Affordable Care Act Primer for Premeds (Part 2)

The Affordable Care Act is comprised of ten titles that include three focus areas: improving access to care, quality of care, and reducing costs. An overview of the ACA (aka, "Obamacare") was posted on January 24, 2013.

Title I: Quality Affordable Coverage for All Americans

Title I addresses private (also referred to as “commercial”) health insurance plans. It mandates that states create health insurance “exchanges” which are essentially web portal for individuals to comparison shop and enroll in a health plan if their employer does not have affordable coverage options. This portal should also help determine if the applicant (or their dependents) are eligible for programs such as Medicaid, CHIP (for children), or other subsidies. This is designed to increase access by 1) helping people connect with affordable plans and 2) enrolling individuals who are currently eligible for government programs. 

How might this play out? It may lower costs by getting more individuals covered in private plans so that their care is not written off (and thus passed along to everyone else) by hospitals and providers. Conversely, it may raise costs by increasing the number of people who are enrolled in state and federal programs that are notorious for low reimbursement. When providers and hospitals are not getting revenue from one source (i.e., government programs), they simply shift the cost to another source (i.e., private insurance).

Title I is also designed to increase access to care by providing clear regulations for private health insurance companies.  Health plans will no longer be able to refuse coverage to certain individuals or kick them out because they are too sick (read “too expensive”).  This is called “rescission” in insurance lingo.  One of the most talked-about benefits of the ACA is the mandated option for individuals under 26 to remain on their parents’ insurance.  Young adults are some of the least expensive individuals to insure, however, they are often left in coverage limbo because they have not settled into a full-time career with benefits. This provision will be most beneficial to individuals with chronic conditions developed in childhood.

These regulations also mandate insures to cover preventive services as defined by the US Preventive Health Services Task Force (with an A or B rating). These services are to be covered at 100% with members not sharing in the cost.

There are two specific mandates that have been hotly debated: one is the individual mandate and the other is the mandate for employers that have more than 50 employees.  The Supreme Court ruled that the individual mandate penalty is a tax and, therefore, is legal. In 2014, the penalty (aka, tax) starts out at $95. By 2016, the penalty will be $695.  Premium subsidies for individuals with a household income of 100-400% of the federal poverty level are designed to ease the economic impact of getting coverage.  For a family of four in the contiguous US, 400% of the 2012 FPL is $92,200. These subsidies are available for those who purchase through an exchange.

The Small Business Health Option Program (SHOP) creates an exchange for companies that have 2-50 employees. There is no penalty for small businesses who utilize this exchange, but there are also no subsidies.

One of the regulations I find most interesting is the provision that private insurance companies must spend 85% of the money they collect (80% for small markets) on honest-to-goodness health care. Administration and profits can’t be more than 15%. I think that this may lead to more consolidation among the plans as they are force to restructure their business model. My concern is that many plans may discover that they are not viable and quality may suffer or they might simply close down shop, leaving fewer options for consumers.

Title II: Role of Public Programs

This section focuses on Medicaid and CHIP (Children’s Health Insurance Program). The biggest change is an increase in Medicaid eligibility. It is hard to know exactly how this will play out in the market place. Some argue that this will increase the pay to family physicians and pediatricians (the lowest-paid medical specialties) due to the increased number of people able to access care. The problem I see with this argument is two-fold. First, I have yet to meet a family doctor who told me she simply wasn’t busy enough and wished her waiting room had more people in it. Second, Medicaid is notorious for a lower-than-market reimbursement rate. If every provider’s practice was comprised of 10% Medicaid patients, that lower reimbursement wouldn’t have too much of a financial impact. But when more providers begin to feel that Medicaid is more trouble than it is worth, the practices that do take it see their income drop as private insurance becomes a smaller proportion of their business. A friend of mine stopped taking Medicaid when her accountant informed her that she was losing $40 every time she did a certain procedure;  the reimbursement was less than the cost of medical equipment utilized. That adds up quickly—and that was just one procedure.  I’m sure that there will be some clinics that remain economically viable, but I can guarantee that they will need to see an incredibly large volume of patients.

