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I'm going to tell you 3 college GPA's, and not give you any context. I want you to look at each for a bit longer than usual and remember (or write down) your reactions to each number:3.863.503.36Done?If you're like most people, you automatically assumed the highest GPA was the best.But what if I told you the 3.86 came from a state party-school with rampant grade-inflation, the 3.50 came from Harvard (which is an excellent school for graduate and professional studies- but actually doesn’t live up to many undergrads’ expectations, and is known for its grade-inflation), and the 3.36 came from Cornell or Princeton (both of which have incredibly hard academics, and Cornell has particularly harsh grading- in fact a 3.36 was the last published median, a few years before I graduated…)Would THAT information change your assessment of those GPA's? It should. In reality, all three GPA's are probably about equal after accounting for the context- but the GPA from the party school is most impressive in isolation.Medical school admissions processes typically screen GPA's below a certain number long before they are ever viewed by the admissions committee. Many schools might screen Cornell or Princeton grads with a 3.36 without ever taking a closer look at their applications, for instance. Therefore, for many applicants, the hardest part about getting into medical school is simply getting past the initial screen.The way applicants are screened by GPA right now in US medical school admissions is highly suboptimal, and cuts many good applicants while allowing many sub-par applicants to take up valuable interview slots.Yet it persists because it has institutional inertia, and because the people who RUN medical schools (the not-so-beloved administrators) can make it look, ON PAPER, like they are doing a great job of attracting top applicants when the average GPA for the incoming class goes up (even if in reality this just means the medical school is showing greater favor to applicants from schools with more grade-inflation), and conversely, they would look bad if the average GPA went down on their watch (even if this meant the school was better accounting for grade-inflation in their admissions, and actually selecting BETTER applicants for the incoming class…)This is, of course, the natural result of attempting to run medical schools like businesses. This insidious cancer that everything should be run “like a business”, and that for-profit corporations are clearly the best model for how the rest of society should be run has, unfortunately, crept even into medicine.In running a medical school that business mindset translates into hiring management based on their ability to maximize a set of arbitrarily-defined criteria: instead of profit and Return On Investment, with medical schools that becomes average GPA's and medical school rankings (which are, stupidly, based heavily off of average incoming GPA's and created by people with no actual medical expertise…)A business mindset has no place in medicine. Doctors are not businessmen or entrepreneurs- they are skilled and caring practitioners in the arts of healing. Anybody who wishes to treat medicine like a business has no place in medicine- and yet this has ironically become the dominant mindset in many medical school and hospital administrations…One can't change the weather, and rebelling against the machine is often a recipe for disaster- so though I write scathingly about this problem, I myself hope to someday become a doctor and participate in the politics of how medicine is administrated.The best way to fix a broken system is sometimes from the inside- by “playing the game” and holding true to your values, yet applying persistent and gentle pressure to move things in the right direction. Many doctors don't participate in American Medical Association discussions and conferences about the future of medicine and the next generation of doctors, for instance- discussions I plan to be reasonably active in if I should ever become a doctor…I advise anyone reading this who is thinking of making a scene or planning drastic action to practice similar restraint.For all the problems in medical school admissions, the body of doctors still hold the real power in how medical schools are run- and most of them are caring and involved people who are simply unaware of the problems that are festering in admissions- having much greater challenges to deal with in treating their patients and taking advantage of new 21st-century technologies to advance the art of medicine.Even the politics of Obamacare, Medicaid and Medicare funding (the last of which heavily determines the number of residency slots- and indirectly the number of medical school class slots as a result) take much higher priority on most of their lists than whether the criteria medical school applicants are chosen by have become somewhat arbitrary, and of poor accuracy in predicting success in medicine.The hardest part of getting into medical school is, for many applicants, simply getting past the filters that would unfairly disqualify them from a career in medicine.Applicants take many approaches to this problem- from giving up, to doing something exceptional (like serving in the Peace Corps) that they believe might give them a chance to get drawn out of the main stream of applicants for special consideration even before hitting the filters.Others simply play the game- and go back to school for a PostBacc or 1-year