Ami Parekh: Tools for Navigating Care

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

Howard Forman: I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare.

This week, we’ll be speaking with Dr. Ami Parekh, but first we like to check in on current health news. Harlan, what’s on your mind today?

Harlan Krumholz: Yeah. I thought I’d talk to you about a study that was presented at the American College of Cardiology this weekend, was a trial called the CLEAR Trial. This was a test of a new agent. Well, actually one that’s been approved for lowering LDL cholesterol but hadn’t been shown to affect outcomes. Bempedoic acid, which is a drug that is along the same pathway as statins, a little bit earlier in the pathway, and it can reduce LDL cholesterol. There’d been a question about whether or not this could improve outcomes.

You may ask, “We have a whole bunch of agents that can lower LDL cholesterol. Do we really need one more?” What these people did was they said, “Well, how about the people who say that they have trouble taking statins? Maybe this could be a good alternative.” What they did was they conducted a double-blind, randomized, placebo-controlled trial involving patients who were unable or unwilling to take statins, owing to what they perceived as unacceptable adverse effects.

These people are often called “statin-intolerant,” but it just means that these are people who perceive that they have side effects for statins. In fact, they had to in the informed consent say, “I can’t take statins because of side effects.” They enrolled 13,970 people from all over the world, and they ended up finding that this drug compared with placebo, reduced the risk of major cardiovascular events by about 13%, which is in the range of things, kind of modest.

Statins have generally reduced risk by about 20%, 15% to 20%, high-intensity statins more toward the 20%, 22% range—13%, even though it wasn’t head-to-head with anything else, it was a little bit less. The people in the placebo group were allowed to take other lipid-lowering drugs, not statins, like for example ezetimibe. People thought that might have diminished some of the impact. But what I wanted to focus on quickly, was that the focus on people who were statin-intolerant, this was promoted as, “This is now a drug that can be used for that.” Major news outlets were reporting it like that.

But in a previous episode, I’ve talked to you about how there’s this nocebo effect. For some reason, people who take statins have this perception of causing side effects like muscle aches and exercise intolerance. But when you really look rigorously, like you do an N-of-1 study, meaning you give them a statin or you give somebody a placebo, and they don’t know which one it is. What they report it out as, it doesn’t seem like actually the rates of intolerance to statins is very high at all.

Many people perceive it when they’re taking placebo. If you look at all the major trials, you pull together, for example, 19 of the major statin trials. It’s really hard to find much of an effect that it’s causing people to stop taking statins, and yet there’s this buzz about statin intolerance. Many people have this perception, and it was really interesting. This drug will cost about $4,000 or $5,000 a year. Should you start switching people over because they’ve got this idea that the drug is causing a problem, which when it may not be the drug and they should be switching over.

A lot of the cardiology experts were celebrating that now we have an alternative for people who think that they’re intolerant. I think we ought to be thinking about strategies to help people through this. Because when they get rechallenged with statins or they’re shown that if they take placebo, they get the same effect, that this actually isn’t the statins. People can sometimes get through this. I don’t know what you think about this, but I thought there should have been more discussion at the meeting about why are people getting this perception about statins? What can we, as physicians, do to help people through?

I heard some people tell me, “Our visits are too short, 15 minutes, we can’t work people through, might as well just switch them to another med.” But like you’re talking about switching from a med that’s pennies a day to a med that’s going to be much more expensive, and maybe not quite as effective. Anyway, it was quite an interesting topic of discussion.

Howard Forman: Yeah. No, you pointed the article out to me and I looked at it. I want to point out for our listeners, that the nocebo discussion occurred in our very first episode of Health & Veritas.

We’re on episode number 71 now, so I felt like we talked about this a few months ago but it’s been a while. I’m on statins; I don’t remember if you are or not.

Harlan Krumholz: No.

Howard Forman: I am grateful that I’m on statins because my father had a heart attack at 49, and his father had a heart attack at a young age. I really think statins work very, very well. I don’t know whether any things that are going on with me are related to statins or not, but I seemingly tolerate it well.

But I have friends, who have been recommended to be on statins, who actively have put it off for years, despite having a family history of atherosclerosis, purely because people do talk about these things in big ways. I hope this, I do think it’s good to have more options.

