MedPod Today: Are MA ‘Extras’ Used? USMLE Cheating Scandal; Keto for Mental Health

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody, welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insights into the week’s biggest healthcare stories. I’m Rachael Robertson, your host for this episode.

Today we’re talking with Cheryl Clark about whether people actually use their Medicare Advantage benefits. Then I’m going to talk about the recent cheating scandal and the class action lawsuit that came out of it related to the USMLE exam. Then Jennifer Henderson shares her reporting on how the ketogenic diet might have some surprising uses for treating mental health conditions.

Let’s get into it.

You know the TV ads for Medicare Advantage plans with “extra benefits” — like transportation, home-delivered meals, dental coverage, and even cash cards to use at the drugstore. Now a new survey raises questions about the value those extra benefits really have. Reporter Cheryl Clark is here to tell us more.

Cheryl, what did the survey actually find? Were there any surprising results?

Cheryl Clark: Well, yeah, Rachael, I’ve always wondered whether Medicare Advantage enrollees actually use those extra benefits. And this survey commissioned by the Commonwealth Fund provides some answers. It appears that while those benefits are big selling points for the plans — like vision, hearing, and dental care or cash for over-the-counter medications — get this: one-third of Medicare Advantage patients surveyed hadn’t used any benefits in the last year!

Also, the survey asked almost 3,300 people who were either enrolled in MA or traditional Medicare, what they valued about their coverage. And there were some real surprises. One might assume that Medicare Advantage enrollees were more satisfied because they got better care coordination or access to better services/more services. In fact, the responses were about equal except that more Medicare Advantage enrollees reported longer delays in getting care. And this is important because MA plans get nearly $2,000 more per patient each year than Medicare spends for traditional Medicare beneficiaries. So this raises questions about whether that extra spending is really worth it.

Robertson: What did the survey find about extra benefits?

Clark: Well, for dental care, 58% hadn’t used their benefit in the past year, 59% hadn’t used vision benefits, like eyeglasses, and 93% hadn’t used their hearing benefit. It really surprised me that 81% hadn’t used their gym membership. And 54% didn’t use their allowance for over-the-counter drugs.

Robertson: So a lot of these advertised benefits just go unused by beneficiaries. You had another story this week about the Medicare enrollment window and deadline. How does that fit in?

Clark: So every year between January 1 and March 31, people who are already in Medicare Advantage plans have a window in which they can switch to another Medicare Advantage plan, maybe to get a different doctor or a new provider network – and we’re in that window now.

But studies done in past years say that people just don’t check those benefits. This year it’s especially important and here’s why: we know that the Centers for Medicare and Medicaid Services is trying to limit how much MA plans received per month to take care of their enrollees. And there is some sense the plans are trying to gird themselves by cutting back some of those benefits. That means higher co-pays for services like imaging or a visit to the doctor. The problem is, every plan is different. The benefits offered can be different and the changes can be different. And that’s why beneficiaries are strongly urged to check to see if their benefits have changed. Sometimes the doctor is no longer in network — the patient shows up for a regular appointment, and is told she has to pay out-of-pocket or go home and get an appointment with a different doctor. And it’s a huge hassle. So this year and next, it’s especially important to check.

Robertson: Thank you so much for this report, Cheryl.

Clark: Thank you, Rachael.

Robertson: MedPage Today reporter Sophie Putka is going to take the host seat for this next segment.

Sophie Putka: The U.S. Medical Licensing Examination scores for some Nepali applicants were invalidated following a National Board of Medical Examiners (NBME) investigation. That investigation revealed a pattern of suspicious test results mostly from Nepal. One of the applicants whose score was invalidated filed a class action lawsuit against the NBME. Rachael will tell us the latest updates on this topic.

So Rachael, fill us in on what has happened since the USMLE announced that some people’s scores would be invalidated. Has that actually happened yet?

Robertson: It did — and we finally know the scope. The scores for one or more levels of the USMLE were invalidated for 832 Nepali medical graduates. Before, we only knew that this was less than 1% of test takers, not the actual number. The USMLE said in a statement that “highly irregular patterns can be indicative of prior unauthorized access to secure exam content.”

I spoke with Bryan Carmody, MD, who’s been following the scandal pretty closely. He told me that he’s heard about “recalls” for years — where people take the test and then they write down as much as they can remember afterwards and then sell it online. A quick Google search turns up plenty of these for sale for sometimes hundreds of dollars.

So after the USMLE sent out all of this information, people whose scores were invalidated had until February 16 to do one of three things: they could ask the NBME to reconsider its decision, which could take up to 10 weeks, they could retake the test, or they could do nothing. If they chose either of the first two options, they waived their right to sue the NBME. After this announcement, one of the examinees, who had all three of her scores invalidated, well, she sued the NBME.

Putka: What does the lawsuit against NBME allege?

