Maintenance of Certification (MOC) and the IRS: where money and power meet

We've heard a lot lately about MOC and its finances: in 2012 the president and CEO of the American Board of Internal Medicine (ABIM) pulled down $628,952 and of that amount $465,687 was "base compensation" while $44,742 was "bonus and incentive compensation" These figures come from line (i) of Part II,  Schedule J, re "officers, directors, trustees, key employees and highest compensated cmployees" as listed in ABIM's IRS 990 report, 2012. 

On the same line in Schedule J the president and CEO is listed as having received $83,654 in "retirement and other deferred compensation." We aren't told what type of compensation format comprised this prize, e.g., was it "defined benefit," 401-K, or something else?

To that was added $34,869 in "non-taxable benefits."

The total for Line (i) for 2012 was $628,952.

Then comes Line (ii): base compensation was $155,229. "Bonus and incentive compensation" was $14,914. "Retirement and other deferred compensation" was $27,885. "Non-taxable benefits" was $11,623. The total for line (ii) was $209,651.

The total for lines (i) and (ii) is $838,603. Not bad, not bad at all for an internist!

Plus there are 15 others at or near or above the $200,000 level. 

Where does this money come from?

One answer is possibly from donors, e.g., in 2012 the ABIM Foundation contributed $245,000. The Joshiah Macy Jr. Foundation contributed $151,632 while the Medical University of South Carolina contributed $62,789.

Another answer is that the majority of the money comes from MOC, testing, courses, and programs put on by non-board independent but nonetheless contingent organizations that charge for course attendance that in many cases contributes to MOC recertification. The point is that MOC in its current format cannot be sustained without MOC fees paid by doctors who submit to the programs as though they were necessary to maintain certification in a country where CME (Continuing Medical Education) is available in all 50 states.

The continuing clamor to set MOC aside in favor of alternative programs such as NBPAS (National Board of Physicians and Surgeons) is growing. It won't be the first time that lust for power and money brought down a financial empire, this time possibly the American Board of Medical Specialties (ABMS) where, not incidentally, the president and CEO took down annual compensation of $779,487 in 2013 (Form 990, Schedule 3, Part II -- Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees). 

In the ABMS case the declared "base compensation" was $681,188 to which was added $12,500 in "bonus and incentive compensation," $71,000 in "deferred compensation," and $14,799 in "non-taxable benefits." The 990 Form doesn't state if the "deferred compensation" is in the form of "defined benefits" or 401-K or other. 

Finally, our observation that some Form 990s don't include all of the officers, directors, trustees, key employees, and highest compensated employees is quizzical. Why not? 

How so-called "guidelines" become hard-and-fast "regulations"

Our previous post showed how Utilization Review decisions sometimes turn out to be regarded and applied as actual practice mandates and how 80% of such decisions are actually denials of care that get upheld by Independent Medical Review. 

The quizzical situation is that many of the UR doctors are not licensed in California. Neither are many of the IMR doctors. More to the point is that the UR doctors and their IMR colleagues often reject diagnostic studies and treatment that has been recommended by MPN (medical provider network) doctors that have been selected by the same companies that approved the UR panels that then denied treatment. Practicing doctors and their patients who know that an injury is real have long since figured out that cost-control, not patient care, is the name of the game. Even the AMA has gotten into the game, purveying and selling to any and all willing buyers a book called Guidelines to Impairment. This book has proved to be a goldmine for insurance companies and their employers who don't want to pay for whatever they can get away with denying as a "covered" item.

Meanwhile, seeing the business success of the AMA Guidelines, other organizations have jumped onto the regulatory bandwagon, e.g, the ABMS boards who now sell "recertification" and "maintenance of certification" programs to their own members. In fact, the eagerness with which physicians' own organizations have sought to subjugate its own members has actually provoked enough ire among physicians that 14 states have already passed legislation modifying the greed-encrusted thrust of the ABMS boards to sequester themselves as well paid bosses (about $800,000 for the ABMS chief, see previous post).

