Maintenance of Certification has become part and parcel of medical practice in the United States, but more physicians are starting to ask where there fees are going.

In 2014, the American Board of Internal Medicine (ABIM) imposed new regulations on physicians governing maintenance of board certification. These regulations, which required ongoing medical education, patient satisfaction assessment, and other tasks were met with a strong backlash from physicians who saw it as a waste of time,  money, or both. The ABIM backed off of the 2014 recommendations, but the damage may have already been done. Closer scrutiny of specialty boards financial records led to questioning of the business practices of these non-profits. I spoke about these issues in this doc-to-doc segment with Dr. Richard Baron,the President and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation. 

A full transcript follows the video:

Perry Wilson, MD: Board certification and maintenance of board certification has become part and parcel of medical practice in the United States. But as the requirements for maintaining certification have increased, a growing backlash has arisen among physicians frustrated with the time and monetary costs associated with board certification. To discuss these issues, I am joined today by Dr. Richard Baron, President and CEO of the American Board of Internal Medicine. Dr. Baron, thank you for joining me today on Doc-to-Doc.

Richard Baron, MD: Thank you for having me.

Wilson: Dr. Baron, let's start in 2014 when the ABIM introduced new requirements for maintenance of certification, which included more frequent knowledge assessments as well as practice assessments and patient surveys. Many physicians I've spoken with called this "a bridge too far," and you released a statement at the time stating the ABIM got it wrong and would revisit these policies. What's your understanding of why there was such a strong backlash against the new requirements?

Baron: Well, it is a really challenging time right now to be a physician. Most of our colleagues are struggling with all kinds of regulation. Meaningful use was coming online at that time. The Affordable Care Act was coming online at that time. Lots of aspects of physician practice were transforming, and I think the ABIM wound up catching a lot of the frustration that physicians were experiencing, and I don't think we communicated as clearly as we could have what we were doing and why.

Wilson: Now you put a temporary hold on those new requirements for MOC I believe in 2015 for a two-year period as you sort of reassess the more frequent requirements. Where are we now? We're kind of coming up on that two-year hiatus. What's the plan going forward?

Baron: Well, we'll have an announcement about that by the end of the year. The important thing to recognize here is we are a transformed organization that is in much closer communication with the diplomats, the professional societies. So the decision to pull back on a requirement for Part IV was really informed by what we heard from colleagues, from the community, from leaders, and we now organizationally are building our program in active conversation with the community.

Wilson: So more engagement, perhaps a different set of requirements, or less frequent requirements, or do we just have to wait and see?

Baron: No, I think, first of all, where we are in the practice improvement space today is it is much more seamless for doctors to get recognized for those activities. Today, what we're doing is we recognize and reward physicians who participate in improvement activities, but we don't require them. We will be announcing before the end of the year what our policies will be in the future, but we've been focused a lot on trying to be more nimble and to recognize and reward things the doctors are already doing.

Wilson: I just wanted to touch base about when you say you don't require them. Are you referring to the fact that you can be board certified, but not participating in maintenance of certification? Is that what we're driving at here?

Baron: You were asking about what we call Part IV or practice improvement, the bridge too far part, the part that we pulled back in February 2015. That is no longer a requirement to be certified. That is something that we recognize and reward, but we don't require participation in improvement activities. That was the bridge too far for which we apologized in February of 2015.

Wilson: Let's touch a little bit about costs. There's a time cost in terms of maintenance of certification, which is a bit hard to quantify, but the monetary cost is much easier. The initial certification exam fee according to the website is around $1,400. The recertification fee is just shy of $2,000. Are physicians getting that amount of value out of this process?

Baron: Oh, I think there's no question about that. The $2,000 fee that you suggested, just shy of $2,000, is for a 10-year period, less than $200 a year. Less than $200 a year. Well, I pay more than that for a Pennsylvania license. I pay more than that to maintain my DEA with the feds. There's data that suggests that board-certified doctors actually earn more money than not-board certified doctors. So, that's one way people are getting value. The other most important thing is they're getting their knowledge and expertise recognized in a very public and widely recognized, nationally recognized way.

Wilson: Some physicians I spoke to, nevertheless, were worried about sort of where their money was going. The public tax statement, which I think is from 2015, lists ABIM revenue at $58 million, almost all of it comes from exam fees. It looks like about $13 million or 23% of that is spent on administration of the exam and maintenance of certification, 23% of revenue going to that presumably primary process of the ABIM. Does that suggest that there's too much overhead at the ABIM?

Baron: One of the ways that we deal with questions about the finances is full transparency. You referenced the tax statement. I encourage all your viewers to go to abim.org/finances. That shows where all the revenue comes from and it all does come from doctors. It doesn't come from industry. It doesn't come from pharma. It doesn't come from government. It's professional self-regulation. We fund this ourselves. We think that's a feature, not a bug. It also shows where the money goes, and it shows it in a functional way, and people can hover over and see more.

We also post our audited financial statement, and we've had clean audits every year for the last five plus. Because doctors are not accountants and these statements can be complicated to read through, we've got a reader's guide for the 1099 and a reader's guide for the audited financial statements so people who want to see what we spend on what can go right to the places that they want to see.

Wilson: I certainly appreciate the transparency. I've spent a number of days now preparing for this interview looking through all of this information, and as you say, it's all right there available for you. But nevertheless, the ABIM is a non-profit entity and put it simplistically, if I gave $100 to a charity that is going to provide meals to impoverished people and only $23 of my $100 went to those meals, I might be concerned about where that money is going. I don't think this is necessarily a perfect analogy, but can you understand why some physicians might look at those financials and agree that they're on the up and up, but might just suggest that the money is not being spent where they expect it to be?