Even though this section focuses on access to care, Title II also sets out to improve quality and control costs through innovation demonstration projects and the creation of accountable care organizations. One example of cost control measures: If a patient’s condition is caused by seeking care (such as a hospital-acquired infection), the services required to remedy the situation must be rendered without payment.

Affordable Care Act Primer for Premeds (Part 1)

Working in public health has been a definite plus for me when it comes to the inevitable Affordable Care Act questions that surface during interviews. Interviewees must have a general understanding of the ACA as its ramifications will impact health care (in what I believe are some uncertain ways) over the coming decade.

The ACA was passed in 2010 as the “Patient Protection and Affordable Care Act” and was dubbed “Obamacare” by opponents. President Obama has encouraged supporters to use that term to remove any negative connotation and to help clarify that they are one in the same. Imagine, if you would, a person who is in favor of the benefits offered under the Affordable Care Act, but is opposed to mandatory coverage under Obamacare. It isn’t too hard to see the confusion that stems from Democrats and Republicans using different names.

I must offer this disclosure: The ACA is extremely long and I have not read it all. What I have read is information from the Center for Medicare and Medicaid Services, a variety of provider newsletter editorials, articles written in the popular press, and documents prepared specifically for public health professionals.  I have also attended multiple workshops on various aspects of the quality innovations and demonstration projects that stem from the Act.

My goal in writing this synopsis is not to persuade you that the ACA is either good or bad, but to help you feel a little more confident about fielding interview questions. Frankly, I think that it is a mixed bag. There are many good aspects of it, but implementation posses many problems. Many, many problems.  Sometimes great ideas can go amiss. In the 1980s, the HMO was seen as a remarkable concept that would save US health care, only to bring us where we are today: one of the most expensive places to get care with some of the most abysmal morbidity and mortality among the developed world.

The Act contains ten “Titles” that fall under the general scope of improving access to care, quality of care, and reducing costs. One of the titles was struck from the act prior to passage, but the numbering remained the same.  Because the ACA is so big, I’m breaking up my posts to reflect the three main focus areas. Stay tuned.

Don't let the turkeys get you down

My father was fond of saying, "Don't let the turkeys get you down." He'd usually quickly add, "Gobble! Gobble!" and a big smile.  Shortly before Father's Day one year, I found a button (it was the '80s)  with an illustration by Sandra Boynton. A somewhat clumsy-looking elephant was pinned down by a rafter of clueless turkeys.

 As a kid, I had a vague idea of what Dad meant. I thought of it as "don't get sad about things idiots do  or say to you." As a parent, I've hoped to instill a sense of resilience in my children. Life has many upsets and learning to roll with it--to adapt--is a valuable skill. It just seems that, at times, the turkeys are just a little too close to home.

Dozens of congratulations popped up on my wall when I posted my acceptance to Facebook last week. It felt great. It reminded me of the many people who have been cheering me along the way over the past few years as I headed back to school and prepped to apply. One person made a comment reminding me not to forget my kids while I was in medical school. Nice. I just shrugged it off. I've been a mom long before getting into medical school, and I'll be a mom long after finishing medical school. That turkey didn't get me down.

But then Christmas happened. Or, rather, dinner at my in-laws happened.

On the way to their house, my 14-year-old daughter asked, "Mom, are you going to tell Grandma that you've been accepted to medical school."

"I don't know if I'll bring it up," I answered. "When I told Grandma and Grandpa a few months ago that I was applying, they just kind of stared at me." I thought for a moment. "Yes. Definitely. If they ask, I'll tell them."

"What if they don't ask?"

"Well, I guess that means they don't care. Maybe?" and I just shrugged my shoulders.

I've been struggling this week with the idea of going to school out-of-state. Moving means losing so many familiar things, especially for my kids.  My father's parents were gone before I was born and my mother's parents lived on the other side of the country. With both of my parents gone, it has been important to me to make time for my kids to see their grandparents who live just an hour away.

Not too surprisingly, my in-laws did not ask me how the application process was going. Back in October, I explained to them that I already took the classes and the "big exam." My applications were turned in and I was waiting for invitations to interview at places that might be interested in me. Hopefully, medical school would be part of my near future. "What are you going to do with that?" my father-in-law had asked.

