Category Archives: millennials

Hope and Skepticism about the New MCAT

by Karan Chhabra and Allan Joseph

The MCAT (better known as every pre-med’s recurring nightmare) just went live with some pretty big changes intended to better prepare premedical students for the healthcare system of tomorrow. We’ve got a guest post over at Dan Diamond’s Forbes blog examining and reacting to the changes. A small excerpt:

That’s why we applaud the AAMC for resisting this bias and placing social science, psychology, and the humanities on the same plane as pure science — where they belong. The new MCAT sends a new signal to aspiring docs: they need this knowledge just as much as they need hard science, and the medical community now demands they have it…

But unless admissions committees firmly commit to selecting “broader” applicants in all aspects of their applications, the newest version of the MCAT will fail in the same way its ancestor did.

This is something we’ve thought a lot about, but we’re really interested in hearing your thoughts — take a read and let us know your thoughts on Twitter (see below) or in the comments.

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Karan is a medical student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. Follow him on Twitter @KRChhabra.

Allan is a third-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

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The Real Problem with Medical Student Debt—Investors, Look Here!

by Karan ChhabraAllan Joseph, and Josh Herigon 

America might never agree on how much doctors deserve to earn. But there ought to be much less debate on the immense debt today’s medical students incur on the way to becoming doctors. Few people are more aware of the stress of medical student debt than med students themselves and there is evidence that it affects our specialty and practice decisions later on down the line.

Enter this tweetchat. What began as a typical med student complaint about their debt load evolved into a provocative discussion about the underlying factors and potential solutions to the debt problem. We’ve incorporated some notes explaining perhaps unfamiliar concepts, but otherwise this is the unvarnished product of a few med students procrastinating on a Sunday night.

@JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded [original tweet]

@krchhabra: ARGH RT @JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded [original tweet]

@allanmjoseph: @krchhabra @JoshHerigon Yes, but…more demand than ever for spots, & vastly higher teaching/resources since then. Complex issue. [original tweet]

AJ: The easiest way to tell if med-student debt is becoming an acute problem is if the demand for medical-school spots (easily measured by the number of applicants) is declining relative to the supply. That’s just not happening. In fact, the opposite is.

@krchhabra: @allanmjoseph @JoshHerigon I’m skeptical that teaching is any more resource-intensive than it once was (except perhaps for standardized pts) [original tweet]

KC: Standardized patients are actors paid by medical schools to act out clinical scenarios as we pretend to be doctors. They’ve been a useful component of clinical skills instruction for several decades—but their help isn’t free.

@allanmjoseph: @krchhabra @JoshHerigon At least here, our student:instructor ratio is insanely good, and so are our useful support structures. [original tweet]

@allanmjoseph: @krchhabra @JoshHerigon Not saying it’s all reflected, but I also don’t think it’s an apples-to-apples comparison. [original tweet]

@JoshHerigon: @allanmjoseph @krchhabra Our campus is probably nicer… [original tweet]

JH: Even more than a decade ago when I was an undergraduate, the arms race between universities to build bigger and better facilities was well underway. Examples are not hard to find. Medical schools and academic medical centers are active participants in this trend. In 2007, my own institution announced a 10 year, $800 million expansion. It’s not clear how capital improvement projects impact student tuition—administrators argue such projects are paid by dedicated capital funds, supported by the state, private donations, and/or bond initiatives. But, new facilities increase annual maintenance budgets and in the face of shrinking annual operating budgets, where do administrators make up the difference? Again, the impact of capital projects is not obvious; what is obvious is that tuition rates have not decreased with these projects.

@krchhabra: @JoshHerigon @allanmjoseph But we’re talking about secular time trends. Is your student/teacher ratio better than it was 20 years ago? [original tweet]

@krchhabra: @JoshHerigon @allanmjoseph of course there’s more small group learning than there used to be. But that doesn’t justify 3x price increase [original tweet]

@krchhabra: @JoshHerigon @allanmjoseph I use “price” intentionally – schools can charge whatever they want; the govt and students will always oblige. [original tweet]

KC: Once an English major, always an English major. I’m trying to highlight the difference between prices and costs here–costs the amount of resources expended in providing a service (a pretty objective quantity), whereas prices are chosen by the seller (often based on the highest amount the market will tolerate). What I’m trying to say is, the rapidly rising price of medical education doesn’t necessarily reflect increases in its underlying costs.

