Ben White

ABR Lawsuit: The Amended Complaint

02.17.20 // Radiology

If you’ve been keeping up, the original motion to dismiss filed by the ABR was granted by the court, basically parroting the similar intially dismissed case filed against the ABIM.

So an amended complaint was filed on January 24, 2020.

(Also, a reminder: I’m still not a lawyer.)

The Honorable Jorge Alonso’s opinion was basically: “I’m not convinced initial certification and MOC are separate products. They seem like two parts of one product: ABR certification. That used to be a one-time thing and now it’s not—tough luck.” As such, you can’t illegally tie the two components together if they’re really two aspects of one thing. The logic rests largely on the established interpretation of the Sherman Antitrust Act that if there is no separate market for the contended service, then you can’t argue that it’s an illegal tie-in. Everything else in the complaint either relies on that to matter or was a “conclusory” allegation (an accusation not demonstrably supported by facts).

The amended complaint, dated January 24, 2020, spends a lot of time describing MOC in lines of another umbrella term: a continuing professional development (“CPD”) product (i.e. CME). Just because you creatively title your CPD product “MOC” after selling one-time initial certifications for over half a century doesn’t change what it is. The amended complaint says that MOC is basically a CME product, and, hey, look, there are tons of those around and a robust market to buy them. While doing so, the plaintiff attorneys also point out that none of those other CPD providers sell initial certification. Therefore, ipso facto, there is a separate market, and the ABR is being naughty.

Everything in the suit, including the relevance of some of the great zingers in the filing, rests on convincing the judge that IC and MOC are different products. There may be a practical monopoly, but so far no judge in these ABMS lawsuits has been interested in allowing a challenge to the party-line interpretation to stand and let these suits go to trial. To progress, MOC must be interpreted as just another CPD product. Without that, it’s all dead in the water, and interesting bits such as the inbreeding between the National Committee for Quality Assurance (NCQA) and the ABMS (page 17) don’t get to make it to a jury’s ears (and I suspect a trial would probably be more of a downhill victory in court than the case getting through the judge to a trial in the first place).

For Alonso, I suspect it will be hard to convince him that MOC = CPD. Clearly MOC is basically CPD, but not all CPD is exactly “MOC” at least so far as MOC has been engendered by the ABMS specialties (whether that form is meaningful or valid, unfortunately, is something the judge had no interest in entertaining in his granting of the defense’s motion to dismiss). It’s not the ABR’s “fault” that its “voluntary” certification product has become a requirement for hospital credentialing or insurance panel acceptance.

I mean I’m pretty convinced, and the history outlined in the suit is both instructive and compelling (seriously, read it), but I’m just a radiologist.

And while there is more supporting evidence provided in the amended filing (e.g. see the interesting points 51-56 starting on page 12), there’s also nothing here to force him to change his mind. The ABR can argue, bullshittingly, for example, that MOC includes both a knowledge assessment, CME compliance, and a QI project component and is, therefore, a more holistic view of the practicing radiologist. We know this is largely nonsense. The ABR is a profitable question-bank company where the questions are largely written for free by volunteers. But that fact doesn’t necessarily mean the ABR itself cannot change the terms of its own certification product.

And what’s really at stake here?

Plaintiff asks only that ABR be prevented from revoking the certifications of radiologists who do not also buy MOC, and that ABR report, without any qualification, whether radiologists have purchased an ABR certification, regardless of whether they have also later bought MOC.

I’m not that hopeful anything like that will come to pass.

But a real solution that could actually benefit the field of radiology would probably need to be one of two (or both things): a well-organized competing board with a clearly superior product that gets buy-in from residencies and the ACR and subsequently organizational and licensure stakeholders. I believe this would need to include initial certification to really have a chance of meaningful impact and is extremely unlikely (after all, the ABR managed to get the fledgling “National Board of Radiology” shut down within a few months of its creation). Or, continued grassroots opposition culminates in serious ABR structural reform. This would also likely require substantial and unyielding support of the ACR and other radiology organizations.

But since you’re here, I’ve pulled some choice quotations for your reading pleasure:

Through 2017, the last year for which data is publicly available, ABR has forced tens of  thousands of radiologists to buy its redundant, worthless, and superfluous CPD product or have their certifications revoked, realizing an estimated $90 million in MOC-related fees and revenue as a result.

