Dr. Mandy Cohen: Delivering Health, Not Just Healthcare

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, and we’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Mandy Cohen, but first we’d like to check in on current health news. And Harlan, what’s caught your attention this week?

Harlan Krumholz: One of the things on my mind is, what’s one of the biggest threats in the world around health? It’s war. It’s war, Howie. When do we ever talk about war being a risk factor? I mean, how many years of life lost are lost to war? There are some people who count that, but we don’t actually surface it when we think about world global threats. Are the threats that we humans pose to each other and what kind of harm we create and the number of lives that are lost as a result of what we do to each other, and probably we should be surfacing that. We talk a lot about “social determinants of health.” Isn’t this one of the major social determinants of health? I was on a call with Chinese colleagues a while ago, and we were talking about collaboration between the countries. This was after the chill had set in. But many of us who are friends and colleagues and have been working for some time had continued meeting and talking about how we might be able to afford some collaborations. And we were talking about issues of common interest.

So, for example, we’ll talk with Mandy about payment models. You know, how can we create new payment models? How is Chinese healthcare systems organized so that they can produce the greatest value? How are U.S. healthcare systems organized? But I said in the middle of that conversation to that group, how are we going to stop war between the U.S. and China? How are we going to lower the tenor of the relationship such that we’re actively preventing war? And for many of us, there was inspiration around work like Bernard Lown and others who are international physicians for the prevention of nuclear war. And that’s sort of fallen away.

But if we really think about one of the major causes of loss of life and suffering, it is this. And so as we look at Ukraine in particular, I mean, it’s riveting. I think many of us are so inspired by what we’ve seen around the strength of the population and the leadership of Zelenskyy. And many of us have now invested in learning about Ukraine. I mean, it only regained its independence in 1991. And there’s a whole history, of course, in Europe where countries actually weren’t about countries, but they were about ethnicities and nationalities. So there were lots of different groups that saw each other as unified by who they were and not by a singular idea of a constitution, like occurred in this country. But I guess I just wanted to bring up this idea about how active we need to be in figuring out how we can all live in peace and how we can avoid this kind of situation. I don’t know, this is mediated by an autocrat, and it’s hard to figure out what we could have done to stop it. But it’s on my mind around health.

There’s one other issue I wanted to raise to you, which was, what’s our responsibility as physicians and as scientists to support the quest of peace and to defend the efforts by the Ukrainians to try to resist the invasion? For example, should we be also contributing to the isolation of Russia as long as they’re going to be a rogue state and be part of this invasion?

And so I’ve heard people say, should we isolate Russian scientists, for example, should we isolate Russian science? You can see on the athletic field, people are isolating the athletes from Russia, even though they have nothing to do with the war. And even though there are many Russian scientists who’ve signed a petition at great risk to themselves to try to call for an end to war.

And so anyway, I’m part of a lot of discussions now about what the proper response is. How do we strengthen the voices of dissent within Russia that is calling for peace, for them to lay down their arms? And would it be more helpful to support them, or is it more helpful to do as the world community is now doing, isolate the country? Even though there may be harm to innocent Russians as a result because it puts pressure on the country. Or should we be saying that one of the best things we can do is still reach out to those who are like-minded? Anyway, I don’t have an answer, but I’m just saying that those are the things on my mind this week.

Eager to try to figure out what we can do in the cause of peace and what we can do to help stand with Ukraine in this moment of difficulty and challenge for them.

Howard Forman: I’ll just add to that, because I couldn’t agree more, but I’ll just add to that. That they have a small but growing polio outbreak that started before the invasion. They’re about to run out of oxygen right now. Omicron still is pretty high levels there right now.

And the invasion did surprise a lot of people. So much so that Doctors Without Borders had to suspend their operations rather than initiate humanitarian assistance. So there’s a lot of work that healthcare and humanitarian groups are going to need to do very quickly to shore up that country and do what we can to protect the lives of people there.

Harlan Krumholz: Yep. Yep. Lots of work to do.