Harlan Krumholz: It’s an example of our for-profit system, Howie, where that there’s no pay to sit down with people and help them think about and manage their fears and concerns, and maybe unfounded beliefs about the connection to a side effect. It’s easier just to write another script. Even if that script’s expensive, it ends up being paid for by some third party.

Largely, let’s assume people aren’t paying out-of-pocket for it, and then it ends up raising healthcare costs generally, but there’s no one who wants to sit down with a health educator and actually work through this. This becomes we default to just giving a med.

Howard Forman: I agree, and I agree with you that once these drugs go generic, there’s no for-profit impulse to market or even help clarify issues for patients.

But there is a motive for companies with novel pharmaceuticals that are highly profitable to market. We’ve got a lot of work to do.

Harlan Krumholz: Anyway, I just thought that was an interesting thing this weekend. By the way, kudos to the team for having a positive trial conducting this. It’s not easy to do clinical trials. Kudos to the company for bringing forth a new agent.

I’m just raising this issue about the utility and how we think about what the place is for. But anyway, let’s pivot to our guest. We have a really interesting person coming. Go ahead, Howie. Why don’t you introduce her?

Howard Forman: Dr. Ami Parekh is the chief health officer at Included Health, where she leads clinical vision and strategy. Included Health’s mission is to raise the standard of healthcare with connected delivery platform encompassing healthcare navigation, virtual primary care, behavioral health, and urgent care. Prior to that, Dr. Parekh was chief medical officer for population health and clinical integration at UCSF Health. She’s also worked at McKinsey and the Clinton Foundation.

She serves on the Blue Cross Blue Shield of Massachusetts Board of Directors and has been named in Fierce Healthcare’s Women of Influence in 2020, and San Francisco Business Times’ Most Influential Women in Business in 2021. She received her bachelor’s degree from Williams College and her medical and law degrees from Yale Medical School and Yale Law School. She then completed an internal medicine residency at Harvard’s Brigham and Women’s Hospital, where she was elected to serve as chief resident at the Faulkner Hospital.

First of all, I want to just welcome you to the Health & Veritas podcast. I wanted just go back to that decision to do the law degree, which you did during medical school, and you were one of the first Yale students to do that. We have had several since, by the way. I always mention your name, first of all, when those students come to me. I always say, “You got to talk to two people.” I mention Rahul Rajkumar and I mention you, and I think they reach out.

But I want to know what informed that decision and how has that informed your career, both in population health and now with what you’re doing with Included Health?

Ami Parekh: Well, Howie and Harlan, thank you so much for having me. First of all, I know you both probably don’t remember, but when I was a med student, first and second year of med school, I walked in both of your offices at various times and probably asked you, “Howie, Harlan, how do I make the biggest impact in healthcare that I possibly can?” You probably had some role in me deciding to go to law school. But I would say the real reason, Howie, was I had already worked at McKinsey & Company prior to going to medical school.

During my time there, I had started to understand a little bit of how the money works in healthcare. I started my third year of med school just so excited about actually taking care of patients. I was one of those ready-to-go third-year medical students. Couldn’t wait to take care of my patients to the best of my abilities. You very quickly realize that no matter how great of a doctor you are, no matter how much you care about getting the outcomes you want for your patients, there are systemic ways that we regulate healthcare and that we deliver healthcare that make it actually impossible for you to get the outcomes you want for your patients.

There are very specific patients I remember. Patients, who at the time, this was also pre-ACA—Affordable Care Act, for those of you who don’t know what that stands for. I would have patients who couldn’t get their inhalers outside of the hospital but would repeatedly come back to the hospital with COPD exacerbations or asthma exacerbations. Could not figure out how to live a life where they weren’t exposed to smoking but continue to take care of them in the ICU at times. I had moms who I was taking care of as a med student, who they wanted to breastfeed their children, but WIC, which is Women, Infants and Children’s program, only paid for formula and not for lactation specialists. It was really that moment, my first couple months of third year of med school, where I realized I needed to understand how policy and regulation actually affected what I could do for my patients.

That prompted me to apply to Yale Law School and go get that education. I take that with me in everything I do today. That combination of truly clinical insight—you’re doing this for the patients, at the end of the day—with an understanding of how the larger ecosystem works. There’s nothing like what’s going on in reproductive health today or transgender health today, that doesn’t show that policy and healthcare intersect daily in our lives. Bringing that economic lens from the consulting experience to really try and make healthcare better for as many people as possible, day in and day out.

