Dr. Seth Trueger: When the Doctor Becomes a Patient (Health & Veritas Ep. 37)

On the Health & Veritas podcast, Yale physician-professors Howard Forman and Harlan Krumholz talk about the latest news and ideas in healthcare and seek out the truth amid the noise. In the latest episode, they’re joined by Dr. Seth Trueger of Northwestern University, who was diagnosed with a rare autoimmune disorder in 2020. They discuss his experience navigating the healthcare system as a patient and what he’s learned about the challenges facing people with complex medical issues.

Howard P. Forman
Professor of Radiology and Biomedical Imaging, Economics, Public Health, and Management; Co-founder, Pozen-Commonwealth Fund Fellowship in Health Equity Leadership, MD/MBA Program, and MBA for Executives Program
Harlan M. Krumholz
Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation
Seth Trueger
Associate Professor of Emergency Medicine, Northwestern University Feinberg School of Medicine

June 09, 2022

Listen now:

Links

2022 Medicare Trustees Report

“A Cancer Trial’s Unexpected Result: Remission in Every Patient”

“PD-1 Blockade in Mismatch Repair–Deficient, Locally Advanced Rectal Cancer”

Seth Trueger: “The Best Bad News”

“Public Finance Balance of Smoking in the Czech Republic”

Learn more about the MBA for Executives program at the Yale School of Management.

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TRANSCRIPT

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Seth Trueger, a emergency physician and associate professor at Northwestern University. But first, we like to check in on current health news. Harlan, what has got your attention?

Harlan Krumholz: Well, there are a couple things got my attention this week. But first of all, I want to say how happy I am that we’re having Seth on today. I think people will enjoy hearing what he has to say, and his journey as a patient, as a doctor, and as a, really, social media influencer. It’s really great that he’s joining us. So there were just three things I wanted to point out, two things quickly and then one, I thought I would just spend a little bit of extra time on. One is, can’t resist just mentioning something about COVID. So almost everyone I know now seems to have come down with COVID. But the good news is that the deaths keep declining. And if you really look at the worldwide deaths from COVID, we’re still on a trajectory towards lower and lower. We’re above, of course, the time when it began.

But if you look at the seven-day rolling average from lots of different sources, it’s good news. So these variants seem to be more highly transmissible between, again, the way we’ve changed, having been prior infections or vaccinations, and with the treatments, the death rates continue low. It doesn’t mean that we need to stop our vigilance, but it’s good news. And I thought, I at least would celebrate it. The deaths seem to be declining.

There’s another piece that came out this week that caught my attention around COVID that I thought was so interesting, and it has associated with it a little tidbit that people might like to know. And that is we’ve been focusing more in science and in medicine about the power of the circadian rhythm and how the times you may take medications or the times that you get a vaccine may actually affect how well you respond to these things. And a group put out a paper that was quite interesting, that looked at, in essence, the benefits of morning vaccination compared with afternoon and evening vaccination. And this one—so interesting because they looked at lots of different aspects of the immune response. They looked at antibody levels. They looked at the chemicals that are released by the immune system, called cytokines. They looked at the B and T cell responses—these are lymphocytes that are involved in defending the body. And they looked at the percentage of monocytes.

Anyway, a whole range of things that they looked at. And in almost every case, people who got vaccinated earlier—and this was either, by the way, they looked at more than one vaccine. They looked at tuberculosis vaccine; they looked at influenza vaccine; they looked at SARS. They were pulling together the evidence in the literature. And getting vaccinated before, say, 11 o’clock in the morning compared to 3 to 5 in the afternoon or 6 o’clock, in one case, you had a better response, immune response. Now this wasn’t measuring, “Did people survive more?,” “Did it protect them against disease?,” because they were basically just looking at how the immune system responded. I just thought this was fascinating. And it was enough to say that if I get another vaccine, I’m going to schedule it in the morning.

Howard Forman: Yeah. We have so many questions still to answer, but that’s fascinating.

