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 insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

Sophie Putka will kick off the episode interviewing me about a medical education rundown. Then we'll swap seats and she'll share some of her reporting on the first doctor of chiropractic program at a major research institution. Lastly, Cheryl Clark will talk about how MedPAC is questioning the value of the "extra benefits" touted by Medicare Advantage plans.

Over to Sophie.

Sophie Putka: There has been a lot going on in the world of medical education recently, and Rachael covered several stories about it last week. She's here to tell us about the updates.

So Rachael, let's start with residency applications. You wrote a few stories about updates on how changes to the process this year impacted applicants and programs. Tell us about that.

Robertson: Yeah, so this was the first cycle where ob/gyn was using its own independent residency application platform, which is called ResidencyCAS. And ob/gyn designed this new system to be cheaper than ERAS – the Electronic Residency Application Service. ResidencyCAS also has program signaling, where applicants can signal particular interest in a program by sending a limited number of gold or silver tokens. And the goal for this was to decrease the number of applications that each applicant sends, which saves everybody involved time and money.

According to preliminary data from the American College of Obstetricians and Gynecologists, ob/gyn applications remained steady this year, and on average, applicants actually applied to fewer programs, which was the goal. In past years, the average number of applications per applicant has been in the 60s or 70s, but this year, the average was just 59. ERAS made some similar changes to its pricing this year too, and the specialties adopted varying numbers of program signals in the past few years. The AAMC, the Association of American Medical Colleges, they run the ERAS, and they shared some of their preliminary data with me as well. And according to that data, some specialties saw decreases of 35% to 40%, though most specialties saw more in the like 10% range.

I spoke with Brian Carmody, MD, who follows medical education really closely, and he pointed out that the specialties with the most decreases in number of applications have higher numbers of signals, so programs are less motivated to consider applicants who don't signal. He explained it this way, if say, an applicant gets like 25 signals, "every program gets so many signal applications that there's no reason for them to look at applications that don't come with a signal when the applicant has already told you that ... you're 26 on their list at best."

The last thing I'll say on the residency application front is that we also learned last week that emergency medicine is considering an exodus from ERAS as well. The Council of Residency Directors in Emergency Medicine told me that the specialty is looking into working with ResidencyCAS, which is the same platform that ob/gyn now uses. Carmody told me that this would be huge if emergency medicine left ERAS, since it would be by far the biggest specialty to do so.

Putka: There was a mishap involving ResidencyCAS last week as well, right?

Robertson: There was. It involved the COMLEX, which is the Comprehensive Osteopathic Medical Licensing Examination, which is the osteopathic equivalent of the U.S. Medical Licensing Examination. Both COMLEX and USMLE include three different exams, and for both, level or step one is pass/fail. And unfortunately, the National Board of Osteopathic Medical Examiners, or the NBOME, who run the COMLEX, they told test takers that the level one scores were mistakenly shared with ob/gyn programs through ResidencyCAS. For a week, programs could see students' three-digit numerical score when they should have only seen a pass or fail mark. The kicker is students themselves still haven't seen their own scores, so they don't even know what programs saw.

Reddit users were telling me that this is a knock to DO applicants since no MDs had their scores leaked. Harris Ahmed, DO, MPH, who is a vitreoretinal surgery fellow at Weill Cornell Medicine in New York City, told me that most DO students take both the COMLEX and the USMLE to boost their chances of matching. He also said that students don't put the same level of energy into a pass/fail test, so the leaked scores don't even reflect the student's best effort.

Putka: Yikes. You reported on yet another scandal involving a medical exam this week, too. Tell us what happened with the American Board of Pathology [ABPath] board exam.

Robertson: Basically ABPath announced that a small percentage of people who took the specialty's board exam in the past 2 years were mistakenly told that they failed, when in actuality they passed. They told me that it was 76 people, which was just under 2% of people who took the test. People only have 10 tries to pass this board exam and it costs thousands of dollars each time, and the exam only occurs twice each year.

Edernst Noncent, MD, is an assistant medical examiner for the state of Maryland, and ABPath alerted him that his previous exam score was actually higher than they had previously told him, though he still didn't pass. He just took the exam for the fifth time last week, and he told me that because he isn't board certified, he makes 30 grand less than he would otherwise. He knows multiple people who haven't passed the exam after 10 tries, and at that point you have to quit your job for a mandatory year of training.

For both the NBOME situation and then this ABPath situation, students and early career doctors have had their livelihoods put in jeopardy over careless mistakes.

Putka: Wow. Thanks, Rachael.

Robertson: Thank you, Sophie. My turn to interview you.

The University of Pittsburgh is offering a program that might seem a little unexpected for a major academic center known for its school of medicine. They're offering a Doctor of Chiropractic program. Sophie Putka is here to talk about the program and why this move is raising some eyebrows.

First off, Sophie, can you tell us a little bit about why this decision by Pitt might seem unusual?

Putka: Sure. So historically, chiropractic has been a practice that traditional medicine has kind of dismissed and looked down on, partially because of its pseudoscientific origins and pretty limited evidence that it works for treating spine and back problems in the long run. And the American Medical Association even tried to basically wipe out chiropractic practice and prevent practitioners from calling themselves doctors in a very focused campaign over the years, but that's kind of a different story.

