Ben White

The tale of case review at Cigna in ProPublica:

“Deny, deny, deny. That’s how you hit your numbers,” said Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”

[…]

The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.

[…]

As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases.

// 04.30.24

Needless Customer Antipathy

04.29.24 // Medicine

Luminello, my wife’s (now former) small practice EHR, just shut down, so I thought we’d end our sold-to-private-equity-just-to-be-shuttered-with-gusto story with a final litany of needless suffering and smarm.

Timing

To pressure people to switch to SimplePractice, busy psychiatrists running small private practices were given just two months before their current EHR shut down to research, pick, and migrate to a completely new platform. The plan for this acquisition was presumably always to shut the smaller company down and use its customers to gain a toehold in the physician market. Remove the time pressure so that people have the breathing room to look around, and you might lose some of the customers you bought.

Now technically the April 19th shutdown just was for solo practices. Group practices actually had longer to figure stuff out: until June 14. Haha wait just kidding SimplePractice just changed their mind: now it’s May 15.

Bulk Download

Luminello created a bulk download function to export charts as PDF files. The service intermittently worked and sometimes took over a week to generate the zip file. With that kind of uncertainty, some users felt compelled to request their downloads in advance to make sure they were ready to migrate to a new platform before the shutdown. Little did they know that Luminello would decide the feature was a one-time process and disable the button after using it. The patient care information generated while using the EHR after making the request wasn’t included, which would mean lots of manual document saving.

With enough complaining, you could get them to turn it back on.

Read-only

Luminello repeatedly advised users over and over that access would become “read-only” on April 19th and that no more changes could be made after that date.

Instead, on April 19th, current users were greeted by only the magic bulk download button. You can’t actively look at the EHR contents, and anything not included in that bulk download (calendar, billing, etc) is totally unavailable. That is not what “read-only” means to literally anyone.

They quietly changed the language and now call it “export-only mode.”

People complained.

Users were told that they could have access reinstated if they opt-in to transfer to SimplePractice (and then opt out again before the assigned transfer date if they don’t want SimplePractice to have their data for no reason). An example:

Maybe a monthly fee or two for SimplePractice doesn’t seem like enough money for this to be worth it, so one possible explanation is that this last-minute rug-pull is to juice the opt-in numbers of switching customers so that the sale looks better. For what it’s worth, $3.6 million of the buyout was reportedly tied to post-sale metrics. One imagines this is one of them. Encouraging people to fake switch makes a lot more sense if there are a few million bucks in pending performance payments. (Note: What’s happening is what’s happening. Why it’s happening is just my guess.)

Billing

Last fall, after Luminello sold but while they were still maintaining that nothing was changing, they changed their billing plan from monthly to annual. My wife and many others paid for a full year. At some point later into that new payment term, SimplePractice announced that Luminello was shutting down. (They did eventually switch back to offering monthly billing before the announcement.)

They stated no refunds would be forthcoming.

After a lot of bitching online, Luminello agreed to refund people for the unused months of a product that was shuttered in the middle of a prepaid cycle. I’ll believe it when I see it.

But, for those on the re-instated monthly plan, Luminello has continued to freshly bill some customers after the service closed and entered read-only “export-only” mode. In addition to general incompetence, it’s hard to ignore the more cynical possibility that they assume a fraction of the overbilling will be overlooked or accepted because any customer service interaction or credit card dispute is a hassle that takes time.

Data Shenanigans

One of the fun things in SimplePracrice’s terms of service is that they want to play with your data:

Nevermind that the software you use for patient care has no business pretending to own people’s private health information or your practice’s work, but I personally find it offputting that they want to use everyone’s practice information for data mining and other sketchy stuff like some tech bro startup. I don’t think anybody wants their notes to be used without specific permission or compensation for training some AI tool (or anything else).

The Irony

The irony here is that by most accounts, SimplePractice is actually a decent product. It has a clean design and is—as promised—simple to use. While some of the physician features (better templates and dot phrases) are not fully baked and others don’t exist (lab/imaging order integration, flowsheets for vitals etc), the mission-critical ones like e-prescribe are now functional as promised.

If they had just waited a few months to actually have a physician ready EHR ready to demo and use before all this drama and communicated better, they would’ve had a higher sign on rate and fewer angry physicians.

And to their defense, this isn’t Vista Equity Partners Management’s first rodeo. I would guess that—despite a vocal contingent of very upset physicians—the majority of doctors took the path of least resistance and stayed with them as customers. Researching the EHR market and migrating to a new platform on short notice is really hard.

Reportedly, for many users, the migration process has been relatively smooth, even if customer service isn’t always helpful.

Everything I’ve described here and in the last post is entirely needless.

The foundational problem here is that there is a difference between having a good product and being a good company. What does it mean for healthcare if we keep rewarding the not-so-good companies?

FTC Attempts to Ban Noncompetes

04.24.24 // Medicine, Miscellany

Yesterday, the FTC passed its proposed ban on noncompetes along party lines.

