ABMS Maintenance of Certification – Its Origins, Realities, Ongoing Legal Challenges, and Implications for Medicine

If you’re a board-certified internist, you’re probably quite familiar with the controversy surrounding the American Board of Internal Medicine (ABIM) that began when lifelong board certification mysteriously became time-limited in 1990.

Physicians were told the justification for this change was that doctors needed to keep up with ever-changing medical innovations and that their skills and intellect atrophied with age. Never mind that the physicians who insisted on this change exempted themselves from the process and a system was already in place that addressed continuing professional development (CPD) of physicians using ACCME-accredited Continuing Medical Education (CME).

The annual market for physician CPD products in the US is massive: about $3 billion per year. Faced with the limited income stream of initial board certification of physicians in their specialty, CPD products were an attractive target for the American Medical Association and their subsidiary organizations, the ABIM and the ABMS (American Board of Medical Specialties). With the stroke of a pen, and with the help of medical societies and clever politics, the era of board “re-certification” and lifelong “Maintenance of Certification” (MOC) was born.

To assure physicians participated in board re-certification, the “Task Force on Recertification” threatened “uncertain circumstances” if physicians failed to “maintain” their board certification through repeated testing. As physicians confronted increasing regulations to practice medicine independently, more of them became employed. Thanks to their hospitals insisting that their staff physicians be ABMS board-certified to garner admitting privileges, doctors could no longer buy the CPD products of their choosing, but rather had to purchase CPD products that offered “MOC points” if they wanted to practice medicine.

MOC soon grew to include not only testing of physicians but added requirements for “practice improvement modules” and “Patient Voice” modules (whatever those were). A “Director of Test Security” was appointed to catch physicians who might share test content with their colleagues and compromise the money-gathering process. That individual was well-suited to the task, holding felony and misdemeanor convictions for impersonating a police officer and carrying an unregistered firearm in Washington DC after he was fired from the Washington DC police force for targeting a journalist.

Through political lobbying disguised as “consultant” work on tax forms and with the help of medical “stakeholders,” MOC was quietly added to the Affordable Care Act (ACA) as a “quality registry.” No one ever mentioned to physician diplomates of the ABIM that the President and CEO of their organization also sat on the boards of Kaiser Health Plans and Hospitals and Premier, Inc, the largest Group Purchase Organization for hospitals and nursing homes at the time the Affordable Care Act was being passed in Congress.

 A close look at MOC enrollment shows physicians must agree to an adhesion contract that makes them a “business associate” with ABIM. MOC is not about physicians “keeping up” any more, it’s about diverting CPD funds to the ABMS member boards and selling the data the ABMS member boards collect on physicians via the for-profit ABMS subsidiary, ABMS Solutions, LLC at our expense. 

Might the ABIM’s press release that was leaked to the Wall Street Journal about doctors cheating been timed for the passing of the ACA law later in 2010? Since the former President and CEO of the ABIM was a member of the President’s Council of Advisors on Science and Technology and soon began serving as the director of the National Quality Forum, the timing of these events is remarkably coincidental.

As I face the prospect of board certifying in cardiology and cardiac electrophysiology for the FOURTH time (I am “grandfathered” in Internal Medicine), I can’t believe this program has been allowed to continue. But as I hold my nose and reach deep into my bank account to pay nearly $3600 dollars for study materials worth one-fifth of my re-certification bill, I now completely understand.

Ten years ago, I began looking into the activities of the ABIM and other member boards of the ABMS, especially since the side effect of their policies on US physicians (and their legality) have never been studied. I reviewed 75 of their “studies” they published, many behind firewalls, to justify their extortion of working physicians. Most were written by ABIM officers themselves, some by members of Washington think tanks, and at least one included a veterinarian as author.

