With the class-action antitrust suit filed against the ABR earlier this year, a post looking deeper at the finances that make an appearance in the lawsuit is overdue. You can find the recent filings that I used for this post collected here.
I promise this is a more interesting read than one might think.
Background
The ABR is a 501(c)(6) organization.
Readers may be familiar with the more common 501(c)(3) designation, which is the non-profit status used by religious, charitable, scientific, and educational organizations (and is the type generally required to qualify for loan forgiveness within the Public Service Loan Forgiveness (PSLF) program).
A 501(c)(6) organization is a business league or association organized and operated primarily to “promote the common business interests of its members.” I’m not really sure how the ABR qualifies as that, but it’s a self-reported designation and that’s their purpose as far as the IRS is concerned. (burn!)
Regardless, as a tax-exempt non-profit, the ABR must make public their Form 990 annual returns for the past three years. The most recent returns (2017 tax year, filed in 2018) are also available on several sites including ProPublica and GuideStar, both of which maintain a searchable database of all non-profit tax returns.
But before we go through the returns and try to make sense of the ABR’s finances, a disclaimer: I am a radiologist with a hobbyist understanding of the tax code, not a CPA, tax preparer, or financial anything (let alone a forensic accountant). This is all for entertainment purposes only.
Disclaimer #2: Form 990 is light on details. I emailed the ABR for clarifications about several issues. Unsurprisingly, they ignored me.
Revenue Breakdown
Tax-exempt non-profits can, in fact, have taxable income if the income derives from activities separate from their mission. In 2016, the ABR claimed $45,605 in taxable income on line 7. In Part VIII, this was described as real estate rental income. I don’t know what they’re renting or to whom they rent to. In 2017, it was down to around $30k.
Total tax-exempt revenue is mostly from “certification fees.” Over the past five years, total revenue (which includes investment income):
2017: $17,430,259 (up $1,138,815, 6.9%)
2016: $16,291,444 (up $530,424, 3.4%)
2015: $15,761,020 (up $585,430, 3.9%)
2014: $15,175,589 (up $1,635,419, 12.1%)
2013: $13,540,170
For reference, the inflation rates over this period according to the US Labor Department were 0.8% in 2014, 0.7% in 2015, 2.1% in 2016, and 2.1% in 2017. So the ABR has reported true growing revenue.
Though not specified as such in the 990, the substantial year over year increase is primarily related to increasing MOC enrollment.
In 2017’s Part III, the ABR says that it administered 4,790 total exams and that approximately 27,000 diplomates were enrolled in MOC. As a reminder, MOC costs $340/year, so the revenue from MOC was approximately $9.2 million in 2017. Note that because older radiologists were grandfathered with “Lifetime” certifications whereas all new diplomates immediately enter MOC, this number will enlarge annually until a steady state is reached, presumably sometime in the next 10-20 years. I’m sure the ABR has a better idea of when the gravy train will hit its coasting speed.
To wit, the number of MOC-enrolled physicians was 26,140 in 2016, 25,000 in 2015, and 24,000 in 2014. With over a thousand new diplomates automatically enrolled in MOC every year, the ABR can anticipate rising revenue for the foreseeable future.
Also note that MOC revenue scales fantastically, as the incremental cost to service an individual enrollee approaches $0 but each one brings in $340 every year throughout their career.
Subtracting MOC income from the total fee-related revenue of $16,271,311 would leave around $7 million in revenue from exam services ($7.4MM in 2016). As I’ve discussed before, around $3 million of that comes just from residents, who spend around 1% of their pre-tax income directly to the ABR annually without exception.
In the 2018 annual report, ABR president Brent Wagner made this comment on the first page of content:
As a non-for-profit, the ABR collects fees to cover the expenses of administering the programs. Reserves are maintained to cover unexpected capital expenses, but fees are set as closely as possible to approximate administrative expenses.
Based on the numbers you just read, I think you can see where this is going. But let’s see how that holds up.