Robertson: The lawsuit alleges that the NBME didn’t follow previously established procedures when invalidating scores, which usually allows people to appeal before a final decision is reached. It also claims that the NBME violated the Civil Rights Act for singling out Nepali test takers based on national origin. The case moved pretty quickly, and it needed to, because the decision determined whether or not she and the others could move forward with the Match or whatever other stage of the process they were in. But the district judge denied the emergency motion to restore USMLE score validity for the 832 Nepali medical graduates. So their scores remain invalid.

Putka: Did the lawsuit reveal any more information about the situation?

Robertson: Yeah, so the lawsuit revealed a few things. We now know that the NBME has examined some data from other countries too, including Jordan, Pakistan, and India. And we also know a little bit more about how the NBME found this pattern of suspicious results. In one of the court documents, there’s a chart that shows how Nepal scored significantly higher on USMLE compared to all other countries. In other court documents, they detail how someone on behalf of USMLE was actually able to “gain access to an exclusive online Telegram Messenger group in which USMLE exams are discussed, with approximately 1,300 members.” Telegram is a social media platform. They posted some of these screenshots of this Telegram group as well as messages telling test takers not to leave the exam too early, and thus raise attention. All of these are available in the court documents.

Carmody pointed out on Twitter that the plaintiff’s scores weren’t particularly outstanding. But the court documents do show that her score times were unusual on certain questions. Questions that typically take like 90 seconds to respond, only took her 20 to 30. And she had really high accuracy on these questions. Her legal team maintains that she did not cheat and she studied hard to achieve her scores. There is still a lot we don’t know, especially about the people whose scores were invalidated who are already in residency. I’m sure we’re gonna have updates later down the road.

Putka: That’s wild news. Thanks, Rachael.

Robertson: The ketogenic diet has long been known for its use in treatment-resistant epilepsy. But attention is now turning to its potential benefits in mental illness as well. Experts are wondering whether something as simple as a diet could actually improve notoriously difficult-to-treat conditions, like major depressive disorder, bipolar disorder, and schizophrenia. Jennifer Henderson is here to tell us more.

So Jennifer, what is the overall state of research? Could you remind us what the ketogenic diet is?

Jennifer Henderson: So ketogenic diets vary, but typically focus on high fat and low carb intake. The evidence to date has been less rigorous than gold-standard randomized controlled trials, but new studies are underway, and more clinicians are keen to explore reports of patients whose psychiatric conditions improved when they adhered to a ketogenic diet.

Drew Ramsey, MD, a nutritional psychiatrist and member of the American Psychiatric Association told me this: “There have to be randomized trials before we can make enthusiastic and evidence-based treatment recommendations. That said, I’m hopeful and optimistic that patients are going to have more tools to treat their mental health disorders.”

Robertson: So has there been any recent research?

Henderson: Yes, there has. Georgia Ede, MD, a nutritional psychiatrist based in Massachusetts, told me that the body of research is very much beginning to grow. Ede co-authored a French study published in Frontiers in Psychiatry in 2022. More than 40% of patients experienced remission from their diagnosis, Ede noted, and 64% left the hospital on less psychiatric medication than when they entered.

Among other recent research, a feasibility pilot study of the ketogenic diet and bipolar disorder was recently completed in the U.K. Findings from this study were published in BJPsych Open last October showed that of 27 participants, 20 completed 6 to 8 weeks of the ketogenic diet. A majority of participants reached and maintained ketosis, indicating adherence to the diet, and adverse events were generally mild and modifiable, the researchers found. The National Institute of Mental Health also pointed me to two trials that it is supporting and an investigation of the effects of the ketogenic diet on mental illness, one led by researchers based in Maryland and another by a team in California.

Robertson: Okay, so those results sound pretty promising. But what are the challenges?

Henderson: Deanna Kelly, PharmD, of the Maryland Psychiatric Research Center, who is leading an inpatient randomized controlled trial of a gluten-free diet in a subgroup of people with schizophrenia, said that securing federal funding can be difficult — in part because of the need to show targets of engagement. Kelly, whose team is one of those being supported by the National Institute of Mental Health, also pointed to added costs for inpatient stays during clinical trials and the lack of pharmaceutical funding for dietary interventions as potential hurdles for researchers.

Mackenzie Cervenka, MD, medical director of the Adult Epilepsy Diet Center at Johns Hopkins Hospital in Baltimore, and a member of the American Epilepsy Society, said that it’s also important to remember that there can be long-term side effects of the diet. She noted that short-term studies “might not be sufficient to indicate what the benefits could be in real-world applications.” And nutritional psychiatrist Ramsey cautioned that “not everything works for everybody.”

In the meantime, more research will certainly help to better understand the relationship between the ketogenic diet and mental health.

Robertson: Thank you so much, Jennifer.

Henderson: Thanks, Rachael.

Robertson: And that’s it for today. If you like what you heard, leave us a review wherever you listen to podcasts (on Apple or Spotify), and please hit subscribe if you haven’t already. We’ll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were MedPage Today reporters Cheryl Clark, Rachael Robertson, and Jennifer Henderson, with guest host Sophie Putka. Links to their stories are in the show notes. MedPod Today is a production of MedPage Today. For more information about the show, check out medpagetoday.com/podcasts.

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