With the help of a forensic accountant, I began investigating the ABIM’s finances in 2013. In December 2014, I published my investigation on the ABIM Foundation, the Choosing Wisely campaign, and their undisclosed $2.3 million 2-bedroom condominium purchase using our test fees. Later in 2017, with the help of a diverse set of physicians and doctors of osteopathy, I co-founded Practicing Physicians of America, (PPA) a non-profit 501c6 organization with free membership, to continue our work fighting MOC and supporting working physicians.

At nearly the same time, Paul Teirstein, MD created a recertification board with academic colleagues to compete with the ABMS medical boards’ CPD product called the National Board of Physicians and Surgeons (NBPAS). Unfortunately, for physicians who work at teaching hospitals, the ACGME accreditation requires ABMS-board certified physicians, so NBPAS is not recognized at academic hospitals that wanted to remain ACGME-accredited (The ABMS is a member organization of the ACGME), nor has it been able to penetrate this political firewall as of this writing.

In response to an outpouring of negative feedback from physician diplomates and others, ABIM began amending the MOC process in 2018 to introduce it by another name in 2022—the Longitudinal Knowledge Assessment (LKA). This new program promised more frequent testing and money-gathering pushed to doctors’ cell phones.

Working physicians explored multiple avenues to end maintenance of certification, including the passage of an AMA resolution, having a “vote of no confidence” issued by the PA Medical Society, and a state-by-state effort to pass legislation to end the ABMS member boards stranglehold on physicians. None of these efforts succeeded in ending ABIM’s monopoly on certification.

What options did working physicians have to end the injustices and discrimination that the implementation of MOC created?

Legal action.

The Legal Challenges to ABMS Maintenance of Certification

ABMS board certification is not voluntary (despite ABMS member board claims), especially as specialization in medicine is the norm today. And thanks to regulatory capture, physicians who work at ACGME-accredited medical training hospitals in particular must pay for and participate in MOC before funds can be devoted to personally directed continuing professional development (CPD) products provided by others.

Forced participation in MOC and the harms it imposed on physicians have resulted in multiple federal class action antitrust lawsuits being filed against different ABMS member boards beginning in late 2018. These include Kenney v. ABIM (2:18-cv-05260), Siva v. American Board of Radiology (1:19-cv-01407), and Lazarou v. American Board of Psychiatry and Neurology (1:19-cv-01614). Kenney was filed in Philadelphia, PA while the Siva and Lazarou cases were filed in Chicago, IL. Here’s how this non-lawyer physician interprets what has occurred with these cases so far.

Background: Antitrust Law for Dummies

In layman’s terms, federal law prohibits any agreement that creates an unreasonable restraint of trade. One type of restraint of trade is when a seller creates a “tie” by forcing a buyer to purchase separate products together. Here, certification is separate from MOC, and physicians are forced to buy MOC because if they do not their certifications are revoked.

Kenney v. ABIM (2:18-cv-05260)

In Kenney, ABIM argued that MOC was merely a component or modification of certification, and that the two were one product and not separate. Plaintiff argued that ABIM’s analysis failed to examine the two products before MOC was implemented. The court sided with ABIM.

Siva v American Board of Radiology (1:19-cv-01407)

The American Board of Radiology used the same argument as Kenny that certification and MOC were not separate products. The lower court agreed. But the appeals court found (page 12) that certification and MOC were, in fact, separate products:

“In the pre-tie world, Board certification was not something that needed to be “maintained” through completion of any CPD program; it was valid for life. So the district court was right to observe that “CPD products serve a different purpose from certification and had nothing to do with it” prior to the introduction of the MOC program. But the district court never went the next step to see that, in Siva’s view, this is precisely the problem: CPD products, he alleges, still have nothing to do with certification—in other words, consumer demand for the two products remains distinct. As such, Siva says, the Board’s decision to name its CPD product “maintenance of certification” is nothing but a clever means of dis-guising a tying arrangement. Siva therefore urges that we see through that strategic naming decision—that marketing ploy—in conducting the separate-products analysis.”

