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Episode 47
Duration 36:56

Dr. Jeremy Faust: Is COVID Over? It's Complicated.


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

Howard Forman: 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. Jeremy Faust. But first, we like to check in on current health news. What has got your intention this week, Harlan?

Harlan Krumholz: Yeah. Howie, I wanted to talk about something that you and I were both involved in this week, actually today. And get your thoughts about this. Somebody we know was coming to us about someone that they knew, living in our area, who was needing access to a monoclonal antibody for an exposure to COVID. It’s a person who’s got some reasons to be vulnerable to COVID but is generally healthy and had an exposure. This person who is highly knowledgeable, knows the Yale system really well, is well connected, was like, “Hey, I talked to somebody else.” In fact, they talked to some bigwig somewhere who should be in the know. That person said, “I really think that this person that was exposed ought to be getting the monoclonal antibody that was authorized in February of 2002, called Bebtelovimab, that provides a monoclonal antibody.”

I’ll talk about in a second what that is, but just monoclonal antibody treatment, that can help protect them. Then there’s just all this stuff, Howie, that just made me realize that there’s several options here for monoclonal antibodies. There’s a lot of confusion, people confused about authorization. The person contacted is a doctor, and nobody seemed to know. She emailed a whole bunch of us. You may have had some of those.

Howard Forman: And by the way, I’m the radiologist in the group. Almost everybody else on that email was an internist by training. I was shocked at how little people knew about what to do. So, I was with you. I actually wanted to talk about this too.

Harlan Krumholz: This particular monoclonal antibody has got an emergency use authorization. Let me just unpack that, because some people may have been hearing about all these new treatments, including the vaccines, who get this thing called an EUA, emergency use authorization. That’s different than an FDA approval. So people may go, “Oh, this sounds like inside baseball. Do I really care?”

Well, it actually is important, because approvals is what the FDA usually does after a period of deliberation, where they’re weighing the risks and benefits, looking at whether something is safe and effective and they’re putting it out into the marketplace. But particularly in the middle of a pandemic, there are ways of accelerating that decision-making, and also, to say that the urgency of the situation requires us to take a little different approach. That again, this EUA, the authorization is different than an approval. In determining whether to issue this, the FDA evaluates the totality of the available scientific evidence. Like usual, they balance the known risks and benefits for the products. But it may be that there’s not as much evidence as they would like to see for them to get to a final determination, that gets them to this word “approval,” which is what most medications—

Howard Forman: Or just long-term evidence.

Harlan Krumholz: That could be what’s lacking. They’re lacking evidence, and some of it may be that, it’s not enough people. Because in some cases, particularly some of the COVID tests got emergency use authorizations. That they would’ve liked to have seen more people studied. As Howie suggests, in many cases, it’s like, “Well, this was just short-term because by the way, the pandemic, especially at the beginning, didn’t have the opportunity for us to be able to look long-term.” So, you get a whole bunch of these treatments that are authorized for this purpose. Just to give you a sense of this particular one, an antibody, it’s the body’s defense system. It’s producing these proteins that can neutralize, go after invaders.

In this case, this particular one, instead of your body making them, you’re being supplied with them. And what it’s giving you is a whole bunch of these antibodies that combine to the spike protein. Most everyone’s heard now about how the coronavirus looks. And there’s these spikes coming off. The spikes are the means by which they enter into cells. It’s also the way that the vaccines are targeting the spike, to a large extent, parts of the spike. So, these bind to the spike protein of the virus. Similar to some of the other monoclonal antibodies that have been authorized, the idea is that this can mitigate the severity of the infection. It can help to minimize both the entry into cells and can help the body to clear the virus.

This was authorized for high-risk patients with mild to moderate COVID. And it’s shown a benefit in reducing the risk of hospitalizations or death. But I think what everybody’s confused about too is, you got Evusheld, which is another monoclonal antibody, which is really pushed for prevention of infection, that is sort of pre-infection. This one, Bebtelovimab, is more for people who have mild to moderate disease. It’s a later one. It’s thought to be, this is a better one for Omicron, but it’s really authorized for people who have mild disease, so it doesn’t progress.