Expenses
Expenses also continued to rise from $13,758,299 in 2015 to $15,590,929 (a 13% increase) in 2016 to $16,468,080 in 2017 (a 5.6% increase). Payroll-type expenses increased from $6,932,139 to $7,342,360 (a 6% increase) to $8,256,080 (a 12% increase).
Revenue minus expenses yield a “non” profit of $962,179 in 2017, down from $1,329,124 in 2016.
So despite $17.4MM in revenue, the ABR claims its expenses take out all but a single mil. Let’s look at some of those.
Salaries
We don’t need to name names of every ABR officer and their compensation, but we can at least track the highest paid, who is Dr. Valerie Jackson, the ABR’s executive director during the studied period.
| Year | Salary | Non-salary (retirement + benefits) | Total Compensation |
| 2017 | 690,106 | 48,925 | $739,031 |
| 2016 | 693,583 | 33,429 | $727,012 |
| 2015 | 711,577 | 39,730 | $751,307 |
| 2014 | 316,495 | 21,828 | $338,323 |
2015 was a good year to hold the reins.
These numbers are interesting in how they may or may not correlate with the recent changes to the ABR board certification process that occurred in 2013 as well as the rising profits from MOC endeavors (common among ABMS members) and then perhaps coincidentally followed by small token decreases in light of increasing physician frustration with MOC across the country, increased scrutiny of member-board financials (like these wonderful reads from Newsweek about the ABIM), or the recent series of class action lawsuits.
Or that could totally be a coincidence. What any reader can agree on is that being the head of the ABR is certainly a livable income.
Another reason payroll increased? In 2017, the ABR hired a “Director of External Relations” whose base salary is $135,033. Trying to make the ABR look good is apparently a challenging full-time task. To round out the A-Team, they also hired a similarly paid “IT Director” (possibly as a result of Mammogeddon) and a “Managing Director,” to, um, manage and direct things?
“Other” Expenses
Other expenses make up the majority of the ABRs expenses and totaled $8,248,569. What are “other” expenses you ask? Look no further than Part IX (“Statement of Functional Expenses”)
These include things like credit card processing fees, office expenses, insurance, etc. I wouldn’t pretend to have any idea about how much the ABR should spend on staplers and toner.
Expenses are hard to parse because they’re grouped into large nebulous categories.
- In 2016, the ABR spent $2,204,166 for Exam Services. Given that the ABR owns its own testing center, the exams are administered by employees, and the questions are largely written by volunteers, I would personally be interested in having these big numbers broken down some more. In 2017, this dropped down to $466,472.
- $1,292,317 was for conferences, conventions, and meetings. The ABR does reportedly convalesce in Hawaii twice annually. This is down from $1,534,608 in 2016.
- Legal services accounted for $45,439 in 2017. Watch for that number to rise substantially in 2019.
- $1,051,695 was for “Other fees” — who knows? These are often payments made to various independent contractors that don’t fall into the other categories likes investment management fees, IT, etc.
- Another mil for office expenses. Another mil for occupancy (rent, utilities, real estate taxes, etc).
- And a big $5.4MM for salaries/wages of the nonexecutive rank and file.
What we do know from Schedule J, which details compensation information, is that the ABR does “reimburse board members for companion’s travel.” That could even be housed separately in the $640,464 figure for travel, which is distinct from the $1.3MM above for conferences/meetings. Twice annual all-expense-paid trips for the family to Hawaii do sound nice.
The ABR doesn’t run lean.
War Chest
Rising revenues have nicely padded the ABR’s current assets, which totaled $51,737,127 in 2017, up from $49.5 million in 2016 and $45.7 million in 2015.
The ABR does claim $10.8MM in liabilities, so according to its 990, the net assets total $40.8MM. However, these liabilities include $8,914,139 in “deferred revenue.” This is to say, the lower figure is meaningless in a common-sense interpretation. Deferred revenue is a mostly BS accounting technique used to refer to payments made in advance for services not yet rendered. In this case, it’s a convenient way to make it look like you’re making less money than you really are. Based on the figure, it would seem the ABR jams all the MOC fees in there, though it’s not as though they offer refunds.
