番茄社区

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody, welcome to MedPod Today, the podcast series where 番茄社区 reporters share deeper insights into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

I'm starting off today's episode with a report on leaked emails from the AAMC that reveal concern about an exodus from the standard residency application pathway. Then Michael DePeau-Wilson shares about the APA's thoughts on the rise of ketamine clinics. Then Cheryl Clark tells us about a conversation about Medicare Advantage she had with Don Berwick, MD, who was the CMS chief under President Barack Obama.

But first, Michael is going to take the host seat for this first segment.

Michael DePeau-Wilson: Leaked emails from the Association of American Medical Colleges, or the AAMC, were posted online by Bryan Carmody, MD, MPH. AAMC runs the Electronic Residency Application Service, ERAS, the platform that most specialties use for residency applications. However, plastic surgery and ob/gyn have both left the platform for their own independent ones. And it seems the AAMC is concerned about what this exodus means for the future of ERAS. Rachael is here to tell us more.

So Rachael, what do we know about the leaked emails? And what did they say?

Robertson: The leaked emails are from Alison Whelan, MD, who is the AAMC's chief academic officer. She sent the emails to the Council of Deans, which is a group of deans from more than 150 medical schools. And the email suggested that these deans request meetings with their specialty and residency leaders, basically to encourage them to stay within the ERAS.

The email also cites "fragmentation" as a potential issue in the residency application process when specialties break from ERAS. They said that the deans could discuss "potential risks and disadvantages to applicants, additional administrative burden for schools, and obstacles to transparency for everyone." The AAMC confirmed to me that the leaked emails were indeed sent by Whelan.

DePeau-Wilson: Did the other email say the same thing?

Robertson: One of the other leaked documents gives specific talking points for deans to tout recent improvements made by ERAS and give some more background information. And that document is from February 22. There's also a leaked email template for deans to use in this outreach.

Whelan told me in an email that she shared all of this with medical school leadership because some had expressed concern about having multiple residency application services. She also noted that a key piece of information was omitted in this leak, which she then shared with me. It's cross-application data from the 2023-2024 academic year. And she said that those learners are the ones most negatively impacted by multiple application platforms.

DePeau-Wilson: Okay, and are other specialties planning to leave ERAS? And how would that impact the AAMC?

Robertson: So in that talking points document, the AAMC says that they're aware that some specialties and residency programs may be considering leaving ERAS. Again, they say this would cause fragmentation that would be "bad for everyone." For all this talk of fragmentation, it's unclear if the AAMC is referring to ob/gyn and plastic surgery or if other specialties are a flight risk, too.

Online, a lot of people have pushed back on this idea of fragmentation. Carmody, who shared the screenshots to social media, he told me this: "When you say fragmentation, I see competition. ... I hear monopoly. ... I think that competition will make ERAS better and I think that it'll make things better for applicants and programs, too."

For instance, ERAS changed its pricing structure to be cheaper for some applicants for this upcoming cycle, which happened to be announced after ob/gyn also announced cheaper pricing. Though, the AAMC has maintained that this was 2 years in the making. It's worth noting that the ERAS brings in a lot of money for the AAMC -- nearly $120 million, or half of their total revenue according to tax records.

Again, Carmody told me: "Our goal in medical education is not to limit clerical work in the Dean's office. Our goal in medical education is to train people ... to take care of human beings."

DePeau-Wilson: Well, thank you so much for joining.

Robertson: Thanks, Michael. Time to switch seats.

For our next story, we take a look at the proliferation of ketamine clinics across the U.S., which has been a major departure from the clinical recommendations outlined by the American Psychiatric Association -- the APA. The current APA consensus statement regarding the use of ketamine for treating mood disorders was published back in 2017. The new crop of ketamine clinics appear to be veering far from the recommendations of that statement, leading APA to call the current status of these clinics the "wild west." Michael DePeau-Wilson is here to tell us more about the concerns from the APA over this growing trend.

So, Michael, the APA has called these clinics, the "wild west." Can you give us a little insight on what they mean by that?

DePeau-Wilson: Of course, yeah. So I spoke with Smita Das, MD, MPH, PhD, who chairs the APA's Council on Addiction Psychiatry. And she told me that IV ketamine is being offered in these smaller clinics off-label and that there's currently no practice guideline from the APA that recommends ketamine use in this way. In fact, according to the guidance, clinicians who deliver ketamine should have an advanced cardiac life support certification and be licensed to administer Schedule III medications. It also recommends that when ketamine is being administered in a facility that it should be equipped with basic monitoring for cardiovascular conditions and have the ability to stabilize patients in the event of a respiratory event.

So Das told me that many of these clinics failed to meet those standards, and that in fact, most of them don't even involve psychiatric or mental health professionals. So as for the "wild west" comment, she emphasized that these clinics are touting ketamine as a "miracle treatment," but that really they're just taking advantage of vulnerable patients by offering them treatment without properly informing them of the very real downsides.

