Focus on the drive, not the distraction

NYT Columnist David Brooks writing about “The Art of Focus” back in 2014:

If you want to win the war for attention, don’t try to say ‘no’ to the trivial distractions you find on the information smorgasbord; try to say ‘yes’ to the subject that arouses a terrifying longing, and let the terrifying longing crowd out everything else.

There are whole books written about The Power of No, but I wouldn’t discount how our environments shape our behavior. Whether or not willpower is muscle or decision fatigue is real, there are plenty of data to show that making suboptimal activities harder improves outcomes in a variety of contexts.

I can tell you, for example, that the proximity of a Panera to one of the imaging centers I work at is not helping me make good lunch choices (bread bowls are my kryptonite).

But Brooks does reframe the classic “If you do what you love, you’ll never work a day in your life” adage to make it more approachable.

I think “find your passion” is generally terrible meaningless advice in most circumstances. If you have one, great. But if you don’t, it’s not exactly straightforward to meditate for a few minutes, analyze your innermost desires, and manifest your calling.

However, there’s also no denying that having a “pull” to do something (say, teaching others or writing) is the antidote to other less impactful activities. If you are drawn to something that matches your desired identity and goals, then it automatically makes it easier to avoid the “trivial distractions.”

As in, it’s easier to focus when you don’t want to escape the thing you’re trying to do.

Diganostic FOMO

From Suneel (brother of Sanjay) Gupta’s Backable: The Surprising Truth Behind What Makes People Take a Chance on You:

Apply the following quotation to why doctors don’t want to make the call:

If the fear of betting on the wrong idea is twice as powerful as the pleasure of betting on the right idea, then we can’t neutralize the fear of losing with the pleasure of winning. We can only neutralize the fear of losing with…the fear of losing. Enter FOMO, the fear of missing out. For backers, the only thing equally powerful to missing is…missing out.

Gupta goes on to discuss how potential backers initially too scared to be the first investor eventually pile on to avoid missing out on rare unicorns.

The fear of betting on the wrong idea in medicine manifests through overtesting and hedging. More than our desire to be right, we really don’t want to be wrong. But we can’t use the usual FOMO to our advantage, because medicine isn’t about making pitches or raising money but about directly helping individual people.

We don’t want to miss anything and so are forced to entertain everything, even if that means everyone in the ED gets a CT scan or a radiologist gives an impression a mile long with the words “cannot be excluded” featured prominently next to something extremely scary.

The true solution is this: we need to disentangle the outcome from the process. You can have good outcomes from bad decisions (dumb luck) or you can have bad outcomes after good decisions (bad luck). Luck and uncertainty are part of life, and they’re a big part of medicine. We should expect some bad outcomes even when doing the right thing, and we shouldn’t forget that overtesting and overdiagnosis have their own costs, risks, and harms. Passing the buck to the future doesn’t mean it won’t be paid.

By not making the call, we are making a decision: a decision to abdicate the diagnostic yield of an encounter or examination.

There are absolutely times when uncertainly is prudent. There are true “differential” cases. But the FOMO of diagnostic medicine should be passing up an opportunity to clearly define the next steps in a patient’s care.

Price Transparency and the True Cost of Quality Healthcare

When you read healthcare reviews online, so many of the 1-star reviews relate to prices: patients frustrated by high costs or surprised by high bills. It’s easy to think that price transparency rules will help. One key problem is that healthcare consumers are intermittently if not completely insulated from the true costs of their care due to the filter of commercial insurance. It’s hard to blame people for feeling that their doctor’s time is “worth” a $35 copay instead of the hundreds of dollars they really pay indirectly.

When my family moved from typical employer-provided health insurance to a high-deductible plan, I finally started seeing firsthand how much things really “cost,” and how ludicrous billing gamesmanship practices have become.

I’m a physician, and even I find it striking.

I recently received a bill for hundreds of dollars for an annual well-person patient visit that should have been covered at 100%. If you manage to complain about anything during the intake, you see, you also get billed for a problem visit at the same time.

Is that nuts? Well, yes, of course it is. But this is the world we live in and how institutions pay the bills.

Dr. Peter Ubel had an interesting article in The Atlantic back in 2013 called “How Price Transparency Could End Up Increasing Health-Care Costs” that holds up pretty well. His main thought experiment centers on imaging, which is an easy but sort of plus/minus example.