Nonetheless, the appeals court upheld the dismissal of plaintiff’s claims because it did not feel MOC was a substitute for other CPD products. This argument was new and had not been addressed before by either the lower court or the parties.

 Lazarou v American Board of Psychiatry and Neurology (1:19-cv-01614).

The lower court recently requested that the Lazarou parties file a brief addressing the impact of the Siva opinion. Plaintiffs explained how Siva had found certification and MOC to be separate products, and described in detail how MOC was indeed a CPD product, and that MOC and other CPD products are substitutes for and interchangeable with each other. Whether the Lazarou case can go forward now lies in the judge’s hands.

Implications of MOC

Regardless of how the judges have ruled or will rule in these cases, MOC has already had far-reaching effects on the US health care system. In my opinion, the MOC story reflects a remarkable betrayal of working physicians by other physicians for one reason: greed. The physician-sycophants who head these organizations have become incredibly wealthy at working physicians’ expense and failed to actively deal with their organizations’ numerous conflicts of interest permitted by their very own bylaws. Physicians are leaving our profession in droves as they are gaslighted, no longer feel valued, and are forced to buy MOC to remain privileged at hospitals, receive insurance payments, and lower their malpractice costs, despite no credible proof that MOC improves patient care or safety.

Worse, countless hours of patient care have been wasted on test preparation and performing worthless data entry exercises. To have never considered that thousands of patients suffer as a result of MOC is bizarre – unless, of course, patients are of no real concern to those that impose the extortionate MOC program.

It is disturbing when organizations like the Physician Consortium for Performance Improvement (ThePCPI.org) with the same address as the American Board of Medical Specialties, magically disappear from the internet when their collaboration with the medical industry is exposed. Thanks to the digitization if health care, MOC tears a playbook sheet directly from the old AMA CPT-coding and Facebook-Cambridge Analytica playbook: data make you rich and can advance a political agenda.

Being slippery about MOC’s purpose voids any semblance of trust by physicians in our health care system. Moral injury is playing a large role in physicians’ disillusionment.  All the cute websites in the world called “BuildingTrust.org” made by the ABIM Foundation that secretly re-purposed tens of millions of dollars from physicians for political and retirement fund purposes certainly doesn’t help. Rather, it is a sick example of how low medicine has stooped to transfer working physicians’ forced-MOC fees to others in return for political favors.

Worst of all perhaps, in a clear and present danger to all patients, MOC promotes the silencing of scientific debate. ABIM, American Board of Pediatrics, and American Board of Family Medicine recently issued a statement with the Federation of State Medical Boards that threatens revocation of certification and even state licensure as a cudgel to quell anything they consider “dissemination of misinformation” by physicians. Meanwhile, Orwell and Semmelweis are rolling in their graves.

All these activities and wasteful spending make me wonder if certification should be continued at all. Our bureaucratic House of Medicine has lost its way. The drive for money and political influence have become so dire that even our own medical specialty societies are now partnering with the ruse.

As I near retirement, I have a choice: use my forty-plus years of medical experience to help train and teach my younger colleagues, continue to care for patients, and pay up and shut up to perpetuate the ruse, or quit medicine to avoid another round of extortion to remain certified in order to practice at the hospital system I have served for 22 years.

I wish I didn’t have to make such a decision. Medicine is what I do. My patients are what matters, not the ABMS member boards’ retirement funds.

I serve in the trenches with some of the most sterling, heroic physicians I’ve ever had the privilege to work with. I am sure you do, too.  I’d just like our regulatory bodies to have the modicum of honesty and credibility that we deserve.

Wes Fisher, MD

Find this article helpful? Consider donating to PPA’s legal efforts to end MOC nationwide.

Why Every Hospital System Should Recognize Re-certification by the National Board of Physicians and Surgeons (NBPAS)

The time spent, costs, and conflicts of interest inherent to the American Board of Medical Specialties’ lifelong physician re-certification process have become excessive. As a result, competition in the physician certification marketplace is needed.