All this becomes very difficult in the timing. “Hey, I was just exposed. What should I do?” In this case, somebody who in the know, actually, was suggesting they use this monoclonal antibody in a situation where it’s not really being pushed by the guidelines. And then these, there’s a couple of them that are good for people with mild to moderate. But do you get it right away? Do you wait to see if you’re going to get better? Oh my god, Howie. When I think about the implementation science part about this, how you move from the science, the trials to actually what people do. And then I’m seeing a lot of smart physicians on that email today. They’re all shrugging their shoulders. I don’t know how to get this stuff.

Howard Forman: Nobody knew, and I was shocked to find, it was very easy to find out that Yale New Haven Hospital actually had a lot of doses of this available, as of September 12th. So we know it’s here, at least according to the government documentation of inventories. Very frustrating. The other thing that I noticed when they sent the email, this is a person who’s very high-risk. This is why you might take certain license and physicians have that license, to make decisions to use medications that are effectively off-label.

Harlan Krumholz: Well, exactly. I didn’t actually think that it was a bad idea that this person might get some protection, given the risk. But it does speak to the need for us to communicate more clearly, both to doctors and patients, about what to do. You identified a website, we’ll associate it with the podcast today, where people could look and see how many doses are available. Where are they available? I didn’t know about this website. You want to just say a word about the website?

Howard Forman: Yeah, it’s shocking, but you can go on this website and it shows you where all the therapeutics are. You can literally go and find your institution. It’ll show you every one of the therapeutics, whether they’re available and how many doses are available, as of two days ago.

Harlan Krumholz: And where you can get it, right? Where you can get it.

Howard Forman: That’s right. At your institution, you pick your area.

Harlan Krumholz: So, this just strikes me as, here the government did everything right. They put together a website. They have an inventory. They’re telling you, Evusheld, there are 176,000 doses available, where they’re available. Every doctor, in the midst of a pandemic, should be able to say, “Hey, I know exactly what to do in this situation.” I’m a doc. I’ll say, “I’ll take some responsibility. I’m working in COVID.” I just feel like, gosh, my reflexes just aren’t as strong as they need to be. I think, mostly where we’ve defaulted to is, “Hey, if you get sick, we’ll take care of you.” But in this prophylaxis kind of use, and many people have raised this, we’re just not optimally utilizing the tools that are available to us.

And I think it’s something we can all do better. But just both for people listening, to say there is a website, where you can look and see where these are. And if you’re exposed and people are high-risk or having early symptoms and are high-risk for progression, then they should be treated. They should be treated.

Howard Forman: I agree. All right. Today, we welcome Dr. Jeremy Faust. Jeremy Faust is an emergency physician, Brigham and Women’s Hospital, in the health policy and public health division , as well as an instructor at the Harvard Medical School. We’ve had several guests who might be described as Renaissance men and women, but nobody’s going to top Dr. Faust. He graduated from Williams College with honors in music, holds a master’s degree in music composition and theory from UC Davis. He subsequently went to Mount Sinai School of Medicine, where he also completed his residency, before taking his current position. While medicine is his full-time vocation, his involvement in music performance has not faded. He most recently was board president of Roomful of Teeth, a Grammy-winning vocal ensemble and currently is the conductor of the Longwood Chorus, an assembly of medical students and professionals.

But he is much more than that. Besides being an exceptional and active clinician, he’s also a leader in free open access medical education, also abbreviated as FOAM, co-hosting FOAMcast, a medical education podcast that has been downloaded over three million times. He is the editor in chief of MedPage Today, on the editorial board and writes for Annals of Emergency Medicine and has been prolific in his scholarly writing in scientific and lay commentary, particularly as it relates to our most recent COVID pandemic. I could go on and on about this multi-platform educator, scholar, musician, and talented writer, but I’ll just start off asking a similar question to one that I asked of Dr. Esther Choo last week. Why are so many emergency medicine physicians expertly equipped to communicate with disparate audiences and to do so in such a rapid and responsive manner?

