The Choosing Wisely campaign is a program of the American Board of Internal Medicine Foundation, the 501c3 foundation arm of the American Board of Internal Medicine, and has a campaign goal to “reduce waste in the healthcare system and avoid risks associated with unnecessary treatment.” On the surface, the campaign seems like a worthwhile endeavor to help decrease costs in healthcare. ABIM Foundation has enlisted 80 U.S. clinical and pharmaceutical specialty societies to join their campaign, but many practicing physicians and other medical organizations are calling foul. Emergency physicians have challenged the Choosing Wisely recommendations, the American Association of Clinical Endocrinologists withdrew its support of the campaign citing unintended consequences that could potentially drive a wedge between physicians and their patients, stunt communication, and impact the level of care provided to the patient.
ABIM Foundation’s campaign to reduce waste in the health care system may have some large gaps. Although healthcare expenditures are among the highest in the United States, the costs associated are not necessarily due to procedures and prescriptions. Unfortunately, the primary drivers of health-care spending vary considerably and the bulk of medical procedure payments go to hospitals and device manufacturers. Additionally, according to the Centers for Medicare & Medicaid Services (CMS), $360 billion is spent annually for administrative costs and 85 percent of excess administrative overhead can be attributed to the insurance system. Physician salaries on the other hand, according to health care economist Uwe Reinhardt “aren’t a large enough chunk of health care spending in the United States to make a difference”. Physicians’ net take-home pay amounts to only about 10 percent of overall health care spending.
ABIM then ABIM Foundation, What You’re Selling, We Aren’t Buying
The other reason why practicing physicians are not embracing ABIM Foundation recommendations is due to the antagonistic relationship ABIM has with physicians. ABIM provides board certification for physicians who completed Internal Medicine residency. ABIM is one of 24 subspecialties that fall under the umbrella of the American Board of Medical Specialties (ABMS), a 501c4. ABMS member organizations are private, nonprofit entities that administer the specialty exams.
Physicians have tolerated certification, for decades. Yet, in the 1990s the ABMS implemented a maintenance of certification (MOC) program requiring physicians under a certain age to obtain re-certification throughout their careers, while older physicians were “grandfathered” under previous lifetime certification guidelines.
Upon further inspections of their 990’s, a modification having little to do with quality and much to do with the rate of return could easily be seen. Dr. Niran Al-Agba’s post in KevinMD noted that “Between 2003 and 2013, the ABMS member boards’ assets ballooned from $237 million to a staggering $635 million, an annual growth rate of 10.4 percent. MOC is outrageously lucrative. Almost 88 percent of their revenue came from certification fees.” ABMS member board salaries are excessively high in comparison to the market.
For example according to the most recent 990, the CEO of the American Board of Pediatrics(ABP) earns $1.3 million dollars, while the average salary according to the Bureau for Labor Statistics (BLS) for a pediatrician is $184,240. The ABIM Foundation has total assets of $81,831,953 and moved some of its assets offshore to the Cayman Islands and Ireland in the form of non-publicly traded investments. NPQ recently reported on the dubious perception of offshore investments by nonprofits and why it should raise suspicions.
The seemingly voluntary nature of MOC has also been called into question. If physicians choose not to take the MOC exam or pay the fees, they are faced with the loss of hospital privileges and being removed from insurance panels. Yet, there is no evidence to support the benefit of MOC or that it improves outcomes for patient care. In fact, a retrospective study conducted at four Veterans Affairs Medical Centers, including 105 primary care physicians covering 68,213 patients, found no significant difference on ten primary care performance measures between primary care internists with time-limited certification and those with time-unlimited ABIM certificates.This ultimately prevents physicians from being able to take care of their patients and practice medicine. Physician grassroots efforts have caused 20 state medical societies to write resolutions against MOC and approximately 27 states have introduced legislation to prevent MOC hospital credentialing, insurance company participation, and state licensure.
Various organizations such as the American Medical Association (AMA), Docs4PatientCare(D4PC), Practicing Physicians of America (PPA), American Association of Physicians and Surgeons (AAPS) have called for an end to forced MOC. Physicians have taken to social media with websites such as changeboardrecertification.com and of course, Rebel.MD. It has made top online news for the last few years in Medscape, a web resource for physicians and health professionals, a constant topic on Sermo, a leading global social network for doctors, with 800,000 members from 96 specialties and other health news sites.
Practicing physicians have been voicing substantial concerns about mission drift, conflict of interest, financial improprieties, and collusion. There is much room for debate as to whether any of these organizations have fulfilled the obligations required by the IRS and whether these organizations truly have the best interests of practicing physicians and patient.