In an effort to help physicians change their hospital credentialing bylaws by way of their local Medical Executive Committee, Practicing Physicians of America has produced the following evidence-based Powerpoint Presentation available to all physicians for their adaptation and use. The presentation’s content may be modified as needed and used without attribution.

We sincerely hope this presentation generates interest and acceptance in the medical community nationwide. Suggestions to improve its content are welcomed in the comment section of this post.

Hyperlink for the Powerpoint presentation file: https://practicingphysician.org/wp-content/uploads/2023/02/NBPAS.pptx

Hyperlink the the pdf of the presentation: https://practicingphysician.org/wp-content/uploads/2023/02/NBPAS.pdf

A Bad Prescription for American Patients

Practicing Physicians of America, and the the Free2Care coalition are staunchly against the passage of the highly partisan Inflation Reduction Act (IRA). Like many health care measures before it, there are consequences in the bill that will decrease access and innovation, and increase consolidation and costs for all patients, all while disproportionately harming those with cancer and chronic disease. 

Free2Care experts prescribe four major issues with the bill and legislative priorities that would actually address the issues of affordability and accessibility of health care.

  1. Pharmaceutical middlemen—Pharmacy Benefit Managers aka PBMs—  collect legalized kickbacks and are responsible for 80% of the cost of insulin, get a gift in the Inflation Reduction Act. 

Almost 50% of what is called “deficit reductions” come from repealing the Trump Administration’s ‘rebate’ rule. The rebate rule would have forced PBMs to pass on the ‘rebates’ they collected to seniors at the prescription counter instead of pocketing the rebates themselves.

Rebate is not the appropriate word for the money collected by the PBMs from the drug manufacturers: the PBMs were granted an exemption from the anti-kickback statute in 2003, and thus rebates are actually kickbacks. . Remarkably, the kickback collecting PBMs get to create the formularies—the lists of drugs covered by the insurance companies. A bigger kickback lands a drugmaker on the formulary, so more expensive medications are preferred for the PBMs and the insurers who have now consolidated with the PBM, and in some cases, even the big box pharmacies. The cost of the kickbacks is in the range of $200 Billion per year, all of this is explained elegantly by attorney David Balto.

By denying the “rebate rule” and declaring it to “pay for” new spending, the Inflation Reduction Act is a win for PBMs at the expense of seniors’ savings at the pharmacy counter. Former DNC chair Howard Dean, himself a physician, recognized the gimmick behind using the “rebate” rule as a pay-for.

Furthermore, Pharmacy Benefit Managers have been the driving force behind the cost of many medications necessary to sustain life for patients with chronic diseases or pre-existing conditions. Like Insulin. 

A 2019 bi-partisan report, produced by Senators Wyden and Grassley, found that PBM fees and rebates were responsible for 80% of the cost of the inflated cost of insulin.

2. Chronic disease and cancer patients will lose access, consolidation will increase, and costs will rise down the road.

A new Avalare study has found that part of the Build Back Better Act, now folded into the Inflation Reduction Act, will reduce payments for Medicare providers that furnish Part B drugs (drugs that are given by infusion and therefore delivered in a clinical setting ) by an average of 40%. Drugs for cancer, immunodeficiencies, and rheumatologic diseases such as rheumatoid arthritis fall into this category. 

Remarkably, the payment reduction is substantially higher for physicians in independent practices as opposed to those owned by hospitals. Besides the fundamental unfairness, the increased reduction will lead to the early retirement of independent oncologists and rheumatologists, and the continued consolidation of medical practices into ownership by hospitals. 

Consolidation has been shown to increase costs in a Stanford study. Worse yet, quality of care, and the all-important personal and attentive care required by the vulnerable, especially among the elderly are decreased when independent practices are forced to sell out to hospital systems.