Jeremy Faust: Well, thanks for having me. It’s great to be here. I think that emergency medicine is a real discipline. It’s a real framework of thinking. It’s not just a set of skills or a set of knowledge that’s on boards. It’s actually a way of thinking. And the way we think is about the problem in front of us and never allowing perfect to be the enemy of the good. So, it’s probably one of the more practical cognitive disciplines that I’ve ever encountered: “Here’s the problem. What’s the most important part of the solution? What can we achieve in the most efficient amount of time?” And I think that we squeeze a lot out of the first five minutes of every interaction. And I think that’s really where the training is designed. Not, what does the patient have, but what does the patient need? And I think once we get through those first few minutes, everything else can sort itself out.

Howard Forman: Before we get to the science, can you tell us a little about the journey from being a dedicated musician, which you still are, but basically that as a career path, growing up, I think on the West Coast, to being a medical student and then an emergency medicine resident on the East Coast? Can you give us a little glimpse into what went into that thinking?

Jeremy Faust: I wanted to do medicine for as long as I could remember. Sitting in an office job sounded terrible to me. Running around, talking to people, and helping them seemed cool. But then simultaneously, I just was absolutely sucked into vocal music and choral music from a very young age. They always were sort of in parallel. And the thing that happened to me, when I was 19 years old, is that I had this vision for my future, which did not come true, but basically is the reason I’m here today. Which is that I read an article in Scientific American, by Robert Sataloff, an ENT in Philadelphia who’s also a doctorate in music, has a doctorate in music, who conducts choirs. And I thought, “I want to be that guy. I want to be an ENT who works in music.” And I didn’t do that because it turned out that I didn’t love OR, didn’t love ENT as a discipline as much as I thought I would, but I loved seeing patients and I loved working in music and instead of merging my interests, they became sort of parallel competing interests.

And only at times have they really interacted in interwoven in terms of, “Oh, I write about medicine and music” and that kind of thing. But in fact the journey has been sort to apply one set of lessons to the other one and then back and forth. So the performance aspects of music inform my patient care. It’s always a performance and the discipline of studying for a board exam is not that different than memorizing a piece that you’ve got to perform in front of people. So in a way I think of their connection much more as borrowing cognitive lessons from each one.

Howard Forman: I just want one follow-up to that. Between the master’s degree and medical school. Just tell us about that gap or if there was a gap? I’m not even sure there was.

Jeremy Faust: Yeah, so I was a pre-med music major and dropped the bio major, smartest thing I ever did. Not only because it meant that I was not going to be competing with people who are going to get their PhD in biology for grades, but also it allowed me to dig into the liberal arts education instead of taking those biology classes. I took constitutional law, modern drama. I took things that really informed my overall, the things that actually I carry with me. And I knew I wasn’t ready for med school, both sort of academically at the end of college and also just cognitively, I was not one of those people who just knew they were ready to be a doctor. I knew I wanted to do that, but I was really feeling like the people I look up to, I’m not going to be them in five or ten years, I’m just not going to be there.

And I had an opportunity to go study music and grad school and to get paid to do it. Basically, I taught my way through UC Davis, and it’s really inexpensive living there. It was a great life, and it was actually hard to leave that because I was having a great time. I started a chorus in the Bay Area called the International Orange Chorale. They’re still going today. A wonderful, one of the better amateur choirs in the country at this point. And it was really hard, but I looked at the calendar and said, “Okay, now I’m in my mid-twenties. If I don’t go back to science, it’s never going to happen.”

And so it was really hard to leave, and actually it made my student life in science and medicine very difficult. I was quite terrible because I wasn’t in it. I’d like to say that I wasn’t good because I suspected that so much of what we were learning was BS, but it was really not. That wasn’t the reason. The reason why is that I was just asunder between interests and it took a long time to figure out the balance, but once I did it was really fulfilling.

Harlan Krumholz: One of the things, Jeremy, I wanted to talk to you about was, you’re one of the best thinkers I know on the pandemic and have contributed in so many different ways, opinion pieces, science, perspectives, educating the public through a wide variety of outlets. I just wonder what you’re thinking about it now. It’s, you know, masks are off, most people are acting like “pandemic’s over.” Where’s your head right now in terms of what we should be doing, how you’re living your life, what you’re telling other people?