According to a medical journal article written by three ABMS employees in 2016, “underlying the creation” of this new product was its emphasis, unlike certification, on “performance in preference to knowledge” with its “focus on improvement rather than on elimination of candidates” for entry into a specialized practice of medicine.

So, yes, exactly what you would expect: multiple-choice questions.

If instead of the labels “initial certification” and “maintenance of certification” the original and accurate terminology of “certification” and “continuous professional development” is substituted, ABR’s tying, forcing, and other anti-competitive conduct becomes clear. Creative product labeling cannot insulate ABR from the truth that certification and MOC are separate and distinct.

Thus, MOC is nothing more than a device to force radiologists to pay tens of millions of dollars in MOC-related fees for a redundant, worthless, and superfluous CPD product.

Little information has been made available by ABR about how radiologists will know whether they are “passing” OLA, other than that the “passing standard” will “vary slightly” among radiologists, without an explanation of what “slightly” means.

If OLA is criterion-referenced via Angoff panels as the Core and Certifying exams are reported to be, then the passing thresholds should be set ahead of time (even if that threshold is a binary TBI or no?) Assuming questions of varying difficulty are administered in the correct frequencies, there should be a predetermined true percentage correct passing threshold. Well, what is it?

In short, radiologists need spend as few as 52 minutes per year (one minute for each of 52 questions) answering only those questions they choose to answer, that are designed so as not to require studying, and for which ABR anticipates neither incorrect answers nor a high failure rate. Because OLA has been designed so that all radiologists pass, it validates only ABR’s ability to force radiologists to purchase MOC and continue charging supra-competitive monopoly prices for MOC.

ABR is not a “self”-regulatory body in any meaningful sense for, among other reasons, its complete lack of accountability. Unlike the medical boards of the individual States, for example, as alleged above, ABR is a revenue-driven entity beholden to its own financial interests and those of its Governors, Trustees, management, officers, and employees. ABR itself is not subject to legislative, regulatory, administrative, or other oversight by any other person, entity, or organization. It answers to no one, much less to the radiologist community which it brazenly claims to self-regulate.

It took about 9 months for the initial dismissal, but I suspect we’ll have some more news in the spring.

Pass/Fail Step 1: Initial Thoughts

02.14.20 // Medicine

I was going to write a lengthy post, but then my medical education spirit animal Bryan Carmody did and said most of what I have time to say at the moment better than I would have anyway. Take the time to read it: USMLE Pass/Fail: A Brave New Day. He’s created an impressive collection of excellent writing about acronym fiends like the AAMC, NBME, and NRMP, and this is no exception.

This is a Brave New World. It will be a period of change, and it may very well be a rough transition. I know in this post-fact world we live in that people are cynical and want to cling to an objective measure. The system was flawed but in many ways predictable, and that comfort goes a long way. Students know what to expect. For those who put the time in and succeed, doors can be reliably opened.

Everyone’s concerns about shifting pressure to Step 2 CK, replacement by other likely useless metrics, elite schools, etc etc are all valid. A better future isn’t guaranteed, and Step 2 CK will certainly be the new default if it’s allowed to be (though even that would be an improvement since it’s a better test; I suspect it will become pass/fail within a few years as well).

But Step 1 is not good measure.

It doesn’t measure what matters, creates false distinctions across similar applicants, and may even select for some negative qualities. It’s turned medical school into an overpriced correspondence course and forced students to waste all of their energies spending more and more time mastering less and less useful material. None of our knowledge assessments from the MCAT to the USMLE to any of the board certification exams actually do what they are designed to do. And that’s a huge problem when we’ve absolved ourselves of meaningful holistic and true performative review and instead let a bunch of basically anonymous Angoff panels decide what it is a doctor is and does.

Arthur Jones of Proctor & Gamble once remarked that “all organizations are perfectly designed to get the results they get.” Well our system—from medical admission to MOC—is designed to get unsustainable negative results.

Schools and residency programs have a couple of years to figure out a more meaningful way to evaluate students and select residents. Pass/Fail Step 1 is a lit fire under everyone’s tushes. It’s not a solution; it just opens a door.

 

Believing Anything and Nothing

02.12.20 // Miscellany

The political theorist Hannah Arendt once wrote that the most successful totalitarian leaders of the 20th century instilled in their followers “a mixture of gullibility and cynicism.” When they were lied to, they chose to believe it. When a lie was debunked, they claimed they’d known all along—and would then “admire the leaders for their superior tactical cleverness.” Over time, Arendt wrote, the onslaught of propaganda conditioned people to “believe everything and nothing, think that everything was possible and that nothing was true.”