So when it came time to get our coats back on and head out the door after the visit, I had a very odd feeling. I didn't want to keep a secret from them, especially if it meant we would be moving, but I also didn't want them to burst my bubble. Then my husband spoke. "Guess what? Vieve just got the best Christmas present imaginable, and it wasn't from me."

My mother-in-law's face lit up. She leaned in, "What was it?"

"She just got accepted to medical school," and he put his arm around me.

Suddenly, I felt swept away with excitement. "Yeah. I had three interviews last month, and I was really afraid I wouldn't hear back from any schools before Christmas, but Med School in Another State let me know on Friday that I was accepted and I'll even get a scholarship, and I'm just so excited!"

She leaned back and looked perplexed. "Are you going to do that online?"

Pop.

"Um," I couldn't help but smile a little, "there are no online medical schools in the country." Feeling a bit confused, wondering if they were a bit confused, I added, "I'm going to be an MD."

My father-in-law spoke up. "You know what 'MD' stands for, don't you?"

He was standing directly behind me, so I turned around to meet his smiling face. He always has a corny joke to tell, and I thought that it might help take the edge off of the disappointment I felt. I smiled broadly, "No, what?"

"Mostly Dumb. After all, they can only practice and never get it right."

I just hugged him and said, "Merry Christmas."

I hugged my mother-in-law, too, and thanked her for dinner. My sister-in-law and her husband were also standing by the doorway and had said nothing so far. She just looked at me and said, "Uh. That's exciting news."  I gave them good-bye hugs as well.

Maybe it isn't fair of me to expect them to be excited about this. Maybe they are just deeply concerned about the welfare of my children, like the aforementioned Facebooker. Maybe they're just turkeys.

It happened!

This morning a co-worker asked me if I had heard anything yet. Sigh. I told him how hard it has been waiting and that I probably wouldn't hear anything until schools are back in session in January. John is close to retiring. He gave me a big smile and told me not to worry.

But I have been worrying for months now. That's just part and parcel of applying to medical school. Everything in your life is up in the air as you wait to hear back. As you wait for that one, magical email. And so, at 11:30, I refreshed my email one last time. I had to laugh at myself for refusing to give up hope that I just had to get my most-wanted Christmas gift. It was time to give my mind a rest and so I log out.

My sons get out of school early on Friday, so I packed up some paper-work and headed off to get them. My 12-year-old let me take a few moments to feel sorry for myself. "No word until January. Some how I need to not think about it for two weeks." He just smiled and told me not to worry. This has been a journey for them as well.

Around 2:00 PM I opened up my personal email account again, looking for a reciept from a recent purchase, and there it was. Stamped as delivered at 11:35--just minutes after I told myself to let it go. My offer to enroll in medical school. Unbelieveable.

Words cannot express the deep, abiding sense of gratitude I have. This whole process has just been amazing. Yes, I needed to have the attitude to keep with it and not let myself get derailed over the past few years, but there is no way I could have done this without the love and support of my children, my husband, and my friends. So many things have come together just-so in order to get me here. How blessed I am.

Self-doubt costs $170

Two weeks ago, I was feeling great about having five interviews scheduled (three MD and two DO).

But...that was two weeks ago.

Each week of silence during interview season is painful. No, not feverishly-sick-in-bed painful. More like did-I-really-do-everything-I-could self-doubt painful. You know, the feeling that despite evaluating MSAR data for over 80 different schools, I didn't consider every school that I should have. Conventional med-school applicant wisdom says that you need to apply to at least 10 "go-for-it" schools in addition to a couple of "reach" and a sprinkling of "safety" schools. The problem is, where do out-of-state schools fit in? Most of them hold residents to a different standard than out-of-staters, but exactly what that standard is, is not always clear. If the average MCAT for a school is 31 and 80% of students are in-state, what's a reasonable score to consider that school a "safety"?

I truly believe that there are schools that might still invite me to interview in January or February. The problem is, there are a lot of schools that haven't said anything. At times I think "no news is good news" and at other times I think that no news simply means that the window of opportunity is closing. (Did I mention that I got my first rejection? Mayo said "no" to me on Halloween. It's a little relieving not wondering where I stand.)