Howard Forman: Excited to introduce Dr. Mandy Cohen. Dr. Cohen is one of our distinguished Yale Medical School alums, and I’ve eagerly followed her amazing career since that time. After completing her residency in internal medicine and an MPH degree at Harvard, she helped start Doctors for America before landing in a leadership position as deputy director for comprehensive women’s health services at the Veterans Administration.

She then joined the Centers for Medicare and Medicaid Services, or CMS, as a senior advisor, helping to implement Obamacare regulations and ultimately serving as the chief operating officer of CMS.

For the last four years, she served as secretary of the North Carolina Department of Health and Human Services. She helped advance the health of children, attack the opioid crisis, and was an outstanding national figure in fighting the COVID pandemic, helping North Carolina to have some of the best outcomes. She has been awarded and honored too many times to mention. And this week she joins Aledade Care Solutions, helping them implement value-based care solutions to thousands of primary care practices across the country.

So, first of all—

Harlan Krumholz: Wait a minute, Howard, I just want to ask you, who’s our booker? Because we get these amazing guests on the program. And then it’s just incredible, I just want the audience to know that you’re the booker, you’re the booker, because—

Howard Forman: We both work together in tandem, but we’re both fortunate to know what Mandy—

Harlan Krumholz: Mandy’s incredible. We’re lucky to have her, for sure.

Howard Forman: We are.

Mandy Cohen: Thanks, guys.

Howard Forman: And one of the themes that is obvious to me is that from the moment you started working in government and in healthcare, the incentives that drive healthcare, not necessarily physicians, but healthcare in general, make a huge difference. And whether it was working at CMS with the Innovation Center, or CMS itself and the way it reimburses, or then moving over to North Carolina and guiding the managed Medicaid contract through the 1115 waiver and now moving on to Aledade, that seems at the core of what you do. Can you tell us what motivates you about that and what you think the future brings?

Mandy Cohen: Well, first, Howie and Harlan, thanks for having me. What a great podcast. I listen all the time and learn a lot. So it’s an honor to be on. Thank you for the kind introduction as well, Howie.

I feel so lucky to have had 15 years in public service, where I also hit the jackpot of time, where the Affordable Care Act was being passed and implemented, and just got to watch so many ups and downs of that. I happened to lead through a couple of crises, so built some muscle on how to lead through some hard times, as well as some really exciting times of expansion of coverage.

But I think that you’re right in starting with thinking about incentives and payment incentives. Because I do think that is so important. It does drive how our system operates right now. The system we have, people are unhappy with it. Well, it’s just the system we have and the rules we’ve set up. And if we want a different system, we actually have to change what we pay for and how we pay for it. So I’ve always been incredibly interested in that. And it was why I was employee number 8 or 9 at the CMS Innovation Center when I joined the CMS team to think about new ways to pay for care, to see if we can get better outcomes.

Because that is, that is the North Star for me. Is how do we get health for folks? Not healthcare, I’m not interested in just buying healthcare. I want to buy health. I want grandparents to be able to run around with their grandkids. I want folks to live long, productive, fruitful lives that are happy and healthy. And that’s mental health, physical health, emotional health, all of that.

So I really do think those payment models and the incentives matter. And I’ve always been excited to think about how do you get that alignment to do the right thing for the payers, the folks that actually provide the care, whether that’s doctors or others, and great for patients. Where is that magic moment where all that can happen? And so that’s what I’ve worked for a lot.

But I will say the other part of this that I’ve learned is you can’t just tinker with policy and payment models and expect everything to fall into line. I do think there’s investments you need to make on the infrastructure side. And that’s the other part of my brain, the operator part of my brain, that thinks about, what is the infrastructure? Whether it’s data infrastructure or the relationship-building and trust-building infrastructure that you need to make those models work.

So I’ve had the opportunity to see that at the federal highest levels, to really create those frameworks. And at the state level, when we were really tactically implementing a change in our Medicaid program. That was our biggest change in moving to managed care and really deciding where we were putting new resources and building new infrastructure.