Robertson: So what are those downsides? What does the current research tell us about the safety and efficacy of prescribing ketamine for conditions like depression?

DePeau-Wilson: Great questions. There's only been one ketamine product approved for treatment of mood disorders, and that's esketamine (Spravato). And that's a nasal spray made by Johnson & Johnson. It was approved only to be used along with oral antidepressants in adults who have treatment-resistant depression. So it's a very specific use case. And that is actually also only available through a Risk Evaluation and Mitigation Strategy (REMS) program.

So these precautions are in place, in part because ketamine has been shown to induce hallucinations, and it's possibly prone to addiction, according to some experts. So in addition to those concerns, the APA and the FDA say that there's just not sufficient evidence to suggest that ketamine is safer or more effective than any other FDA-approved medication for the treatment of certain psychiatric conditions or disorders. But despite those restrictions and cautions, it seems to have had little impact on the public demand for ketamine to treat mood disorders. And these off-label IV ketamine clinics are showing up to meet that demand.

Robertson: So there's a lot of reasons to be cautious about this drug, it seems. What is the APA doing to address the sudden rise in these ketamine clinics then?

DePeau-Wilson: Well, the organization is currently standing by its 2017 guidance, which Das said remains strong on the approved clinical uses of ketamine. But she also said that they're closely watching this trend. And that guidance was drafted by the APA's Council of Research Task Force on Novel Biomarkers and Treatments. Das said that this group has been monitoring these trends as well as some of the emerging evidence behind the use of ketamine. And she expects that that council will update the guidance when there's sufficient additional evidence to do so.

Robertson: All right, we'll be sure to talk to you if that happens. Thank you, Michael.

DePeau-Wilson: Thanks, Rachael.

Robertson: For decades, Don Berwick, MD, has been a leader in health system improvement. During the Obama years, he headed the Centers for Medicare and Medicaid Services and helped implement the Affordable Care Act. As a Boston pediatrician, he worked with managed care groups because he believed that they could help cut fraud and waste. He supported the concept because in theory, when providers have a stake in the game -- if they avoid unnecessary services -- everyone saves money. But today with managed care as it's implemented in Medicare Advantage plans, Berwick is singing a different tune. Cheryl Clark is here to tell us more.

Cheryl, why has Don Berwick soured on Medicare Advantage?

Cheryl Clark: Well, Berwick spoke with me for an hour and a half about his serious concerns. He actually said that there are so many flaws in MA structure and payment that their growth should be slowed or stopped. For starters, enrollment has been growing so rapidly from 11 million people in 2010 to 33 million in 2024. More than half (52%) of eligible beneficiaries are in these plans. And MA marketing campaigns leave many not understanding what they've given up.

So one of his biggest concerns is there's so much money that's being taken up by these Medicare trust funds to pay these plans. In 2024, they will be paid $88 billion to $120 billion more than if the same patients were in traditional fee-for-service Medicare. And the reason they're getting that money? He said this: "They comb through patients' histories and try to stuff in as many diagnoses as they possibly can, even if they have nothing to do with the care of the patient."

By adding in these diagnoses, they get more money -- a lot more. Now, he said a lot of these plans can pressure doctors to find these codes because they're now employing the docs. He said the plans game the system for profits.

Robertson: Jeez, what are some of the other concerns he mentioned in your conversation?

Clark: It might be okay for the plans to receive more money if they were providing better care. But Berwick said there's no evidence that they do. Studies have to overcome the problem that they are comparing apples to oranges because you got MA patients who are coded to look sicker than they really are. And he also worries that in many MA plans, you aren't going to be covered to see a specialist like those in some leading academic medical centers. He said, "Well, if I have cancer I want to go to a cancer center. If I have a traumatic brain injury, or need complex coronary cardiac surgery, I want to go to a center that specializes in that. And I don't want any insurance company telling me I can't."

Robertson: Did Berwick offer any hope for fixing this problem in the future?

Clark: Well, he did. But it involves massive restructuring and Congressional approval. First, we need to make traditional Medicare more attractive. How do we do that? Well, by reducing cost sharing, which is now 20% of Part B and $1,600 every time you get hospitalized. So by adding in some of these extra benefits that the Medicare Advantage plans are now offering -- like hearing, dental, and vision -- he thinks that might solve the problem. Of course, that would cost money. But Berwick has got just the solution: that $120 billion could simply be rerouted to shore up traditional Medicare.

Robertson: Awesome. Thank you so much, Cheryl.

Clark: Thank you, Rachael.

Robertson: And that's it for today. If you liked what you heard, please leave us a review wherever you listen to podcasts and hit subscribe (on or ) if you haven't already. We'll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were 番茄社区 reporters Rachael Robertson, Michael DePeau-Wilson, and Cheryl Clark. Links to their stories are in the show notes. MedPod Today is a production of 番茄社区. For more information about the show check out medpagetoday.com/podcasts.

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