– McKay Coppins, writing about political disinformation for The Atlantic.

F. Scott Fitzgerald is often quoted as saying that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”

What microtargeting of vulnerable people has created is the opposite: minds that filter all ideas, opposing or not, through a distortion filter that makes them unable to think critically on anything. Facts don’t matter, because everything is just a predictable reaction based on a fundamental premise, world-view, or political exigency.

That article is extremely depressing. But if you’ve ever wondered what would happen if/when the internet became so drowned out by bots and misinformation noise that it becomes useless, you’d enjoy Fall by Neal Stephenson.

About those Letters of Recommendation

02.11.20 // Medicine

This study was from 2014 and titled, “What Aspects of Letters of Recommendation Predict Performance in Medical School? Findings From One Institution.”

Do you have a guess?

Being rated as “the best” among peers and having an employer or supervisor as the LOR author were associated with induction into AOA, whereas having nonpositive comments was associated with bottom of the class students.

Best = good

Nonpositive comments = a nice way of saying you don’t really know someone or think they were lame = bad

Now, this was in reference to medical student performance based on college LORs, but some parallels exist in any situation where the current evaluation and the future task are not substantially similar, and—most importantly—bias knows no bounds.

Almost all LORs are positive, even if most people will, by definition, end up somewhere closer to average.

And because most LORs are based on classroom performance, they’re useless. We have more objective measures of classroom performance. They’re called grades (and—blech—the MCAT), and even those aren’t very good at predicting outcomes. At least your boss, whether in the lab or at a paying job, actually knows if you can show up to work and get stuff done.

I’d almost completely forgotten about the LOR process in applying to medical school. I remember I had one from my lab PI/thesis advisor. And then…I honestly have no clue.

When Danger is Only Online

02.10.20 // Miscellany

Jonathan Haidt, author of The Coddling of the American Mind: How Good Intentions and Bad Ideas Are Setting Up a Generation for Failure, in an interview for Next Big Ideal Club:

Back in the 1990s, the Cold War was over, the fear of nuclear war was gone, the [United States] ran a surplus, the crime rate plummeted—and the music was pretty good, too. The risks kids were at from diseases, car accidents, and crime were all plummeting. It was the safest time ever.

But because of changes in the media environment, we were divorced from reality—we got a steady diet of stories about childhood abductions. Almost nobody gets abducted in the United States—there are about 100 true kidnappings a year in a country of 350 million people. It almost never happens, but each time it happens, especially if it happens to a middle-class white kid, there’s constant coverage.

…

Throughout history, there have been innovations that link us closer together, and whenever that happens, there are all kinds of unforeseen effects. Take the automobile—people can move around, so it changes sex life, and dating, and marriage. The automobile, the telephone, the airplane—all of these things have effects on society, and it takes decades for that to work out. But with social media, we’ve never had something come in so fast that was so transformative in changing social relationships.

And the problem is not the internet, and it’s not screen time. Research that I’m collecting shows that it’s not time spent watching Netflix, and it’s not even time on the computer. It’s specifically social media that has pushed us over the edge, and I think it is a major cause of the rise of depression and anxiety, [especially] for girls.

Had Facebook, Instagram, and Twitter never been invented, I do not think our politics would have blown up. I do not think Donald Trump would be president. I do not think Brexit would have happened. I do not think that our democracy would be as imperiled as it is. Of course, Facebook and Twitter do a lot of good things, too, but the downside is so severe that I’m beginning to worry that social media is incompatible with a functioning democracy.

I wonder.

Social media is seductive even though it’s most effective as a way to literally waste time. But I’m older than the generation Haidt is worried about. And even to me—as someone who has written exclusively on their own platform for over a decade and grew up with just AOL instant messenger—it’s amazing how easy is it to fall prey to the endless feed.

The Rise of the Consultancy

02.07.20 // Miscellany

Management consultants insist that meritocracy required the restructuring that they encouraged—that, as Kiechel put it dryly, “we are not all in this together; some pigs are smarter than other pigs and deserve more money.” Consultants seek, in this way, to legitimate both the job cuts and the explosion of elite pay. Properly understood, the corporate reorganizations were, then, not merely technocratic but ideological. Rather than simply improving management, to make American corporations lean and fit, they fostered hierarchy, making management, in David Gordon’s memorable phrase, “fat and mean.”

