If, like me, you are certified by the American Board of Internal Medicine (ABIM), you should be confused, and even angry. ABIM is one of 24 subspecialty boards of the American Board of Medical Specialties (ABMS) which “assess and certify doctors who demonstrate the clinical judgment, skills, and attitudes essential for the delivery of excellent patient care” and “answers a public call to establish uniform standards for physicians to achieve and maintain board certification.” This board certification, through aggressive lobbying by ABIM of the federal government, American Hospital Association, and the insurance industry, has become essential for today’s practicing physician. It is written into the Affordable Care Act (Obamacare) under Section 1848 which specifically identifies Maintenance of Certification (MOC) and the ABMS. It is a requirement for credentialing for hospital privileges. Likewise, it is required for credentialing or provider enrollment with individual health insurance companies. As a result of all of this, most employed physicians, like myself, have board certification written into their employment contracts. Simply put, if I don’t maintain board certification by ABIM, I am unable to work and provide for my family.
This fact has led to the class action lawsuits alleging both abuse of power, monopolistic practices and inappropriate use of physician funds by these organizations as well as the development of the National Board of Physicians and Surgeons (NBPAS.org), an alternative to ABMS for certification that only some states and hospitals have adopted as an option to ABMS certification. This lengthy process is well-detailed at Dr. Wes (drwes.blogspot.com) by this practicing cardiologist/electrophysiologist who has been a vocal opponent of ABIM and their MOC process. Some highlights of what has been elicited in these investigations include:
- ABIM misuse of physician MOC/Certification funds including the purchase of a $2.3 million luxury condominium complete with a chauffeur-driven BMW 7-series town car in historic Washington Square, Philadelphia
- Salaries for CEO and board members of ABIM and its foundation in the hundreds of thousands of dollars (CEO Dr. Richard Barron’s estimated 2015 salary/compensation of $860,926)
- Questionable accounting practices and tax documents including creation of the ABIM Foundation, a non-profit, tax-exempt 501(c)(3) corporation interested in promoting “medical professionalism” and transfer of millions of dollars into the foundation as well as transfer of some of its assets offshore to the Cayman Islands and Dublin, Ireland in the form of non-publicly traded investments
- ABIM’s poor management of funds to the point of near financial insolvency at times.
- ABIM’s development of MOC and limited time certification as a means of generating themselves a never-ending revenue stream after previous attempts at an optional lifelong learning option were unsuccessful
Further rubbing salt in the wound is the fact that ABIM’s board of directors chose to grandfather in all the physicians who were certified prior to 1990. Not only for the reason that it would appear to make ABIM’s claim that continuous maintenance of certification is a keystone to keeping oneself up to date on the latest medical information (and certainly these older clinicians are more likely to be out of date than younger physicians recently out of training) but also because the ABIM Board of Directors who made this decision all fit into this age group (they essentially passed a law that does not apply to them-”Do as I say, not as I do.”). However, there are other significant questionable issues related to their changes in requirements for lifelong certification. In the development of lifetime certification requirements, they guaranteed lifetime revenue in testing fees from candidates. These fees are by no means minor, including the fact that candidates need to travel to testing centers and stay in hotels, not to mention the loss of productivity at work to take time off for testing. Additionally, with the institution of recertification requirements, ABIM developed MOC requirements and materials which serve as another revenue source for them. ABIM has allowed only specific sources for MOC (outside of their own material) and likely have worked out some sort of sweetheart deal with these outside sources for the business. In addition to the $650 fee for the 10-year exam, they charge a yearly fee of $165 to be part of the MOC Program. In terms of time costs to individual internists, estimates have ranged from $23,000-$40,000 in MOC costs over a 10 year period. In aggregate, that puts the cost for all internists in the U.S at $5.7 billion over a ten-year cycle.
The certification process continues to get more confusing with ABIM’s frequent changes in order to continue to generate their revenue. From 1936-1990, ABIM Board certification was a lifetime credential. From 1990 to 2005, ABIM ended lifetime certification and began requirements for 10-year recertification exams (except for those grandfathered in with certification prior to 1990—I missed that cutoff). In 2006, “Maintenance of Certification” was branded with requirements for physicians to earn 100 “MOC Points” (often generating ABIM further revenues) in addition to the 10-year recertification exam. In 2013, ABIM added a “MOC Activity” that had to be completed every 2 years involving patient safety or “Practice Improvement Modules” every 5 years and changed the 100 MOC Points requirement to every 5 years. In 2018, ABIM developed a “Knowledge Check-In” (KCI) involving testing on a smaller scale every 2 years as an option to the 10-year examination (I missed this cutoff as well and was required to take my recertification via the 10-year exam in order to “qualify” to enter the KCI). They made the 2-year KCI exam an “open-book” exam allowing physicians access to ‘UpToDate’ as well as allowing them to take the exam from home with a videocam watching them for security. Contrast that with my 2017 experience for the 10-year recertification exam requiring me to be frisked, roll up my sleeves and pant legs, remove my glasses for examination by a proctor, and undergo video and audio recording during the exam to ensure no “irregularities.”
ABIM has now announced that they will end the 2-year Knowledge Check-In at the end of 2021 and roll out the “Longitudinal Assessment” which will run on a five-year cycle and require candidates to answer 500 of 600 questions (120 per year with the ability to skip 100 questions per 5 year cycle) and determine if you have met a passing score at the end of the fifth year. The ABIM website (ABIM.org) doesn’t have much in the way of specifics at this time, although once again, there are exceptions and time requirements related to both the (soon to be phased out) 2-year KCI and 10-year exam. Both as a result of confusion and frustration, I have resolved to hold out for the 10-year recertification exam in the hopes that the testing requirement will be ended, or else I retire by that time. In the meantime, I have made it a weekly habit to log on to the ABIM website in the hopes of seeing a message that they have suspended recertification testing. At the same time, I log on to my retirement accounts to see how close I am to retiring.