Harlan Krumholz: There’s so much to learn. So I’m going to say one more thing that came up that I thought was really interesting. This is the week when the cancer society has their big meeting, it’s called ASCO. And in this meeting, they pull together a lot of big things that are going on in science. And one of the papers that came out, it was just amazing, and you may have even seen it reported in the newspaper. But it was a study of only 12 patients came out of Sloan Kettering in New York where they took people who had advanced rectal cancer. Now, this is a pretty tough diagnosis, and it’s one that usually requires people to have chemotherapy and radiation followed by surgical resection, and there are a lot of complications associated with it. Even if it’s successful in helping with the cancer, people are often left with problems subsequently.

And what they did was they found that they could use molecular mechanisms to identify a certain type of rectal cancer, this is called mismatch repair deficiency. It’s where there are mutational changes in certain genes that are having trouble correcting mistakes in the DNA. But for listeners, it’s just a certain type of all the rectal cancers. And then what they did was, they’re able to take these medications that have been evolving over recent years, they’re called immune checkpoint inhibitors. And what they do is, the body has ways to protect itself against the immune system, sort of friendly fire, causing problems of our normal organs. And we have signals on cells that tell the immune system, “Hey, this is yourself. Don’t attack me.” And what we’ve been able to do is kind of change that in cancer cells so that the immune system of the body can see it as foreign, not self.

And if you use that kind of approach in this kind of rectal cancer, all of these people ended up having remarkable responses to the point where they’re thinking they don’t even need additional chemotherapy or radiation therapy or surgery at this point. And it was almost a miraculous finding. It’s a small number of people. No one knows what’s going to happen long term, but it gives me a lot of hope. When I start seeing situations where we’re characterizing the cancers to a very specific extent using molecular assays, using molecular testing, and then we’re matching it with treatments. It seemed to be perfect for that problem, and it may be in the future that we’re going to be in a situation where we can be much more successful in treating cancers because of this kind of matching.

So that was my third thing. It made me feel happy. So only 12 patients, it’s just the beginning, but it’s a proof of concept about this that should bear out. We’ve seen it in others, by the way. It’s not the first time. But now we’re starting to see it spread more, this kind of matching, and we’re in the midst of a revolution about this. But this one was nice because rectal cancer, advanced rectal cancer, can be very hard to treat.

Howard Forman: Oh my God, yeah. I saw that this morning, and Gina Kolata has a really good review of it in the New York Times. You’re talking about the difference between people living a completely different life and potentially being fully cured. It’s a huge leap. And even if it’s half as good as it sounds, it’s a major step forward.

Harlan Krumholz: Yeah. It’s something to feel good about in medicine. And like I said, there have been other situations where this matching has occurred, but this is just saying we’re really hitting maybe a moment where this is going to take off even more. Great, let’s get to Seth now.

Howard Forman: I’m really delighted to introduce Dr. Seth Trueger. Seth Trueger is an emergency medicine physician. He’s an associate professor at Northwestern University and digital media editor for JAMA Network Open. His research focuses on emergency department crowding, emergency airway management, and the use of social media for medical education. He’s a graduate of Cornell, Loyola Stritch in Chicago, George Washington University, where he got his MPH.

But he’s so much more than that. I first met him through Twitter, where he goes by @MDaware. And he’s one of the most eclectic, fun, honest, smart feeds that I’ve seen. Doesn’t shy away from challenging topics and adds very helpful context to nuanced issues. But in the past year, he did something that few of us do through both social media and a perspective piece in JAMA Neurology. He detailed his incredible and heart-wrenching journey from good health and an active emergency medicine practice to, quote, disease of unknown origin.

He begins this narrative in July of 2020, when he began to notice mobility and speaking difficulties or dysarthria taking eight more months to receive a diagnosis of a paraneoplastic syndrome, simultaneously becoming aware that he had presumed cancer. I’d urge you all to read the full piece in JAMA Neurology. I will say I had the good fortune of meeting him in person, not just on Twitter, about one month before the pandemic began. And so for me, when I hear him now, he has noticeable dysarthria, and he’s aware of that as well.