From “How McKinsey Destroyed the Middle Class” by Daniel Markovits, subtitled “Technocratic management, no matter how brilliant, cannot unwind structural inequalities.”

I do enjoy his inclusion of Kiechel’s apt Animal Farm reference.

On the WCI Podcast

01.31.20 // Finance, Miscellany

I had a lot of fun talking to Dr. Jim Dahle on this week’s episode of the White Coat Investor Podcast about student loans:

 

 

I honestly think we may have talked more about my journey on this episode than I have with my actual writing on this site for the past eleven years, but I hope listeners found the contribution of another writer/blogger to be interesting  (also, don’t turn up the volume or you may hear my sniffles; kids…).

As Jim mentions, he actually started The White Coat Investor a couple of years after I started writing here. But he’s since built an impressive empire, steadily produced a ton of content, basically singlehandedly changed the level of discourse for physician finance, and taught/inspired a generation of young doctors to think critically about money. It’s just an incredible achievement.

I’m really looking forward to speaking at WCICON20 this March and meeting some of you there!

 

 

Student Loans: In Print and Online

01.29.20 // Finance, Writing

I published the first edition of Medical Student Loans: A Comprehensive Guide in 2017. Waiting almost three years to put out a print version is what happens in the perfect storm of total DIY, extreme retentiveness, and being a generally lazy procrastinator. Oops!

But I’m happy to say I finally put the finishing touches on the print editions for both of my loan books this month, so those of you hankering for the perfect beach read need wait no further:

Hurray!

Even better?

But in what is surely a terrible business move, I’ve also put the entire text up online at benwhite.com/studentloans/.

So yes, you too can join the ranks of folks still exchanging money for that hard-fought knowledge (thanks!).

And yes, you definitely still download a nice ebook file in the format of your choice in temporary exchange for your email address so I’ll have a nice big audience for that infrequent newsletter I’ll probably never actually start. (PS I even put the unsubscribe link in the first sentence of the download email; did you know it actually costs a bunch of money to have an email list? Crazy.)

But if you just want to scroll through 45k words in a web browser, now you can do that too.

Student loans are crippling a generation of Americans and have a chilling effect on personal+financial wellbeing. I’m just trying to do whatever I can to help you get the information you need to make thoughtful decisions about managing your debt.

Match Fever, AAMC Apply Smart, and Oodles of Bias

01.28.20 // Medicine

Brian Carmody is a pediatric nephrologist, associate program director, and man after my heart. He’s been publishing an impressive series of excellent, well-researched, and well-argued articles about basically everything wrong with the current medical school-industrial complex and the biases of its major players that have resulted in the general crapifying of medical education.

And here is a great investigative video/podcast to boot.

It’s an excellent video that illustrates one way in which the people who should know better (the AAMC, who own ERAS) subtly encourage students to overapply to residency programs, wasting valuable time, money, and stress in the process (and under the guise of trying to fight against the growing cluster of application shotgunning that has proliferated in recent years no less!)

If you haven’t seen any of his articles, check out his site. It’s excellent and is a must-read for anyone involved in medical education or residency training.

If You Have a REPAYE Subsidy: Maximize It, Don’t Pay Extra

01.22.20 // Finance

A general rule of debt repayment is that it’s never a bad idea to put extra money towards paying down your debt faster. More money means getting out of debt faster and less money spent on interest. This is true for credit cards, most student loans, car loans, etc.

However, this is actually not necessarily the case in the context of income-driven repayment in the setting of negative amortization (i.e. when calculated monthly payments are unable to cover the amount of accruing interest).

If you can’t dent the principal, then there’s no point rushing to put extra money toward your federal loans. But why?

How Much Will It Take to Make Real Progress?

The average medical resident has big loans and relatively low income. While some intentional living can certainly free up some extra money for debt payoff, it’s much harder to have enough extra to completely mitigate negative amortization, let alone begin actually making progress on paying those loans down.

For example, $200k at 6% accrues $12,000 interest a year. A single resident earning $60k in PAYE/REPAYE has a monthly payment of around $344/month, or $3,864 for the year. In order to break even, you’d need to spend over $8,000 extra. Not chump change, especially on a resident salary.