This is not a done deal. The US Chamber of Commerce (which is a large lobbying organization, not a part of the government) intends to sue immediately, and they won’t be alone. Among other complaints, the Republican members of the committee who voted against it and the future litigants do not believe the FTC has the authority to do this.

The FTC’s final rule—including a very long full discussion of their rationale and authority—is here.

One of the exceptions of interest to those following consolidation in healthcare:

The final rule does not apply to non-competes entered into by a person pursuant to a bona fide sale of a business entity.

The original proposal had a limitation to the sale exception that defined a “substantial owner, substantial member, and substantial partner” to “mean an owner, member, or partner holding at least a 25 percent ownership interest in a business entity.”

The final rule does not require the seller to have a minimum ownership stake for the exception to apply.

This presumably means that, for example, all doctors who sell their practices to private equity are still bound by their noncompetes, regardless of practice size. (Non-legacy “partners” who weren’t partners at the time of sale would be free).

The new rule, if it survives, will be retroactive to essentially all noncompetes starting on the effective date ~120 days from now.

The FTC has argued it has authority over at least some nonprofits here. They bookend their argument thusly:

The final rule applies to the full scope of the Commission’s jurisdiction. Many of the comments about nonprofits erroneously assume that the FTC’s jurisdiction does not capture any entity claiming tax-exempt status as a nonprofit. Given these comments, the Commission summarizes Commission precedent and judicial decisions construing the scope of the Commission’s jurisdiction as it relates to entities that claim tax-exempt status as nonprofits and to other entities that may or may not be organized to carry on business for their own profit or the profit of their members.

[…]

The Commission stresses, however, that both judicial decisions and Commission precedent recognize that not all entities claiming tax-exempt status as nonprofits fall outside the Commission’s jurisdiction.

See pages 50-54 of the final rule above for their argument regarding jurisdiction over nonprofits.

The only true exceptions to the ban are senior executives and the bona fide sale provision.

The press release is here.

If you have HBO Max, standup comic Alex Edelman’s one-man show was excellent. The official description of its main narrative thread: “In the wake of a string of anti–Semitic threats pointed in his direction online, standup comic Alex Edelman decides to go straight to the source; specifically, Queens, where he covertly attends a meeting of White Nationalists.” Here’s the trailer.

// 04.21.24

Dealing with a USMLE Failure

04.19.24 // Medicine

This post is for anyone who is lost and dejected after failing one of the Step exams.

§

First, I’m sorry that you’re going through this. The path to becoming a doctor is long and hard, but there’s something unique about high-stakes testing that adds stress and uncertainty.

I know this may sound a little odd/dramatic, but I think dealing with a big testing disappointment is ultimately the same as any other grieving process. The world today isn’t the world you wanted to live in, and it takes some time to bridge the gap between where you thought you were and where you currently are. The silver lining is that—unlike losing a loved one or a serious injury—you can still get back on the path.

At the same time, while it would be nice to get the failure notice and be able to immediately double down into an amazingly efficient targeted revision process for your next attempt, you’re also a human being. You’re a human being who deserves to grieve.

Maybe you won’t go through the classic stages of grief like denial, anger, bargaining, depression, and ultimately acceptance. But you might, and there’s nothing wrong with that. Just because there are so many worse things in the world doesn’t magically make this experience not suck. Don’t add insult to injury and beat yourself up for being acutely sad.

(On a related note, I think this would also be a good time to take a serious look at your media diet)

Once you have the timeline for your next attempt and know your school schedule, it’s time to be systematic about how to use that time effectively. That should absolutely include some time initially to reset psychologically. For a week or two, make specific time and force yourself to do some things that you enjoy and find centering. You need a less heavy heart to remember why you are on this pathway and why you’re willing to work hard to get to your destination. You can’t only punish yourself for this disappointment with things that rub salt in the wound.

Next, it’s time to analyze your current performance abilities for areas of weakness, both subject matter and testing approach (see below). It may be tempting to add a bunch of new resources or completely change how you study. In some cases that may be the right choice, particularly if you haven’t been incorporating enough questions or have never heard of spaced repetition, but for many people the answer is doubling down on a limited number of high-yield resources and not breadth. If you were close to passing, you probably don’t need to reinvent the wheel.

You do need to prioritize your mental and physical health (trite but true). Diet, exercise, and sleep are huge performance factors that you have a lot of control over.

The bottom line is that you are allowed to feel sad, and you’re allowed to mourn for the world where your pathway to becoming a doctor was smooth and straightforward and where you never need to question yourself or prepare a story for others. It’s something you can and absolutely will deal with, but there’s no reason to pretend that you don’t deserve to be bummed. That’s just toxic positivity. It does suck, and it is a bummer.

But you also need to believe that you will absolutely get past this. It’s a hurdle. And hurdles are meant to be overcome.