Likewise professional organizations such as the American Academy of Neurology (AAN) which recently published a "position paper" on chronic pain and opioid medication -- without submitting a draft to the California Neurology Society (CNS). THAT caught the attention of  then CNS president Robyn Young, MD, who also reviewed a similar advisory from the Medical Board of California (MBC) which seemed more in line with CNS practices than the AAN paper which was widely regarded as one-sided and biased.

That situation in turn led to CNS' asking its own Director of Government Relations to testify at the MBC hearing in October of 2014. The MBC considered several subjects one of which was a unified and reasonable approach to the treatment and management of chronic pain. Accordingly, the CNS Director of Government Relations, Steve Cattolica, stated "these guidelines are not the only treatment of this issue prescribing controlled substances for non-cancer pain." It was acknowledged that such guidelines, however,"should represent the standard of care for physicians in California ... that fact begs the question how these guidelines will be used or IF they will be used as the Board has intended."

Cattolica then pointed out that "our constituents with heavy emphasis in treating injured workers face a difficult situation" because "any inconsistency will cause all physicians to perhaps compromise the standard of care." Using the Division of Workers Comp (DWC) as an example Cattolica stated how "the DWC's treatment guidelines have a long and proven track record of being misapplied ... to control costs and identify physicians they no longer want in their medical provider networks."

The MBC chair, Ms. Yaroslavsky, was quoted as having said that guidelines are just that, guidelines, not regulations. Cattolica then stated why vigilance is essential: "the physician community's experience with the application of treatment guidelines in the workers' compensation system is as rigid criteria." In other words, it needs to be emphasized that AAN Policy Paper on the use of opioids in non-cancer pain is a guideline, not a regulation, and that the same goes for the guidelines proposed by the MBC. It can be anticipated that the MBC and the AAN recommendations will compete for attention from treating physicians. Either way the mere presence of written guidelines opens the way for automatic rejections of treatment by utilization reviewers in all walks of medical practice including government plans such as Medicare and Medicaid, or managed care plans such as HMOs and PPOs, or workers compensation where remote control medicine is already rife among UR doctors and their legally anonymous IMR counterparts.

Cattolica advised a change in wording-- drop the phrase "very consistent" from the recommended statement of Guidelines and replace it with the word, "equivalent." 

DO DOCTORS EXPIRE IN 10 YEARS?

"Do doctors expire in 10 years" is the title of the lead article in AAPS news from the Association of American Physicians and Surgeons, Vol. 70, No. 5, May 2014. Our readers may enjoy comparing this piece with items from The Weinmann Report, www.politicsofhealthcare.com, "How Physicians Eat their Young," 12 Feb 2014 and "Money and Medicine," 21 July 2012.

The subject is recertification and reveals how boards, associations, and other organizations may use Maintenance of Certification (MOC) to enrich themselves and their organizational coffers at the expense of their own members. The AAPS poses this theoretical question: if "one day a highly trained, experienced physician may be board certified -- and the next day, after examination results are revealed or a deadline for MOC compliance passes, he may be decertified and unemployable. In that one day, could he have become demented, or fallen behind in keeping up with this field?"

The article points out that "resolutions against MOC have been enacted recently by the American Medical Association and the state medical societies of New Jersey, Michigan, Ohio, Oklahoma, New York, and North Carolina."

In the same issue, Larry Huntoon, MD, PhD, points out that the American Academy  of Neurology (AAN) was to feature an MOC International Session but did not feel required to file a conflict-of-interest disclosure from Lois Margaret Nora, MD, CEO of ABMS. In 2012 Nora earned about $330,000 in compensation from ABMS and associated organizations according to the ABMS form 990."

AAN reportedly told AAPS that no such disclosure was necessary because AAN did not give CME credits for attendance at this session.

Once again we see an assault on physician autonomy, this time from within, from persons who benefit financially by imposing MOC requirements on hapless physicians whose evolving practices may not meet the confinements of MOC predators.

Additional References

Journal of American Physicians and Dentists, V. 18, # 3, Fall, 2013, "Maintenance of Certification (MOC) : the elite Agenda for Medicine," Christman, Kenneth, "the elite medical establishment correctly foresaw that there as a huge treasure in the medical certification  business").