Primary Care Coercion?
The largest ABMS’ certification organization is ABIM and certifies approximately one-quarter of all physicians. As Americans are facing an increasing shortage of primary care physicians, the burden of MOC and the consequences falls squarely on their shoulders. The highest revenues for certification come from primary care physicians.
|Organization||Nonprofit Status||Gross Receipts||Total Test Revenue||MOC Revenue||MOC Percentage||Increase from Previous Year|
This can be perceived as a systematic approach to control physicians while undermining the public’s confidence in a physician’s ability to keep their skills up to date. This bias is repeated often by these entities by continual use of the phrase “lifelong learning” in conjunction with their products, as if ABMS is the only source of “lifelong learning”. Hospitals, insurance companies, and the media follow suit with under the guise of “quality measures”.
The staggering revenue generated from the MOC process shows there is a significant financial incentive for these organizations to promote the value of MOC. The costs of MOC in terms of true program costs or decreased physician productivity and access are inevitability passed on to the public, with little or no awareness. While physicians may be opposed to lifelong credit card processing, it seems the dedication to their craft proves their dedication to lifelong learning. Pressuring physicians into the MOC process, to the exclusion of alternative CME courses can be viewed as a measure to not only eliminate the CME competition but to influence health care markets to pursue ABMS as the “standard”.
In a Health Affairs opinion piece, Federal Trade Commission attorney Daniel Gilman, writes “Standing alone, the demonstrable quality benefits of re-certification and MOC are underwhelming and provide no tangible gains for consumers. Within the context of the high costs imposed upon physicians, the balance of costs-benefits for re-certification and MOC are even lower…State lawmakers, learning from the experience of the federal government and the Medicare program, should be wary of enshrining a specific certifying board into state law for medical licensing requirements.”
NBPAS to the Rescue
While the attempt to pressure ABIM/ABMS to change its practices, largely seems to go unnoticed, the creation of the National Board of Physicians and Surgeons (NBPAS) created waves and has become the first credentialing organization to stand up to the ABMS monopoly. Their business model, upends the ABMS nonprofit business model, in many ways. Their certification standards are straightforward, inexpensive, and physician-focused. A board examination must be passed once, physicians must hold an active unrestricted state medical license and demonstrate commitment to ongoing education through 50 hours of CME every 2 years. None of the board members are paid.
All NBPAS board members are practicing physicians at prestigious academic institutions across the country. Whereas, many ABMS board members are non-clinical physicians who have are far removed from patient care and are firmly embedded in the non-profit, academic, and public policy circle. First-time NBPAS certification is $169 for MDs and $189 for DOs. Discounts are available for fellows and military.The majority of the cost goes directly to ABMS in order to verify initial certification. Other revenue comes directly from donations.
Physician grassroots efforts have enabled 20 state medical societies to write resolutions against forced MOC and over 20 states have introduced legislation to prevent MOC from being required for hospital credentialing, insurance company participation, and state licensure. This year, due to NBPAS Advocacy, 11,000 physicians across the country wrote their legislators about making MOC reform a priority. And yet, it seems like practicing physicians are fighting organizations that have financial conflicts with many associating organizations and wield large amounts of monetary resources at their disposal in the way of lobbying and have a quite the uphill battle.
No matter how great the mission, hiding behind it will not clarify some of the serious questions behind the numbers. While the impetus for change may have been to try and motivate physicians to be more vigilant about remaining up to date, the manner in which it has been handled leaves room for questions. It seems what is being called into question is the nonprofit business model of ABIM and ABMS. Despite efforts to promote continuing medical education, it seems that these nonprofits have disparaged practicing physicians as ill-educated and disinterested in remaining up to date. The Institute of Medicine reported that “published studies whose conduct involved financial relationships between academia and industry have been shown to disproportionately support the use, safety, and desirability of the companies’ products and services, leading to the perception that industry sponsorship results in a systematic bias in favor of industry.”
When state medical boards already provide physician regulation and standards for continuing medical educations, the role of nonprofit test taking companies seems conflicted. Particularly since many questions have arisen about the nature of their nonprofit status and whether they are coercing practicing physicians to purchase a product that only seems to benefit the financial coffers of the nonprofit and associating organizations, but does not benefit patients or practicing physicians. At the end of the day, the high costs of MOC just add to the already high cost of healthcare. Practicing physicians seem to strongly believe that there is a moral liability inherent in these companies and they shoulder a responsibility to behave ethically. This movement has given practicing physicians new power to demand and to reward corporate practices that raise the bar on organizations that claim to advocate for practicing physicians and patient advocates.
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