The widely used biomarker contributes to the hundreds of millions of dollars spent annually on cardiac care, but adds no value in evaluating patients with suspected acute coronary syndrome, researchers say.
The widely used creatine kinase-myocardial band testing provides little value for detecting damaged heart muscles and should be eliminated from clinical settings, according to a paper published this week in JAMA Internal Medicine.
The research also cites studies showing that troponin testing is a more definitive predictor of in-hospital mortality and severity of disease.
The efficacy of CK-MB testing has been called into question since at least the turn of the century.
The report is the first of several peer-reviewed implementation guides co-authored by faculty from the High Value Practice Academic Alliance, a coalition created by The Johns Hopkins University School of Medicine. Faculty from more than 80 academic institutions, representing 15 medical specialties and subspecialties, have joined HVPAA to advance quality-driven value improvement.
“This article is the first in a series of collaborative multi-institutional publications designed to bridge knowledge to high-value practice,” said lead author Jeffrey Trost, MD, an assistant professor of medicine at the Johns Hopkins University School of Medicine.
“We present multiple quality improvement initiatives that safely eliminated CK-MB to give providers reassurance about trusting troponin levels when managing patients with suspected acute coronary syndrome.”
The efficacy of CK-MB testing has been called into question since at least the turn of the century. As recently as 2014, American Heart Association/American College of Cardiology guidelines concluded that CK-MB provides no value for diagnosing heart attacks.
Despite that assessment, Trost said, a 2013 survey conducted by the College of American Pathologists found that 77% of nearly 2,000 labs in the U.S. still use CK-MB as a cardiac damage biomarker. Researchers estimate that all blood tests for diagnosing heart attacks add $416 million each year to the cost of care.
Trost said the JAMA report provides a four-step plan to phase out CK-MB based on the U.S. Health Resources & Services Administration’s quality improvement initiative.
The four steps listed include:
Design and implement a hospital-wide education campaign.
Partner with clinical stakeholders in cardiology, emergency medicine, internal medicine, laboratory/pathology to remove CK-MB from standardized heart disease routine order sets.
Enlist information technology/laboratory medicine staff to create and integrate a best practice “alert” that appears on any computerized provider order entry system when clinicians order CK-MB.
Measure use of the test and patient care quality and safety outcomes before and after the intervention.
As far back as 2000, the American College of Cardiology and the European Society of Cardiology identified cardiac troponin as the ideal biomarker due to its high sensitivity for detecting injury to the heart.
Fifty-six percent of physicians in a Merritt Hawkins survey support a single-payer healthcare model, while 41% oppose it. The results are a direct inversion of the same question posed by the physician recruiting firm in a 2008 survey.
A plurality of physicians strongly supports a single payer healthcare system, according to a survey by physician recruiters Merritt Hawkins.
The survey of 1,033 physicians indicates that 42% strongly support a single payer healthcare system while 14% are somewhat supportive. Thirty-five percent strongly oppose a single payer system while 6% are somewhat against it. The remaining 3% are neutral on the issue.
The results are a near-exact inversion of a national survey of physicians Merritt Hawkins conducted in 2008, which found that 58% of physicians opposed single payer and 42% supported it.
Jack Ende, MD, MACP, president of the American College of Physicians, said he was not surprised to see the shift in physicians’ attitudes toward single payer, and said that “several factors are in play here.”
“First, the proportion of physicians in private practice vs. employed-salaried positions has decreased, so there is less concern with direct reimbursement,” Ende said in an email exchange with HealthLeaders Media. “Second, the average age of physicians has decreased, and along with that there has been a generational decrease in concern about physician autonomy and economic independence.”
“And third, the recent ‘sturm und drang’ of the healthcare imbroglio over the ACA has made physicians somewhat distrustful of leaving healthcare to the whims of politicians, and more aligned with settling this issue once and for all with a system that will provide universal access to healthcare, and enable us to move forward, i.e. with a single payer system,” Ende said. “And so we find a more egalitarian, socially committed physician community that is more comfortable with a government controlled system of payment than was the case in 2008.”
Merritt Hawkins Vice President of Communications Phil Miller, responded by email to a query from HealthLeaders Media, and offered a handful of theories for the inversion.
