I started medical school in 1975. That’s 47 years ago and a lot has changed since then. The way we practice medicine has changed, but the way we educate doctors is much the same. Is that a good thing or a bad thing? Let’s talk about it.

Robert Pearl, M.D. says a lot needs to change. In a series called Breaking the Rules of Healthcare, Dr. Pearl challenges conventional thinking about medicine in several areas, including medical education. Today we’ll talk about what he says about the way we choose doctors – and medical students.

Dr. Pearl says all doctors adhere to two different sets of rules. There are the written rules, covering everything from human anatomy and physiology to the current law and regulations that govern the profession. Then there are the unwritten rules, which dictate the “right way” to act. These rules, he says, which heavily influence clinician behavior, aren’t taught in textbooks or lecture halls. They are observed and subconsciously absorbed by medical students and young doctors whilst trying to learn the ropes and earn the respect of physician leaders.

He says most of healthcare’s unwritten rules were established long ago, prior to 21^st century advances in science, technology, and medical practice. Many of them are now outdated – obstructing clinical excellence and holding our nation back. He believes this accounts for statistics that show Americans receive the most expensive and least effective care in the developed world. (He doesn’t give the source of this information.)

To address this problem, Dr. Pearl suggests we break the rules of healthcare, beginning with Rule #1: The best doctors are the ones with exceptional memory.

It is true that without an exceptional memory and the ability to regurgitate enormous quantities of facts, no student striving to become a physician will succeed. The system of pre-med college courses and the medical school curriculum demand this of all doctors. Dr. Pearl says roughly 50,000 graduating college seniors apply for 20,000 medical-school openings each year. The most important determinant of success is their scores on the MCAT or STEP exams. If you’re below the 80^th percentile, you probably will fail.

The reasons for reliance on these tests are their shown ability to identify the best minds at retaining information. However, in today’s world of hand-held smartphones, a wealth of information is available literally at our fingertips. It only takes a moment to look up the facts that previously you needed to memorize.

Therefore, Pearl says to find the ideal doctors for the 21^st century, a better rule would be to identify candidates who can:

(a) use modern technology to access reliable information

(b) synthesize medical data into a coherent treatment plan

(c) effectively communicate that information to patients from diverse backgrounds.

He says physicians who do these three things, consistently, can deliver far better care than doctors of the 20^thcentury ever could.

To make this transition and help medical schools and residencies identify and train the ideal doctors of tomorrow, he suggests two initial steps:

• Modify standardized testing – Instead of the MCAT and STEP exams, which are day-long marathons of applied memorization, he suggests a more useful exam would require participants to employ 21^st-century tools to solve 21^st century medical problems, the kinds of complex challenges doctors encounter in real life. He would allow mobile technology during the exam to test their ability to use it to solve problems.
• Change the curriculum – Change the STEP exam to a PASS/FAIL to diminish the emphasis on memorization and cramming for the exam. He thinks second-year medical students are spending too much time in preparation for the exam and not enough doing classwork.

Dr. Pearl says, “Breaking the outdated rule for selecting medical students and residents is only a first step toward transforming American healthcare. There are many more rules left to break.” His series will cover four more rules he recommends breaking. We will discuss those in the future.

Healthcare is certainly changing. I wrote a book about it called Changing Healthcare! I vividly remember the first day of medical school when the Dean told us, “Half of what we teach you in the next four years is wrong. We just don’t know which half that is. Therefore, the practice of medicine is a life-long commitment to education.”

For now, I am somewhat skeptical of Dr. Pearl’s suggested changes, as you might expect someone to be who was trained in the “old school.” There is no getting around the need for every medical student to inculcate large volumes of information in order to effectively function as a physician. While modern technology does avail us of instant access to a wide variety of information, the time needed to find that information is often unavailable in clinical situations. When a patient’s life is on the line, I hope my doctor won’t be burying his nose in his cell phone, grasping for answers.

In a recent blog, I talked about the Biden Administration trying to buy votes by throwing more money at ObamaCare (Buying Healthcare Voters). It’s bad enough to shamelessly bribe voters with free government handouts, but it’s worse when that’s probably illegal.

The Wall Street Journal editorial board weighed in on this issue and I learned a lot more. Seems this idea dates back to the Obama Administration and even President Obama himself couldn’t fix this problem. But now Uncle Joe thinks he can do it just by executive order.

What’s the problem?

The problem, often referred to as the “family glitch,” concerns who qualifies for subsidies under ObamaCare. As currently defined in the legislation, a person is eligible if he doesn’t have an offer of “affordable” coverage at work, defined as one that costs less than roughly 9.6% of household income. This calculation is tethered to the cost of insuring only the worker, not the spouse and kids, and a family plan can be more expensive.

The Biden Administration is now planning to fix this by turning on the subsidy spigot for family members who aren’t currently eligible. The Kaiser Family Foundation estimates that 5.1 million are affected by the family glitch, but 4.4 million – 86% of these – have employer insurance. Only 9% (451,000) are uninsured. The White House predicts that 200,000 people who are uninsured will gain coverage on the ObamaCare exchanges once they’re subsidized under the new rule. About one million more will drop their current plan and move onto the exchanges. This government handout will cost $45 billion over 10 years according to the Congressional Budget Office.

The real question is why this didn’t happen before? “If the family glitch is such a big deal,” as economist Douglas Holtz-Eakin asked this week, and “can be easily rectified by a Treasury rulemaking, why didn’t President Obama and Vice President Biden fix it a decade ago?” The answer is that Team Biden is less concerned with the legal or policy merits than offering more “free” healthcare in an election year.