Harlan Krumholz: I wanted to just take a little bit and talk about Included Health. Would that be okay?

Ami Parekh: Absolutely.

Harlan Krumholz: By the way, is this connected to Grand Rounds, or it’s what Grand Rounds became, Included Health?

Ami Parekh: That’s right.

Harlan Krumholz: What is Grand Rounds, and how did it become Included Health? Let me just start there.

Ami Parekh: Absolutely. When I started here four and a half years ago, it was Grand Rounds Health, and we did a few things. We matched patients to the highest-quality in-network providers for them. That was using a lot of data and data science to identify who the highest-quality providers were and about the patients. We also did expert medical opinions where we would help members get second opinions by experts—places like Yale, places like UCSF. Because many people in America don’t have access to institutions like that and doctors like that, and so getting people to the right care.

Grand Rounds two years ago merged with Doctor On Demand, which was a national scaled behavioral health primary care and 24/7 urgent care provider across the entire country. We also acquired a company called Included Health that at the time did LGBTQ-specific navigation for the population that has been historically marginalized by the healthcare community. Together these three companies, we decided to call ourselves Included Health. What we do at Included Health now is full-scale navigation, which means if you have any problem in healthcare, you call us first.

We help you find a doctor if you need one. We help you understand your bill if that’s the thing you’re struggling with. We help you understand if something’s in-network or out-of-network. We also can provide you with virtual primary care if that’s how you want to receive your primary care. If you can’t get access to in-person primary care, we provide you with behavioral health if that’s what you need, both therapy and psychiatry. 24/7 we have doctors available for urgent care as well.

If you’re of the LGBTQ+ community or the Black community, again, these historically marginalized communities from healthcare, we have specific products to help engage you with healthcare.

Harlan Krumholz: What’s the business model? Who’s paying you, and how does it work?

Ami Parekh: Yeah. We have two primary clients. The first is large self-insured employers. Harlan, I think you recall, I like to align incentives in healthcare with the outcomes you want to deliver. One of the advantages of our clients being primarily self-insured employers is we have very aligned incentives with them.

They pay us to really keep their employees and those dependents healthy and keep their total cost of care down and keep their health outcomes improvement so they can actually show up and do their jobs and focus on their lives. We also do sell to health plans. That’s primarily on the virtual care side of the business, health plans that want to improve access for their members through virtual primary care, behavioral health, and urgent care.

Harlan Krumholz: I just want to unpack just a little bit about this issue about the top doctors. I appreciate the interest in trying to identify the top doctors, though I often say, unfortunately the top 5% of doctors can’t take care of 100% of the people. What I spend a lot of time thinking about is how we can raise a level of performance for everyone, in the same way that I don’t have to worry about who the pilot of the plane is.

I don’t have to look for the top 10% pilots because we’ve created a standard that works, but I get that there’s tons of variability here. How do you identify these top doctors? I know you said data science and data, but can you unpack it for us a little bit? Then aren’t those doctors busy? How can they manage the demand for their services?

Ami Parekh: I’m going to answer the question in a couple ways. The first is you just asked the how, so I’ll just give you the how a little bit. We were the first purchaser of the full commercial claims database at the NPI level. For every single NPI, which is basically a number that goes with any provider who can prescribe in America. I have a number, Howie has a number, Harlan has a number, they’re all unique. We purchased the entire claims database for all of those patients.

We were the first company to have that set of data. Then we said, “Well, what actually makes a provider high-quality?” We started to build models with specialists. If you start with primary care, you’d be the middle of cardiology, you have to go really specialty by specialty to say, “Well, what are the outcomes that matter in that specialty?” That’s where the partnership between clinical, so we have a large data science team. We also probably have one of the largest clinical teams in the industry today.

I have over a thousand clinicians who report up to me at this point in time. But even when we had Grand Rounds, we had a very large clinical team. It’s really the matching of the clinicians with the data science team to say, “What are these models that actually lead to better outcomes?” Primary care, I’ll just use some examples. Preventive screening rates for behavioral health, depression, outcomes for cardiology, ACS results. It’s nothing that’s rocket science.