Journal of American Physicians and Dentists, V. 16, #2, Summer, 2011, "Board Certification -- a Malignant Growth," Dubravic, Martin, MD.

MONEY AND MEDICINE:  a new series in keeping financial score.  

Assets of boards that are members of the American Board of Medical Specialties (ABMS) according to IRS Form 990 for 2009.

Total assets of the American Board of Internal Medicine were $57,586,843. Total assets for the American Board of Pediatrics were $41,759,971.  It is reasonable to ask how this money was earned.

The Chairman of the American Board of Medical Specialties was paid about  $800,000 (OK, maybe a little over that) whereas the Chairman of the American Board of Allergy and Immunology was paid $98,000 (OK, OK, he reportedly worked about two hours per week).  The Chairman of the holding board, the ABMS, received salary of $492,517. It is also reasonable to ask what tasks these chairholders undertook for this level of payment.

As to how the money was earned, our information is that recertification for an allergist in 2011 cost $2,700 while maintenance of certification cost $2,850. These costs don't include costs of courses to prepare for the exams. The boards have found it even more profitable when they oblige their members to take recertifcation exams on a periodic basis with new fees each time.

Reference: Dubravic, Martin, MD: J of American Physicians and Surgeons, V. 16, # 2, Summer  2011, "Board Certification ... A Malignant Growth," 

How about Hospital Administrators?

Hospital adminstrators and CEOs basically command a force of state-licensed professionals including nurses, physicians, and technologists. Yet there is no requirement that the CEO be board-certified or state-licensed. This discrepancy came to light recently at Washington Hospital in Fremont, California where the hospital non-physician CEO was recommended for a salary increase from $614,000 per year to $632,000 with total compensation set at about $857,000 with $245,502 in performance bonuses.

Reference: Artz, Matthew: San Jose Mercury News, 12/27/12

Several years ago State Senator Dan McCorquodale authored legislation to require licensure of hospital administrators. The hospitals squawked loudly and poured money into defeat of the bill. All the same, there were unexpected supporters who also poured in money, e.g., universities  that taught courses in hospital administration and that suddenly saw their walls papered with greenbacks. In the end, the issue became a "juice" bill with each side contributing money hand over fist.

How about the American Board of Medical Specialties?

The Federation of State Medical Boards (FSMB) and the American Board of Medical Specialties (ABMS), non-profit private business entities, reported annual gross receipts in excess of $350,000,000 (see annual IRS Forms 990).

The FSMB reported a corporate lobbying budget of $221,222 although it provides no continuing medical education (CME) to physicians and no direct patient care.

How about the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)?

Gross receipts for JCAHO were reported at $148,737,915 according to its 2009 IRS Form 990.

References: Orient, Jane, MD: "White paper in opposition to Federation of State Medical Boards," J Am Phys Surg 2008: 13: 23-26.

Kempen, Paul Martin, MD, PhD: "Wrong methodologies to improve medical care."

Conclusions: financial incentives in medicine are now tied to factors other than clinical excellence. Caring for corporate health in medicine is the goal to which many otherwise superb clinicians are redirecting their efforts. Academic associations in addition to boards, seeking profitable affiliations  and courting political influence, are pointing the way. These organizations have become profit centers. National organizations seek clones at the state and county levels. It is not unusual to find that a national academic organization seeks state and regional affiliates so that members pay dues at both national and state or regional levels.

Meanwhile, hospital CEOs eschew demands for licensure even though their responsibility is as much to the public as nurses, physicians, and technologists. In a state of flux such as this one, opportunities are abundant, but not in the care of patients. In due course specialty boards may seek empowerment to license clinical practitioners and in so doing reduce the authority of state boards or even render them obsolete. 

Individual physicians may want to ask their specialty boards and national academies for copies of their IRS Forms 990, then learn how to interpret and  use the knowledge for individual assertiveness.

Our intent is to update this piece from time to time and to include as many readers' comments as possible.