So, excited to take wherever you want to take the conversation. I’ve been lucky to see a lot of things. And I think actually my move to Aledade is really just a continuation of that mission to work in a space where there’s alignment to put primary care at the foundation of navigation for patients and care for patients and see what we can build from there.

Harlan Krumholz: Yeah, it’s an incredible path you’ve been on. I want to dig into some of those issues about payment. But I would like to ask you a little bit about your career and how did you veer in this direction? Because it’s not a natural way that physicians go. I mean, we’re focused on the patient in front of us, and to be thinking about the system is a little bit different. And so, when did you make that pivot in your mind, that I actually might go on this career path?

And then one other piece to it which is, lots of people will look at your career and the amount of impact you’ve had in such a short period of time and think, “Gosh, I could never replicate that. Like that is just, how could I possibly do that?” So for people in training, medical students, I mean, what do you tell them about getting involved?

Mandy Cohen: Sure. Well, first for me, my brain always gravitated towards system thinking before I even had a language for it. I always felt my skill sets were a bit ... I always wanted to have my feet in two different worlds. And so I never fully felt like I fit in any one world.

Early on when I was in college, I was doing an internship on Capitol Hill. I was working for the late Senator Kennedy at the time. And I ran into someone who’d become a very important mentor to me, who was leaving, being the head of CMS, it was then called HCFA, Bruce Vladeck, you may know Bruce. And I wound up spending my summer as an intern for him right as he was leaving CMS. And he was the first person that I articulated out loud. Again, I didn’t really have a language for this, I was 19, I was 20. Where I said, “I think I want to be in the field of medicine, I love this interaction with patients and the immediacy of that. But my brain keeps gravitating towards the systems changes.”

And he was the first one that validated to be like, “You absolutely should do this. You can have a foot in both worlds.” And I didn’t know what that would mean at first. And it has evolved over time, and my thinking has evolved on it.

I had thought for a long time, I’d be able to do this mix of clinical practice and systems work. But the kinds of things where I saw, what are my skill sets, what do I think my best value-add to the world is, is more around the systems thinking, the leadership, the operations. And so I gravitated towards that much more quickly.

And I would say for folks who are getting into the career now, one is read a lot, read not just New England Journal of Medicine, which is a wonderful publication, or JAMA, but read other things just about what’s going on in the business of healthcare and the other pieces of things. And then figure out how you can get exposure to different parts of medicine and policy.

I did that originally through the American College of Physicians when I was a med student. And did a lot of work in D.C. and was on some of their leadership councils. And again, it was just an exposure. You heard I worked on the Hill even before I went to med school. I did my master’s in public health while I was finishing med school. But I did it in a way that I was focused on healthcare administration. So just a different look at things.

And I would say, I learned just as much from my professors as I did from my peers. And putting yourself in situations where you can learn just as much from the students or your colleagues sitting next to you as you can from mentors and leaders who may be years ahead of you in their career.

Howard Forman: So for about 15 years now, I’ve heard people tell me that we’re going to “move from volume to value.” And by that, people mean that we’re no longer going to incentivize our hospitals and our physicians to do more; we want them to do better. As you said, deliver health, not healthcare. And you’ve been doing things along those lines for a while.

Can you give our listeners, many of whom don’t work in healthcare but have a serious interest in this, a little bit of an understanding of what you think needs to change? And maybe a little bit about how Aledade works to facilitate that change so that we can do better at delivering value and not just volume?

Mandy Cohen: Well, I think the reason we’ve been at it, and we haven’t had as much change as I’d want to see, is that the system is big, and it was built to buy pieces of things, not to buy health. It was meant to buy a CAT scan or a blood test or a physician visit. And that’s how it’s all set up. It’s the underlying infrastructure.

And so what I actually like about Aledade is that it meets the reality where it is. It’s not saying, “I wish everything were different, and we’re going to go to this idyllic place.” It’s like, “Okay, here’s the reality. We do pay for pieces.”

So how, within that context, can we create payment incentives to get some more alignment so that we think about health outcomes before we think about buying more pieces of things or additional widgets? And so I love that about Aledade.