A lot of medicine isn’t rocket science; it’s really just doing the basic stuff. Then there’s some stuff that nobody had done before. Turns out there’s no national database of sanctioned providers. You and I, we all know that actually to get a sanction is not that easy in a state. There are still providers, I’ll give you an example. We knew of a provider who was sanctioned in eight states and yet still providing care to patients in a different state.

We did some stuff that wasn’t claims database but was really just taking other types of data, like sanction data, and using that on the more lower-quality side of the spectrum. That’s a little bit of the how. Obviously, I could talk about this for hours, and a lot of people in our company could talk about this for hours because we get so excited about it. But then the supply problem, and I think that’s a really good question that you ask. Okay. But then at the end of the day, there’s a supply issue here.

If only 50% of providers can be in the top half, well, how do you support 100% of patients? There’s a couple of things there. One, no two patients get the same list. We actually don’t believe in a top one person. Harlan, if you and I were both in New Haven and we are both looking for primary care doctors, you would get a different list than I would get, because I have a very different claims history and different conditions than you do.

I’ll just say in my family, we have a lot of diabetes, and so I need a doctor whose diabetes outcomes are actually rated very high. You might have something else that you need to be weighted high in the score of the doctor. It’s really about the match. The top 50% is different for every single patient, which helps to some extent with some of the supply problems. But 100%, the goal is to raise the standard for everyone. That means we got to get all doctors performing better, no matter where they are on the list.

Howard Forman: I want to ask a different question. I know this is near and dear to your heart. You already said it at the beginning, and that is one in four people in this country is on Medicaid at some time during the year. There’s a whole bunch of others who are uninsured or really have limited access to our healthcare system.

They don’t get Included Health at all. Tell me what’s in it for them? How do we get this second tier of citizens, these people who are not able to access the employer-based system, that really is a more enriched insurance system, how do we give them the benefit of what you’re doing?

Ami Parekh: You’re right. At this moment in time, we don’t offer navigation services to Medicare or Medicaid patients. This is primarily a solution. We include a health cell to commercially insured patients. I think there’s a couple of things that if I were sitting in a Medicaid office at a state or in the Medicare in CMS right now, which is the Center for Medicare and Medicaid Services, I would be thinking about this. I’d be asking, how do we get these types of services to our members?

Because my parents are on Medicare, I’ll use them as an example. They want Included Health so badly. They’re like, “We wish we could have a phone number we called where somebody helped us with the bill, helped us figure out who actually takes Medicare, because a lot of providers don’t.” I know that is true for Medicaid patients as well across all of the states, but there’s a lot of regulatory complexity.

One of the nice things for self-insured employers is they have a lot of freedoms in what they can do from a benefits plan, that is really hard to implement when you have 50 states doing different things in Medicaid. Medicare has always been tougher. The only way you can get some of this stuff is if you’re in a Medicare Advantage plan, where they again have a lot of the same freedoms as an employer does in terms of the benefits they can provide.

But a lot of this, as we drive innovation in Medicaid, as we drive innovation in Medicare, I think it will be how do you take models that have grown up in the commercial space, just because of simplicity in many ways, and make it easy to implement across these different populations?

Harlan Krumholz: One of the things that I was wondering about, given that there is limited access to your platform right now. Obviously, you guys must have some strategies to think it’d be really good to give more people access to it. If someone randomly says to you, “I’m trying to find a doctor,” and they don’t have access to all the toots and whistles that you guys have, what advice do you give people to be able to find someone and navigate this?

Because I do think our current system is very challenging on two sides. One is figuring out who might be best for you, absent being able to access a platform like yours, and getting in. Because actually, even when you do find someone, it can be quite a challenge to actually get on someone’s schedule. What practical strategies might you tell people who are listening?

Ami Parekh: Yeah. I’m going to say a personal story and I don’t know if I’ll get in trouble for this, but that’ll make fun.

Harlan Krumholz: We don’t want you getting in trouble.

Ami Parekh: Harlan, if you actually did ask me, “Hey, Ami, I need to go see a doctor,” honestly, what I’ll probably do is I’ll look at my own app and I’ll say, “Well, here you go.” Here’s where I put your zip code in.

Harlan Krumholz: Well, I appreciate that.

Ami Parekh: I would say, “Well, this is what the data science tells us.”

Harlan Krumholz: She’s my new favorite person, Howie, I want to tell you.