Brian Blasé, also writing in The Wall Street Journal, says the whole idea is illegal. He says, “Mr. Obama’s presence at the White House was ironic given that the IRS’ s proposed policy now reverses its decision from a decade ago when he was president. At that time, the IRS believed it had to follow the law as written. The reversal shows that the enforcement of the tax code has become deeply politicized. Through this rule, if finalized, the IRS will expand ObamaCare subsidies by billions of dollars a year beyond what Congress authorized.”

He notes the current provision of the law regarding subsidies was the result of compromises necessary to enact it. A decade ago, when the Obama administration was writing ObamaCare regulations, the IRS and Treasury department spent enormous time on the issue. Many progressives pushed a broader interpretation, with affordability measured on the cost of family coverage. But the IRS and Treasury stuck to the law. Blasé says, “IRS career staff are loathe to revisit settled tax policy questions, and they likely came under enormous pressure from the White House to renounce their decade-old position and disregard the law.”

Blasé also points out this is not only illegal but bad policy. Since nearly 9 of 10 of the five million people affected by this plan are currently covered by a spouse’s or parent’s employer plan, an illegal fix would mostly displace private spending (employers) with government spending as dependents replace employer coverage with subsidized exchange coverage. All this to increase coverage of the uninsured by only about 200,000 – at a cost of $45 billion over ten years.

If it’s good policy and legal, Congress should pass such a change in the law. If it’s bad policy and illegal, then leave it to the Biden Administration to do it on their own.

When your poll numbers are in the tank and there’s an election coming soon, what do you do? The Democratic Party solution seems to be all about purchasing healthcare voters. This is certainly in keeping with their healthcare philosophy of putting the government in control of your healthcare.

Two examples of this new campaign strategy were on full display recently. First, the Biden Administration went to their most reliable bullpen reliever when they invited former President Barack Obama to the White House for an event to reinvent ObamaCare. Knowing that “free stuff” is always popular with voters, they announced changes to ObamaCare to put even more Americans on this government-dependent healthcare.

Since its introduction in 2010 under the Obama Administration, ObamaCare has undergone many changes. This new healthcare legislation, passed without a single Republican vote, has struggled to live up to its hype. More Americans are now covered under this healthcare insurance, but the same individuals who can’t afford the premiums can’t afford the deductibles either.

The latest twist that the Biden Administration is proposing would extend coverage to the whole family for any employee covered under the plan. Currently workers can’t get ACA subsidies to lower their premiums if they get affordable health insurance coverage from an employer. But the definition of affordable is determined by the cost of the coverage for the employee and not for the whole family. This change is estimated to impact about five million people according to the Kaiser Family Foundation.

The result will be more people with healthcare insurance coverage – but not necessarily more people who can afford their healthcare. The underlying reason for this problem is the high cost of insurance under ObamaCare, because they require every policy to have coverage for essential health benefits – which includes unneeded coverage such as mammograms for males and prostate exams for females. This “one size fits all” philosophy only increases the cost of insurance, which increases not only the premiums the government is paying, but the deductibles the patients must pay, too.

Second, the Democratically controlled House of Representatives is proposing a price control cap on the cost of insulin. The Affordable Insulin Now Act (sounds like the Affordable Care Act) is a bill to solve a problem that doesn’t really exist. The Wall Street Journal editorial board says the bill caps the cost-sharing for insulin at $35 a month for diabetics with private insurance or on Medicare Part D. The bill’s Democratic sponsors call it “a critical drug pricing reform” to deal with “the skyrocketing cost of insulin.”

But the real story is more complicated. Sticker prices for insulin have increased, but those calculations ignore discounts negotiated by pharmacy-benefit managers. Over the past five years, net revenues to drug manufacturers on diabetes drugs “have been declining and patient out-of-pocket cost has been flat or risen only slightly,” says a 2020 report from IQVIA Institute for Human Data Science.

The gap between list and net prices can be huge. In 2019 patients paid less than $30 out of pocket for 74% of all diabetes prescriptions, according to IQVIA’s analysis. More than nine of ten were less than $75. But those without insurance may get stuck with higher prices or they must burn through a large deductible in their plan before coverage kicks in.

According to WSJ, the House bill would do nothing to change this. But it treats insulin makers as villains, even though many are trying to help their customers. Eli Lilly’s Insulin Value Program offers a discount card for $35 a month for insulin. The Trump Administration also tried to help in 2019 by allowing high-deductible plans to cover more care for chronic conditions before the deductible, including insulin.

The real solution to rising insulin prices is more competition – the opposite of what the House bill encourages. A better approach would be pushing the FDA to make it easier for generic equivalents to win approval, which would certainly lower insulin prices. Former FDA commissioner Scott Gottlieb was a strong proponent of speeding generic approvals under the Trump Administration.

WSJ says, “Democrats haven’t been shy about their broader plan to control the price of medicine through the euphemism of Medicare “negotiation.” This tells investors: Move your money out of better medicines or long-shot cures and into businesses that aren’t under political assault. That would be a terrible development for diabetics, especially as cell therapies may someday provide a cure. As former FDA commissioner Scott Gottlieb put it recently, it’s essential that diabetes treatments are affordable, but Congress and the public shouldn’t forget that the ‘ultimate goal is to free patients from insulin.’”

Beware the salesman who is selling snake oil just to get your money. Beware the politicians selling healthcare reform just to get your vote.