Master's in “medical science” (programs that rarely provide much in Financial Aid- and by that I mean grants or scholarships rather than loans- and often charge exorbitant tuitions— essentially the exclusive reserve of the children of wealthy and generous Upper and Upper-Middle Class parents who are willing to pay for their children to obtain these advantages, or students who are willing to spend the rest of their life in debt to become a doctor)— programs that are usually designed either to help applicants buff their GPA's, or as a backdoor to medical school admissions far more accessible to the children of the rich…Either way, the American system of medical school admissions is unfair, suboptimal, and badly in need of improvement before it eats away further at the very foundations of our medical system- the quality of staff who care for patients…But it is also, it should be remembered, a system that is *trying* to do the right thing. That it has become as twisted as it has. and ruins the dreams of so many applicants who aren't rich (so they can't afford a post-bacc or a MMS program) and simply happened to go to a school with little or no grade-inflation, is at least as much (and likely far more) a result of trying to make the system more meritocratic (and, ironically, actually making it less) and a misguided American instinct to model systems after corporations, as it is a result of any kind of greed or self-interest on the part of a handful of medical school administrators or anything so cynical as that…So, to answer the question, the hardest part of getting into medical school is often simply getting to the point where human eyes read your packet (which only comes after a set of automatic filters based on GPA, MCAT scores, etc.) After that it's simply a matter of letting one's passion for medicine shine in the essay and the interview…

What happens if you refuse to pay social security?Pretty much nothing if you have an exempt status which you can get! The “Old Order Amish” and possibly other Amish sects do not pay social security. They were granted “exempt” status. Here’s an explanation.Taxation Tidbit The Amish – Social Security and Medicare Taxes Parman R. Green, MU Extension Ag Business Mgmt. Specialist Some religious groups including the Amish do not believe in commercial insurance because it is seen as not trusting in God and additionally, they believe in “taking care of their own”. While the Amish believe in “render unto Caesar what is Caesar’s”, they objected to paying into Social Security’s “Old Age, Survivors, and Disability Insurance”. While the government initially argued this was just another tax – they later admitted it was not. In 1965 when the Medicare bill was enacted – the Old Order Amish and other religious sects who conscientiously objected to insurance, were exempted from paying Social Security and Medicare taxes, provided the sect had been in existence since December 31, 1950. With the exception of Social Security and Medicare taxes, members of these religious sects pay the same income, property, sales, and other taxes as everyone else. In order to be exempt from Social Security and Medicare taxes, a member of these sects must obtain a Social Security number and file Form 4029 – Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits. This application when approved – waives all rights to receive any Social Security benefits for the filer and anyone else who might have been eligible to receive benefits on the filer’s Social Security record. This exemption from Social Security and Medicare taxes is applicable for self-employment income and wages. However, for wages to be exempt, both the employer and employee must have approved Form 4029 exemptions. Thus, wages paid to an Amish employee by an employer who is not a member of the sect would be subject to Social Security and Medicare withholdings.

The American health care industry wastes $1T by some estimates, and possibly as much as 30% of health care spending by others. US health care expenditures are twice the OECD average – for instance, we spend twice what the UK does on health care (as a percentage of GDP) – and American health care costs are growing at 5% a year.Healthcare presents one of the greatest policy challenges for our country because profit incentives and care for the patient are often misaligned. It’s clear that the government is going to play some role in making sure the least well-off Americans have access to medicine, but we need healthcare policies that incentivize providers and payors to educate patients to make informed, data-driven choices. Only intelligent consumer choice will stimulate functioning, competitive markets in insurance, patient care, the pharmaceutical industry, and elsewhere. Today, pharmaceutical companies, health providers, electronic health record (EHR) systems, and other actors often have misaligned incentives and fail to enable more efficient solutions that do more for the patient per dollar - indeed, often the winners in these areas are those that unnecessarily charge more. Aligning incentives will spur top technology startups to develop innovative healthcare solutions, bring down costs, and deliver superior outcomes to American patients. Here are a few necessary reforms:Medical SchoolsExperts project a total physician shortfall of between 42,600 and 121,300 by 2030.