§

For further test-taking reading:

Radiology Micro Job Board

04.18.24 // Radiology

It’s recruitment season, the radiology job market is hot, and there’s a lot of corporate noise. I’m thinking of maybe starting the world’s smallest radiology job board right here, open exclusively to a limited handful of 100% independent private practices.

If your group is interested in advertising on this site (and also therefore supporting my writing), email me at ben@benwhite.com.

Recruitment is a big challenge. While the ACR subsequently addressed the issue I wrote about here, I originally had the idea because of this.

Relying on “A Guy”

04.08.24 // Miscellany

Incredible story briefly detailed in NYT’s “Did One Guy Just Stop a Huge Cyberattack?” by Kevin Roose:

In the cybersecurity world, a database engineer inadvertently finding a backdoor in a core Linux feature is a little like a bakery worker who smells a freshly baked loaf of bread, senses something is off and correctly deduces that someone has tampered with the entire global yeast supply. It’s the kind of intuition that requires years of experience and obsessive attention to detail, plus a healthy dose of luck.

This could have been an unmitigated disaster. So much of the world’s infrastructure relies on random individuals being generally good or exceptionally thoughtful, in this case, the diligence of some dude who describes himself as a “private person who just sits in front of the computer and hacks on code.”

But, on the darker side: Given the seemingly miraculous nature of this catch, what are the odds there aren’t other backdoors already in place in our key systems?

Show Your Work

04.04.24 // Writing

In Show Your Work, Austin Kleon argues “the best way to get started on the path to sharing your work is to think about what you want to learn, and make a commitment to learning it in front of others.” That’s what I’ve been doing since 2009.

One downside of Showing Your Work is when the showing of the work is the only work you do. I never set out to be a blogger (cringey moniker that it is). Not that there’s anything wrong with this site (I think it’s pretty good?), but it’s undeniably the lower-hanging fruit that I’ve been doing for 15 years while mostly not writing the books and stories I originally intended to write. We could call it productive procrastination.

Now that’s not entirely fair, because it turns out that I also like whatever this is. I like writing short, I always have—I edited a nanofiction literary journal for 14 years for heaven’s sake—and I like curating, sharing, teaching people, helping others, and yes, even being a curmudgeon when the situation calls.

Kleon quotes David Foster Wallace, who said that good nonfiction was like watching “somebody reasonably bright but also reasonably average pay far closer attention and think at far more length about all sorts of different stuff than most of us have a chance to in our daily lives.” Which is I think is both generous and true.

So, I wish more people had websites, took the time to have a position or make something to share/teach, and then put it online.

For anyone considering graduating from transient social media reactions to starting a site to show their work, this gem from Clary Shirky:

The stupidest possible creative act is still a creative act. On the spectrum of creative work, the difference between the mediocre and the good is vast. Mediocrity is, however, still on the spectrum; you can move from mediocre to good in increments. The real gap is between doing nothing and doing something.

Medicine is, on the whole, underserved in the public sphere by its physicians. And the field of radiology, which has made up a significant fraction of my writing over recent years, certainly deserves more independent perspectives online than mine and a handful of others.

Don’t be scared to start small and reduce the barrier to entry for yourself. You can curate more than you generate, as old tech writer Jeff Jarvis advised: “Do what you do best and link to the rest.” (Last year I even added a smaller post-style microblog here to encourage myself to share more.)

I’ve enjoyed writing in my little corner of the internet and have no intention of stopping.

But, maybe there will be another book soon.

Post-match Life Research

03.27.24 // Finance, Medicine

Post-match fourth year is a great usually “less-stressful” time to get your required education in personal finance. My free book is a nice, readable, and to-the-point primer on the essentials of personal finance including student loans. Read (or download it) here. Note that the new SAVE plan has simplified the student loan part for the majority of borrowers going forward.

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Not everyone should try to buy a house during residency. With the recent housing boom and higher interest rates, home ownership is probably out of reach for a larger proportion of residents than at any other time in recent history.

But, if you are considering trying to buy a home as a trainee, you’re likely going to need a physician mortgage. One quick way to get your feelers out to several potential companies at once is LeverageRx, a totally free handy platform that will let you rapidly comparison shop multiple physician loan lenders.

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Senior medical students are also eligible to try to lock in their eligibility for disability insurance. Disability insurance isn’t cheap—and you may not be able to afford it on your current budget—but again this is a great time to at least learn about it and price out some options and see. A small ~$2k/mo benefit medical student policy will often cost in the $40-60/mo range and will lock in future insurability. The folks at LeverageRx and Pattern both offer a great no-cost no-commitment way to see what your choices look like.

It’s always good to price out different options through different agents, and it’s possible the discounts available through your medical school affiliation are better than the ones you’ll have access to as a resident. Also, you’re unlikely to get younger and healthier. It’s worth doing some due diligence.

Life insurance, on the other hand, is straightforward: if you have a spouse or dependents that are relying on you, you need term life insurance.

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(Those are both affiliate links, which means that using them supports this site at no cost to you. My aging book is just free, no strings attached.)