Faced with the discomfort of waiting, I decided to do what I could do. I finished another secondary to a school that I wasn't all that interested in. I will finish another secondary this weekend. I signed on to AMCAS today and selected five more schools with a primary deadline in December, paid $170, and hit "submit." I suppose that many people in my position would spout off that it is too late and why bother, but then again, bothering means that I'm doing something while I'm waiting. Somehow I feel like I'm keeping myself in play.

First Interview

I recently attended my first med school interview. There were a dozen other applicants with me that day. Some how, I felt like I was behind on my make-believe timeline with my first interview happening in mid-November. As it turns out, only two other people in our group have had a previous interview, and one of those was earlier that same week.

I must admit, I was surprised with how happy the med students were. We were divided into groups of three for tours given by first-year students. It was casual and informative. Our tour guide stated, repeatedly, that he had "lots of free time" and he felt like it was pretty easy to balance studying with the rest of his life. Lunch was in the cafeteria with a group of second-year students. One of the students seemed like she had a chip on her shoulder. But, hey, sometimes I have a chip on my shoulder, too. Even so, she still was very positive about the school and the level of student support that was offered. Going on campus and talking with students tells you so much more about a school than any website.

Here is my interview schedule thus far:
November: one western school, two Texas schools
January: one midwestern, one Appalachian (WVU's finally came via good ol' USPS)

Med School Application Process

My daughter's a senior in high school. She's already decided on the school she wants to attend. She applied online, paid $30, sent her transcript in, and designated the school on her ACT. This process was moderately stressful for her. Her acceptance envelope came in the mail the next week.

Lots of people tend to think that applying to medical school is just like applying to undergraduate school. When they say to me, "Where are you applying?" I don't think that they are really expecting me to list off all 21 schools that have received a primary and secondary application from me. In July, a few people asked if I was applying for this fall. No, med school isn't quite as "open-enrollment" as the local community college. Here is a brief run-down of the application process.

The MCAT is the greatest obstacle you must overcome on your way to medical school. The colleges classes requisite to taking the MCAT include biology, general chemistry, organic chemistry, and physics. Having taken a physiology course was very helpful for me. Starting in 2015, the MCAT will also include biochemistry as well as social science (psychology) questions. After taking these courses, you need to buckle-down and work through some good study guides. Doing well in these classes is no guarantee that you will do well on the MCAT. It takes devoted study time to review the concepts and work on timing. One of my biggest challenges was working on my "testing stamina." The exam is five hours long. Prep-time for the exam should be around three to four months. Ideally, the MCAT should be taken before May of your application year (the calendar year before you wish to start).

There are three main application systems for medical school. One is for the allopathic (MD-granting) medical schools in the US, another is for the osteopathic (DO-granting) medical schools, and the third is for the eight Texas schools (7 MD, 1 DO). Texas used to be its own country, so it isn't such a surprise that it has its own med school application process. You can create your log-in to these sites in May. You will use these sites as electronic receptacles for a slew of data.

May is a great time to begin requesting letters of recommendation. If you do not have a letter-writing committee at your school, you will need to collect a minimum of three letters from professors. Two of these professors must be from science departments and the third should be from your major if you did not major in science. I had a letter from my physiology professor as well as my organic chemistry professor. For my third professor, I request a letter from my thesis chair for my master's degree (public health).  Many schools have additional, school-specific letter requirements. For instance, some may want a supervisor or someone who can attest to your professional work (if you are currently employed full-time). One school that I applied to wanted a research reference. My thesis advisor was able to address their concerns. Many DO programs request letters from physicians you have either shadowed or work with. All of these letters can be managed on-line so that your writers only need to upload their documents to a single website (or three websites at most). Your accounts with AMCAS (MD) and TMDSAS (Texas) include letter delivery. The DO site, AACOMAS, is run by Interfolio, and Interfolio collects an additional fee for each "packet" of lettes you send out to schools. Managing letters is a nuisance, but the electronic format makes it easier. One of my writers submitted to AMCAS, but not TMDSAS. That left me in the awkward situation of sending lots of reminders. If I had the letter just sent to Interfolio, I could have had only one address to send it to.