Doctors want clarity and stability. The fits and starts of health reform and the complexity of our current hybrid system are a daily strain. Many believe single payer will reduce the distractions and allow them to focus on what they have paid a fairly high price to do: care for patients.
It's generational. The surveys we have conducted for the Physicians Foundation show that younger doctors are more accepting of Obamacare, ACOs, EHR, and change in general than are older physicians. As the new generation of physicians comes up, there is less stigma among doctors about single payer.
Part of it is resignation rather than enthusiasm about single payer. Doctors see the writing on the wall and want to get it over with. The 14% of physicians who said they "somewhat" support single payer are probably in this group.
There is a philosophical change among physicians that I think the public and many politicians now share, which is that as a society we should cover everybody. That wasn't always the case and is one area where Obamacare should gain some credit. It established that as a society we need to do better when it comes to providing care for our citizens.
The survey was emailed to 70,000 physicians nationwide on Aug. 3, and has a margin of error of +/- 3.1%. Miller said the response rate to the question “is not the only factor to consider.”
“Net number of responses also is significant,” Miller said. “If you got 1,000 doctors in a room and asked them a question, their answers would have some significance: 50 doctors, not as much. We submit our surveys to a Ph.D. in statistical response analysis at the University of Tennessee to determine margin of error rate. He put the survey at +/- 3.1% -- well within the accepted range for credibility.”
Miller says the Merritt Hawkins survey findings are consistent with a survey from LinkedIn that came out earlier this year showing 48% of physicians support single payer, and 32% oppose it.
Emergency physicians call for partnerships between emergency medicine and primary care to reverse the trend of failing health in underserved parts of the country.
The ongoing and well-publicized struggles of small, isolated hospitals to keep the lights on and the doors open has prompted calls for significant reforms for care delivery in rural America.
The latest proposal comes from a group of emergency physicians in Michigan, who have called for better coordination of care between emergency and primary care clinicians.
“The traditional urban model of healthcare has been ineffective at improving rural health," said Margaret Greenwood-Ericksen, MD, MPH of the Department of Emergency Medicine at the University of Michigan in Ann Arbor, lead author of a paper published online this week in Annals of Emergency Medicine.
"Our emergency medicine-primary care model embraces the role that emergency departments play in providing primary care in rural areas while also connecting patients to other physicians and resources in the community,” Greenwood-Ericksen said. “Rural hospitals can serve as a hub for emergency care, primary and preventive care, and social services for improving rural population health."
The model proposed by Greenwood-Ericksen would supplement – not supplant -- the existing outpatient rural safety net, comprised of federally qualified health centers and rural health clinics.
The paper cites Carolinas HealthCare System Anson in Wadesboro, NC as an example of a new rural hospital designed to provide both emergency and primary care, calling it "a test of a new model of rural healthcare delivery." The final design has no physical walls separating emergency and primary care.
Similar partnerships in other communities could optimize emergency care, meet unscheduled acute care needs, address rural social determinants of health across the care continuum, achieve financial solvency and support public health, Greenwood-Ericksen said.
"There is an urgent need for a rural-specific model of care aimed at improving the sharply declining health of rural Americans," she said. "The partnership we propose is novel yet practical and acknowledges that an emergency department might be the closest source of health care for rural patients. Emergency medicine-primary care partnerships can address rural populations' most pressing social and medical needs."
Affiliation will enhance medical, surgical and related healthcare services around San Francisco by improving coordination of primary and specialized care.
Dignity Health and UCSF Health have entered a formal affiliation that the two health systems say will bring the academic medical center’s clinical expertise to community-based care settings in the San Francisco Bay Area.
The affiliation puts UCSF Health's clinical expertise into three Dignity Health hospitals: Sequoia Hospital in Redwood City, and Saint Francis Memorial Hospital and St. Mary's Medical Center in San Francisco, according to a joint announcement this week.
The two health systems have signed a letter of intent for physicians at Dignity Health Medical Group Sequoia and at Dignity Health Medical Group Saint Francis/St. Mary's, both services of Dignity Health Medical Foundation, to collaborate with UCSF clinical faculty to share best practices and improve access, quality, efficiency and coordination of care. The Dignity Health hospitals have joined the Canopy Health accountable care network to provide a continuum of care during the transitions between primary and specialty care.
