Wednesday, July 29, 2015

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? 











Monday, June 29, 2015

MEDICARE VERSUS THE INDEPENDENT PAYMENT ADVISORY BOARD (IPAB)


Here is how it works: The Affordable Care Act (ACA) grants coverage to about 15 million persons not previously covered by what passed for health care coverage before passage of the ACA. Trouble is that Covered California and other ACA derived plans have now raised their premiums to cover the influx. But the premiums can't be raised enough to cover this influx. It has been determined that a better way  is to reduce utilization to keep costs below or equal to the pre-ACA expenditure. This method is a form of rationing with a special dagger aimed at the hearts of the elderly. It is called the Independent Payment Advisory Board (IPAB). 

Here's a pre-IPAB example: programs that provide vision care advise patients that refraction is not covered by Medicare or by most commercial PPO plans. Refraction is the method by which corrective lenses are prescribed. Medicare and the commercial PPOs determined that refraction isn't a medical procedure after all. Medicare and the involved PPOs conveniently decided that refractive errors requiring prescribed lenses are a result of changing eye-shape and are not because of disease.  Hence, coverage is denied.  

How about something more current than refraction? Let's take a look at what's happening to cardiac pacemakers. The Center for Medicare and Medicaid Services (CMS) has determined that as of 6 July 2015 coverage for cardiac pacemakers will be restricted to patients with "non-reversible symptomatic bradycardia." This decision means that patients with asymptomatic complete heart block would not be covered and that the exclusion will apply even to patients with asymptomatic Mobitz Type II heart block. So far our information is that the American Medical Association (AMA) has not filed a protest. We're now obliged to ask would-be presidents of AMA and contingent state medical associations where they stand on this matter.

We all recall Sarah Palin's barbs about "death panels" for Medicare. Suddenly, it doesn't seem as though she was all that far off the mark, does it?

That's where the Independent Payment Advisory Board (IPAB) comes in -- the IPAB was formed to manage costs that the ACA might run up due to the influx of previously non-covered patients. The IPAB owes its existence to Sections 3403 and 10320 of the ACA. The official job of the IPAB will be to control and cut Medicare spending. The IPAB according to the ACA will be appointed, not elected, and will not be obliged to report to Congress. In effect this technique will remove Congressional  oversight of Medicare spending. Instead,  unelected IPAB members will have this power. The salary for the 15 IPAB members is proposed to be about $165,000 annually -- once again we see there's money enough for bureaucracy but not for patients and citizens. The IPAB is ripe for repeal before it can do damage.

In the second Obama-Romney debate, Gov. Romney asked President Obama who would be appointed to the IPAB. Obama's answer, and I quote same in toto, was "doctors et cetera."
Although the reply was short, it was also wrong. Trouble is neither Romney nor Obama knew it. The fact is that there is nothing in Sections 3403 or 10320  or in the rest of the ACA that requires even one physician to be appointed to the IPAB. While it's likely that an acquiescent physician can be found, the fact is that there is no legal requirement under the ACA to appoint even one physician to the IPAB. The IPAB should be repealed forthwith -- so doing will improve the ACA by removing what to all intents and purposes looks as close to Palin's death-panels as one can get without handing the IPAB a portable gallows. 

Friday, May 15, 2015

MAINTENANCE OF CERTIFICATION (MOC): a rising business opportunity!


Continuation of our Money and Medicine Series

Maintenance of Certification (MOC) has become the latest repository of profitability for physicians and others with an ear to current business practices in America. The idea put forth is that MOC is useful for making sure that physicians keep up to date -- never mind that all 50 states have already imposed mandatory Continuing Medical Education (CME) that requires physicians to take post-graduate courses to maintain licensure. These courses are expensive and often require travel. These programs have generated money for the entrepreneurs who run them. Now the specialty boards want in on the loot. The American Board of Internal Medicine (ABIM) is an example of the extravagance to which these programs may go.

If we study the IRS Form 990 for ABIM for Tax Year 2012, we see that the ABIM president and CEO received base pay of $465,687 to which was added $44,742 in "bonus and incentive compensation ." One may ask with reasonable curiosity why a base pay of nearly one-half million dollars would need another forty-four grand for "incentive compensation." We'll have to put that question to the ABIM board. We may presume with reasonable medical probability that it was not to avoid a "consolation" stipend.

However, that's not all. In addition to the $465,687 for base pay and the $44,742 for "bonus and incentive compensation," the president and CEO was also awarded $83,654 in retirement and other deferred compensation, plus "non-taxable benefits" of $34,869.