The same kind of consumer pressure rarely exerts a similar influence on the cost and quality of health-care goods. For starters, most patients have little inclination, or motivation, to shop for health-care bargains. Insurance companies pick up most of the tab for patients’ health-care. A patient who pays a $150 co-pay for an MRI (like I do with my insurance) won’t care whether the clinic she goes to charges the insurance company $400 or $800 for that MRI. The MRI is still going to cost the patient $150. Even patients responsible for 20 percent of the tab (a phenomenon called co-insurance) face a maximum bill of only $160 in this circumstance. That is not an inconsequential amount of money, but it is still not enough money to prompt most patients to shop around for less expensive alternatives, especially when most consumers don’t realize that the price of such for services often varies significantly, with little discernible difference in quality.

To make matters worse, patients often don’t shop for health care in the kind of rationally defensible way that economic theory expects them to. According to neoclassical economics, when making purchasing decisions consumers independently weigh the costs of services from the quality of those same services. If toaster A is more expensive than toaster B, the consumer won’t buy A unless it is better than B in some way — unless it is more durable or has better features — and unless these improved features are worth the extra money.

While some patients shop around for imaging services, many stay within a larger system for all their care or go where their doctor tells them. A more meaningful scenario in a large metro would be to compare broad costs across multiple specialties/types of care across multiple health systems. Say, in Dallas, would you generally pay less at UT Southwestern, Health Texas, or Texas Health? Does that hold true for primary care and specialty care? Are there certain categories of chronic diseases that one network does better or worse with? What about labs and imaging?

Due to network effects, a consumer may not meaningfully be able to choose where to do every little thing, but rapidly comparing systems is perhaps not beyond reach. It would be nice to know, for example, which places are playing games to maximize insurance payouts at patients’ expense and which (if any) aren’t.

Sometimes, however, cost and quality are not perceived by consumers as being independent attributes. Instead, people assume the cost of a good or service tells them something about its quality. For instance, blind taste tests have shown that consumers rate the flavor of a $100 bottle of wine as being superior to that of a $10 bottle of wine, even when researchers have given people the exact same wines to drink. Other studies show that expensive pain pills reduce pain better than the same pills listed at a lower price. Price, then, leads to a placebo effect.

Such a placebo effect is no major concern in the context of wine tasting and pain pills (even if it suggests that consumers could save themselves some money if they didn’t hold this strange belief that higher cost means higher quality). But suppose your doctor asks you to get a spinal MRI to evaluate the cause of your back pain, and you decide to shop around for prices before getting the test. Would greater price transparency cause you to choose an MRI provider more rationally? Or would you instead mistakenly assume that higher price means higher quality? There is reason to worry that price transparency won’t lead consumers to make savvy decisions. It is too difficult for people to know which health-care provider offers the highest quality care.

If patients are not going to make savvy use of price information to choose higher quality, lower cost health-care, some health-care providers, like doctors and hospitals, will probably respond to price transparency by raising their prices.

And there’s the rub: is it a race to the bottom or a slow creep to the top? And if it’s both, how do we predict and influence the outcome? If the growth of debt-fluid corporate and private equity has taught us anything, it’s that competition is fickle, and it doesn’t take much for a dominant position to be abused.

Imagine you direct an MRI center in Massachusetts, and the state government requires you and your competitors to post prices for your services. You consequently find out that the MRI center around the corner from you charges $300 more than you do for their spinal MRIs, and that this increased price hasn’t hurt their business. Imagine, also, that you are convinced that your competitors don’t offer higher quality MRI scans than you do — your MRI machines are just as new and shiny as theirs; your radiologists and technicians are just as well trained. In that case, if patients are not going to be price-sensitive, you are going to raise your prices to match your competitor’s. Otherwise you are just leaving money on the table.

Quality in healthcare is a theoretically important metric but it is so, so poorly measured and understood. Customer satisfaction? Not so good. Outcomes? Highly influenced by patient selection. Healthcare is heterogeneous and complex.

Ultimately, the problem is complex and nuanced, but we should keep this in mind. Efforts to increase price transparency through state and federal law need to be carefully crafted and closely followed. Such laws should include research funding that would enable experts to evaluate how the law influences patient and provider behavior.