JH: Federal support of education through student loan programs has increased access to higher education, but at what cost? Students are now insulated from the true price of their education. Their tuition payments are abstract numbers on a page they see once a semester. Financial aid counselors (in my limited experience) fail to explain the true financial impact of student loan payments. Students are sold on the various deferment options, repayment plans, and forgiveness programs (most of which students won’t qualify for or will increase the overall cost through deferred interest payment). Even with sufficient explanation, it’s hard to fully conceptualize until you make that first payment.

@allanmjoseph: @krchhabra @JoshHerigon Fair enough. Aside: I also think med students whining about debt can come off as tone-deaf, even if justified. [original tweet]

AJ: Quite frankly, when physician unemployment is nonexistent and even the lowest-paid specialties average six-figure salaries, we don’t have a lot to whine about. The reasons to care about this, from a policy perspective, are the positive externalities (that don’t accrue to doctors) from having the best and brightest students enter medicine.

@krchhabra: @allanmjoseph @JoshHerigon in light of future incomes? Perhaps. Though I think the average doc’s income will drop vs those trained in 78. [original tweet]

@allanmjoseph: @krchhabra @JoshHerigon From a systemic standpoint, they probably should, at least in many specialties. (Shh, don’t let the AMA hear!) [original tweet]

@krchhabra: @allanmjoseph @JoshHerigon it’s okay. There will always be surgicenter facility fees for when we need a quick buck (right?) [original tweet]

KC: Historically, doctors and hospitals have been paid separately for work that happens within a hospital’s walls. Doctors get a “professional fee” for their time and expertise, and hospitals get a “facility fee” for nursing care, materials, and all the other costs they incur in providing care. But in physician-owned surgical centers, doctors get both the professional fee and the facility fee. It’s as lucrative as it sounds, though Obamacare plans to curb these arrangements.

@JoshHerigon: @krchhabra @allanmjoseph Ha! Or you can always moonlight during residency… [original tweet]

JH: Moonlighting is when a doctor works outside their regularly scheduled hours (typically overnight, hence the name). Residents have historically done this during their training to supplement their paltry salaries. However, resident work hour restrictions are now decreasing this (moonlighting hours count against the total hours worked).

@JoshHerigon: @krchhabra @allanmjoseph Not saying med school should be free or even debt-free, but we need lower prices and better loan terms. [original tweet]

JH: I believe loan terms are the core issue and have been for a long time.

@krchhabra: @JoshHerigon @allanmjoseph You nailed it with loan terms. Super generic, don’t account for reliable, delayed income doctors get [original tweet]

AJ: Most medical students borrow for medical school through the federal government’s Stafford loan program, as well as the Graduate PLUS program if needed. It looks like there’s a lot of repayment options, but when you dig into it…they’re all variations on very few themes.

KC: And the problem with that is, the incomes of med school grads have little in common with those of other grad schools. Most grads (law, business, PhD, etc.) see a healthy income soon after graduation, increasing steadily thereafter. Medical school grads look forward to 3–10 years of paltry income while they’re training, followed by a huge jump once they’re board-certified. Loan payments can be suspended while in training, but the debt still accrues interest at a rate equal to other graduate loans. This makes little actuarial sense when you consider how low physicians’ default rate ought to be, compared with graduates of other programs. (Physicians’ unemployment rate is 0.8%, versus 2–3% for graduates of any graduate/professional school.) A tailor-made loan for medical students would adjust for physicians’ comparatively low incomes at graduation as well as their substantial, reliable incomes after residency. Though I’m not an actuary, I think loans on these terms would be much more fair and affordable.

@allanmjoseph: @krchhabra @JoshHerigon Absolutely. 100 percent agree with you there. [original tweet]

@JoshHerigon: @allanmjoseph @krchhabra One of you guys should create a start-up that buys up med school debt at better terms. 😉 [original tweet]

@krchhabra: @JoshHerigon @allanmjoseph I’ve actually given this some thought. Just need a few wads of money I don’t currently have 😉 [original tweet]

@JoshHerigon: @krchhabra @allanmjoseph Me too. [original tweet]

@allanmjoseph: @JoshHerigon @krchhabra And now I’m giving it thought instead of reading about NK cells. Let’s find an angel investor. [original tweet]

@allanmjoseph: Hey, followers, @krchhabra, @JoshHerigon and I have a killer business idea. Who wants to give us a few million to make it happen? [original tweet]

AJ: We joke about this, but it’s moderately surprising some enterprising financial firm hasn’t found a way to make this happen. (There’s probably a regulation about federal student debt that hampers it, but still.) More obviously, though, there’s room for policy changes to improve this system.