The total for this compensation package was $628,952. not bad for not even having to lift a scalpel or a stethoscope! And, yes, we have similar information for other boards, more on the other boards in future issues. In the meantime, know that there were 15 or more persons at ABIM who were compensated $190,000 or more. Impatient scanners of this information may on their own look up Form 990 for each of the specialty boards and for the ABMS itself (American Board of Medical Specialties). In short, ABIM has itself become a rising business prospect.

As for the purported usefulness of MOC, one respondent to this unproved assertion wrote  (viz., blog of Dr. Wes, 5/14/15) that "there is no evidence MOC improves performance ... this is just poor marketing and another ABIM/ABMS fabrication."  The Florida Medical Association (FMA) voted that MOC should not be used as part of the criteria that hospitals use to designate medical staff. More  state medical associations should follow this example. In the meantime, MOC appears overrated as an educational tool and underrated as a money-making machine.

References

"Maintenance of Certification Controversy," Dr. Wes, drwes.blogspot.com, 05/14/15

"Do We Really Need Physician Re-Certification Testing? There has to be a  better way," Manisha Juthani-Mehta, MD, www.psmag.com/health-and-behavior, 4/24/15 (this doctor describes having had to spend $1,720 in 2010 for MOC and $775 for the infectious disease exam, a total of $2,495. She states that the current internal medicine exam costs $1,940. This testing is clearly beyond what is necessary and reasonable; however, it makes doctors jump through hoops while enriching the board and its paid personnel including officers, trustees, and directors). 

"When does a $681,000 salary require additional incentive compensation," The Weinmann Report, www.politicsofhealthcare.com, 04/17/15

"Florida Doctors Fight Back," The Weinmann Report, www.politicsofhealthcare.com, 09/18/14

"Do Doctors Expire in 10 years?" The Weinmannn Report, www.politicsofhealthcare.com, 05/12/14

"Maintenance of Certification," JAPS, V. 18, # 3, Fall 2013, by Christman, K.

"Board certification - a malignant growth," JAPS, V. 16, # 2, by Dubravic, M.

"Disillusionment invades medical practice," The Weinmann Report, www.politicsofhealthcare.com, 02/22/14

"How physicians eat their young," The Weinmann Report, www.politicsofhealthcare.com, 02/12/14

"Money and Medicine," The Weinmann Report, www.politicsofhealthcare.com, 07/21/12












Saturday, April 25, 2015

NEUROPSYCHOLOGY MEDICAL-LEGAL EVALUATIONS (Neuropsyche QMEs): Does someone want to sabotage neuropsychological evaluations?


Assembly Bill 1542 (Mathis and Cooley)

Seemingly erudite and arcane, the question of when to use Neuropsychological QMEs as opposed to Psychology QMEs is not only crucial to industrial medicine and workers compensation, but also  to Medical Provider Networks (MPNs) and Managed Care everywhere (especially to Health Maintenance Organizations or HMOs). We'll tell our readers up front that this publication supports AB 1542. The rest of this article explains why and states some likely consequences of non-support.

Neurospsyche QMEs evaluate brain-injured patients with discrete neurocognitive techniques to make decisions about future medical needs and eligibility for employment. These techniques are separate and distinct from neurological tools such as EEG, EMG, or MRI scanning. The tests neuropsyches use are different from the techniques used by general psychologists who, although well versed in general psychology, are not as highly versed in the evaluation of specific traumatic brain injury as are the neuropsychologists who assess whetheoor not particular brain-damaged workers will be able to return to their usual and customary jobs, or, for that matter, to any job at all.

These evaluations are also critical for employers and for insurance companies. The insurance companies are obliged to cover future medical costs. Wrongful evaluations can result in incorrect job assignments, worsening impairment or disability, generation of useless medical expense, and, for employers, to further impairment of production and additional on-site work injuries.

The fact is that Clinical Neuropsychologists as a sub-specialty within the general framework of psychology has been accepted as such for over 20 years. All the same, the Division of Workers' Compensation (DWC) wants to drop the Neuropsyche QME sub-specialty category and treat all psychologists as a single group. Here's the rub: so doing would mean that brain-injured workers could be assessed by general psychologists who would not have had the specialized education and training that their Neuropsyche colleagues have obtained. By analogy, it might be said that so doing would be akin to putting all the MDs into the same group without consideration of specialty so that an injured worker with a broken leg might be evaluated by an obstetrician.