Harlan Krumholz: Howie, you want to say what dysarthria is?

Howard Forman: Yeah. So I’m not sure I can do a good job describing that. So I’ll let Seth describe that more. But I’m describing it as speaking difficulties or where language is slightly impaired or comes out in a way that’s not how you intend it.

I want to start off by asking you how you are today, but I just want to start with one line from your piece, which resonated with me. And that is: “I cannot fathom how normal people navigate this.” You’ve been through this incredible journey. Can you tell us how you are, and how do you navigate this?

Seth Trueger: Well, thank you, Howie. That’s really so nice of you to have me on. Everything you’ve said, I really appreciate. I’m doing fine. I think my medical situation is so strange in many ways. The good news is, I’ve been stable on treatment for over a year now, and I’m also off the big gun chemotherapies, which is nice. I’m on immune suppression, which is frustrating, especially in a pandemic and for collinear reasons. But overall, day to day, I have mobility issues. There’s a cane at home and a walker outside the home, for the most part. And I have trouble speaking, as you noted and as your listeners can probably hear, a bit. It varies a ton, but I’m able to work. I’m able to do both my office editing job and my clinical practice, especially in the academic setting where I’m supervising teams of residents and APPs [advanced practice providers]. I’m doing well, I guess as best as I can.

Howard Forman: Can I ask you to just describe for our audience a little bit about what do you understand your diagnosis to be right now and why, if you’re so well controlled, why you still have symptoms, so they understand that as well.

Seth Trueger: Sure. So the technical term is, I have a paraneoplastic syndrome. In lay terms, it’s an autoimmune reaction to a cancer. In my case, I had microscopic testicular cancer in my chest, which makes no sense. And my immune system recognized that and then it attacked part of my brain. I believe what we think the actual damage and the reason I still have symptoms is because there’s these microscopic granulomas in part of my brain tissue that affect balance and coordination. And they cause some sort of interruption in those pathways, but because I’m on treatment, I’m on immune suppression, there’s no further damage going on. So I have not been getting worse.

Howard Forman: And just to answer the question though of when you said that line. You know, I’ve had a lot of interactions with healthcare. I’ve spent over five weeks in the hospital as an inpatient. That line just hits me like a rock. “I cannot fathom how normal people navigate this.” When you’re the physician who’s the patient, can you just give us a little taste of what you mean by that?

Seth Trueger: Anyone who works in or has been the patient in our healthcare system, I think has probably made the joke that we don’t have a healthcare system. We have a lot of people who experience and provide healthcare. But the way things are structured, the way things are organized, it’s so hard to cross silos. There’s the paradox of, we need these incredibly subspecialized experts, but then it’s so hard to move parallel across the system and to figure things out. I think many at academic centers, so much of our practice is just care coordination. I feel like as an ER doc, so much of what we do is just figuring out how to get the person in the right place in the system with the right people.

And as a patient, that’s basically what I had to do. I had the fun experience of having a very rare and hard-to-diagnose problem. And I have all sort of privileges: great insurance, great access to care, great access to informal expertise in aid. And even then, it’s just so hard to figure things out. I think, one example, I spoke about this in the piece a bit was when my PET [positron emission tomography] scan showed a lymph node in my mediastinum, near my heart. And the plan was, try to get a biopsy and see what it was, and this was before we knew what was going on. And I get this read, I get told by one of the experts who’s helping me, we get this biopsy. And I’m like, “Okay, how do we do that? Who does that? What specialists do that? How do you get them?”

I, at this point, had swallowed my pride and started pulling all my strings as a professional. I called a colleague who I know, or emailed a colleague in the ICU I know and said, “Hey, is this something that interventional pulmonology can do? How do I contact them?” I know interventional radiology does these too. I literally called the ER, asked someone for the number for the resident reading room and said, “Hey, like this is totally casual, not involved in real patient care, is this something that your colleague can do? Who do I talk to? How does it get done?” Because I can’t just call the hospital number, wait through three minutes of recordings on COVID and say, “Hey, I need this thing.”