In May, you will also want to start ordering copies of your transcripts. You will need your own copy of your transcript--whether official or not--as each application system requires you to manually enter your classes, credit hours, and grades, and then assign each class to a system-specified category. Having finished a bachelor's degree a while back meant that I took quite a few "postbacc" classes. I also had my graduate school courses to enter. I wish I could say that this was the most time consuming part of the application process, but it wasn't. It was tedious and slow, but the narrative writing took me much, much, much more time.

Ah, yes. The narratives. You will write like you are enrolled in an intensive freshman composition class during this process! The most important document is your personal statement. Admission to medical school is riding on it. All three systems require a personal essay on what motivated you to apply to medical school. The essay is limited to 3,800-4,500 characters including spaces. (The character limit is different for each of the three systems.) I did about eight drafts of mine before I felt happy with it. Yes, eight. Most revisions were deciding which elements to trim out.  Additional narratives are allowed for each of the 10-15 extracurricular activities you list. These are about 300 characters each. Much of what you write in one system can be saved as a plain text document and used in another system.

With the best of intentions, it was not until early July that I had all of my electronic applications ready to submit. Letters, transcripts, and writing took a fair chunk of my not-so-free time.

After submitting your application, a few schools will automatically send "secondary" applications. Secondaries generally (but no always) entail any where from two to five additional essays. Rarely can you "recycle" an entire essay, though you may find enough overlap to do a quick revision to tailor the essay to the school's prompt. Secondaries often cost $50-$100 a piece. If you apply for financial assistance, many schools in the AMCAS system waive the secondary fee.

The "complete" application consists of your primary, your letters of evaluation, and your secondary. The admissions committee at the school will begin reviewing your file in the order in which it was complete. Most schools don't begin the review process until July or August. Interview season begins in either September or October, depending on the school.

You are only considered for an interview after your secondary application is received by a school. The complete application usually takes about a month to be reviewed. Sometimes you might hear back from a school in less than a month, but most people do not get interview that quickly. Of course, an interview is not the only possible outcome. In fact, an interview is not the probable outcome. After schools review your complete application, they may reject you or put you on hold. "Hold" is kind of like being wait-listed to interview.  Interviews are always face-to-face. The interview day includes an orientation to the program and a campus tour. Interviews are offered on a rolling basis. Some schools will schedule your interview within a couple of weeks of inviting you, and others may schedule your interview date as far as two months later. Texas schools finish interviewing in December. Most other schools continue to interview for real spots (not just the wait-list) through January or even later. It's pretty nerve-wracking waiting for interview invitations.

It's estimated that about half of interviewees get accepted. For me, that means that five is the magic number. Five interviews roughly translates into 1- (50% x 50% x 50% x 50% x 50%) = 96.875% chance of getting in somewhere. Of course, each schools acceptance rate of interviewees varies dramatically. "Acceptance" rate data is rarely released. In-state versus out-of-state status may translate into slower acceptance times for out-of-staters. Don't be surprised if you don't hear back for a month or more. You might even find yourself on the wait-list until all in-state positions are filled. Again, this varies from school to school.

Once an offer for admissions is extended, you must respond with a deposit to hold your spot. You may hold more than one spot until May 15. Both you, and the schools, must decide who they want by that date. Many people will hold more than one acceptance up to that point, and so there is quite a bit of wait-list shuffling that happens. Schools routinely admit more students than they have space for, knowing that many applicants will wait until this deadline to decide. For instance, Mayo Medical School has only 40 students per class, yet they admit about 70 students knowing that just over half will matriculate. What does this mean? It means your odds for acceptance just might be better than they appear based on out-of-state matriculants.

So far this lengthy process has taken us from May (actually before than for MCAT prep) of one year to May of the next. If you don't already have an acceptance in hand, you might just get a surprise offer in June. Yes, that really does happen. Remember, that is just two weeks after the wait-list shuffle really begins. If you haven't already, it is time to pack up and move. Most schools begin orientation to medicine in early August, though some start in July.