"Healthcare works best when we collaborate to offer the best thinking and the latest medical advances to our patients," said Shelby Decosta, senior vice president and chief strategy officer for UCSF Health. "Dignity Health's focus on excellent care, as well as the humanity of that care in a community setting, is the perfect balance for UCSF Health's depth of knowledge and specialty services. Together, we can draw upon each other's expertise for quality and service improvements, and best practices, and to provide specialty care with shorter wait times and a better patient experience."
Dignity Health and UCSF Health have previously collaborated to improve pediatric burn care, acute rehabilitation, and cardiac arrhythmia, among other conditions.
Cleveland Clinic study disproves suggestions that gouging price hikes do not reduce access and utilization of medications. In turn, this decreasing demand could restrain pharmaceutical price increases.
The in-hospital prescribing by physicians of two heart medications fell precipitously after drug makers jacked up the price, according to a new study from Cleveland Clinic.
“In public testimony, it had been stated that these price increases would not decrease patient access or utilization of these two critical drugs, both of which have been used for decades in patient care,” said study lead author Umesh Khot, MD, vice chairman of Cardiovascular Medicine at Cleveland Clinic. “However, our research shows that these price hikes are not benign. Further research will determine if there has been any effect on patient outcomes, but it’s clear that utilization has been impacted.”
From 2012 to 2015, nitroprusside prices increased 30-fold from $27.46 to $880.88, while isoproterenol prices increased nearly 70-fold from $26.20 to $1,790.11. These medications are used only in the hospital, with no external patient demand and no direct-to-consumer advertising. Therefore, researchers were able to objectively examine the effect of the price increases on physician prescribing behavior.
Researchers looked at utilization data for nitroprusside and isoproterenol in 47 hospitals between 2012 and 2015. They also obtained data for nitroglycerin and dobutamine – two intravenous cardiovascular drugs with stable pricing – for use as controls. During this period, the number of patients treated with nitroprusside fell 53% and with isoproterenol fell 35%. In comparison, the number of patients treated with nitroglycerin increased 118% and those treated with dobutamine increased 7%.
Nitroprusside lowers blood pressure and is used in the treatment of critical hypertension and congestive heart failure, as well as to keep blood pressure low during surgery. Isoproterenol is used primarily for treating bradycardia (low heart rate) and heart block. It’s also used during electrophysiology procedures and specific cardiothoracic surgery cases to increase heart rate or contractility.
“These are medications that physicians are very familiar with, and for which there are no direct alternatives. As a result, hospitals have had to reevaluate use of these drugs and potentially bring in other therapies,” said study co-author Michael Militello, Pharm. D. “Understanding how physicians, pharmacists and health systems have addressed their use of these medications is an important area of further study.”
U.S. News & World Report’s widely read hospital rankings, now in their 28th year, compare more than 4,500 hospitals and medical centers nationwide in 25 specialties, procedures and conditions.
For the second straight year, the Mayo Clinic sits atop the “Honor Roll” of U.S. News & World Report’s Best Hospitals.
The Honor Roll is awarded to 20 hospitals that demonstrate high-level care in multiple areas, the magazine said. After Mayo, the other prestigious hospitals and medical centers played musical chairs with the rankings from previous years. Cleveland Clinic held steady in the No. 2 spot, the same as last year, while Mass General swapped places with Johns Hopkins Hospital, falling from No. 3 in 2016-17to No. 4 this year.
The U.S. News hospital rankings, while often derided by healthcare industry insiders, hospital executives, and clinicians as simplistic and flawed, are nonetheless widely read by those same healthcare industry insiders, hospital executives, and clinicians. Each year, when the list is released, it triggers a flurry of emails from the winning hospitals. U.S. News allows hospitals to post the rankings on their websites, for a fee.
“Covering nearly every hospital in every U.S. community, U.S. News offers deep, rich data that patients can use to help them make informed decisions about where to receive surgical or medical care,” Ben Harder, managing editor and chief of health analysis at U.S. News, said in a media release announcing this year's list. “We know outcomes matter most, which is why U.S. News is committed to publishing as much data as possible on patient outcomes.”
The University of Michigan Hospitals and Health Centers in Ann Arbor made the biggest leap on the Honor Roll this year, bounding up to No. 6 from No. 18 in 2016. NYU Langone Medical Center saw the biggest drop, falling from No. 10 in 2016 to No. 19 this year.