Harlan Krumholz: Maybe just to give a fuller picture here, for those who don’t get a chance to read about this, what happened? As I know, you were healthy, active, hyper-performing individual who was balancing a lot of complicated things in your life and doing it really well. And then what happened? Maybe you could just tell folks a little bit about the story.

Seth Trueger: Sure. So basically, the summer of 2020, so around July, right after the first big COVID wave was really over and things seemed normal, I noticed this trouble walking a bit, mostly things like going downstairs. The first thing I noticed that I knew was wrong was, I was going for a jog and it seemed like it had rained, the asphalt was a little bit slippery, but it hadn’t and it wasn’t. I was like, “Oh, maybe it’s my shoes are worn down.” Just little stuff like that started adding up. I was going downstairs, my heels were hitting the back of the stairs and that I couldn’t carry a plate of food down the staircase with me or that just, this staircase, the banister is on the wrong side, just not right, it’s just harder than it should be.

And then I started noticing some slurred speech at the end of the day. It was strange to me. And some of it, both ignorance and I guess optimism, I was hoping it was something minor like, “Oh, it’s knee problems and maybe proprioception in my knees from some made-up thing in my brain about proprioception in the menisci in the knees. Who knows?”

And I actually, again, got some informal advice from a physiotherapist, did some home PT, and things were just getting worse. One of the most interesting things to me was, when I saw my first neurologist, I really don’t think they would’ve given me any concern or credibility had I not been a physician. It was, I think, so minor. And not that I’m hyper-attuned to my symptoms. I’m not a star athlete or anything. I think it was just that I’m now a 40-year-old physician at a big place and speaking with a colleague, “All right, you say you have trouble walking. I guess so. I don’t see it.” But I’ve got a lot of reasons for people to have given me the benefit of the doubt, I think.

Harlan Krumholz: It’s such an amazing journey you’re on, and it just strikes me also in this moment with long COVID and lots of other things where people think, is there something wrong with me or is it in my head? Is there something I need to get attention for? And then sometimes seeing a doctor for whom it’s—the pattern that’s appearing doesn’t ring bells. And you’re in emergency medicine, you’re doing diagnosis all the time. And we’re doing pattern recognition. But sometimes the pattern doesn’t quite fit. And then when to know to push through and say, “I really need someone to take a good, hard look at me, and this just isn’t who I am. There’s something that’s not right.” It can be hard in our system. And I just wonder if at this stage that you’re at now, you’ve got thoughts about what should we do to fix some of these things.

Every time someone in the medical profession gets sick, they come out of it and go like, “Whoa, when I see through these eyes, I can’t believe the system that we’ve got.” It’s death by a million cuts. “And I’m a doctor or I’m a nurse or I’m someone who knows how to navigate,” just like you’ve said. How are we going to fix this? Because in a way, it was a system that was not built to delight the customers that we’re trying to serve. And I hate to call patients “customers,” but just to say, if they’re the ones that we’re here to serve....

I’ll say my final thing about it is that somehow along the way, we developed this battlefield mentality where we’re in a constant, it’s just like, “You should be happy that we put a tourniquet on. You should be happy, we’re dealing with so many people. We’re so overwhelmed, we got so much to do.” That we almost expect all the patients just to be grateful for any crumb of attention or a benefit. And that’s just not how we should be running healthcare. And yet, we’re still here in 2022.

Seth Trueger: Yeah. I think you described the problem very well. I don’t have a good answer for it. I think there’s, in some way, we need to make it so systems are built to help people navigate, because these—if you have a straightforward problem that fits a specialty, it’s fairly easy to find the right place. If you have chest pain and EKG changes, you’ll see a cardiologist and get the heart thing that you need. If you have a symptom without a clear answer or without a clear person to go to, it’s really hard. And then some sort of, I think, way to incentivize, I think either navigation of care or problem-solving within the system of how to get to the next person the right way, I think it’s helpful. I think in some ways, every time I talk about this or think about it, it’s we need to figure out a way to enable or better prioritize primary care.