3. Fewer cures and treatments for patients with cancer, chronic and rare diseases. 

The bill before the house imposes a 95% excise tax on innovative drug manufacturers unless they accept a price set by the HHS Secretary.  

This is not negotiation, it is price controls.

A Univ. of Chicago September 2021 study estimates up to a 60 percent decrease in R&D and up to 342 fewer new medication approvals. Loss of life from loss of innovation over the next decade is conservatively estimated as 20 times more than COVID-19 deaths at the time of their study. There is no measure in loss of quality of life as many new meds have immeasurable improvement on quality of life.

Oncology patients will be the hardest hit as half of the medication pipeline is for cancer medications. Innovative research for cancer sufferers will decrease by nearly ten times the amount that the cancer moonshot increased it

Small and emerging companies in California alone will have an 88%         reduction in new medications brought to market according to the California Life Sciences Association. This will fundamentally shift the formation of small emerging bio markets across the United States.

4. Higher prices for other medications will lead to higher premiums and overall health care costs.

The Inflation Reduction Act would control the prices of a chosen set of medications. On August 4, the CBO confirmed that price controls will lead to higher prices for new prescription medications. 

In turn, all Americans will pay higher insurance premiums and out-of-pocket costs at their pharmacies. Only the wealthiest Americans will be able to afford many cures. 

PPA and Free2care have been supportive of the Lower Costs, More Cures Act, with bipartisan provisions to lower drug prices while increasing transparency for PBMs and preserving innovation. We are supportive of Senator Wyden’s call to have both CMS and the FTC intervene in the practices of corrupt PBM middlemen.  

We are strongly supportive of Chairman Pallone’s HR-7666, which increases access for mental health and substance use disorder among other measures while reining in PBM.  HR-7666 has the added benefit of having passed the house by more than 400 votes, thus demonstrating the call for the bipartisanship that America craves.

The Inflation Reduction Act will be harmful to the long-term health of Americans, especially those with chronic and pre-existing diseases. We call on all house members to reject this bill and ask the Senate to get back to the drawing board, this time reaching across the aisle.


PPA is part of Free2Care, a coalition of member organizations dedicated to the doctor-patient relationship and making healthcare affordable, accessible, and of high quality. The 34 member organizations represent over 8 million Americans and include over 70 thousand physicians. 

In the recent request for comment by the Federal Trade Commission, the Free2Care Coalition represented approximately 75% of the 24,100 comments calling for a thorough investigation into the anti-competitive practices and behavior exhibited by pharmacy benefit managers.

 HHS called for comments on the behavior of GPOs and Free2Care submitted comments representing 80% of the 11,930 submitted

For media inquiries contact info@free2care.org

The White House Conference on Hunger, Nutrition, and Health: A practicing pediatrician’s comments

Let’s grow and eat what we grow!

The White House Conference on Hunger, Nutrition, and Health is a national effort to reinvent all of our nation’s nutrition, hunger, and health policies with inclusive input from stakeholders. Briefly, the goals are to:

Improve food access and affordability

Integrate nutrition and health

Empower all consumers to make and have access to healthy choices

Support physical activity for all

Enhance nutrition and food security research

In 2021, former USDA Secretary Ann Veneman, Tufts Friedman School of Nutrition Dean Dariush Mozaffarian, and former USDA Secretary Dan Glickman, co-proposed the idea of a White House Conference Hunger, Nutrition & Health.

On May 4th, President Biden formally announced the White House Conference on Hunger, Nutrition, and Health.

This is a first-time-in-50-year historic effort to reinvent our nation’s policies related to food with inclusive input from public stakeholders.

PPA, with thousands of physicians and a board comprised of two pediatricians, a pediatric psychiatrist, a cardiologist and two surgeons can see the value of this conference to all of our patients.