Baron: I, too, would be concerned if only 23 cents on the dollar was being spent on what they expect it to be. We have a highly professional staff. The work they do involves designing the exam, delivering the exam, supporting committees that produce the exam. So, all the staff costs are about delivering and supporting an exam.

In recent years, we've posted by some accounting methods a loss. We have not had a surplus. The thing about non-profits, they don't have access to the capital markets, so they need to maintain surpluses some years because not every year is going to be a year that you'll have a surplus. That's been part of our own financial planning, but I can assure your viewers that the overwhelming percentage of the money is used to create, deliver, support, service the exam, to respond to the questions that they have, and to be sure that they get recognized for the special expertise that they have.

Wilson: There's another organization that you lead sort of parallel to the ABIM called the ABIM Foundation. Can you tell us what the difference is and what the focus of the ABIM Foundation is?

Baron: Sure. The ABIM Foundation focuses on improving healthcare by strengthening medical professionalism. It's a very resonant theme for doctors today. There's people who say, "Oh, it's all about payment. Oh, it's all about incentives and disincentives. Oh, it's all about making people do stuff." The foundation really asks the question, "Aren't there ways to make healthcare better by activating professionalism?" We're most known for a campaign called "Choosing Wisely," which focuses on identifying services that are done more than they should be and stimulates conversations between doctors and patients. We've got over 60 medical professional societies participating in that campaign, Consumer Reports participating in that campaign, and it's been a real bright spot in the professions' leadership around important issues about resource allocation and stewardship.

Wilson: The current net assets of the ABIM Foundation, again, according to the public filing that you provided are just over $70 million. Is it correct to say that the majority of that comes from the ABIM?

Baron: All of the funding for the foundation has come from the ABIM, and in fact, it's a consolidated organization. Finances get tricky. I don't go to an accountant to put in a stent. I don't go to a cardiologist to do my taxes. The ABIM and the ABIM Foundation file a joint consolidated financial statement, and the net assets of the two organizations are not $70 million. The foundation does represent the net accumulated assets that have been transferred from ABIM to the foundation, but it's part of a broad management strategy for assuring the stability of ABIM and also achieving a very important professional mission. We're completely transparent about where the foundation came from, where the money went. That's on the foundation website. It's also on ABIM's website.

Wilson: Should we consider the assets held by ABIM Foundation as an endowment of sorts, something that they'll make interest on, potentially invest in to feed back into the professionalism imperative that they're supporting?

Baron: I think that would probably be the most familiar way to think about it, that organizations have endowments that help them achieve their mission and help them maintain stability. It is not organized legally as an endowment, so that's not an entirely accurate statement. But for doctors who are familiar with the concept of endowments for non-profits to assure stability and longevity, that would be an accurate way to understand it.

Wilson: I'm wondering what you think of some physicians have actually formed new certification entities. Paul Teirstein led a group forming the National Board of Physicians and Surgeons, which offers to provide certification in parallel to ABMS or as an alternative to ABMS, with a focus on sort of lower costs. I'm wondering, do you endorse a little competition in this space or does the presence of other organizations like this concern you?

Baron: The presence of other organizations doesn't concern me at all. We're focused on value and substance. We don't believe that continuing medical education alone is an adequate demonstration of continuing ability. People raise the evidence question all the time. Dr. Teirstein is an interventional cardiologist. There's actually published evidence that procedures done by board-certified, time-limited interventional cardiologists are less likely to result in death, less likely to result in emergency coronary artery bypass grafting.

As far as I know, there's no similar evidence with respect to a CME-only program. So, we're interested and focused on value. We believe we can compete based on the substance of our credential and the value of our credential, and our credential is recognized broadly by the healthcare system because it has standards behind it and people need to actually demonstrate something. A credential is only as good as the standards behind it.

Wilson: Take me forward five years from this point in time. Where do you think the ABIM will be? What are you looking forward to? What's going to be exciting for physicians like me?

Baron: We believe that physicians want to be recognized for their special skill. In fact, in a world where physicians are increasingly being devalued, we think that distinguishing themselves with our credential is an important way to reclaim that value. I think the world of the future is going to have a lot of really wacky Internet credentials where people will be able to claim all kinds of expertise based on things that patients have no way to recognize.

My son got married last year by somebody who went to Ministries.com, spent $100, and got authority to marry him in the state of New York. My wife got cancer last year and was treated by board-certified oncologists. It made a difference to me that those people knew what they were doing. I think our colleagues care that their knowledge is recognized. We need to do it in a different way than we did it 70 years ago. 70 years ago we were an authority-based organization, and frankly, medicine was an authority-based profession. We told patients what to do and they did it.

Every doctor today knows that's changed, that the way that we move forward with patients is through conversation, engagement, identifying what they care about and helping them get there. That's where ABIM is today. We're in dialogue with the community. We're figuring out what is the best way to recognize and reward and acknowledge special expertise that doctors have, do it in a way that it results in a credible credential that adds value to their professional ability to do what they do.

Wilson: Well, Dr. Richard Baron, once again, you're the CEO of the American Board of Internal Medicine, board certified in internal medicine and geriatrics. Thanks so much for joining me today.

Baron: I appreciate your time and interest in this story. Thanks, Perry.