Leverage Instead

Leverage the extra money you can earmark for loans to earn some interest elsewhere. A tax-advantaged retirement account (at least get the company match from work if available) or a Roth IRA are great options. When the question is between investing vs. paying down loans, the real answer is yes.

But if you specifically want to put money toward those loans, put it somewhere safe for now that earns some interest and then use it toward your loans. Don’t rush; it’s a waste.

To understand why you should wait, you need to have an understanding of how interest works with federal student loans and how payments get applied.

How Federal Student Loan Interest Works

1. Loans grow with simple interest, and capitalization is only triggered by very specific events. Capitalization is when accrued interest is added to the principal, thus resulting in a bigger loan accruing more interest at a faster rate. The main triggers are loan consolidation, the end of the grace period, changing repayment plans, and if/when you lose your partial financial hardship while in the IBR or PAYE plans.
2. You can’t pay down the principal by making extra payments until you’ve paid off all the accrued interest for a specific loan.

What this means is that once you begin repayment, you should never be surprised by a capitalization event. Your interest will continue to accrue every single day but it will not be added on to the principal unless one of the above factors takes place. Because the principal does not change, the amount of interest accruing remains constant. No matter how big the number gets, the rate of interest accrual remains the same until a capitalization event occurs. Paying down a little extra interest itself now as opposed to later does not change the natural history or your loans or alter the amount needed to pay them down.

In the REPAYE program, half of any accrued interest that is not covered by your monthly payment is forgiven. Therefore, the lower your monthly payment, the lower your effective rate. That doesn’t mean you shouldn’t still set aside more money every month toward debt repayment, just that there is a real financial benefit to paying as little as possible directly to the servicer in the short term until you are able to dent the principal.

That Money is Still Spoken For

To reiterate, I am not suggesting that you take this extra money that you could otherwise put your loans and spend it toward lifestyle inflation.

That money should be in some kind of loan payoff slush fund, such as a CD or interest-bearing online savings account like Ally Bank.

Earning 1 or 2% risk-free in a savings account will make that money go further when you finally use it on your loans. A lot different? No, of course not. But it does help just a little bit to mitigate what can be relatively high federal loan rates. Sure, it can function as an emergency fund too, but you should give that account a name like “loan money.” It’s not for vacations.

When to Deploy

If you’ve been saving money on the side for loan payoff, there are several situations in which it’s time to pull the trigger and make a large lump sum payment.

  • Right before a capitalization event, such as losing your partial financial hardship in IBR or PAYE.
  • Right before a private refinance.
  • When your income increases enough that you’re actually able to start making substantial progress on your loans, then you can jumpstart it with your slush fund.

Caveat: if you have not consolidated your loans and have some plus loans at a higher interest rate, one could conceivably put all extra funds into paying off that loan first. Given that an individual loan will be a smaller amount, it may be feasible to make progress on it. However, in general, I recommend most people consolidate for the reasons outlined in this post.

Maximizing the REPAYE Subsidy

One of the common REPAYE questions has been if I pay extra will it eat into my repaye subsidy and thus ultimately lose money? There has been some discussion, but the answer is supposed to be that you can. That said, I would almost never trust a servicer to ultimately apply these things correctly. As we’ve discussed above, there isn’t a great reason to do this on a routine basis. In most cases, you’d be better off leveraging that money elsewhere.

One thing to consider is that placing money into a traditional pre-tax retirement account like a pretax 401k/403b reduces your adjusted gross income (AGI), which reduces your payments by 10% of the contributed amount the following year, which in turn increases your amount of unpaid interest thus increasing your unpaid interest subsidy and ultimately lowering your effective rate. That’s a mouthful, but it means that the more you can lower your AGI, the less interest accrues on your loan.

That said, the income-lowering strategy is much more effective in reducing payments toward PSLF than in saving money on the accrued interest. For example, a $100 pre-tax contribution will lower payments the next year by $10 and would thus result in $5 of forgiven unpaid interest.

Lastly, if you are considering the possibility of PSLF

Never spend a dollar more than absolutely necessary directly on your loans until you are ready to permanently give up that plan. Any dollar extra you pay is a dollar wasted in the event of achieving loan forgiveness. Again, if you are nervous about the PSLF program, then you hedge your bets by being financially prudent in other ways, not by tilting at your loans.