Thus PPA shared the comment link on social media channels, reaching thousands of physicians and patients and other stakeholders

As a co-founder of PPA and a pediatrician , a longtime volunteer for wellness in her community’s schools, and a volunteer teacher for organic gardening, Dr Marion Mass submitted the following

  1. We need enriching foods to be available in areas that can be considered food deserts. We need opportunities to exercise, and to meditate for mental health to be available in areas that are economically disadvantaged.

It would be best if this were to be achieved with those who live in those areas to become entrepreneurs and small business owners themselves, and to create sustainable jobs for others.  

I suggest that for any US citizen to make a donation, either of money, tangible resources or time to a start-up business or school in an opportunity zone (https://www.1031crowdfunding.com/qualified-opportunity-zones?leadsource=GoogleSEM-OppZones-DT&c_searchKeyword=opportunity%20zone&gclid=CjwKCAjwoMSWBhAdEiwAVJ2ndufpH3doLxJoUNByvVD5UwBfVRcX1NPnEkiMnB6mpo9HAlP0RWbymBoCEnIQAvD_BwE) a tax credit for this donation be applied to the donor.

Imagine if a Garden center, or a lumber company in a more advantaged zip code is incentivized to donate products to create a meditation garden, a yoga center, a walking path, an organic food repository in an opportunity zone?  This is a win for everyone.  It will create connections between communities in a very personal way.  It will lift up those hungering for opportunity.  It will create jobs all while promoting health.

  • We need to empower schools to utilize local resources when possible to get local good nutritional products into schools.  Local products should be given equal opportunity to sell to public schools and override existing food contracts that work with corporate vendors.
  • We need to allow and empower schools to reduce food waste by allowing them and encouraging them to compost for their own gardens, to donate whole fruits that were given out for school meals but untouched by student mouths.  It was a wonderful idea that in school lunches, a piece of fruit or a veggie must be given out.  However, much of this food is sadly wasted.  If an apple or an orange were untouched on a lunch tray, it ought to be possible to gather it and donate to local food pantries.
  • Schools need to be teaching about the history and culture of food and gardening within their history, literature and other classes as well as in home economics and nutrition classes.  For example, the Spanish dish of Paella came into existence in the following way:  During the Spanish Inquisition, those that had been forced to convert to Catholicism were still fearful, as many were ostracized, or even executed.  They cooked paella over an open fire, a dish utilizing pork, pork fat and shellfish, items forbidden in other religions.  While a shameful epoch in the Catholic church, knowing about the dish and even eating it or tasting it as part of a class would be a more enriching experience than a mere lecture.

Many foods that are international and quite delicious ought to be a part of home economics classes.  Mexican Tamales, Indian Pulao, Persian kuku, Puerto Rican black beans and rice, Moroccan couscous, Ethiopian groundnut stew are all complex dishes with plant based ingredients and quite healthful.  Students being taught about the rich history of food and origins of ingredients of these foods would not only improve their health but increase pride in individual student’s cultures.

  • Enriched funding for cooperative extensions and agriculture based colleges that help create gardens in schools and communities, and provide teaching in these gardens.  (This idea is from Tara Meritt a primary care and sports medicine physician from near Athens Georgia, home of UGA)
  • We need to have an investigation to discover how social media sites and apps might have algorithms that are distorting body image leading to children and teens unhealthy perceptions of their bodies, and unrealistic expectations of how they believe they are ‘supposed to look’.  The same sites need to be investigated to ensure that gentle healthy habits and messages are represented, and unhealthy habits are discouraged.  

    This same method needs to be employed on social media with respect to parenting.           Sadly, in America, so much of parenting has become a contest of sorts, with many feeling as though they are not measuring up.  Parents need to be empowered to know that they can succeed as parents without feeling the shame and guilt of not being ‘perfect parents’.  As a pediatrician, this is something mothers discuss with me all the time, but I rarely see discussed.  Especially mothers feel as though they are not as good as the perfect mom they see on social media.  Algorithms regarding this phenomenon must be explored.