Thomas Jefferson University Hospitals in Philadelphia and Mayo Clinic Phoenix were new to the Honor Roll in 2017, ranking No. 16 and No. 20, respectively. Brigham and Women’s Hospital in Boston, which ranked No. 13 in 2016, and Houston Methodist, which ranked No. 19 last year, did not crack the Top 20 this year. Nationally, 152 hospitals were ranked in at least one specialty this year.
Here’s the 2017-18 Best Hospitals Honor Roll. The numbers in parentheses are the 2016-17 rankings.
1. Mayo Clinic, Rochester, MN. (1)
2. Cleveland Clinic. (2)
3. Johns Hopkins Hospital, Baltimore. (4)
4. Massachusetts General Hospital, Boston. (3)
5. UCSF Medical Center, San Francisco. (7)
6. University of Michigan Hospitals and Health Centers, Ann Arbor. (18)
7. Ronald Reagan UCLA Medical Center, Los Angeles. (5)
8. New York-Presbyterian Hospital. (8)
9. Stanford Health Care-Stanford Hospital, Stanford, CA. (14)
10. Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia. (9_
11. Cedars-Sinai Medical Center, Los Angeles. (17)
12. Barnes-Jewish Hospital, St. Louis. (11)
13. Northwestern Memorial Hospital, Chicago. (8)
14. UPMC Presbyterian Shadyside, Pittsburgh. (12)
15. University of Colorado Hospital, Aurora (20)
16. Thomas Jefferson University Hospitals, Philadelphia.
17. Duke University Hospital, Durham, NC. (16)
18. Mount Sinai Hospital, NY. (15)
19. NYU Langone Medical Center, NY. (10)
20. Mayo Clinic Phoenix, AZ.
U.S. News bases its rankings on measures that include risk-adjusted survival and readmission rates, volume, patient experience, patient safety and quality of nursing, and other care-related indicators. This year’s findings rely upon five years of Medicare data covering more than 60 million hospitalizations. Findings in previous years relied on only three-years of data. U.S. News said it adjusted its measures to account for hospitals that treat higher numbers of low-income patients, or that take on high-risk cases transferred from other hospitals. The magazine also refined how it measures volume to improve comparability among hospitals.
Top Hospitals in Specialties
In the specialty rankings, University of Texas MD Anderson Cancer Center ranked No. 1 in cancer, the Cleveland Clinic is No. 1 in cardiology & heart surgery and Hospital for Special Surgery is No. 1 in orthopedics.
Cardiology & Heart Surgery
1. Cleveland Clinic.
2. Mayo Clinic, Rochester, MN.
3. New York-Presbyterian Hospital, NY.
4. Cedars-Sinai Medical Center, Los Angeles
5. Massachusetts General Hospital, Boston
Cancer
1. University of Texas MD Anderson Cancer Center, Houston.
2. Memorial Sloan Kettering Cancer Center, NY.
3. Mayo Clinic, Rochester, MN.
4. Dana-Farber/Brigham and Women's Cancer Center, Boston.
5. Seattle Cancer Care Alliance/University of Washington Medical Center.
Orthopedics
1. Hospital for Special Surgery, NY.
2. Mayo Clinic.
3. Cleveland Clinic.
4. Rothman Institute at Thomas Jefferson University Hospitals, Philadelphia.
RAND survey of physicians and nurses at nearly 300 federally qualified health centers across the nation finds increasing dissatisfaction with work conditions.
Clinicians at safety net community health centers are reporting growing dissatisfaction with their jobs and researchers aren’t exactly sure why, a new RAND Corporation study finds.
Declines across most measures of professional satisfaction, work environment and practice culture were reported among both clinicians and staff in a national sample of federally qualified health centers. The survey was taken in 2013 and 2014 and the findings were reporting this month in Health Affairs.
RAND surveyed clinicians and staff whose federally qualified health centers participated in a national demonstration that was designed to help them become patient-centered medical homes.
“There are several possibilities for the dissatisfaction,” said Katherine Kahn, MD, the study’s principal investigator and Distinguished Chair in Health Care Delivery Measurement and Evaluation at RAND, and a professor at the David Geffen School of Medicine at UCLA. “For example, rapid adoption of new electronic health record systems can disrupt practice workflow and distract from face-to-face care. Also, many clinics were simultaneously trying to become a medical home while also participating in other initiatives.”
