ABEM is growing wealthy, alongside the other medical boards, but they should remember their roots and choose a path of transparency.
Drolet and Tandon, in their research letter to JAMA on August 1, dug up some numbers and gave some context to what a lot of practicing physicians were undoubtedly wondering: How does my specialty’s medical board finances compare to others? And the authors begin to shine a light on the question: What are my exam and MOC fees paying for?
ABEM acquits itself well enough. Emergency medicine has the least expensive written board certification fee among 24 specialties – and the only one under $1000. Our overall certification and MOC fees were around the mean for medical boards.
But the JAMA paper shows, in general, medical boards enjoyed an average annual growth rate of 10.4% over the period from 2003-2013, nearly tripling their net balance (assets minus liabilities) which rose to a cumulative $635 million. Wow – that is a great run. And this research into finances doesn’t include foundations and board subsidiaries – if anything, the revenue gains by medical boards are underreported here.
The vast majority of this revenue to these non-profit medical boards is coming from a captive audience of physicians, paying fees. I think it’s fair for physicians to ask, however, why it was necessary for ABEM to raise so much revenue over that time period. It’s possible, I suppose, that board exams are getting more complicated to write and administer. One might think that teleconferencing and web communications would make it easier and faster to write exams. One might think moving from paper to computer-based testing would decrease expenses. Instead, the opposite seems to have occurred.
As is typical for non-profits, Drolet and Tandon’s research shows almost half of revenue is going to officer and employee compensation. So again, questions come to mind – Did the medical boards go on a hiring spree? Or did everyone just get big raises?
There’s a lack of transparency, and an increasingly transactional feel, to the act of certification. When I signed into ABEM.org last fall, I was prompted to agree with a new mandatory arbitration clause, as well as ABEM’s sharing of my personal information with Elsevier. There’s no opt-out, and no explanation of why these measures are necessary, let alone desirable.
Look, every EP owes a huge debt of gratitude to ABEM. Emergency medicine’s existence as a specialty was by no means assured in those early years – it took the effort and brains of a dedicated group at ABEM to silence the critics and blaze this trail.
But ABEM would do well to remember that pioneering spirit today. There’s widespread dissatisfaction among physicians when it comes to our various specialty medical boards. MOC and its associated fees have quickly been adopted and standardized across specialties, without much discussion or evidence. A 2016 survey showed that only 15% of physicians felt MOC was worth the effort; 81% believed it was a burden.
The AMA has come out against MOC, and in August, 33 state medical societies and several national specialty societies – including ACEP – signed a letter to ABMS, highlighting member concerns with MOC. These groups are concerned that a MOC process that’s seen as expensive and irrelevant to practice is a threat to physician self-regulation, and are urging a path forward to solving this, before state legislatures develop their own solutions.
Our specialty exists today because there was a need, and emergency medicine constantly had to assert itself over objections from the other houses of medicine, to best serve patients. ABEM should remember its roots at a time like this. Instead of falling in line with the other medical boards and striving for the mean among specialty fees, ABEM could light a path among medical board, choosing transparency. Let emergency physicians know what their certification fees are buying – and why board revenue needs to rise. Let emergency physicians know what’s behind the arbitration clause and Elsevier agreement.
I am grateful for all that ABEM has accomplished for our specialty. But EPs are a captive, vulnerable audience (if board certification seems expensive, the alternative is even worse). ABEM has an opportunity to inspire a new generation of emergency physicians – just when medical student debt and regulatory burden is at its highest. “This is what everyone else is doing” has never been good enough for emergency medicine.
3 Comments
Excellent discussion, Nick. It is glaringly obvious that “mission creep” (in search of profits) is the culprit in the dramatic expansion of requirements by ABMS boards, spearheaded by my first board, ABIM, which even maintained a luxury condo and chauffered limo in Philadelphia for the comfort, convenience and no doubt conviviality of their leaders until it was exposed by investigative reporters and doctors who were tired of being bullied into submission.
We in EM have always felt proud we were “the guys in white hats”… doing the job no one else wanted to do, doing it well, and often doing it with no hope of compensation for our efforts. I certainly hope that “mission creep” at the top of our specialty in emulation of other ABMS specialties does not allow current leaders to forget that it was the John Wiegensteins, Jim Mills, and similarly high minded founders of EM who did the work required to make us a specialty, and almost certainly without compensation. John W in particular often proved that he believed in getting things done regardless of who got the credit. I can’t imagine him expecting a salary in excess of those practicing the specialty he loved, in return for holding them to arcane examination standards and testing methods “just because we can” (and others do).
Disclosure: I’m a “Senior Director” of ABEM which means I served on ABEM (1986-1995).
Thank you for your essay, Nick. I like your perspective. I note that in the 2016-17 ABEM Annual Report there is one column of narrative text describing a few financial aspects of ABEM. Nearly half of the column of text is devoted to reporting that fees have not been increased though costs increased. I think this sort of non-financial reporting is a mistake in these times and I think it would be useful for the ABEM to embrace transparency through a more typical formal annual report for a non-profit organization including a “Sources and Uses of Funds” and Balance Sheet.
I also think that the newsletter would be a great vehicle to tell the story of a year’s worth of (for example) item writing and validation including some approximation of the costs involved, e-oral examination delivery, qualifying examination preparation and delivery, etc. Let people see how much it really costs for ABEM to operate. In later years tell the story of research, international efforts in certification and other non-core but appropriate activities for ABEM.
Not to mention that ABEM’s website has to be the least updated, least user friendly, web 1.0 style nonsense that I’ve seen in recent memory. For the amount of money that we spend and the amount of profits that they generate, the least they could do is work on making a more visually appealing and user-friendly website.