters: patient outcomes.”
Dr. Fisher and others often refer to a pair of studies published in The Journal of the American
Medical Association in December. The studies found no correlation between maintenance of
certification and better patient outcomes, but they did report a 2.5 percent decrease in Medicare
billings. “One of the studies showed a minute decrease in cost, and the other was neutral,” Dr.
Weiss said. “None of us were blown away by these articles.”
Dr. Weiss speculates that the disconnect between these exams and patient outcomes owes
partly to the fact that closed-book exams do not reflect the realities of modern health care.
“Nowadays, medicine is an open-resource team approach,” he said. “I get all this information in
the room in seconds, and then I use my experience and my knowledge to pull together a plan.”
Some physicians are also wary of the fees — as high as $3,000 — that specialty boards charge
for maintenance of certification. And the traditionally high failure rate for internal medicine
exams means that “applicants have to restudy and retake the test,” Dr. Weiss said. “And you
know what? If you retake the test, you have to pay them more money. One could argue they
have a perverse incentive to come up with questions that are challenging in a way that is not
beneficial to me, but is beneficial to the board.”
Dr. Baron of the internal medicine board strongly disputes these claims.
The exam questions, he said, were written by a committee of academics and practicing doctors
chosen for their depth of knowledge. He said that the material “would be best described as
clinical simulations, the sorts of things that most people don’t look up in practice,” but added
nonetheless that “we are looking at ways to make resources available during the exam.”
Regarding the high price of recertification, Dr. Baron said, “it costs money to produce and
deliver the exam, and we also have the costs of running a business and paying salaries.”
As for the JAMA studies, Dr. Baron stressed that the 2.5 percent savings attributed to
maintenance of certification was not to be taken lightly. “They dismiss that as marginal, but if
you’re spending $545 billion on Medicare every year, 2.5 percent is anything but marginal,” he
said.
In response to outcry from physicians like Dr. Weiss and Dr. Fisher, the internal medicine board
issued an official apology in February. “We clearly got it wrong,” the announcement read,
acknowledging that the group didn’t deliver a program “that physicians found meaningful.”
Although there will still be exams every 10 years, the board committed to reducing certification
fees and suspended some of the required intermittent practice assessments and surveys.
But some physicians are skeptical. “We’ve caught their attention — they’re getting nervous,” Dr.
Weiss said. “But us disgruntled doctors remain concerned that the apology from Dr. Baron is
smoke and mirrors and lip service. The battle is far from over.”