Jeremy Faust: I have many conflicting thoughts. First of all, I’m still being really conservative, because I’ve got a three-month-old baby who’s not vaccinated. Right now these zero-to-six-monthers are unvaccinated and they’re high-risk. This is a group of people who actually are being hospitalized on a population level at a higher rate than 50-to-64-year-olds. That’s not something that people realize. And so the vaccines work, but if you’re not vaccinated, you’re in trouble. And yes, kids are healthier than adults, they’ve done better. But that’s my personal focus, getting my kid through this little tunnel of time between the antibodies she got from my wife who boosted during pregnancy and the six months where she can get vaccinated. So that’s my personal thing. Once that happens, I’m going to start to really relax what I do and my personal risk most of the time, except when I know I’ll be visiting people who are compromised.

Like I’ve got family to worry about. So that’s my personal feeling. But overall, I think that we’re in a situation where two things are true. Yes, it’s a lot better off. The average person, 30-, 40-year-old person without a lot of medical problems can probably relax and not worry as much as I think the concerned caucus would say. But at the same time, the effect on the at-risk population, the patient who gets hospitalized for any reason at all in a course of a year, we are not at a place where I’m comfortable. Harlan, your work shows how much seasonality there is to so many different causes of death. Not just flu, not just pneumonia but heart disease, strokes. There are just so many diseases that are seasonal, and they are clearly exacerbated in a way that we did not ever realize before. By random viruses, by viruses we know: flu, RSV [respiratory syncytial virus].

Well, COVID is just the most contagious one we’ve ever seen. So now we’re going to be, I think, I worry that the new normal is that cold and flu season is now marked by COVID being around and causing all these CHF exacerbations, these heart failure exacerbations, these diabetic crises. And so it’s the people who are really, really at risk, are actually, it’s the risk pool of people who the nihilists really focused on early. They said, “Oh, COVID is not a problem unless you’re a really frail sick person.” And that wasn’t true. That just wasn’t true. It was kind of true on a roll-the-dice way. You’d rather be 30 than 80. But we had excess mortality in every single adult age group in this country. And in fact, a relative increase in excess mortality, all-cause deaths, was highest in youngest people.

So this idea that this was a disease of the old was a fantasy that was not borne out. Now with vaccines and boosters, younger people aren’t going to be hospitalized, they’re not going to die unless they’re the kind of people who get hospitalized frequently for other reasons. So that cohort is the group I’m really worried about. They need to live booster to booster. I really feel that way because it’s not COVID pneumonia that kills them. It’s a diabetic crisis that COVID caused. These are not incidental hospitalizations. Oh, I was—the “for”-versus-“with” problem. Now it’s both “for” and “with,” it’s not COVID pneumonia, but they got COVID and that’s why their diabetes is absolutely in a life-threatening situation. So I think that we’re in this place where people want a very easy answer: “Is it over? Is it not over?” And the answer is, it’s really complicated.

And we’re still in this phase where every week is different. So that’s frustrating for people because they don’t know what to do. Last thing I’ll say in this very long answer: I’m really, really worried that we have absolutely no plan for a surge. We are exhausted. People think that nothing worked and actually what we did, did work, and we actually know which parts of our mitigation were really successful and that we could implement. And if we had a bad surge, what I call “VBV,” very bad variant, if we had that, we can actually do a lot better now. But I fear that we won’t.

Harlan Krumholz: So many aspects of society have evolved since the beginning of the pandemic. Work life particularly for knowledge workers, how people come into the office and so forth. How has the emergency department changed over this course? Is anything different today than it was in pre-pandemic times or did basically your life in clinically in the emergency department of bounce back to this usual chaotic, difficult, challenging job? Or have there been changes since we had this? That market has a very different experience than it was before.

Jeremy Faust: That’s a great question. Certainly there was a major change in the early days. All we saw was COVID, and everything else went away. And there was this narrative that people weren’t coming in because they weren’t getting sick. I think you and I both agree that a lot of the reason that people didn’t come in is because they weren’t getting sick. They weren’t out getting the triggers to have that heart attack or a stroke or pollution went down. So there were fewer emphysema exacerbations. Staying home was actually a far safer thing than I thought it would be. I was really worried that this shutdown would actually cause all kinds of problems. Totally turns out not to have been a big deal. When we reopened is when hell broke loose. So then in the emergency department, as time went on, you started to get this mix again.