* We need more medical schools fast, but the Liaison Committee on Medical Education accreditation process takes 8 years on average and most states require new medical schools to obtain a “certificate of need” before beginning construction. In addition, medical schools are required to sustain the high overhead of medical research rather than focusing exclusively on training doctors, and inflexible requirements prevent medical schools from experimenting with new curricula. Organic chemistry and other undergraduate prerequisites are completely irrelevant to becoming a good practicing doctor, and should be optional.High medical school costs force students to become high-earning specialists, e.g. plastic and orthopedic surgeons, when our country really needs more primary care physicians (PCPs). Primary care physicians, nurse practitioners, and physician’s assistants are far cheaper than specialists, but limited medical school and residency supply as well as occupational licensing concerns keep them out of the market. In addition, foreign doctors are almost always required to complete a full residency before being allowed to practice in the United States. Given a current skills gap of 30,000 doctors, adding 30,000 new PCPs, nurse practitioners, or physicians assistants could save $2.3B, $5.1B, or $6B in salary costs alone relative to the current mix of specialists and primary care doctors.In addition, primary care doctors achieve better health outcomes for patients than specialists by engaging in long-term counselling, tracking, and preventive care. Scholars estimate that replacing specialists with primary care physicians at a density of 1 per 10,000 population could save $931 per beneficiary a year. Adding a supply of 30,000 primary care physicians would save our country about $150-200B a year.*If implemented correctly, data-driven telemedicine can ameliorate demand for physicians somewhat. Doctors should be able to digitally prescribe most drugs, and data from increasingly sophisticated wearables will enable physicians to swiftly and efficiently diagnose patients.Reform PBMsIn 2017 the Centers for Medicare and Medicaid Services (CMS) spent $175B on prescription drugs alone, and there are currently shortages of vital drugs across the country. An oligopoly of Pharmacy Benefit Managers (PBMs) generates $200B a year in revenue by forcing drug manufacturers to pay rebates and other kickbacks in order for the PBM to place their drug on the “formulary”, or list of insurable drugs. Securing a place on the formulary is a matter of life and death for manufacturers, and by one estimate the current value of rebates and other price concessions from manufacturers to PBMs increased from $59B in 2012 to $127B in 2016.After speaking extensively with politicians on both sides, we were thrilled to see the Senate recently outlaw PBM “gag-orders” on pharmacies by a 98-2 vote. We are encouraged to see that Alex Azar’s Department of Health and Human Services (HHS) is planning to subject PBM rebates to anti-kickback law, but we would go further and require full price transparency on PBM contracts in the style of Colorado HB 1260. Although some rebate money flows to insurers, we estimate that reforming the space could save America on the order of $50B.End of Life Palliative CareAlthough discredited by hyperbolic language about “death panels”, counselling patients at end-of-life is both cost-effective and humane. 30% of Medicare expenditures are attributable to 5% of beneficiaries who die each year, and acute care in the final 30 days of life accounts for 78% of the costs incurred in the final year of life. While acute-care for the dying should obviously be available to those who want it, our country must shift to a model of counselling and palliative care at the end of life.Just having an end of life discussion with the cancer patient reduces medical costs by 35.7% on average, and given that there are roughly 600,000 cancer deaths in the United States a year, would have saved $687M a year for cancer patients in the last week of life alone! In addition accountable care organizations (ACOs) have saved $12,000 per patient during the final three months of life by implementing home-based palliative care. If extended to all cancer, end stage renal disease, and congestive heart failure patients this program could save the country $11.7B a year.We all agree that we must treat families of the dying with delicacy and compassion. But introducing a program by which families will share in Medicare/Medicaid savings from palliative care would help families and patients factor the overall social cost of end-of-life care into their decision calculus. We estimate that extending proven programs and testing different incentives structures could save our country $30-50B a year.FDA ReformClinical trials are an arduous multi-year process and have become drastically more costly in the last 30 years. Phase II and III efficacy trials cost roughly $400M per new drug, which severely limits the number of drugs that make it to the final stage of Food and Drug Administration (FDA) approval. A “progressive approval” approach would allow drugs to be repurposed for other uses and possibly sold after passing Phase I safety trials, which establish that a drug has a favorable risk balance and qualifies as value-based care. Drug companies could gradually establish efficacy by logging the effects the drug has on each person who opts to use it over the next several years.The extreme costs of clinical trials and FDA approval not only stymie drug development and the application of treatments to new indications, they effectively privilege Big Pharma over other