PBM: Unmask the Villains of Healthcare’s High Costs

Marion Mass, M.D. and Christina Dewey, M.D.

Would you like to lower healthcare costs, restore quality and improve choice? Yes? Then you MUST learn about Pharmacy Benefit Managers (PBMs).

If you look on the Fortune 500 top 12 companies, you will find three companies who own PBM. Dig deeper, and you’ll discover these companies are CVS  health, who owns the PBM CVS Caremark, United Healthcare who owns the PBM Optum Rx, and Cigna, who owns the PBM Express Scripts. These three PBM control 85% of the prescription drug market, and are the biggest revenue generators for their parent companies. 

For example, when the insurance company Cigna, purchased Express Scripts in 2019, their revenues tripled. Take a peek under the hood of CVS Health, and you will discover that CVS’s  PBM CVS Caremark is, to put it frankly, its prize cash cow, its biggest source of revenue.  Moo.  

Until recently, many Americans had no idea what a PBM was, and blamed insurance and pharma and physicians for the high cost of care. The truth is much more complicated, and those making the money don’t want you to pull the mask off the villain of high healthcare costs.  They aim to prevent  the Scooby Doo denouement and keep Americans from discovering the biggest, richest, most devious villains in the healthcare space are the PBM.

Some really important clues to why we should suspect that the PBM are villainous profiteers:

–    The PBM and insurance companies now own one another, and some, like the CVS Health empire, also own pharmacy chains

–    The PBM controls the pharmaceutical companies, by creating the formularies, aka the list of medications that the insurance companies will “cover”. Physicians play no part, nor have any say in  this choice.

–    The PBM can collect legalized kickbacks, called ‘rebates’ from pharmaceutical companies because the PBM were granted an exemption from the anti-kickback statute in 2003 by GW Bush’s HHS secretary. This anti-kickback exemption allows pharmaceutical companies to simply pay for placement on the formulary.  Americans are not necessarily getting the best medication, but the best med a legal bribe can buy.

–    There is no transparency for these kickbacks (aka rebates) but sources have revealed that in 2020, the total amount of kickbacks approached $200 BILLION (yes with a B).

–    PBM like CVS Caremark are now facing charges of preventing elderly Medicare patients, including those with End Stage Kidney Failure from access to affordable life sparing medications.

–    In multiple states, PBM have been found to be helping themselves to Medicaid money… not a small helping, either: In Ohio alone, the PBM subsidiary of Centene as well as CVS and Optum were pocketing $244million per year.


–    The big PBM that own pharmacies, like CVS are utilizing shady practices to put trusted Mom and Pop pharmacies out of business.    


–    In an NBC News exclusive with Cynthia McFadden, the PBM mail order pharmacies were found to be delivering ineffective medications.  One young pediatric patient with cystic fibrosis was hospitalized after wasting away because of medications delivered by PBM giant Express Scripts, whose agent pooh poohed the concerns of the patient’s mother.

Do you need to hear more? 

Yes, you need to understand who is granting more favors to the behemoth companies responsible for the maleficent behavior noted above.

Let’s look at several recent congressional bills in chronological order of passage. 

The Affordable Insulin Now Act was passed by the House and Lingers in the senate

Although those who support the bill  claim to have lowered the cost of insulin, Lloyd Dogget, a Texas Democrat correctly stated that the bill does not lower the cost of insulin by even a penny.  He’s correct.  It lowers the co-pay, but the uninsured, and those who pay insurance ( whether they be employer or independent purchaser)  will continue to pay the full bloated cost of insulin, 80% of which is flowing to the PBM via kickbacks and fees.  In other words, this bill simply ensures that the taxpayers keep paying the PBM in the form of kickbacks.