I’ll joke that I’m otherwise fairly a healthy guy. I didn’t have a primary care doctor. I got one toward the beginning of this to help maybe figure things out and navigate. And I’m pretty sure they think I still have beriberi—which I don’t have, never had, clearly is not part of the problem—because they’re busy and doing things, and also, at the point I saw them, I wasn’t able to figure out who I needed to see, schedule what I needed to. But we don’t know how to figure out what people need and how to do that. And some sort of overall, I think, care coordination, management access system is I think the answer, but figuring out what level of training, what level expertise that people need, who manages that and how to pay for that is the trillion-dollar question.

Harlan Krumholz: You were talking about how you’re able to work full-time still. And one of the things that strikes me, an unfortunate fact about medicine is that despite the fact we’re in the health profession, we don’t treat ourselves and our colleagues in ways that promote the best of their health and recognize their need for rest and recovery and account for disability or challenges that they’re facing. There’s this archetype within medicine of this superhuman superhero person who gets up before dawn, works after dark, and is giving up a lot for their patients. And it requires superhuman stamina, just go back to superhuman things, superhuman stamina, superhuman capabilities. And what I really liked about what you said was that it seems like your work has accommodated the situation that you’re in, to enable you to do that.

And that’s another thing that I don’t think we see enough of in medicine. And by the way, sometimes it can be physical, sometimes it can be a mental health issue. Sometimes it can be social issues that challenge people in health professions to do the kind of job that they want to do. And we too often in the past have not been flexible enough to be able to create the environment where that’s possible for people to be their best despite or accommodating whatever it is that’s challenging them. And how have you found that? Because I’m sure that required some sort of negotiation. What did you encounter as you tried to say, “How can I configure this, because I can still do my job, but I need some help to configure it correctly?”

Seth Trueger: Yeah. First of all, I’ll say, I’m back at work. I’m not totally full-time. I’m at about 75%. I basically went down as little as I could in my clinical hours because I still have physical therapy. I get exhausted. I have scans, appointments and things. I’m also very lucky where my department, in many big and small ways works well with what I can do. Like I said, we’re a very traditionally staffed ER where I’m working with the residents and APPs all the time. I’m doing this supervisory role. I’m not doing all the legwork, which to me has also always been a big source of my professional satisfaction, where the residents are doing, they’re calling consults and putting most of the orders in and getting most the bulk of history and teaching.

But most of the time, they’re right. We have residents, everything’s fantastic. But I get to sit with the patient and listen and make my dumb jokes and hold their hand and all that stuff. I think, not to brag too much, but in my department, we also have great leadership who’s very supportive. We also have good base of faculty where almost everyone does something besides clinical work. So everyone’s kind of part-time on the schedule. So it’s very flexible, it works out well. We have a couple nocturnists; we have a couple people who are full clinical. So it just all works well, what I need. And I actually don’t need a lot of specific accommodations, which is great. Because also, I’m sure like you both are, I don’t want to be the squeaky wheel and be a problem. And I also want to save my capital for if there is an issue, to be able to spend it. But I, so far, haven’t needed to, and it’s been great. But yeah, it’s hard.

Harlan Krumholz: You see what I mean? In many parts of medicine, maybe, that’s not quite that way. That’s the other thing is actively not making you feel bad that you’re not able to do, you’re able to different things and that your contributions are just as important even as you contribute in different ways. I just feel the need within medicine, like I said, for people with physical challenges, mental and social challenges, for us to be able to start to create a work environment that doesn’t make someone feel like it’s bending for your benefit while everyone else has to work harder. But in fact, it’s configured in a way so each person can do the best that they can with what they can do, and nobody feels guilty about what someone else has to do as a result. I just feel it’s an aspiration for us to think about how to get there.