A further fact is that according to DWC in 2013 there were over 2,000 cases of concussion and that in 2014 there were 633 neuropsyche QME panels as opposed to 8,436 general psychology panels.  The reason for this divergence is clear: the general psychology panels focus on general psychological issues, not on the specific issues of traumatic brain injury, rehabilitation, and cognitive retraining.

If the Neuropsyche QME is eliminated, the brain-injured worker will not get the assessment he needs. From the industry perspective, neither will the employer or the insurance company. The likely outcome under this scenario would be wrongful return-to-work work assignments, or no return-to-work assignment when one such could have been made, wrongful deployment of insurance company resources for unindicated services, and, most sadly of all, failure to dispense indicated future medical treatment that could have been properly recommended by the Neuropsyche QME


For these reasons, we advise favorable consideration of AB 1542.

For private doctors not involved in workers comp, we have a warning: elimination of neuropsyche in workers comp could easily be taken up as model by managed care plans everywhere and by government covered entities eager to cut costs even if it means disenfranchising plan participants.

Friday, April 17, 2015

WHEN DOES A $681,000 SALARY REQUIRE "ADDITIONAL INCENTIVE COMPENSATION?" Is there a reasonable argument that ABMS and other board salaries are tied into MOC (Maintenance of Certification)?



According to Form 990 from the IRS for 2013 for the American Board of Medical Specialties (ABMS), Lois Margaret Nora, MD, JD, MBA, president & CEO of the ABMS,  got base compensation of $681,188 plus "bonus and incentive compensation" of $12,500 plus "deferred compensation" of $71,000 plus "nontaxable benefits" of $14,799 for a total of $779,487.

Net assets by contrast, pages 1 and 12 of Form 990 are listed as minus $1,238,805.

Of interest is that Dr. Huntoon in AAPS reported $330,000 in remuneration for Dr. Nora for 2012 (see references below) whereas our copy of Form 990 shows remuneration for 2013 of $779,000 -- if we have actually documented a raise, kudos for Dr. Nora.  All ABMS specialists should look over their organizations' Form 990s as a matter of ordinary due diligence. 

According to Form 990 for the American Board of Pyschiatry and Neurology (ABPN) for 2012, Larry R. Faulkner, MD, president and CEO, was compensated at $560,522 for base compensation plus $260,713 for "retirement and other deferred compensation," $22,356 for "nontaxable benefits" for a total of $ 843,591.

Total revenue for 2012 is listed on page 4 of the form in the amount of $17,122,985 (expenses were $12,389,987). Page 10 of the ABPN document, under "Statement of Functional Expenses," shows "assessments of ABMS" in the amount of $687,884. Page 11 shows end-of-year net assets of $65,083,864.

MAINTENANCE OF CERTIFICATION (MOC)

MOC has become one of the most controversial programs within medical practice with a myriad of organizations willing to take it on and offer their own Continued Medical Education (CME) at prices ranging from bargain-level to exorbitant. The point is that the selling of education has become its own business with ABMS boards devouring their own members as fast as greed allows digestion.

When the American Academy of Neurology (AAN) filed a timid letter in protest to ABPN and asked that MOC Part IV be repealed, that organization got the response of feckless organizations everywhere. Doctor Lois Nora, quoted in NEUROLOGY TODAY, 04/02/15, said with pithy candor, "I don't see us moving on that."

Current AAN president, Tim Pedley, MD, is quoted on page one of AAN News, April 2015, as stating that the MOC Part IV "process is unnecessarily cumbersome" as though a less cumbersome inconvenience would not distress AAN. Meanwhile, in NEUROLOGY TODAY, 04/02/15, Pedley practically apologizes for his support of several hundred disgruntled AAN members and seeks to dissociate AAN from ABPN ("AAN is an independent association with no control over ABPN, the American Board of Medical Specialties, or the MOC rationale and process"). It may eventually turn out that the members no longer need AAN and reconsider paying dues.

Meanwhile,  ABPN's $843,591 salaried president and CEO, Larry Faulkner, MD,  timorously stated in NEUROLOGY TODAY, " ... wiping out part of the requirements (he means MOC Part IV) is not something we at ABPN believe we have the authority to do. The American Board of Medical Specialties sets the standards, and unless they decide to change them, we don't have a choice but to follow them." We disagree. ABPN is not supposed to be anybody's subject or hand-maiden.

MORE TO THE POINT: MONEY

As we pointed out above, the ABPN form 990 IRS document from 2012 lists $687,884 as "assessments of ABMS" which itself showed negative net assets for 2013 in the amount of $1,238,805. Under these circumstances it is reasonable to inquire further to what extent fiscal issues between the specialty boards and ABMS may be inextricably intertwined.