In everyday terms, most would argue that all of the ABR’s revenue is “unearned.” Regardless, outside of clever spreadsheets, that cash isn’t really a liability. It’s all sitting in the bank.
So, the ABR was really holding on to a war chest of almost $52 million in 2017.
Even with questionable payroll, staffing, and vacation meeting practices, the ABR still has an annual operating revenue surplus (aka a profit) of a million bucks. What size of “reserves” will finally be sufficient to “cover unexpected capital expenses,” so to speak? Maybe the slush fund was to cover the inevitable lawsuit. Outside of its testing business, the ABR investment portfolio itself gained almost a million in 2017 and almost two million in 2016.
Even if the ABR stopped making a profit on fees (hard to do even with an impressive meeting budget), they would still likely make money every year. The portfolio proceeds would certainly be enough, for example, to drop the resident and fellow fees down to attending levels from their current $300 premium ($640/yr for trainees vs $340/yr for MOC).
The ABR Foundation
The ABR does maintain a separate “Foundation” that is a 501(c)3 organization. The ABR Foundation, unlike the ABR, is able to receive tax-exempt charitable donations. The nebulous purpose of the ABR Foundation is “to demonstrate, enhance, and continuously improve accountability to the public in the use of medical imaging and radiation therapy.” Like you, dear reader, I have no idea what that means.
Later, the mission of the foundation is described: “The Foundation carries out the scientific, educational and charitable purpose of the mission of the American Board of Radiology.” I have a hard time picturing that too. The final description of the mission: “to demonstrate, enhance, and continuously improve accountability to the public in the use of medical imaging and radiation therapy.” Darn, that still doesn’t help.
In 2017, it only made money from investments on its net assets (now $1.6MM). No one gave them any money, and they awarded no new grants. Why?
Because, since 2015:
“The Foundation is re-evaluating program services offered to determine how to most effectively achieve the mission statement. During this period of re-evaluation, no new contributions are currently being accepted. Current program commitments for sponsorships continue to be serviced.”
In 2014, the ABR awarded two grants:
1. $95,000 to create a national brachytherapy registry and QA program
2. $25,550 to create ethics and professionalism instructional modules
But 2013 was a much more interesting year:
The ABR Foundation somehow managed to receive $202,348. Total expenses were $305,982:
1. $95k again went to the brachytherapy project
2. $77,599 went to “summit meetings/conduct symposiums to optimize a national strategy for safe and appropriate medical imaging”
3. An additional $115,908 were also “meetings expenses”
So, it’s meetings all the way down.
Either way, the foundation seems mostly defunct now.
American Board of Radiology International
Is a “disregarded entity” that made $178,750 for total assets $539,649 in 2016. Its stated purpose is to “provide guidance in a radiology certification exam program.” Yes, a program. I have no idea.
Conclusion
Whew.
So to summarize, I am not an accountant. If you or someone you love has more information about the ABR’s operations or financial workings, please feel free to contact me. I would love to update this post (or all my posts, for that matter). I feel strongly that there should be more information available to candidates and diplomates, and it would be much better if it came unwhitewashed from the ABR itself rather than from someone throwing snarky potshots from the sidelines like myself.
The ABR makes a lot of money from trainees and radiologists who have zero say in its operations and to whom the ABR does not feel accountable.
The ABR’s expenses are hard to parse but are clearly not super-duper efficient in their use of very generous certification fees.
The war chest was around $52 million in 2017, is almost certainly higher now, and will continue increasing every year for the foreseeable future due to essentially compulsory MOC.
Assuming any of the current lawsuits progress to discovery and aren’t confidentially settled, we can eventually expect some fascinating news in the years to come. In the meantime, those legal fees certainly aren’t going to help their bottom line.
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