Ami Parekh: I will say, so over 10 million Americans today have access to Included Health’s full suite of services, and 50 million people have access to our virtual care services. We have grown exponentially. Our goal, 300 employers are our partners today in delivering this. That will continue to grow, and I think we’ll grow in commercial, and hopefully at some point Medicare and Medicaid can access these services as well.

Howard Forman: I want to give you a chance to talk about the origin of Included Health. I know that you joined the organization later on in its history. But I’m fascinated by it because I’m a gay man and I grew up at a time where we had a seemingly almost covert list of gay-friendly physicians that we would share in our localities when I lived in St. Louis, for instance. To this day, I hear from gay individuals, primarily physicians honestly, who say to me, “Who can I see?”

Because they’re contemplating PrEP [pre-exposure prophylaxis] or they’re contemplating something else or they’re HIV-positive and they’re looking for care. It’s not that easy. It is interesting in a lot of other ways, LGBTQ individuals are not as marginalized at all as they once were. But when it comes to healthcare, there still is a lot of stigma around disease, around treatment, about not just sexual orientation.

Harlan Krumholz: Maybe lack of expertise, Howie, too, lack of expertise around the specific issues?

Howard Forman: From the clinicians, absolutely, to even know what they need. Really would love to hear a little bit about what Included Health started off, and how you’re continuing to include that, particularly in your community where you actually do have a larger LGBTQ community than other parts of the country.

Ami Parekh: Yeah. LGBTQ+, I do wish Colin Quinn were here. He’s a co-founder and he still obviously works for our company and leads a lot of our efforts on this. But to your point, Howie, it is incredibly hard, if you are of the LGBTQ+ community, to find compassionate, affirmative, and competent care, Harlan, to your point around competency. Those are the three things, the legacy Included Health, we now call it LGBTQ+ Communities product. Those are the three things they look for, as they look for providers that would be right for that membership.

They actually started, it’s classic Silicon Valley in some ways. Like they started with the problem, these were the things the founders struggled with this. They said, “Well, how do we start screening?” They would call providers’ offices and ask a bunch of questions about the competency, the compassionate, whether these providers were providing affirmative care. They didn’t necessarily start it from a data-informed way. They started it from, we’re just going to start building these networks and having that list of providers who provide this care for patients.

It obviously got a lot of traction. They also sold primarily to the employer community, partnering with employee resource groups in these companies. Now the nice thing of the post-acquisition is, now we can use data so that it doesn’t have to be so manual to find these providers. Because there’s some things around the competence that you can actually see in claims data. You can actually see whether a provider knows how to prescribe PrEP or not.

You can actually see, are they doing the appropriate screenings for these populations that they should be doing? How do we bring data with still some of the qualitative pieces for those populations? Then that team just launched the Black Community Health, which individuals of that community have also been historically marginalized by the traditional healthcare system. How do we help build trust and get that going as well?

Harlan Krumholz: No, wanted to first thank you for taking the time to be with us and we’re getting to the point where we have to close this up.

But I wanted to ask you one final question, just given your vantage point in healthcare. What are the most important thing that you would like to see happen in the next decade in healthcare?

Ami Parekh: Well, that’s a really big question, Harlan. But ultimately, I think where we want to be in 10 years—and you should tell me if it’s not where you all want to be—is where no matter who you are, no matter what state you are born in, you can access the care in a convenient way that works around your life that you need. People don’t actually want to be spending 25% of their pocketbook or 25% of their mental capacity on healthcare. They want to live their life. They want to be the mom, they want to be the kid, they want to be the soccer coach, they want to be the highly effective employee. How do we wrap healthcare around the people and really get them the best care they can? That’s like the vision, that’s probably not even going to happen in our lifetime. If I say in the shorter term, I do think incentivizing behaviors that put the member at the center. Let’s make virtual care accessible to everyone.

Let’s actually make it such that we can have clinicians in rural parts of this country where there’s incredible clinician shortage right now. How do we get access to those people? Let’s actually move towards value-based care step by step, but a lot of that momentum has been lost. Those would be some of the shorter-term things.

Harlan Krumholz: No, I think that’s a terrific response. I think better access and more affordable, get rid of the financial toxicity, and give people access to high quality. I think it’s a great response.