So Aledade doesn’t own any physician practices. But they work with independent physician practices to help them succeed in different types of payment arrangements so that they can think about doing the things that I went to med school for and what I know many doctors is, we just keep our patients healthy! But sometimes you feel like the monetary system doesn’t actually reward you for keeping your patients healthy.

And I think the payment models that Aledade can bring, whether they’re Medicare shared savings models or others, says, “Okay, we just want to reward you for the things you’re doing, and then let us give you data and tools to help you do that better.” So it gives you both the incentive structure, but it then gives you the infrastructure to do that successfully.

And that’s what I’ve tried to do in my role in North Carolina, which is put in the alignment and the incentives in place in our Medicaid program but recognize that we also have to have the data and the infrastructure and the information flow to make it possible to be successful in those new models.

So in North Carolina, for example, I’ve definitely put quality incentives around whole person health and health outcomes. But we had to create an infrastructure to link together health and human services. We built something called NCCARE360, which is essentially one platform that embeds into EHRs and links to food banks and links to folks who can help with housing. The same way it links to cardiologists and endocrinologists. So that was a really important thing.

So I always want folks who think wonderfully so about policy and the levers, that’s really important, but you really also have to get into the operations and the infrastructure as well.

Harlan Krumholz: Well, one thing I was wondering as we move towards thinking about, again, how do we reward value? You wrote that you believe that policymakers should explicitly consider the effects of human service programs on health and total cost of care. This notion of paying attention to food deserts and other obstacles that people face in their everyday lives, which have important impact on their health and their ability to pursue health when confronted with health challenges.

And of course, Betsy Bradley’s written about this. Other people have talked about the importance of us taking a bigger picture. But yet it still is absent. I mean, it’s largely absent in education and in practice.

And so are you still hopeful that we’re going to be able to bridge this and that we can actually say the investments in social services can be understood part and parcel of our efforts to promote health and achieve health within society?

Mandy Cohen: I am very hopeful, Harlan. The reason is because I think you have to pair that interest with those incentives that I was just talking about. You got to get the payment model right and make folks shoot for that same outcome of total health. And make it worth it for them financially. Look, folks got to keep their businesses running. I get it.

So you first have to make the finances work. And then you have to build the infrastructure to make it possible. But I am hopeful because we are aligning those incentives, and folks are recognizing what an outsized impact food security, housing security, transportation have on someone’s ability to get their diabetic meds. So all of those things ... and get their diabetes under control, their hypertension under control, what have you.

Harlan Krumholz: I mean, even to the extent, we were talking on this program before with one of our guests about how patients who are homeless, after we spend a hundred thousand dollars in the hospital, we discharge them to the street without any real effort to try to figure out how to cushion that. With Emily Wang, we were talking about that.

Mandy Cohen: It’s insane. Yeah. So the Medicaid program specifically prevents Medicaid programs for paying for room and board. It’s in statute. You cannot pay for it. But we know it impacts your health so much.

And so that’s why in North Carolina, we went to them and asked for permission through an 1115 waiver. That’s the authority that essentially allows you to say, “I want to not follow that law, actually. And I want to do something else. Will you let me use our money and Medicaid to basically pay for room and board?”

But you have to do it in targeted, data-informed ways. So we had to very much prove to CMS to say, “Look, here’s the data we are using to show. Why wouldn’t we pay on discharge for temporary housing?”

So there are a limited set of housing services that North Carolina Medicaid is now able to pay for in that context of our 1115 waiver. There are other kinds of services, but we did it again as a waiver service. I’m hopeful that as North Carolina amasses data from that 1115 waiver, which is considered a pilot, that it can inform the larger program.

And hopefully, over time, Medicaid can change to pay for those things. I think you’re seeing Medicare Advantage and other commercial ... understand that a bit more and be more flexible, since they don’t have the same statutory constraints. But I absolutely am hopeful that that is where we need to go.