Also, whenever possible, price transparency should be accompanied by quality transparency. We need to provide consumers with information not only about the cost of their services but also about the quality of those services, so that they can trade off between the two when necessary. I recognize that this is a huge challenge. Measuring health care quality is no simple task. But if we are going to push for greater price transparency, we should also increase our efforts to determine the quality of health care offered by competing providers. Without such efforts, consumers will not know when, or whether, higher prices are justified.

It’s no surprise that optimizing for cost seems like a reasonable plan given how easy it is to compare versus how hard meaningful quality indicators are to measure.

But price selection in the absence of quality selection creates a perverse incentive for the cheapest lowest-quality-but-just-barely-permissible product.


Underwriting is Noisy

An example a brief essay “Bias Is a Big Problem. But So Is ‘Noise.” about noise and decision-making in the NYT by Daniel Kahneman and his co-authors in support of their new book Noise: A Flaw in Human Judgement:

Consider another noisy system, this time in the private sector. In 2015, we conducted a study of underwriters in a large insurance company. Forty-eight underwriters were shown realistic summaries of risks to which they assigned premiums, just as they did in their jobs.

How much of a difference would you expect to find between the premium values that two competent underwriters assigned to the same risk? Executives in the insurance company said they expected about a 10 percent difference. But the typical difference we found between two underwriters was an astonishing 55 percent of their average premium — more than five times as large as the executives had expected.

This is why you don’t buy an insurance policy from a captive agent; you purchase through an independent agent who can get quotes from multiple companies. Every decision is subject to bias and noise, and they are separate and independent problems (i.e. both inaccurate and imprecise).

The easiest way to push both in your favor is through multiple independent attempts.

Don’t forbear your loans during residency (if you can help it)

The most fiscally responsible thing you can do as a resident with student loans is either enter an income-driven repayment (IDR) program like REPAYE, PAYE, or IBR or (rarely) refinance privately. Please see basically any chapter of the book.

Everyone is currently enjoying a 0% federal interest rate, but that’s set to expire this fall. No one gets a permanent pass on student loan management.

But not everyone is willing or able to do the most fiscally responsible thing. There are many reasons trainees forbear their student loans during residency and fellowship. Some live in high cost of living areas like San Francisco or New York and feel they can’t afford to live and spend a few hundred dollars a month on their loans. Others have families or other obligations that require the redirection of their salary. Still a third group could potentially make payments but is frankly unwilling to because they want to use that money to actually live their life, especially those that are tired of putting said life on hold during school and training while their non-medical colleagues continue to enjoy a higher cost-of-living lifestyle and share well-curated streams of filtered vacation photos (at least pre-COVID).

I’m not judging, but I can say this: very few residents should ever forbear their loans.

Not because it’s not financially responsible (though it’s not), but because if you’re not planning on making payments you should at least look into mitigating the growth of your loans. Government forbearance is the worst of all worlds: none of the perks of an income-driven repayment plan or possible loan forgiveness in a reasonable time frame while also stuck with the high-interest rates of federal loans.

These are the IDR perks you lose during forbearance:

  • Interest continues to accumulate on all loans (even subsidized loans, if you have any).
  • You get no IDR-derived interest subsidy and you get no 0.25% autopay rate reduction.
  • Then, at the end of the forbearance period, the accrued interest capitalizes and gets added to the principal (mean you don’t just owe more money then but your loan will also grow faster in the future).

In other words, the longer you forbear, the worse things get.

If you can stick it out in IDR instead:

  • All monthly payments during residency count towards the 120 monthly payments (10 years) needed for public service loan forgiveness. Even if calculated at $0/month.
  • Even if you switch to forbearance later, the qualifying payments you make still count for PSLF (they don’t have to be consecutive). Since your remaining loan balance after 120 payments will be forgiven, it is in your best interest to have these payments be as small as possible, so don’t waste your low-pay years as a resident unless you need to.
  • Any unpaid interest on any subsidized loans from college is forgiven for the first 3 years
  • 50% of any unpaid interest on all loans is forgiven if in REPAYE.
  • You get a 0.25% rate discount for enrolling in autopay
  • Interest will never capitalize again after entering repayment unless you change plans or you lose your partial financial hardship (for IBR and PAYE).

Those are good reasons to not forbear.

It’s also usually unnecessary. Being proactive means almost no one needs to forbear during their intern year: you’ll likely enjoy $0 payments during your PGY1 year (based on when you were a broke student) and very low payments (based on working only part of the year you graduated) during your PGY2.

So, plan for IDR first. If times get tough in the future, forbearance is only a phone call away.