Anyway, chiropractic programs have always been around, but none really affiliated in such a direct way with a major academic research center. Chiropractic has often been put in the same bucket as what used to be known as "alternative medicine" – now known as "integrative medicine," like acupuncture, massage therapy. Now it's going to be a part of Pitt's School of Health and Rehabilitation Services, which is separate from their med school. On Reddit, for example, there were a lot of comments about how the move is likely a money grab by the school which some said reflects a more "corporate" approach to medicine, like a lot of other medical institutions nowadays.

Robertson: Okay, got it. So what exactly has changed?

Putka: Well, a number of things. So chiropractic has gained a little bit of mainstream acceptance in recent years. For one thing, a few clinical trials have suggested a small benefit for some chiropractic techniques compared to "usual care" for certain conditions, namely lower back pain. And in 2017, the American College of Physicians actually came out with a clinical guideline on treating low back pain that recommended non-drug treatments, and they included spinal manipulation. It's a technique typically performed by a chiropractor, though they did give a caveat that it was based on low-quality evidence.

Some other "mainstream" medical institutions, like Brigham and Women's and the University of California San Diego, have endorsed chiropractic practices on their websites, though they haven't actually come out with an academic program. And also Medicare even covers a few chiropractic services, though not all.

Robertson: Okay, so what is this program going to look like?

Putka: So this program is billing itself as a very evidence-based, research-focused program, maybe as a way to set it apart from other chiropractic programs. It's actually not accredited by the organization that does all the other ones, interestingly enough, but this program is planning to enroll 40 students in the fall of 2025. They're still developing the curriculum, they told me, and the program will be eight terms long.

I did talk to the director of the new program at Pitt, Michael Schneider, and he said that they were working closely with other adjacent programs like physical therapy and even the medical school's department of physical medicine and rehabilitation, who apparently gave the new program their blessing. They wrote some letters of support, and he told me, "Chiropractic is no longer seen as this alternative, kooky kind of profession. It has enough evidence now to show that [what] we do works and it's integrated health."

Robertson: Super interesting. Thanks for this reporting, Sophie.

Putka: Thank you.

Robertson: MedPAC, or the Medicare Payment Advisory Commission, advises Congress on issues that affect Medicare's many programs, and at a recent meeting, many of the members had a passionate discussion about their concerns with "extra benefits." Cheryl Clark is here to tell us about it.

So Cheryl, what is wrong with these extra benefits?

Clark: Well, thanks, Rachael. Really nothing's wrong with them. The issue is whether they actually improve health. Extra benefits might range from hearing and dental care and discounts on eyeglass prescriptions, and one can see how they relate to better health outcomes, but Medicare has allowed a liberal expansion of the definition of extra benefits, so that they now include a lot of other services that might be nice to have but may be less tightly aligned with preventing or curing disease.

For example, plans may offer spending cards, transportation, virtual companionship, home improvement, and pest control services, and even money for buying groceries. The issue is that the Medicare program pays these private MA plans, Medicare Advantage plans, $83 billion -- and that's just this year -- for some of these extra benefits. They're called "extra" because traditional Medicare beneficiaries don't get them without paying out of pocket, and now some of the $83 billion is used to reduce drug costs or lower copays. But the issue is that taxpayers are spending some of this money on low-value benefits that some say are used more in sales pitches.

For example, an agent I know was telling me her client would only enroll in a plan if it paid a $500 flex card, and she didn't care about whether there was a hospitalization per diem of $500 or, you know, what drugs were in the plan's formulary. And she should maybe have been thinking a little bit more about the network of providers and the copays for the drugs that she would pay. So that's not the only problem the commissioners discussed. According to the report that the Commission received, Medicare has no way of knowing whether enrollees are really using these benefits or which ones they're actually using. So they don't know whether they're getting the benefit that they're paying for.

Robertson: Could you give us an example of this?

Clark: Well, sure. One of the commissioners mentioned her concern that a Medicare Advantage plan can say it offers hearing coverage, but that coverage has low limits or caps. So for example, it might pay for a hearing evaluation, but not a hearing aid or the fitting.

Robertson: Oh gosh. Okay, so how does a Medicare beneficiary know what is really being offered?

Clark: Well, that's the problem. It's often in the fine print, and seniors may not know to ask. The agents may not take the time to explain the details. There was this other issue that kind of surprised me. The idea behind Medicare Advantage, I've always said, is a wonderful idea, because it's supposed to coordinate patient care – patients, providers talk with each other. But that may not be true for some of these extra benefits. Dental care, hearing care, and vision care might be some of these extra benefits that the plans just contract with a service provider that may not necessarily report back the patient's conditions that are related to their health, like gum disease or maybe an optical problem that might be more of a medical one that their ophthalmologist, who is in the network, should know about.

Robertson: So what is MedPAC proposing to do? Do away with these extra benefits?

Clark: Well, I don't think that's in the cards. These extra benefits are very popular. One of the commissioners, Greg Poulsen, senior vice president of Intermountain Healthcare, suggested the $83 billion that Medicare pays to these plans should only go to those plans that can prove their extra benefits improve health and lower cost, which is what the whole idea was to begin with. Then we'd be able to provide enhanced benefits, not at the expense of the taxpayer, but through efficiencies, he said. And they want to get that encounter data too.

Robertson: Thank you so much, Cheryl.

Clark: Thank you, Rachael.

Robertson: And that is it for today. If you like what you heard, please leave us a review wherever you listen to podcasts (, ) and hit subscribe if you have not yet already. 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, Sophie Putka, 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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