innovators, inhibiting innovation and medical progress. A data-driven approach in which doctors and hospitals verify drug efficacy over time would allow the FDA to concentrate its resources on ensuring safety, particularly as the market for new drugs becomes sophisticated at assimilating information from the progressive approval process. While ramping up the number of drugs approved may not save our healthcare system money on net, a framework which encourages innovation will positively impact millions of lives by improving quality of care.Give Medicare Negotiating PowerTo pass the Affordable Care Act (ACA), the Obama Administration made a critical concession: Medicare would not be able to negotiate the price of drugs by controlling which drugs make it onto Medicare’s formulary. As a consequence, our federal government is a “price taker” that must blindly accept whatever prices drug companies demand, and the American government winds up subsidizing drug development costs for the rest of the world. Drug prices at home are extremely high, representing 10% of total healthcare expenditures, and about $144B of federal healthcare spending.In many other developed countries, governments use their monopsony or near-monopsony buying power to force pharmaceutical companies to sell drugs at much cheaper rates. For instance, Canada spends 70% of what the US spends on brand name drugs, the UK 40% of what we spend, and Denmark only 35%. If the US federal government used its considerably larger “countervailing power” to negotiate reduced drug prices – whether on a case by case basis or by pegging the value of a Quality Adjusted Life Year at a generous but fixed rate - savings could be in the range of $30-40B, possibly even as high as $90B a year.Pharmaceutical industry lobbyists (PhRMA) argue that high drug prices are necessary to stimulate R&D which generates many new life saving drugs every year. But in fact, median R&D spending on new cancer drugs – the most difficult to develop – is only around 40% of total revenue. In addition, most R&D is funded by American universities, and manufacturers of silver-bullet specialty drugs could continue to charge high prices to a federal payor. Giving government negotiating power isn’t a novel solution, but it’s one of the correct solutions to driving down drug costs for Americans.Tort LawThe threat of malpractice lawsuits forces doctors to engage in costly defensive medicine. Although the current administration has made some progress on tort reform (making arbitration legal for federal contractors and nursing homes), Congress must insist on Texas-style reforms including capped punitive and noneconomic damages from healthcare providers, eliminating contingency fees for speculative tort lawyers, reinforced federal preemption doctrine for food and drug products, and more. Unfortunately the trial lawyers lobby – one of the biggest political donors in the country – will fight reform at every step of the way.Some studies estimate that reducing physician malpractice fears to “somewhat concerned” about malpractice would decrease costs by 14%, saving the country $100B a year. Others argue that medical liability reform could save our country up to $210B a year. Congress must protect our doctors from being attacked by unscrupulous prosecutors in order to reduce the cost of healthcare for American citizens. We all agree that we must insist on protecting patients, but unchecked tort lawsuits just punish American patients and taxpayers with an unaffordable system.Data InteroperabilityThe ACA’s “meaningful use” requirements did little to make healthcare data accessible. As of 2015, only 6% of health care providers could share patient data with other clinicians who use an EHR system different from their own. Although 21st Century Cures Act made “information blocking” illegal, big EHR vendors routinely prevent their competitors from importing patient data by disclosing health records in garbled, incoherent formats. As a result, physicians are unable to make fully informed decisions about their patients.Judy Faulkner, CEO of EPIC, famously condescended then Vice-President Biden, “Why do you want your medical records? They’re a thousand pages of which you understand 10.” The answer is that only real, semantic interoperability which makes health data available to third parties via and open application programming interface (API) will allow an innovation ecosystem of apps, medical devices, and novel insurance plans to flourish. Granular, transparent healthcare data will allow entrepreneurs – whether college students or IBM executives – to invent new solutions from the bottom up and swiftly incorporate best practices into their businesses. In addition, direct service-to-service comparisons will allow consumers to make informed decisions about how to stay healthy, stimulating market competition for their dollars.We have been excited to see CMS’s Blue Button 2.0 API program formalize the Fast Healthcare Interoperability Resources (FHIR) standard for health records, which includes programmer resources, a complete API, and gives beneficiaries full control over their data – but EHR providers are refusing to use it. While any EHR system should ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) by storing protected health information on secure servers, we need to make interoperability truly mandatory.If patients could easily share their medical records with new providers and selectively reveal their data to health apps, fitness devices, diagnostic