RAND researchers surveyed clinicians and staff from 296 federally qualified health centers across the nation in both 2013 and 2014 about their work conditions. A total of 564 doctors, nurses, and staff members completed both of the surveys.
Participants were asked about their overall professional satisfaction, burnout, and whether they intended to quit. They also were asked about the level of stress, practice atmosphere, top-of-license activity, and clinic practice culture.
The proportion of respondents reporting high job satisfaction worsened significantly in one year, falling from 82% in 2013 to 74% in 2014. The rate of burnout increased from 23% to 31%, and the proportion of respondents who reported they were likely to leave their jobs increased from 29% to 38%.
Three of five work environment measures worsened, with the proportion of respondents who reported a hectic/chaotic practice atmosphere increasing from 32% to 40%. Twelve of 13 practice culture measures also worsened significantly over time.
The RAND study did not probe the causes of the dissatisfaction, but researchers say their findings are consistent with research in other types of clinics, which has shown an increase in rates of clinician burnout nationwide.
“This is more evidence that we are in a challenging time for health care providers and their staffs,” said Mark Friedberg, MD, lead author of the study and a senior physician scientist at RAND. “Our findings show that the job stress documented in other settings extends to federally qualified health centers as well.”
A researcher who examined the certification fees and finances at the nation’s medical specialty boards suggests it's time to take a fresh look at the board certification process.
Brian C. Drolet, MD, the co-author of a JAMA study examining the certification fees and finances at the nation’s medical specialty boards, believes the non-profit boards under the American Board of Medical Specialties charge too much money, and test clinicians on a broad range of procedures that they likely will never encounter.
Drolet spoke with HealthLeaders Media recently. The following is a lightly edited transcript.
HLM: What prompted this study?
Drolet: I happen to be in the middle of my board certification process. I took my written exam last year and I am taking the oral exam in the fall. I am preparing and paying for all of the steps and as I was doing that I couldn’t help but ask what are the objectives of this process and where are these charges going?
HLM: What is the cost of your certification?
Drolet: In total it’ll be about $5,000 between the three exams. It’s about $1,500 roughly for each exam, written, oral and hand specialty.
HLM: Had you asked your specialty board about the fees?
Drolet: No. It’s really just a final common pathway for most of us. We finish residency and the assumption is we are going to become board certified. For my particular job, I have to be board certified in order to be employed in my position. So, it is not a question so much as it is something that I just have to do.
HLM: Do alternative sources for certification exist?
Drolet: There are some alternative boards that have started in the last few years. The ABMS is the primary place for board certification and for years they really did have a monopoly on certification.
HLM: You also raise questions about the clinical relevance of these exams. Please elaborate.
Drolet: From my own experience, I am trained as a plastic surgeon but I do primarily hand surgery. My board certification exams include questions about cranial/facial surgery, breast reconstruction, procedures and areas of the specialty that I don’t practice and that I won’t ever practice.
That is probably a similar circumstance for many physicians. If you’re a nephrologist and you’re taking the internal medicine boards then maybe you’re answering questions about infectious disease and cardiology, things that are not as clinically relevant as something you will be doing on a day-to-day basis.
HLM: What can be done to resolve the issues you raise?
Drolet: The process of residency training and board certification might be better integrated. Residency training accredited programs have a lot of oversight from the ACGME to say that they are training good plastic surgeons or nurses or whatever particular specialty they are.
They should integrate the residency programs with board certification whereby when I complete my residency in plastic surgery at an accredited program, there is a streamlined process for me to become board certified. Is it possible to have a final certification exam at the end of residency training?
If you’ve done a good job in your residency and they certify that this person has completed all the necessary components to be a plastic surgeon, what is the purpose of the additional step?
That additional step adds a lot of studying and cost and a whole different experience that has to be completed that hasn’t necessarily been shown to make a significant difference in clinical outcomes.
HLM: The ABMS net balance has more than doubled in a decade. What is driving that?
Drolet: The primary income source for the boards are fees from examinations, so about 90% of revenues for the boards comes from examination fees charged to candidates and diplomats of the board, and only 20% of expenditures are towards those examination fees.