References

"Money and Medicine," The Weinmann Report (www.politicsofhealthcare.com), 7/21/12

"How Physicians Eat their Young," The Weinmann Report (www.politicsofhealthcare.com), 2/12/14

"AAN Calls for Elimination of MOC Part IV," AAN News

"Do Doctors Expire in 10 Years?" Workcompcentral, Robert Weinmann, MD, 5/15/14 (In the original AAPS article Larry Huntoon, MD, PhD, pointed out that AAN had scheduled an MOC symposium and that Dr. Nora was to be a speaker but did not feel obliged at the time to disclose as a possible conflict of interest that her 2012 salary at ABMS was about $330,000. AAN then is reported to have told AAPS that no such disclaimer was needed since AAN wasn't giving CME credits to participants)

"Do Doctors Expire in 10 Years?" American Association of Physicians and Surgeons (AAPS News), May 2014 (V. 70, #5)






  







Friday, February 27, 2015

APPORTIONMENT AND SIBTF (formerly SIF): Acme Steel v. WCAB & Borman


When Labor Codes 4663 and 4664 were changed pursuant to SB 899 it was understood by the legal and medical stakeholders that major changes in applicable case law were in the making and that the issue of apportionment was about to become even more difficult than it already was. The upshot is that medical evidence that may be considered substantial and that was not rebutted may still be considered even in cases where Permanent Disability has been awarded at the 100% level. 

In Acme Steel v. WCAB & Borman, Acme Steel appealed the verdict in favor of Borman wherein Borman was awarded 100 percent permanent disability without apportionment for hearing loss. It was Borman's contention that his hearing loss, associated with injury  to other body parts, was attributable to his job with Acme (DOI 10/16/03). Three different AMEs worked the case, orthopedics, neurology, and otolaryngology for hearing loss. 

The hearing loss was reported as apportioned to both industrial and non-industrial factors, 40% to cochlear degeneration on a non-industrial basis, 60% to "occupational factors," e,g., hearing loss caused by on-the-job noise. The applicant's hearing loss was diagnosed as secondary to cochlea degeneration in turn secondary  to congenital disease of the Organ of Corti.  However, it was also understood that in 1994 the applicant sustained loss of consciousness secondary to an explosion that occurred on-the-job and that catapulted the applicant across the room. A workers comp claim was filed at the time. Applicant Borman was awarded 22% disability; however, his hearing continued to deteriorate.

Applicant Borman's hearing loss was bilateral from the beginning. Hearing aids were advised. Ten years later the AME found that there was "further hearing loss" and that this "further hearing loss ... was the result of both cochlear degeneration ... and persistent noise exposure." 

In 2012 the Workers Comp Admintrative Law Judge (ACALJ) found that Applicant Borman's injury was ratable under the post-2004 Permanent Disability Rating Schedule (PDRS) and that Borman showed 100% loss of earning capacity so that he was entitled to Permanent Total Disability (PTD). The WCALJ also said that LC Sec. 4664 was not pertinent because there was no earning loss before the prior award. In other words, Borman had continued to work while his hearing loss got worse. That's about when ACME appealed by stating that the WCALJ failed to apportion injury pursuant to LC 4663. In other words, there was prior evidence showing 40% hearing loss on a non-industrial basis. 

The WCALJ replied that she was not bound by the findings of the AME because there was "convincing vocational testimony regarding loss of earning capacity." In 2013 WCAB denied ACME's petition for reconsideration. It was at about this time that matters got hot. The case came before the First Appellate District Court. Division One, "Not to be published,"  7/16/13.

The discussion led off with this remark: "When a workers' compensation decision rests on the Board's erroneous interpretation of the law, the reviewing court will annul the decision." The Appellate Court then indicated that the WCALJ's decision asserting that Borman could rebut the rating schedule's DFEC by offering vocational expert testimony showing evidence of 100% loss of earning capacity was proper; however, it then also said that the WCALJ erred "by failing to address the issue of apportionment." 

This assertion was based on changes in LC Sections 4663 and 4664 which were enacted in 2004 as part of SB 899. These changes reflected changing concepts re the issues of apportionment and causation in favor of employer and insurance interests for any portion of a disability that would not have occurred but for the current industrial cause and where injured workers had "wide latitude to disprove apportionment based on prior permanent disability awards by demonstrating that they had substantially rehabilitated the injury." 