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Karan is a student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. Follow him on Twitter @KRChhabra.

Allan is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Josh is a fourth year medical student at the University of Kansas School of Medicine with an extensive research background and deep interests in technology. Follow his writing on Twitter @JoshHerigon or at mediio.

Read the fine print before you burn your Obamacare card

by Adrianna McIntyre

Forgot to link this on Friday, so have some semi-stale ire to go with your case of the Mondays. Me on The Incidental Economist last week:

People pushing young adults to skip the exchanges aren’t saying, “Don’t enroll now… but hey, if you get sick in a few months, we’ll understand if you have a change of heart.” They’re saying, “Don’t enroll now; pay the penalty instead. And if you fall ill, or become pregnant, or get stabbed while doing a good deed and you can’t buy a plan, well, them’s the breaks. That’s the gamble we asked of you.”

Click through for the full post.

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Adrianna is a graduate student in public policy and public health at the University of Michigan. Follow her on Twitter at @onceuponA or subscribe to the blog.

Friday News Dump: Wonkbites

by Karan Chhabra

Big week for health news! So big, in fact, we couldn’t wait but to give it to you early:

  1. Genes, unzipped: The Supreme Court made a big decision yesterday that companies can’t patent naturally-occurring genes, in light of a patent long-held by Myriad Genetics for the BRCA genes (recently made famous by Angelina Jolie, for those not following this case). You can read about the decision anywhere, but this article on how they botched the science is pretty hilarious, especially to a smug med student like myself. It speaks to an important facet of the case, though—specifically its reliance on metaphors to explain tricky genetics concepts. Every now and then, between analogies to baseball bats and chocolate cookies, something seems to get missed.
  2. Arizona’s in: It’s not every day that a sworn enemy of Obamacare clashes with her legislature to pass one of its provisions. But that happened today in Arizona, where Gov. Jan Brewer (a Republican) pushed Medicaid expansion through her legislature on the grounds that, well, they’re already paying for it.
  3. Soothed by soundAn astounding, well-designed study published this week showed that music and noise-canceling headphones are both more effective than drugs at reducing the anxiety of ICU patients on ventilators. Both headphones and music reduced patients’ need for sedation and improved their anxiety levels more than the usual drugs. But the authors didn’t compare the new Daft Punk album to Justin Timberlake’s, leaving me with a great idea for my next research project.
  4. Wonkery with benefits: CMS’s decision to increase Medicare Advantage funding reportedly made it to far too many people internally before being publicly announced. In typical DC fashion, the decision fed the political intelligence industry with stock trading ideas worth billions. Good times for whoever got the memo. (We didn’t.)
  5. Now if only it came with a bottle openerHey bros, now that we know we probably won’t get screwed by Obamacare, let’s move onto some important issues. This new belt lets us feel babies kick. Real talk.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Shifting Ground Beneath the Rate Shock Debate

by Adrianna McIntyre

Since California released the prices for exchange plans, wonks have been wonkily bickering—yeah, that’s five separate links and still doesn’t capture all of it—about whether or not “rate shock” exists in the state’s new market. The problem with this debate is that the context of the arguments is changing without notice or acknowledgment [1]. One reader pointed out that no one’s even bothered to define “rate shock”; it’s just one of those phrases common to health-wonk parlance. So, here’s my off-the-cuff take: rate shock is a phenomenon where increased premium costs discourage individuals from purchasing insurance. Can we agree on that? Awesome.

Here’s the problem with that definition: it’s relative, and we haven’t specified what we’re comparing the California premiums against. That ground has been shifting—the narrative about California changed from comparing exchange premiums against what was expected on the exchange to considering whether anyone will see rate increases. They’re totally different interpretations of rate shock. “He said, she said” is an inappropriate way to track the debate.

Rate shock argument #1: California’s rates were lower than expected. The initial media reaction to California’s numbers celebrated that they were less than analysts had previously anticipated—lower than the CBO’s 2009 projection of $5,200 and on average lower than premiums on the small-business market, which is the closest “apples-to-apples” comparison available, considering scope of coverage [2]. This was the first iteration of “hey guys no rate shock!” Exchange premiums also come in below the average employer-sponsored plan in the state; California’s average exchange plan costs about $3,850 per year, their employer-sponsored brethren run about $5,250 annually [3].