If you look at the finances, it costs them much less to administer the exams than they charge for the exams. They have a margin year-over-year where they increase their assets by whatever they don’t spend on the administration of exams, and whatever compensation they have for employees and officers.
HLM: What would be a reasonable net balance?
Drolet: They are nonprofit organizations and they need to maintain a certain amount of assets for times when they have financial troubles. There are different recommendations from different consulting groups.
Some say from six months to two years. It would depend upon the boards. Some boards have more expenses so they would need more assets.
But, it’s hard to nail down a specific number. You would want to look at what other nonprofits do and what they have to do to maintain their assets through any financial hardships.
And, then you’d have to ask what is the mission of the boards and what do their expenditures go to. If their mission is for certifying physicians in the specialty of that board, how much does that cost and based whatever assets are necessary on that expense.
HLM: You came up with a net balance of $635 million. That’s a lot of money!
Drolet: That is their net balance. That is their assets minus liabilities. Some of the boards have started using deferred revenue accounting, where they apply the examination revenue as a liability, saying they haven’t administered the exams for the people who’ve paid for it, and so that makes it a little trickier to interpret the finances. But all in all you are looking at a huge generation of assets.
We examined their Form 990s. They are pretty standard after you’ve read a few hundred. For example, I’m looking at neuro surgery certification of exam fees, business code 900099, $29,616,384 in total revenue. So, for most of the boards it’s pretty darn specific. They say this is what it costs and this is what we bring in for the exams and this is what we pay.
JAMA did a good job of scrutinizing our data abstraction. It’s not like a line-item budget.
I am sure the accountants who take care of the boards finances have a line-item that says this is what we bring in for this, this is what it costs us for that.
Until they are willing to share that, we can’t verify that the tax records are exactly what the specific finances are. But, based on reading many, many of these there seems to validate that this is their revenue and this is their expenses based on their reporting to the federal government.
HLM: Any idea what they are doing with this net balance?
Drolet: I don’t actually no, truthfully. From the tax forms it looks like most of it is sitting in various investments. Some of their revenue is on their investment income, but I’m not sure how much.
HLM: Was your study peer reviewed?
Drolet: Yes. They were rigorous. We did this a few times to make sure we were fully checked.
HLM: How did these certification boards get so bloated?
Drolet: That’s a great question. I don’t really know the history. When I was a medical student, if you’d asked me if I was going to be board certified, I’d have said absolutely. It’s the final common pathway.
This is the next step in what you do, and all along you pay for licensing exams and it is one test after another. It seems like we have reached the point where people are questioning it and asking if this is what we need to be doing, is this the right thing to do?
HLM: Are you hearing complaints from your colleagues?
Drolet: In my peer class there is definitely discussion that this is an extremely labor intensive process. In the past three weeks, getting my cases together for boards,
I probably spent 30 hours preparing documents and photographs, getting them ready for the tests. That’s time not spent with patients or family. That’s time just spent preparing documents for a test.
HLM: What’s next?
Drolet: The next step is to look at outcomes comparisons between board-certified and non-certified physicians. The problem is most physicians are board certified, about 80%. For my job I can’t have a job without board certification, so it’s what you do.
The review found that 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. In two studies examining storage safety, 73% to 77% of patients said that their prescription opioids were not stored in locked containers.
More than two-thirds of patients said they did not use all of their prescription opioids after surgery and three-out-of-four patients were careless about where and how the drugs were stored or disposed of, according to a report today in JAMA Surgery.
Mark C. Bicket, MD, of the Johns Hopkins University School of Medicine, led a review of six studies that involved 810 patients who underwent seven different surgical procedures. The researchers examined how commonly postoperative prescription opioids were unused, why they were unused, and what, if any, practices are followed regarding their storage and disposal.
The review found that 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. Most patients stopped or used no opioids owing to adequate pain control, and 16% to 29% of patients reported opioid-induced adverse effects.
In two studies examining storage safety, 73% to 77% of patients said that their prescription opioids were not stored in locked containers. All studies reported low rates of anticipated or actual disposal. No study reported U.S. Food and Drug Administration-recommended disposal methods in more than 9% of patients.
“Increased efforts are needed to develop and disseminate best practices to reduce the oversupply of opioids after surgery, especially given how commonly opioid analgesics prescribed by clinicians are diverted for nonmedical use and may contribute to opioid-associated injuries and deaths,” the authors write.