Thank you so much for being with us. Been a delight to have you with us and lots of good messages for people to hear. Thank you.

Ami Parekh: Thank you, Harlan. Thank you, Howie. It was really fun.

Harlan Krumholz: Howie, that was a terrific interview. I do remember Ami now after having this discussion. It’s just amazing what happens to some of these students and the leadership roles they take on and the impact that they have. It’s just such a wonderful that you and I have this opportunity to see this happen. But let’s pivot to your section. What’s been on your mind lately?

Howard Forman: There’s this nice natural experiment reported in The New England Journal of Medicine that caught my eye, because one of the authors is our friend and former colleague, Dr. Julie Sosa, who’s now chair of surgery at UCSF. Because the findings are actually of a median practical value, so it’s awfully hard to measure the impact of policy. You pass a bill and enact it into law and it eventually is being used, but it’s hard to know because there’s so many other factors and other changes that are going on at the same time.

For instance, here’s an example of that. Do employers that offer paid sick leave in order to get a colonoscopy or a mammogram have higher uptake of those screening tests? Or do people who believe in those screening tests choose employers who offer paid sick leave? It’s hard to know what the cause or the effect is, and therefore, it’s hard to judge policy in that realm. But we do know that there is higher uptake when the time is offered, but is it the policy or is it the selection bias? It’s like two possibilities in there.

Dr. Sosa and her colleagues took advantage of a change in policy in municipalities. Certain municipalities put these mandates in, some of them absolutely forbid them. You have adjoining areas and multiple areas with different policies in place, and they’re changing over time. In the end, the authors looked at these areas over time, and they find that individuals that are offered paid sick leave are, in fact, more likely to get screening, are in fact more likely to get colonoscopies or screening mammograms.

The numbers are significant, statistically significant. They’re not huge, they’re in a 1% or 2% or 3% range, but that’s still significant when you’re dealing with population-level change. If we’re going to get to a system that commits to preserving health as much as it commits to treating illness, we should be grabbing opportunities like this. It’s just great to see that a piece of public policy can at least be shown to work. Because I think there are a lot of people that worry that maybe it doesn’t work and maybe we’re passing laws that have no effect. I think this is a good example of public policy that works.

Harlan Krumholz: Yeah. It’s terrific to see this article about paid sick leave mandates and in Julie Sosa, but really a star in the surgical firmament and in medicine in general. Also, great to see a leader, a chair of surgery who’s really focused on pragmatic, practical outcomes research.

Howard Forman: She did this with economists, so it’s a great example of collaborating across fields. We often see only physicians or only economists writing. This is really a joint effort. It was a great paper—

Harlan Krumholz: It’s a clever design to get to causal inference from an observational study piece. It seems to me, I’m glad they studied it, but gosh, isn’t it just the right thing to do to give people paid time off to be able to take care of these things? Also, there’s two things. One is our healthcare system’s not configured to provide care for when people aren’t working. This is paid time off, but many hourly workers simply can’t afford the hit that comes with going to doctors for visits around self-care and health and screening.

I think we need to get to a compassionate healthcare system and in partnership with employers in ways that enable people to get the care that they need. Then it’s nice to see actually studies that are looking at the optimization of these approaches. But yeah, we were talking to Ami about what would we like to see in a healthcare system? We said more access, we said more affordability, and I think more coordination so we can recognize that for some people it is really difficult to be able to take off the time necessary to get the care they need.

Howard Forman: 100%.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

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

Harlan Krumholz: I’m @hmkyale, that’s HMKYale.

Howard Forman: I’m @TheHowie. That’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. 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: Howie, I was thinking, you told me when you were talking about this New England Journal paper that you were going to look at your paper issues. You’re still subscribing to paper journals?

Howard Forman: I am. I’m a little embarrassed to the fact that I still read a print newspaper, and I read print New England Journal of Medicine. I think it’s a generational thing. A lot of other things I’ve pivoted away from, but I love holding the journal in my hand and leafing through it.

Harlan Krumholz: Yeah. I think that probably is, but I will admit, I love holding a newspaper too, yeah. People will now know what generation we are.

Howard Forman: I know, and I do think there’s an environmental consequence, but at this point I haven’t been able to abate it.

Harlan Krumholz: Yeah. We should be thinking about that too.

Howard Forman: Yep.

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

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