companies, insurers, and academic researchers, our entire healthcare industry would become hugely more affordable and effective. Reliable, real-time information about which treatments work, which failed, and what they cost will enable hospitals to identify and minimize cost centers as they strive to produce care more cheaply than federal benchmarks and share in the savings.Financing ReformOvertreatment and poor physician incentives may be the main driver of health care costs. Most hospital networks are local monopolies with limited incentives to innovate or save money. Replacing this broken system with value-based care models will immediately save over $100B in total, and should grow steadily over time to $200-300B as doctors harness digital technology interventions and other new techniques to make care cheaper and more effective. We break down a few potential sources of savings below:Bundled PaymentsThe Bundled Payment Care Initiative (“BPCI”) introduced in 2013 shows serious promise in making acute care clinical workflows more efficient, particularly in orthopedic care and oncology. Results continue to improve as providers adapt to the program.After adopting a bundled payment model, the NYU Medical center reduced costs to Medicare by 10% and reduced patient stays by 25% for total hip arthroplasty procedures, and a private practice joint arthroplasty generated 20% savings for CMS per episode while decreasing readmissions. The Congressional Budget Office estimates that a voluntary bundled payments system could save Medicare $6.6B a year. If CMS makes bundled payments mandatory for both Medicare and Medicaid, achieves health record interoperability, and allows the ecosystem to iterate on data-driven incentives, we expect savings to surpass $100B.Accountable Care OrganizationsACOs are widely seen as the Affordable Care Act’s main instrument to rein in health care spending, and ultimately we expect that bundled payments will be folded into a broader ACO model. To date ACOs have generated modest savings on average, but some, such as the Memorial-Hermann ACO, have generated 11% savings for Medicare. ACO contracts are more efficient if they involve two-sided risk (rewards for savings, penalties for overages), but studies have shown that even early versions of upside-risk only ACOs are associated with a 3% reduction in Medicare reimbursement. In addition, Medicare ACOs have improved quality measures across the board, despite their old, sickly populations.Provider networks are still adjusting to the ACO model, and returns will increase in the future. Projecting savings at 5-10% and assume that all Medicare beneficiaries are enrolled in ACO providers, ACOs would save Medicare $30-60B a year. If extended to Medicare and Medicaid, full ACO enrollment could generate between $56-112B a year.Preventive MedicineThe ACA now mandates coverage for all evidence-based prevention in non-grandfathered plans, so preventative screening and vaccinations have increased since the advent of Obamacare. However we need to drastically increase the scope of preventive medicine under the aegis of value-based care. Preventable chronic diseases are 7 of 10 top causes of death in the country, and account for 75% of health care costs. Half of American adults have chronic disease, and surprisingly, chronic illness among those younger than 65 years accounts for 67% of total medical spending. 70% of American adults are overweight, and 1 in 3 American kids and teens is overweight or obese. Prevalence of obesity has tripled since 1971.Some of the most cost-effective, successful preventive health interventions include childhood immunization, youth and adult tobacco counselling, alcoholism interventions, aspirin use for people with heart disease, and screenings for common cancers, STDs, and chronic conditions like hypertension. Evidence suggests that many other preventive health interventions are cost-neutral or increase long-term medical costs (because they extend lifespans). However critics often miss the fact that preventive health measures will extend the working careers of Americans, and pay for themselves in the long-run.In kidney care, for example, the federal government subsidizes extremely costly dialysis treatments for end stage renal disease patients but has not crafted incentives to perform preventative treatments before a patient advances to this critical, debilitating condition. Rather than fill the coffers of the corrupt duopoly that runs the dialysis industry, we should give providers incentives to halt the progression of kidney disease in its tracks. As a country we spend $42B on hemodialysis. Just getting prevention right here could save our system north of $10B a year.ConclusionFixing our sprawling, tangled healthcare system is one of our nation’s greatest policy challenges. In the coming years, America should move swiftly to embrace value-based care models which align market incentives to produce a wealth of patient data and an ecosystem of new information technologies geared at preventive treatment. At the same time, we must address specific areas where poor incentives have throttled the production and delivery of medical services. Replacing bureaucratic mandates with proven Western values of entrepreneurial innovation and educated individual decision-making will yield better patient experiences and results for Americans from every walk of life while saving our country $600-$900B annually – a transformative amount of money for the well-being of our nation.