I do think that we can’t solve poverty through this. And I don’t mean to be flippant about it. This isn’t about us being able to buy stable housing for every one of the patients that we see in our healthcare system. We are going to need to be targeted and figure out what are the interventions that we need for which populations at what time. And figure how to—

Harlan Krumholz: But people may want to know that there’s a connection between poverty reduction programs and what the total cost of healthcare might be—

Mandy Cohen: A hundred percent.

Harlan Krumholz: And how those go together.

Mandy Cohen: I think that employers, particularly that have lower-wage worker populations, and they can be self-insured, they really need to look at some emerging evidence that if they just increase their salaries, they’re actually going to pay out less on their healthcare side of the ledger. So, give your workers their wages, and you pay out less in healthcare, ultimately. Because it is, poverty are so interlinked to health outcomes.

So I’m hoping to see that more in the water, if you will, to see more employers raise their minimum wage. We’ve seen a lot of health systems do it because they finally have had that data. So there are a number of health systems in North Carolina; I want to praise Atrium as one of the leaders, UNC, have raised their minimum wage for their lower-wage workers specifically because they know that it’s going to help everyone’s ultimate health outcome.

Howard Forman: Speaking of North Carolina, we’d be remiss not to talk about the extraordinary work that you did during the pandemic. I mean, if you look at the data around North Carolina, it is literally surrounded by states that performed either a little worse than North Carolina or a lot worse than North Carolina. You look across the map—North Carolina dramatically outperformed everybody around you.

What was it that you did that helped you succeed in a state that arguably is a purple state—Democratic governor, Republican legislature? Tell us about what the challenges were like and how you did as well as you did? Because you saved lives, Mandy.

Mandy Cohen: Oh, well, that’s very kind. It was a really, really hard two-plus years that I led our COVID response in North Carolina. I think it first started with, I worked for I think one of the best governors in the country in terms of his focus on evidence, data, the science supporting our work in public health. So I want to say that, first and foremost. And he and I were a great team. And that was incredible.

And I think both he and I wanted to make sure that we were incredibly transparent and communicated incredibly often with the people of North Carolina to build trust. Because it was a scary and uncertain time, and things were changing. And they’re still changing in ways where people don’t ... we’re watching science play out in real time, which is not the norm.

And I think at a time where we had a lot of mistrust in government, in science, in the media, in all of the things, we needed to work extra hard to build and maintain trust, particularly in a state that is divided politically. And I think that really mattered. So we did more than 150 press conferences in 18 months. I mean, I was in front of the camera; he was in front of the camera. I never thought in my entire life I’d be in front of a news camera with a chart and a graph every week going, “Up and down, and look at this.” But it mattered.

And it built our credibility so that when I asked folks to do something different or hard, I think that trust was there. There was always folks who were going to not agree. But that was one of it. I think the other part of it was our focus on data. And we really let the operations be driven by data. I think it’s why we were able to have an incredibly equitable response, because we prioritized collecting race and ethnicity data. We had phenomenal race and ethnicity data. So then we could use it literally on a day-to-day basis to say, “I need more testing here or vaccine there or more advertising here,” or “I need to deploy a team there.” And it all starts with having that data in real time to be responsive.

And then I had a great team that both rapidly built data infrastructure, because we did not have it going in, and then I had a team that could then analyze that data and execute on that data and change the operations around. It wasn’t always perfect. And it certainly wasn’t at the beginning. But I think because we put it at that center, that was really part of our success.

Harlan Krumholz: I wanted to just add one question in the end. I know we’re getting close on time. I’d like to hear your view on what you think about the future of primary care. There’s so many groups that are seeking to dis-intermediate the current way that things are done. You’ve got your CVS and Walgreens and Walmart. You’ve got lots of call centers that are trying to provide at least pieces of primary care. The idea that a physician will stay with you your whole life is starting to evolve as people move or just the way that particularly young people seek services.

So as you’re joining Aledade, what do you see for the future of primary care? How’s it going to go? And of course, by the way, there’s one other thing, which is, the huge companies like Optum just go in and buy practices. So, the idea of the independent primary care practice, what’s your view on it?

Mandy Cohen: Well, there are a lot of things in that question. So let me tease out—

Harlan Krumholz: That is the thing I do, by the way. Pick out any part of it you want.