Seth Trueger: Yeah. And I think you’re totally right. And to revise my answer, I think I’m lucky that my department works in such a way that it’s great for that. And what I need and what my department set-up is and what my leadership and colleague can do fits so well. But I’m basically lucky that we have that secret sauce, but I know it’s not like that for everyone or in every specialty. If I was in a community practice that was RVU [relative value unit]-based and I had to bust my hump at work to make my money, it would be totally different.

Howard Forman: I want to end on a lighter note. Food or not food? I’ve always been curious about this whole sort of meme that I feel like is built around you. Can you give us a little bit about Twitter and “food or not food”?

Seth Trueger: Yeah. So this is basically a dumb joke for myself, which most my jokes on Twitter are. But it’s really just actually only my Instagram, but that then posts to Twitter automatically. I started an Instagram years ago, that was kind of this dumb, self-aware, postmodern, absurd, like here’s a picture of food that’s really just a sandwich and isn’t anything special. But I mean the positive feedback I get to dumb meals that I post, which by the way, are the lion’s share of all the food I make. And it’s just so silly and then it kind of became an exercise in, the false dichotomy: what’s food, what’s not food? At some point, I had to make an executive decision that cocktails are food. And it’s just a fun game.

Sorry, one last thing. My favorite part is, it really helps me experience in real life how many lurkers there are online, where I have nurses at work who I never interact with on Twitter or Instagram who will make jokes about “food or not food” in the middle of a shift based on nothing, when I had no idea they like my Instagram, while plugging my Instagram.

Howard Forman: I want to point out for our listeners, your Instagram is the same as your Twitter account, right? @md.aware?

Seth Trueger: Yeah. There’s a dot in between the “MD” and the “aware,” but it’s the same.

Harlan Krumholz: And I was going to ask, why “md.aware”? Where’d that come from?

Seth Trueger: So that’s a dumb hospital joke. It’s not about awareness or wokeness. There’s a lot of, mostly nursing will chart MD awares and there is this clinical situation, like “the patient asked for X or this lab came back as Y, I told the doctor.” The short name for that is “MD aware.” A lot of it is performative absurd stuff where it’s like, the sugar is technically high, but it’s not clinically relevant, but I have to chart that I told them because the number’s red. So MD aware, yeah. And I’m sure you’ve had colleagues who will joke back, like, “Yeah, MD aware. I got it.” So it’s just a dumb hospital joke.

Harlan Krumholz: Really, we deeply appreciate you coming on. I don’t think we can tell enough stories about what it’s like, first of all, just for people to hear you and the kind of activities you’re in and what you’re doing, but also the journey you’re on and the reminder to us about how important it is for us to see through eyes of the patient and to think about what we can do as a system to ease the path and to make it so that, I even say, less toxic environment and more of a nurturing and supportive environment. And it can’t be easy to continue to talk about this, but it’s important for, I think, everyone to hear, and thank you so much for taking the time.

Seth Trueger: Thanks for the opportunity.

Howard Forman: I wanted to say, I was so stupid when I was an intern that when they wrote “HODR aware,” I thought that was somehow an abbreviation for “Howard.” And I didn’t realize that it was “house office doctor aware, house office doctor aware.” And I thought “HODR” was like an abbreviation for “Howard,” for a while, until I started—

Harlan Krumholz: He doesn’t think the world revolves around him.

Howard Forman: Yeah. Exactly. Yeah, yeah.

Harlan Krumholz: So that was really great with Seth, Howie. So now let’s turn to our next segment, and we get a chance to hear what’s on your mind this week.

Howard Forman: Yeah. This is a little odd thing. So first of all, let me just say as background, in 2000, the year 2000, the accountancy of Arthur D. Little issued a report commissioned by Philip Morris that basically in short said that tobacco smoking was favorable to the public finances of the Czech Republic. And the reason was for the most part, they didn’t say it quite this way, smokers would die sooner and that would save on pension and other public costs associated with the elderly. It was criticized for tact; it was criticized far less so for the facts or analysis.