There are caveats to this argument; it’s too soon to say that California’s experience will be the norm. As Sarah Kliff points out, the state took a more active role in the selection of exchange plans, which may have fostered more intense price competition than we’ll see elsewhere. And Alex Wayne latched onto another nuance: California’s small-business market, the reference point used by ACA proponents, already prohibited insurers from turning people away based on health status. Not all states do that, but they’ll be required to under the new health law. Consequently, we might see more evidence of “rate shock” in other states, where we’re comparing new guaranteed-issue exchanges to old mostly-healthy markets.

Rate shock argument #2: Some people will see their premiums increase. The more recent pushback about California’s numbers has changed the argument entirely. Instead of being about exchange prices relative to expectation, it’s about whether or not the young and healthy will see higher premiums. Yes, some will. Yes, this has important implications for attracting us young’uns to the exchanges. No, this will not be the fate of all twenty-somethings.

Those under 26 will have the option of staying on their parents’ insurance, as long as they aren’t offered coverage through an employer. This provision was enacted in September 2010, and there’s already evidence of young adults benefiting substantially from it—insurance coverage among 19-25 year olds increased 6.7%  during the first year the provision was in effect. Admittedly, this measure initially favored families who were already fortunate enough to have coverage. But once the exchanges are up, it will apply to those plans, too. Families who couldn’t previously afford health insurance will receive subsidies and will be able to keep dependents on their plans into their mid-twenties.

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The subsidies are also a BFD. It’s not easy to pin down exactly what proportion of “young adults”—has even anyone defined that parameter for this debate? under 30?—will qualify for premium assistance. But we know this: over half of individuals aged 19-29 who bought insurance on the individual market in 2011 were below 200% FPL (an income of $23,000). A 26-year old making that much can expect to a monthly premium of $121 for a silver plan on the California exchange—and even less for a bronze. Subsidies stay constant; they’re indexed to the silver tier, even if an individual chooses a cheaper bronze plan (but the CA calculator doesn’t offer tiers as a variable). Bottom line: more than two-thirds of individuals under 27 will qualify for financial assistance in some form. Regrettably, the RWJF table below (from here) doesn’t break down the 28-44 population any further, but it’s still informative that over 40% of them will, at a minimum, qualify for subsidies.

RWJF

Here’s what bugs me: there is nothing mutually exclusive about those two debates. Yes, California’s premiums were lower than expected. Yes, there are young, healthy, and affluent individuals currently on the individual market who will see their insurance expenses increase. The second does not contradict the first—it is not evidence that the media was being misleading. The second isn’t even news. I realize the internet has the attention span of a three-year old, but we hashed out the young invincibles argument as recently as February. Really. We had headlines like “Obama Prepares to Screw His Base” out of BuzzFeed and everything (our take on that here).

That said, the two versions of rate shock are related: the actuaries behind California’s premium calculations made certain assumptions about how many young and healthy people will enter the individual insurance market in 2014. If those individuals choose the tax penalty over buying insurance, the risk pool becomes unhealthier than projected and premiums go up. But we don’t know how optimistic or conservative those underlying assumptions are. If you do know, please share—there’s a whole ecosystem of health policy wonks ready to tweak their arguments accordingly.

Footnotes

1. To be clear about what this post isn’t: it’s not about what President Obama or any other politician promised in 2008 or 2010 or any other year. That’s tangential to this debate, which arose specifically out of California’s numbers and the media’s reaction to them.

2. This was the initial “apples and oranges” debate. Some people compared the new exchange rates to the individual market, where insurance costs less—but likely less comprehensive and exclusionary (people could be denied coverage for pre-existing conditions). The small-business market is a more sensible comparison if you want to hold benefits and population as constant as possible under the status quo.

3. Employees tend to be insulated from the true cost of their insurance because the employer tends to pick up a big chunk of the premium each month. There are many reasons employer-sponsored insurance might cost more than the exchange plans, including less cost-sharing (the typical “silver” plan on the exchange will have a $2,000 deductible, though that won’t apply to many “first-dollar” services like routine preventive care).

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Adrianna is a graduate student in public policy & public health at the University of Michigan. Follow her on Twitter @onceuponA.