So it was a mix of COVID and the old stuff. And what I think, the only thing that I think has changed now is that again, our new normal is to have some COVID in the background, which is just a very, very contagious disease that exacerbates other conditions. And so if you think of the ER as a body of water, the sea level has just gone up because it’s just easier for people to get sick now. And that’s my feeling is what’s changed. It’s just easier for the average person to get sick now. The practice environment I think is just as chaotic as it ever was.

I think one just very technical difference which I’m really interested in is that we used to test everyone for flu during flu season. And maybe someone would get an extended viral test to see what did they have, a rhinovirus or a seasonal corona or an adana [adenovirus infection ] or something. Now we’re testing a lot more people for different viruses all the time. And I suspect we’re going to learn a heck of a lot about what is driving all these admissions. And we’re going to learn that masking and handwashing are a hell of a lot better at keeping us sick from those things than they even are from COVID.

Howard Forman: You really are this... I’m not saying this, I try to say nice things about our guests, but I’m sincere in everything I say, but for you it’s like to a different level. You’re a great educator. By all that I’ve heard you’re a great clinician and a teacher, but your scholarly output over these last three years is nothing short of spectacular. Not just being on someone else’s paper or being involved in a project. But you’ve magnified the work that you did before, and you were a scholar before, like tenfold over these last three years. Nine of your top ten papers in terms of citations are just in 2020. And these are highly cited papers. These will be classic papers in these areas. How do you figure out going forward, let’s say that things do actually settle down. Where are you going to spend your time?

Jeremy Faust: Well, thank you. That’s really kind. I actually literally would be nobody without Harlan.

Howard Forman: I say the same thing, and he knows it’s true.

Harlan Krumholz: That’s not true. That’s not true.

Howard Forman: Twenty-six years, it’s true, he knows it, but we’re not going to go into that because he doesn’t deserve it today. But we’ll go into it at another time.

Jeremy Faust: I would be like, someone’s crazy uncle founding my fifth if it weren’t for the brainpower that Harlan and his team bring. Look, I think early in the pandemic I did a lot of thinking, linking big data and what I was seeing on the ground and putting those things together. It’s really important to not be only looking at what you see in front of you, your viewfinder, and in order to just look at numbers and not personalize it. And so linking those two things I think helped someone like me pick up a couple of insights that I thought were important and there were just niches to fill. And so to recognize where that’s at and some of where we’ve gone with the work we’ve done has just been a matter of what’s necessary. We’re not going to be the third person to say something.

Harlan and I were real early figuring out that indoor dining was a problem, and we had a really good little thing going, and then everyone else figured it out and we got scooped. And so we just abandoned it. You know what? It would’ve been a great paper, but it was just “move on.” And so where’s the need? Where’s the opportunity to make a point that no one else is making? That really drove me early on. As time has gone on, and I look towards the future, I actually have very, very... I have two distinct audiences in mind as the work goes forward. One is sort of a surge, developing an idea that we can see a surge coming and do something about it. So it is, really the idea is to develop insights that help the public and public policymakers have better outcomes when we have surges.

So that’s really where I’m focused on one area. The second area is much more meta, and it’s really designed to be written for someone reading in the year 2050. I’m really trying to document what we really know, and there’s so much garbage in terms of what we think we know and all this. That’s why I’m interested in excess mortality because it is so not going to change. No one’s going to come back and say, “No, actually you know what? There weren’t 5,000 more deaths this week than there should have been.” Like the modeling is the modeling. It is solid. We’re not wrong; if we’re wrong, we’re wrong by 1%. Whereas someone could come back and say, “Gosh, you guys really didn’t know what the heck you were talking about with how the boosters really working and in whom and who Paxlovid works on and then in whom and what long COVID is.”

And so what I do want to do, though, is to actually use really good solid methodology to document what’s actually happening and in a way that can help people understand where we’re at. So my audience, the way I think about what to do next is at the two poles, one hyper-local, like what can I do that will help someone tomorrow figure out what to do? And then on the other hand, in 30 years from now, someone’s going to open a book and be like, “So you have an outbreak, you’ve got a pandemic. What should we look for? What do these folks figure out? What do they know? What will they onto? What should we be onto?” So I’m thinking about that reader.