Well, fast forward, 22 years this week, the Medicare trustees issued their annual report of the status and solvency of the Medicare program. And it is mostly an actuary report. I get excited about it every year, but it’s mostly just accounting of what happened in the past and what’s predicted for the future for the Medicare program. And the good news, if you want to call it that, is that the hospital insurance program, also known as Part A of Medicare, is not going to be insolvent until 2028, which is two years later than the prior report. This remains an acute emergency to someone like me, but nonetheless, better than becoming insolvent in 2026. So the question is, why? What actually changed to make a big difference in one year from the last report?

Harlan Krumholz: Can I just ask you a question, Howie, before you go on? What does an “insolvency” mean? I hear this all the time, “Medicare’s going to become insolvent.” Is that going to mean it’s going to stop, or what’s the consequence of insolvency because no one’s going to let it crash like that, are they?

Howard Forman: Yeah. So unfortunately, Part A of Medicare is statutorily restricted in how it can spend money, which means that if it runs out of money, it runs out of money. It will either have to curtail payments to physicians or it’ll curtail some services to individuals. We expect, obviously, that Congress will step in before that emergency moment. But there’s no statutory way that the government, the executive branch, can actually say, “We need to cut an extra check here.” There’s no executive order that can do that. It needs statute, it needs legislation to fix it. It is running out of money. It is of consequence. It only applies, however, to Part A of Medicare, which is the hospital insurance part. It doesn’t apply to the drug benefit; it doesn’t apply to physician reimbursement. So what I said before, I should have corrected, they could reduce payments to hospitals, not physicians. But it can legitimately go insolvent, if not for congressional action.

Harlan Krumholz: It could lead to the death of the hospital part of Medicare if Congress can’t pull it together to sort of figure out what to do.

Howard Forman: Correct. Correct. One way or the other, it would lead to basically the death of Medicare as we know it. So one way or the other, I expect it’ll be fixed. But why did they get these extra two years was interesting to me. And this line in the report is important. It says, “Compared to pre-pandemic Medicare population, the surviving Medicare population had lower morbidity, on average, reducing costs by an estimated 1.5% in 2020 and 2.9% in 2021. This morbidity effect is expected to continue over the next few years but is assumed to decrease over time before ending in 2028.” Basically, the vast number of deaths that occurred during COVID among the elderly and those otherwise eligible for Medicare, which includes the disabled, made the surviving population, on average, healthier than we otherwise would’ve expected. So it reduced the ongoing average short-term costs for the remaining population. And it’s a brutal topic to talk about, the fact that we, to use the cruelest of terms, we cull the herd. We took the sickest and most vulnerable and most disabled in the Medicare population, allowed them to die one way or the other. The remaining Medicare beneficiaries are lower-cost, by almost definition. And it’s just something, a brutal fact that comes out of an actuarial report and one that we sort of knew going into this.

Harlan Krumholz: We’ve been looking at this with regard to the excess deaths in the pandemic and also took a look back at the pandemic from 1914. And what usually happens after a pandemic, by the way, just as a correlate to this, is that there’s a period of deficit mortality. So you get this excess mortality, but then what you’ve done is, many people have died earlier than they would otherwise, or a lot of people who are frail and elderly. And then there’s a healthier population left back.

And it’s interesting, you’re commenting on what the implications economically are for the health system. And yeah, we might expect that there would be a little bit lower healthcare utilization as a result of this unfortunate event. It does, though, make me think, when you start talking about this, how there just needs to be structural reform in the way in which we do the healthcare in this country, because we can’t continue. This is, you’re digging into the issue about why we get two more years, but two more years only brings us out to 2028, and that’s just around the corner.

Howard Forman: Yep.

Harlan Krumholz: Thank you so much for sharing that. That’s interesting. You’ve been listening to Health & Veritas with Harlan Krumholz and Howard Forman.

Howard Forman: So, how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale. That’s hmkyale.

Howard Forman: And I’m @thehowie. That’s @thehowie. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks, Harlan. Talk to you soon.

Department: Faculty Viewpoints

Topics:

Healthcare