Worse yet, the bill grants a delay of the rebate rule for PBM.  The rebate rule was an Executive Order introduced in 2020 and demanded that the kickbacks (aka rebates) would flow to the patient at the point of sale and not the PBM and the insurers.  PBMs are continually telling Americans that they pass on the rebates, yet when the rebate rule was suggested, they have threatened to increase Medicare premiums as soon as the rule is enacted. 

Congress has discovered they can pull the entirely disingenuous accounting sleight of hand of delaying the rebate rule (in other words, allowing the PBM to keep collecting their kickbacks and not forcing them to pass on to patients) and thereby claiming that they are saving money by preventing Medicare premium increases. To put another way, the PBM’s and Insurers are playing Chicken with the rebate rule by threatening Medicare premium increases, and the Congress-people that delay the rebate rule are taking the bait.  I suppose that makes them lower than chickens in the game.  Perhaps they are simply chicken….. oh, never mind. Maybe they simply don’t understand.

The insulin Bill was not the first time Congress  delayed the rebate rule.  Apparently they did it in the infrastructure bill, too.  Howard Dean, a physician and former presidential candidate called them on it in Newsweek, even pointing out that the rebate rule was solid, and potentially the best thing to come from the Trump Presidency. 

Based on the above, we ought to let that insulin bill die and come up with a real way to lower insulin costs.

The recent Gun Bill Passed by the Senate and House and signed into law sneaked in a gift to PBMs.

Why on earth would a bill on guns contain another delay in the rebate rule, yet another gift to the PBM industry?  The same faulty accounting gimmick of using the rebate rule delay as a pay for.  Unbelievable.  Senators Chris Murphy, D-CT and John Cornyn, R-Tx are mum about who put the PBM poison pork into the gun bill.  Interestingly, Murphy’s top donor is the law firm that helps CVS negotiate mergers.  And Cornyn is a top taker from Vizient, a hospital Middleman Group Purchasing Organization.

Good news at last!  PBM reform in the Mental Health Package

Thankfully, some good news exists. .  Some colossally INCREDIBLE news:

HR 7666, the bipartisan mental health bill introduced by Frank Pallone, D-NJ, and Cathy McMorris Rogers –R, Wa passed the house this week with 400 yay votes.

Some of us were really yelling ‘Yay’ when we discovered splendid section 602, quietly added by Rep Michael Burgess (R-Tx), mandating   big time TRANSPARENCY for big PBM/Insurers with shocking penalties of $10K per day for non-compliance.

Requiring  PBM transparency will save $2BILLION/10 years, paying for the bill.  Billion with a ‘B’.  As Mental health and substance abuse medications are largely overpriced due to PBM kickbacks, this provision absolutely belongs in the bill.

Americans will receive  some wonderful services  with this bill for Mental Health and Substance Use Disorders. Full detail can be found in the bill,  but here is a screenshot of some of the high points

WE CANNOT STOP… we must make sure the mental health bill passes in the senate WITH PBM reform Intact

Please CALL and EMAIL  both of your US Senators ASAP, (find their numbers and email contact links  here ) and tell them to PASS  the Senate version of HR 7666 with the Burgess amendment to bring PBM transparency and accountability intact.  Ask  your friends to call.  Ask your neighbors to call. Ask everyone in your circle and beyond. Tell YOUR Senators you now know the PBMs are behind the ever increasing healthcare costs and it’s time for Congress  to listen to we the people and not the profiteering villainous Pharmacy Benefit Managers! 

Drs. Mass and Dewey are proud to be pediatricians for over 20 years each and fierce advocates for patients and physicians!

Dr. Mass, graduated from Duke Medical School and trained at Northwestern. She has practiced in the Philadelphia area. She’s a cofounder of Practicing Physicians of America And leadership in Free To Care .

Dr. Dewey attended Loyola University Stritch School of Medicine . She did a year of surgery internship then two years of pediatric surgery research before training in Pediatrics at University of Minnesota. She is founder and CEO of Peds Mama Doc and has published in multiple outlets