Harlan Krumholz: On some of the previous podcasts. I’ve talked a little bit about our work and I’ve introduced this idea that the excess mortality is a really good metric to understand the net total of the impact of the pandemic at any given point in time. But I know I can’t do as good a job as you can and explaining to people why that is such a key metric and why we should be tracking it. So I just wonder if you would just take a second just to explain why should we care about excess mortality? What does it tell us? And maybe even give a little bit of a foreshadow of some of the work you’re working on with excess mortality.

Jeremy Faust: Sure. So let me define excess mortality. It’s the difference between the number of deaths from all causes, every single death. So it’s the difference between the number of deaths that we expect to occur in a certain period of time and the number of deaths that actually occur in that period of time. And if you look in this country going back over a hundred years, epidemiologists have been tracking every single dead body literally very carefully for a long time. So we know how many people are alive and how many people are not. And so if you look at the trends of mortality from all cause, just month to month, week to week, over a hundred years, it is remarkably stable. Death is just a very predictable part of life. It’s humbling to look at these graphs that they’re so stable over time, a little bit more in January and February, a little less than, and you see these ebbs and it flows.

So if something really out of the ordinary is happening, something really historic, then the number of deaths of all causes should be expected to go up a lot. And if not, then the argument can be made that, well, these are people who would’ve died anyway. We’re just blaming it on the thing that is in the news. But the thing with all cause mortality is it cuts through that because no one is really as good at determining why someone died. As the public might imagine, we think, oh, death certificates, autopsies is really subjective. And it sounds like, oh wait, how can it be subjective? These are forensic specialists. Remember, an underlying cause of death, a single cause of death has to be on every death certificate. Someone has to say, what was the main reason they died? And all this makes it pretty difficult. Here’s the person who has got heart disease, who’s got end-stage cancer, who also got COVID pneumonia, and they were brought to the hospital with signs of all three of those things going haywire. What is that person going to be adjudicated to have died of? There’s no right answer, and there won’t even be a good agreement among specialists, among experts, among people doing an autopsy if such a thing were done.

So it’s so hard for anyone to know why anyone died, even with all the fixings of modern science. And so what we do know is this observed versus expected thing is really reliable. There just should not have been 3.3 million deaths in 2021. There should have been 2.9 million deaths in this country, 2.9. And the year before that 2.8, 2.9, 3.0, that’s where we were headed, the high 2.9 million deaths per year in the United States. And the past couple years we’ve had 3.3 million. This huge, huge increase that tells us that something historic is going on that Martians from outer space would come in and say, “Look at their death numbers. What happened in 1918? Well, what happened there?” And we say, “Oh, there was a war there.” “Oh geez, that looks like it was absolutely catastrophic. Then things got better for a long time. In fact, it looks like you guys made some scientific progress over the year. It looked like you really brought your death rates down over the century and then into the next century. And then, geez, it’s one day in September in 2001, things look bad. But then in other than that, things have looked pretty normal. Gosh, what happened in 2020? What happened in 2021? Why is this still happening in 2022? What’s with this? What happened to these people?” And we tell them about COVID.

And so that’s what excess mortality is really about. It’s about understanding if we are in a historically bad place in terms of mortality and in most parts of the country up until now, we have been since early 2020 at all times. There have been a few moments where places like Massachusetts where we had low case counts for a while, we had a high vaccination rate for a while and we got out of it, but for the most part, we’ve been in this historic moment for two years plus now.

Harlan Krumholz: That’s terrific. I don’t know Howie, if you want to jump in with anymore, but let me just say it’s been such a great pleasure to have you on. Jeremy, It’s a delight to collaborate with you. It’s been wonderful to get to know you, and I’m really happy that we’ve had a chance to have you on the podcast. So I really know your schedule’s so tight. And by the way, all this accomplishments, Howie, and with a recent new baby having arrived.

Howard Forman: Congratulations. I think I saw that on Twitter, and I forgot about that. Congrats.

Jeremy Faust: Thank you.

Harlan Krumholz: Yeah, so, very busy life. I really appreciate all the contributions you’re making in. A concert coming up, right? You got a concert?

