In Part I, I discussed the Educational Commission for Foreign Medical Graduates’ (ECFMG) $900 fee to verify credentials for the 2021 Match.
It’s an eye-popping figure – but it was far from the only one I discovered when I began looking into the ECFMG’s finances.
Here are some of the others.
The number of years since 2001 in which the ECFMG has reported a financial loss.
(Their streak of uninterrupted financial success likely goes back much farther than that – but I could only get their tax records from 2001 on.)
In 2018, for instance, the ECFMG reported an overall profit (revenue less expenses) of $9.3 million.
And yes, the ECFMG is a non-profit organization. That does not mean that they cannot make a profit. It just means that they cannot distribute that profit to shareholders. Instead, they have to invest any profit they make in financial reserves, new programs, or higher salaries for executives and employees.
Net assets of the ECFMG in 2018.
Most of their assets are financial securities, held in a “master trust” with a market value of $108,323,824 in 2018.
That’s the how long the ECFMG could cover all of their expenses from the USMLE program just by using the money in their “master trust.”
(I’m basing that calculation on the $31.5 million in annual expenses reported for the USMLE in 2018.)
In other words, they could give away the USMLE for free from now until 2024 and still be in the black.
Of course, they’re not gonna do that. The ECFMG’s statement justified the new $900 certification fees by noting their operating losses due to the loss of USMLE Step 2 CS revenue. Rather than going too deeply into their own pockets, they chose to put their hand into their customers’ a little deeper.
Some people get it. Unfortunately, none of them seem to work for the ECFMG.
The number of international medical graduates (IMGs) who were certified by the ECFMG in 2018.
Many IMGs who pursue ECFMG certification are unsuccessful – so the total number of IMGs who conduct business with the ECFMG is greater than the number of certificates issued.
However, because more granular longitudinal data are not readily available, we can use the number of certificates issued to get some sense of the number of paying customers the ECFMG serves each year – and how rapidly that number might be increasing over time.
Data adapted from the ECFMG.
Thing is… the number of certificates issued is not increasing over time. It’s actually down slightly from the mid-late 2000s. Which makes this next figure somewhat perplexing…
That’s the percentage growth in the ECFMG’s program service revenue from 2006 to 2018.
Even though the number of core customers – IMGs who receive the ECFMG certificate – did not change, the ECFMG managed to grow their revenue from $45.3 million in 2006 to $76.5 million in 2018.
If we look back even farther, we can see that the ECFMG’s revenue growth has more than tripled since 2001.
“Program service revenue” applies to monies received by a non-profit organization by charging for its tax-exempt services charges (vs. revenue from donations or investments).
How does an organization with a stable customer base triple its revenue? Easy – it just has to extract three times as much money out of each of its customers.
That’s the difference in price between what the ECFMG charges IMGs to take the USMLE Step 1 or Step 2 CK examinations ($965) and what the National Board of Medical Examiners charges U.S. medical students ($645).
It’s the same test… so why do IMGs pay $320 more?
Of course, one does not simply take the USMLE. To sit for the exam, the test-taker has to prove he or she is enrolled in a legitimate medical school. And as the ECFMG is fond of arguing, it’s harder to verify the credentials of an applicant from India than one from Indiana.
So how much expense is justified in verifying credentials?
Cost of credential verification through the Electronic Portfolio of International Credentials (EPIC).
EPIC is a product of the ECFMG – part of a service line that generated over $5.2 million in profit in 2018.
Credential verification for the ECFMG’s highly-profitable EPIC service is only $90.
If the ECFMG can verify credentials – profitably – for $90, why do they charge $320 extra to register examinees for the USMLE?
There’s gotta be a reason, right?
Maybe it’s due to the added expense of administering the USMLE in foreign countries. Maybe that explains the difference.
The ECFMG’s International Test Delivery Surcharge for taking the USMLE Step 1 examination in countries such as Germany, Taiwan, Denmark, and Korea, to name a few.
See, the ECFMG charges an additional fee to examinees taking the USMLE outside of the U.S. For instance, if you want to take Step 1 in Kenya or Nepal, you pay $160; for Step 2 CK in Denmark or Israel, you pay $220; for the USMLE in Japan, you pay $385 to $435 on top of the standard $965.
Whatever extra burden might be involved outsourcing the test to Prometric test centers in these countries, the ECFMG seems to have their expenses covered… and then some.
So why are the ECFMG’s fees higher?
Difference in price for the USMLE Step 2 Clinical Skills exam for ECFMG-registered IMGs ($1600) and NBME-registered U.S. students ($1300).
Bear in mind, both U.S. students and IMGs take Step 2 CS at the exact same test at the exact same test centers, all of which are located in the U.S.
In other words, rather than setting the price point by what the test costs, the ECFMG seems to charge what the market will bear.
(If you needed more evidence, look no further than USMLE Step 3. The Federation of State Medical Boards handles registration for all Step 3 examinees… and somehow, they charge everyone the same price.)
That’s the average annual increase in the registration cost for the USMLE Step 2 CS examination from 2010 to 2020.
A smart person might defend the ECFMG’s price increases by noting that the rise parallels the average annual inflation rate over that time period.
A smarter person may question why any increase in Step 2 examination fees was necessary when the ECFMG’s program service revenue was growing at more than three times the rate of inflation.
Total profit (revenue less expenses) taken in by the ECFMG on the USMLE program in 2018.
Yup, the ECFMG took in $58.8 million in revenue against only $31.5 million in expenses. Not bad, huh?
But I wonder how that compares to the NBME’s profit from administering the USMLE to U.S. test-takers, don’t you?
Profit reported by the NBME on the USMLE program in 2018.