The Supreme Court was quoted as saying that "the plain language of new sections 4663 and 4664 demonstrates they were intended to reverse these features." Apportionment was now to be based on causation such that "the new approach to apportionment is to look at the current disability and parcel out its causative sources -- industrial, prior industrial, current industrial -- and decide the amount directly caused by the current industrial source. This approach requires thorough consideration of past injuries, not disregard of them (italics added)." 

The court ruled that it was the "clear intent" of the legislature in enacting SB 899 "to charge employers only with that percentage of permanent disability directly caused by the current industrial injury." It was then asserted that the WCAB had ignored substantial medical evidence from the otolaryngology AME that 100% of Borman's hearing loss could not be attributed to the current cumulative trauma. 

The court said that the WCAB's failure to apportion the hearing loss portion of the cumulative trauma was contrary to law such that the award to Borman was annulled. ACME's petition for review was granted. The order denying consideration was annulled. 

My Comment

It can now be expected that this determination on Apportionment will have an effect on SIBTF (SIF) cases. The crucial happenstance in the ACME v. Borman case is that the applicant's total disability award was actually vacated by being annulled and that apportionment was then determined to be applicable. The meaning of this determination is that what is lost in terms of apportionment may now be applicable and applied to  SIBTF situations where prior injury resulted in work disability or "labor disablement."  Labor disablement is currently a crucial concept in SIBTF cases which requires its own level of documentation and proof. 

References

ACME Steel v WCAB and Michael Borman, A137915, filed 7/16/13

Opinion on Decision, WCALJ Deborah Lieberman, 10/25/12

California: A Radical/Diametrical Change in the Law of Apportionment, 09/13/13, Raymond F. Correio

Monday, February 16, 2015

WHEN PATIENTS GET TOO EXPENSIVE TO TREAT


What do insurance companies do when medical expenses get too high for comfort?  How may insurance companies deal with expanding medical costs that lower shareholder return and that may cause reduced executive compensation?

Currently, rituxin is one of the newer agents recommended for the active phase of acute demyelinating disease, multiple sclerosis in particular, but also extending to a complicated condition known as "lupoid sclerosis." Robyn G. Young, MD, Alameda, formely, president of the California Neurology Society,  states that this treatment is a preferred regimen for active system disease. e.g., MS/demyelination accompanying systemic SLE.

However, reluctance on the part of payers to cover this regimen has been noticed by frustrated clinicians whose treatment decisions may be delayed or denied by insurers who may assert that a specific treatment regimen is "experimental" and therefore not eligible for coverage under the plan. If that happens, the patient is then denied insurance coverage and may have to pay for treatment out-of-pocket while the insurance company continues to bill for its alleged coverage, whatever of that remains once what the patient currently needs is denied. 

Insurance companies have other ways of controlling costs. One of these other ways is to limit access to physicians to cover the number of enrolled subscribers. That increases the length of time it'll take to see a physician, especially a specialist, which in turn reduces expenses for the insurance company, which in turn allows more favorable financial quarterly reports to be issued. Another technique is to drop physicians from the MPN (medical provider network) based purely on business reasons -- no allegation of poor medical practice need be made. This latter technique reduces short-term expenses, allows for more favorable financial reports on a quarterly basis, and runs little risk of collectively increased long-term expense because of delays of care. Keep in mind that in workers comp, for instance, Temporary Disability (TD) runs out in two years. 

Doctor Young stated that "our patients should not be the victims of either insurance or pharma greed ... the physician has been devalued while all the other entities with financial interests in rationing patient care have been elevated in control and influence."

That is why some medical organizations seem poised to fight simultaneously for their patients' rights as well as for the rights of member physicians lest the latter become indentured servants dependent either on the corporate mentality that rules Big Biz or the other corporate mentality that rules government. In this regard watch for a likely take-down on an aspect of Obamacare (Affordable Care Act). The case is King versus Burwell, Docket # 14-114, set for SCOTUS argument beginning on 4 March 2015. The case deals with an IRS ruling re availability of federal tax subsidies to persons who bought health insurance on exchanges run by the federal government -- we'll cover more on that in future columns.

In the meantime, Doctor Young's conclusion  that "it is time that we (physicians) took back our role as patient care advocates" should be shouted from physician rooftops everywhere.

References

"Regaining Control of Medical Practice," CLINICAL EEG,  c. 1995, V. 26, #1 (reprints available SSAE upon request to Dr. Weinmann, 2040 Forest Avenue, #4, San Jose, CA. 95128)

"Union head urges reform in health care," THE OAKLAND TRIBUNE,  4 November 1998 (White House press conference with then President Bill Clinton)