Jeremy Faust: Yeah, I’ll plug this. This is cool. The World Doctors Orchestra, they go around like country to country, and they do concerts. These are physicians from all around the world, and they do concerts to raise money for a local charity, for a local nonprofit. They collaborate with any local orchestras that may exist, local physician or doctor orchestras. Here in Boston we have the Longwood Symphony, which is a wonderful orchestra of science and health professionals. I’ve never really worked with them much. I’ve done a little bit of work with them here and there, but I was asked to co-direct this concert at Symphony Hall this Sunday, the 18th of September with the World Docs Orchestra. So I’m conducting Stravinsky’s Firebird Suite from 1919 and Barber’s Knoxville: Summer of 1915. This is a joy. This is a board exam for me. It’s fun, but it’s mayhem also.

Howard Forman: Well, congratulations on that. Congratulations in everything you’ve done, and we’re grateful not just for participating in the podcast, but really for all the contributions you’re able to make, both on Twitter, which we didn’t even get to talk about, but where you’re able to amplify your voice and really give reason to so many topics and take the arrows from a lot of people as well, and all the scholarly work and the clinical work. So thank you very much.

Jeremy Faust: Thank you guys for having me. Really appreciate it.

Harlan Krumholz: Hey Howie, that was really great. I really enjoyed listening to Jeremy, and it’s great that we’ve been able to get guests like that, but more credit to you. You’re the one who’s booking all these people. You’re really getting a great group. So hey, what’s on your mind this week?

Howard Forman: Yeah, and by the way, all credit to you. I said before, sincerely, your work with not just Jeremy but so many people is the generativity that you embrace is tremendous and people should know it. I want to talk briefly about insulin costs. And in the interest of full disclosure, my daughter is an insulin-dependent diabetic. She takes it every day. I’m not worried about her ability to afford insulin, but I do remain concerned that large swaths of America are not as easily able to afford it. And I’m just confused about how people defend this market. The average insulin-using diabetic consumes somewhere around $6,000 of insulin annually. The average list price increased by 11% per year from 2001 to 2018 when inflation was actually quite low. And while net prices have more recently declined, they remain unaffordable to many. And there are stories really all over the place of people putting themselves at risk of long-term expensive complications just to save a few dollars here and a few dollars there so they can afford food, shelter, and other necessities of life.

U.S. patients use slightly more of what is a long-acting insulin, which you can inject once a day as opposed to multiple times during the day. And that’s more expensive. And that counts for a tiny bit of the reason why we spend more, but not nearly enough to account for the incredible discrepancy in costs per vial of insulin. So the average list price for a vial of insulin in Canada is $12, and it’s lower than that in Europe. In the United States $98, in Japan $14. Drug prices in the U.S. remain vastly higher in almost all cases than other parts of the world. But that doesn’t mean it has to cost consumers vastly larger sums. Copays, deductibles, co-insurance are generally used to ask consumers to have “skin in the game.” So in other words, we want people to be at least careful about how much they use of medications, that they should only use medications they really want.

And so we often ask them for some degree of cost sharing in choosing the medications and the doses they take. But the vast majority of prescribed drugs are not discretionary. They’re therapies that are necessary for the survival or wellbeing of that individual. And if you want to have a nominal co-insurance to reduce waste, and by nominal I mean $1, $3, or $5, you can make that argument. But when out-of-pocket spending on insulin is reaching more than $60 per month, you’re discouraging some of the most vulnerable people to forego important care.

So as we mentioned in the prior episode, Congress is now capped out-of-pocket spending for Medicare beneficiaries at $35 per month, but they could not get the 60 votes necessary to cap spending for non-Medicare beneficiaries. Senators Warnock and Baldwin have 36 Democrat co-sponsors ready to pass such a private insurance cap. A vote might come before the end of the year. There’s still much work to be done on this and for all consumer drug prices in out-of-pocket spending. And we really need to start with insulin, but start to think more about all populations, and I hope we’re going to start to see more progress here soon.

Harlan Krumholz: Thanks so much for covering that, Howie.

Howard Forman: Thanks.

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

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

Harlan Krumholz: I’m @H-M-K-Y-A-L-E, that’s “HMK Yale.”

Howard Forman: And I’m @theHowie. That’s @ T-H-E-H-O-W-I-E. You could also email us at 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

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

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