Class Action Lawsuit against the ABMS

There are separate class action antitrust lawsuits against the ABIM, ABR, and ABPN.

But there’s also a class action lawsuit against the umbrella organization, the American Board of Medical Specialities (ABMS), which names all of the member boards as “co-conspirators.” The premise is the same in all of the suits: the ABMS and its member boards have a competition-squashing monopoly on initial board certification and use that dominance to illegally tie mandatory lifelong payments in the form of MOC-fees lest doctors lose their hard-earned certifications.

There’s an interesting excerpt from a Department of Justice letter in the middle that I’m going to pull a couple of passages from (emphasis mine):

Because, like other forms of professional standards-setting, certification can become a de facto requirement for meaningful participation in certain markets, a certification requirement may create a barrier to entry. In such circumstances, certification may function more like licensing requirements – establishing who can and cannot participate in a market – rather than voluntary certification that can help patients and others distinguish on quality among a range of providers.

The more certification comes to resemble licensing, the more such industry self-regulation raises similar concerns. For example, as the U.S. Supreme Court has explained, though market participants offer important and needed experience and expertise about their practice and profession, such professionals, when empowered to set licensing requirements without meaningful review, “may blend [ethical motives] with private anticompetitive motives in a way difficult even for market participants to discern.” Similarly, competitive concerns can arise when private standard-setting processes become “biased by members with economic interests in restraining competition.” The governing members of a dominant certifying body may have incentives to set certification requirements more stringently than is necessary to certify that providers have the relevant knowledge and skills. In situations where one certifying body has become dominant, such that physicians cannot turn to alternative bodies for a similar certifying function, market forces might not constrain the dominant body from acting on these incentives.

Which is to say: the DOJ wrote an excellent summary of the current situation several years ago.

The chance of these cases actually going to a jury trial does seem a bit higher when the Department of Justice and Supreme Court have already put words on paper warning of the dangers of “self”-regulation and legitimizing the complaints against these certifying organizations.

Explanations for the 2019 Official Step 1 Practice Questions

The 2019 set was recently updated in February. Of the 117 questions in the PDF, only two have been changed, which I’ve answered below. The order and content otherwise appear unchanged, including the three multimedia questions at the end of the online version.

Please see last year’s 2018 explanations for the remainder.

The many comments at the bottom of that page may prove helpful for those with additional questions. You’re never the only one to struggle.

48. E – When people go camping, you should be thinking of zoonotic infections. Fun fact, New Mexico leads the country in cases of plague. Yes, that plague: Yersinia pestis. The “bubonic” part of bubonic plague refers to the swollen infected nodes (“buboes”) characteristic of the disease, which often involve the groin (bubo is the Greek word for groin, who knew?). In this case, they’re also describing a necrotic epitrochlear node. Classic treatment is with aminoglycosides, which bind to the 30s ribosomal subunit. (Note that Tularemia, caused by another gram-negative bacteria Francisella tularensis can present similarly but is more common in the midwest. Regardless, the two are often lumped together, the antimicrobial treatment is similar, and the answer in this case would be the same).

69. E – Catalase and coagulase-positive gram-positive cocci = staph aureus. mecA-positivity means the bacteria carry the gene that confers methicillin-resistance, hence MRSA. Of the choices, MRSA is treated with vancomycin.

ABPN? Also sued.

Hot on the heels of last week’s anti-ABR lawsuit (which itself followed the ABIM lawsuit), two psychiatrists have submitted a very similar class action suit against the American Board of Psychiatry and Neurology (hat tip Dr. Wes). And by “very similar” I mean it’s mostly the same lawyers, it’s filed in the same Northern District of Illinois, and it really is very similar.

But the financials in question are even more eye-catching:

Between 2004 and 2017, after the advent of ABPN MOC, ABPN’s “Program service revenue” account exceeded its “Program service expenses” account by a yearly average of $8,777,319, as reported in its Forms 990 for those years. During that same period of time, ABPN’s “Net assets or fund balances” account skyrocketed 730%, from $16,508,407 to $120,727,606. In other words, at year-end 2017, as ABPN MOC revenue continued to grow, ABPN net assets (assets less liabilities) more than septupled, which included, according to its 2017 Form 990, almost $102 million in cash, savings, and securities.

$102 million. What could they possibly need a war chest of that size for? Fighting lawsuits, one presumes.

And then:

[Executive compensation includes] overly generous compensation paid to current ABPN President and CEO, Dr. Faulkner, who was hired by ABPN in 2006 as Executive Vice President, its most senior staff position. In 2007, he was paid total compensation of $500,726 as Executive Vice President. Dr. Faulkner became ABPN President and CEO in 2009. In 2017, the last year for which data could be located, his total compensation as President and CEO was $2,872,861, including a bonus of $1,884,920. Thus, as ABPN MOC revenue continued to grow, Dr. Faulkner’s total compensation almost sextupled.

No words.

Goldman Sachs and the Optics of Drug Discovery

Goldman Sachs analyst Salveen Richter, channeling the obvious in a note to clients (excerpted by CNBC):

The potential to deliver ‘one shot cures’ is one of the most attractive aspects of gene therapy, genetically-engineered cell therapy and gene editing. However, such treatments offer a very different outlook with regard to recurring revenue versus chronic therapies. While this proposition carries tremendous value for patients and society, it could represent a challenge for genome medicine developers looking for sustained cash flow.

Ew, go on (emphasis mine):

GILD is a case in point, where the success of its hepatitis C franchise has gradually exhausted the available pool of treatable patients. In the case of infectious diseases such as hepatitis C, curing existing patients also decreases the number of carriers able to transmit the virus to new patients, thus the incident pool also declines … Where an incident pool remains stable (eg, in cancer) the potential for a cure poses less risk to the sustainability of a franchise.

Yes, franchise. Long term profits depend on the riskiness of a cure.

I’m not going to begrudge a private company their desire to make money. The possibility of windfall profits are the main reason why private companies are willing to invest in uncertain and risky biomedical research. That said, when the long tail of a too-good cure only makes tens of billions in profit, it should be hard for even a staunch capitalist to be sad.

This attitude is part of what drives fringe antivaxxers and other patients away from evil “big pharma” and the medical doctors who understand the actual practice of medicine and into the arms of pseudoscience. For my part, I don’t think any company should feel bad if they develop an HIV vaccine so effective it eradicates the disease and relieves the suffering of millions, even if it eventually results in downstream profit loss due to the loss of the chronic antiviral therapy market.

We badly need and will always need public and government research support—for many reasons—but one is because the optics of the patient as a customer mindset are so toxic.