According to their IRS Form 990 tax return, the NBME had $113 million in USMLE revenue, but incurred over $95 million in expenses running the tests.
In other words, even though they had only around half the NBME’s USMLE revenue, the ECFMG made 54% more profit on the USMLE than the NBME did.
Yes, you read that correctly.
In 2018, the ECFMG made more money from the USMLE than the NBME did – and it isn’t even close.
This is the theoretical price to register for the USMLE Step 1 and Step 2 CK exams if the ECFMG sold them at cost (given that their expenses are just 53% of the revenue they take in on the USMLE).
I say theoretical because the ECFMG makes money on all kinds of fees associated with the USMLE. There’s $85 to change testing regions, $90 to extend a scheduling eligibility period, up to $604 to reschedule an exam, etc., etc. – so these ancillary charges probably also make a handsome contribution to their bottom line.
Some of their charges are easier to justify than others.
That’s the cost to apply for ECFMG certification. This basically involves setting up an electronic account.
Yet, it’s seemingly much harder for the ECMFG to set up an online account these days, because the price of this application fee has increased 242% from 2013, when it was just $60.
That’s the price the ECFMG charges to print a paper copy of your USMLE transcript.
(Because I guess their printer is nicer than yours.)
And that’s the price to electronically send your USMLE transcript to ERAS.
(Because, you know, that’s how computers work.)
With revenues of around $4.9 million versus expenses of around $2.9 million, this is the profit the ECFMG reported on its IRS Form 990 for “ERAS.”
Presumably, this reflects the transmission of transcripts and their sale of ERAS tokens at $145 apiece. (n.b. – the thousands of dollars in application fees that IMGs pay directly to ERAS go to the Association of American Medical Colleges.)
Why the ECFMG cannot sell ERAS tokens and transmit USMLE transcripts at their cost – and instead sells them with an overall 70% markup – is completely beyond me.
Total compensation received in fiscal year 2018 by ECFMG president, Dr. William Pinsky.
Before you get all riled up, let me assure you that the ECFMG’s CEO is working hard for his money, putting in 40 hours per week in the service of the ECFMG. (It says so on the organization’s tax return.)
In all seriousness, the ECFMG’s CEO is only getting paid what top executives at similarly-sized corporations get paid. (The ECFMG hires an independent “compensation consultant” to ensure as much.)
I have long been critical of the need to pay non-profit executives so handsomely. In response, I’ve been told that such salaries are necessary to attract and maintain “top talent.”
I call B.S.
Does it really take a CEO with exceptional business acumen to guide an organization to financial success when they have no competitors and a steady stream of customers who have no other option but to buy products at whatever price they are sold?
Cut the salary by 50-75%, and I’m confident you’ll have no shortage of visionary and capable applicants.
Or, if all you really care about is the organization turning a profit, there’s an even less expensive option. Just hire the manager from the local movie theater. (You know, the guy who figured out you can charge $12 for a box of M&M’s or Sour Patch Kids to customers once they’re inside the theater.)
Trust me, he’ll catch on to the ECFMG’s business model quickly.
That’s the salary increase achieved by Dr. Pinsky after just 2.5 years on the job, compared to his predecessor’s salary in his last full year of work. Pretty nice bump, huh?
Of course, those years were very good ones for the ECFMG. Total revenues increased by 16.1% over the same time frame.
In addition to the input of the independent compensation consultant, the ECFMG’s Executive Compensation Committee reviews the CEO’s performance each year and “recommends a salary increase percentage as appropriate given the performance of the CEO and the financial results of the ECFMG for that year.”
In other words, when the ECFMG’s financial tidings improve, their executives’ do, too.
That’s fair, right? I mean, if the ECFMG increases prices and generates more revenue, why shouldn’t their CEO be rewarded?
(Other than the ethical considerations and all.)
That’s the section of the Internal Revenue Code that gives the ECFMG its tax-exempt status.
To be exempt from paying federal income tax, an organization must meet certain requirements and commit to certain standards of transparency regarding their finances. Thus, you can look up the information for the ECFMG or most other tax-exempt non-profits on websites like Guidestar, CauseIQ, or ProPublica’s Nonprofit Explorer.
There’s a reason these financial records are open to public inspection. And that reason is accountability.
We – the public stakeholders in these organizations’ nonprofit missions – are supposed to look at their numbers and ensure that the dollars are aligned with their mission. The figures I collected here aren’t secrets – they’re available precisely because we are supposed to speak out about excessive spending and profiteering.
So if any of the figures above rub you the wrong way, I’d urge you to do your part and speak out. Talk it up to your peers and colleagues or share it on social media.
Better yet, write to the ECFMG’s Board of Trustees – the organization’s unpaid governance, intended to counterbalance the paid executive leadership. Explain to them that the organization’s profiteering is making them look bad. Demand that the ECMFG transparently report their policies for price setting and open those decisions to independent oversight.
Or write to the Accreditation Council on Graduate Medical Education’s Board of Directors. It’s the ACGME who ultimately gives the ECFMG their power (by requiring that residency programs only train ECFMG-certified IMGs). Suggest that, if the ECFMG is unable to lower their costs or constrain their meteoric financial growth, perhaps the ACGME should consider allowing a competitor to certify IMGs more cheaply.
Or, if you’re a U.S. citizen IMG, write to your Congressperson. Ask them to send a letter noting their concern over the ECFMG’s fees, perhaps even suggesting that if the ECFMG can’t regulate themselves, the federal government can help.
The ECFMG provides a valuable service. It is not too much to ask that they do their work fairly, with corporate policies that reflect the sanctity of their mission to the public.
It shouldn’t be that hard – but I’m afraid that for the ECFMG to get there, they’re gonna need a little push.