According to the 2015 National Survey on Drug Use and Health, 3.8 million Americans engage in the nonmedical use of opioids every month.
The Johns Hopkins researchers said their study was limited because the six studies were of intermediate rather than high methodological quality, and the questionnaires completed by patients varied in form, structure, phrasing, and timing across the studies.
In FY 2013, American Board of Medical Specialties members reported $263 million in revenue and $239 million in expenses. Between 2003 and 2013, the change in net balance of ABMS member boards grew from $237 million to $635 million.
Physicians are challenging what they say are high fees and the dubious clinical relevance of maintenance of certification programs offered by the American Board of Medical Specialties.
A study published this week in JAMA also found that the nonprofit organizations that administer the certification process, and which have a fiduciary responsibility to match revenues and expenditures, are collecting a lot more money than they’re spending.
Study authors Brian C. Drolet, MD, of Vanderbilt University Medical Center, and Vickram J. Tandon, MD, of the University of Michigan, Ann Arbor, investigated fees charged to physicians for certification examinations and finances of the 24 ABMS member boards.
"This is a reasonable amount to support a nationally recognized credentialing program that is both respected and valued by physicians, health care providers and institutions, and most importantly, patients and their families."
– ABMS
In 2017, the average fee for an initial written examination was $1,846. In addition, 14 boards required an oral examination for initial certification at an average cost of $1,694. Nineteen boards offered subspecialty verification (e.g., hand surgery within orthopedic or plastic surgery) with an average cost of $2,060. Average fees for MOC were $257 annually, the researchers said.
In fiscal year 2013, member boards reported $263 million in revenue and $239 million in expenses; a difference of $24 million in surplus. Examination fees accounted for 88% of revenue and 21% of expenditures, whereas officer and employee compensation and benefits accounted for 42% of expenses. Between 2003 and 2013, the change in net balance of the ABMS member boards grew from $237 million to $635 million, the researchers said.
Tandon and Drolet said their findings are limited because they relied on data from the IRS Form 990, which does not contain complete and specific financial accounting for the ABMS member boards.
“Board certification should have value as a meaningful educational and quality improvement process,” the two physicians wrote. “Although some evidence suggests board certification may improve performance and outcomes, the costs to physicians are substantial. More research is needed to assess the cost-benefit balance and to demonstrate value in board certification.”
ABMS Responds
On Tuesday afternoon, ABMS issued the following statement:
The research letter entitled “Fees for Certification and Finances of Medical Specialty Boards” published in the Aug. 1, 2017 issue of JAMA offers an aggregate view of the fees charged by the 24 ABMS Member Boards for more than 860,000 physicians to obtain initial Board Certification and as well as continuing certification throughout a physician’s career.
According to the letter, the 2013 Member Boards’ revenue represents approximately $313 per ABMS Board Certified physician. This is a reasonable amount to support a nationally recognized credentialing program that is both respected and valued by physicians, health care providers and institutions, and most importantly, patients and their families.
In addition, the estimated annual cost for continuing certification of $257 per ABMS Board Certified physician is an acceptable cost for physicians for to demonstrate that they have the current knowledge, judgement, and skills to provide the highest level and most up to date care to their patients.
IRS Form 990’s provides information regarding revenues, expenditures and assets. However, they do not outline the actual operation cost involved in creating, sustaining and implementing a rigorous and comprehensive process of Board Certification and continuing certification for the nation’s physicians. ABMS Member Boards rely on a highly-trained and specialized work force including psychometricians, assessment professionals and medical educators to develop, evaluate and administer Board Certification programs.
For this reason, the Boards’ greatest expenditure is appropriately in the area of staff salary and compensation, as noted in their 990 reports.
The assets reported on the IRS Form 990 that the ABMS Member Boards currently maintain are crucial to sustain and evolve vibrant and innovative Board Certification and continuing certification programs. ABMS Member Boards are continually reinvesting in program improvements and enhancements to transform their certification and continuing certification programming, including the development of quality improvement and longitudinal assessment programs.
These investments will ensure that ABMS Board Certification continues to be a relevant, valued and important quality indicator for those who hold the credential as well as those who rely upon it for the highest standard of quality care.