Mandy Cohen: Any part of it. Well, I do want to say that I think that no one care delivery model’s going to meet everyone’s needs. I think young folks are going to be much more okay with intermittent virtual care than someone who needs longitudinal deep chronic disease management kinds of things when they need to be in person and not, or if they’re managing a cancer diagnosis. So I do think that there’s no one perfect model.

But in my mind, what I’m hoping to build is primary care for everyone to feel like they have a quarterback on their side. Someone who they can can go to.... Now, they don’t have to necessarily see that person at every moment, and it may not be in person, but they have a connection point. And that’s what I see for primary care.

But I also think that primary care practices and doctors really need to rethink, “How are we using our time? And are we using it to the highest potential of what’s going to be helping our patients and our communities be healthy? And where are the places where something like an Aledade can help a practice free up their time to use their highest potential?”

So I’m excited about what the future holds. But I don’t know that there is one model that I’m necessarily shooting for. If anything that I’ve learned in North Carolina that is different in the coast and the mountain is, you need always be allowed to have some of that regional flexibility tailored to the communities that you’re serving because folks know them well. But give them capabilities. Give them really good ability to do virtual care. Give them tools to target their patient populations with data to be like, “You know what? Mrs. Jones, we’re flagging there, she could end up in the hospital in the next four to eight weeks. You should have someone in the practice” or blah, blah. Maybe it’s a community health worker that goes to talk to Mrs. Jones because that’s who she trusts, and it’s not the doctor.

So I think there are a lot of ways for us to think about it. But at the core it’s data-informed, it’s flexible, but it feels like you have someone on your side. And I think that’s what primary care can deliver.

Harlan Krumholz: Yeah, it makes a lot of sense.

Howard Forman: You have always been on the patient’s side, I’m so impressed, from the first time I met you, probably around 20 years ago, to today, you’ve always been on the patient’s side, you’ve always been on the right side. The people in North Carolina are lucky to have had you. And Aledade’s lucky to have you now. Thanks for coming and joining us on the podcast.

Harlan Krumholz: Yeah, so appreciate it.

Mandy Cohen: Thanks. This is fun.

Harlan Krumholz: Thank you.

Mandy Cohen: Absolutely. Great to talk to you today.

Harlan Krumholz: Wow. That was a great interview with Mandy. Really remarkable person. Just thinking back to what we were talking about Ukraine. I did want to give you a chance to reflect a little bit. I think your family was originally from Ukraine. And I wonder if this has evoked any thoughts for you about this?

Howard Forman: Yeah, so a little more than 10 years ago when Google Maps became sufficiently well-populated, accurate, and searchable, I came to realize that half my family had come from what we call Ukraine now. When I was about 12, I imagine, I created an extensive family tree for my family. And I had learned that my paternal grandparents had immigrated from the towns of Pechenizhyn and Kolomyya in what I believe to be Poland or Austria, depending on the year, is what my parents always said to me. It depended on what year it was to know whose country it was in the period leading up to and after World War I. And they were effectively driven out by the pogroms and similar activities by whatever invading country was present at the time.

The region at that time was approximately 50% Jewish, and 25 years after my grandmother had left—my grandfather had left earlier—the Holocaust and World War II ended, and the Jewish population there was basically de minimus. Over a million Jews and millions of others, of Ukrainians, lost their lives in those wars, in that war or through genocide itself.

And Ukraine has recently had a Jewish prime minister and now a Jewish president. It’s absolutely an unthinkable thought from decades ago that that could possibly be the case now. But there they are. And yet again, under attack. And while we look to President Volodymyr Zelenskyy as a hero and leader, as you pointed out, I fear for his life. I fear for those of every Ukrainian.

And I think it was touching last night in the State of the Union to see how much of our nation not defined by partisanship, but how much of our nation does stand with Ukraine and realizes that they represent freedom and liberty and democracy. And in the 30 years, as you pointed out, since they became an independent country, they’ve made a lot of progress. And we’re hoping they’re not set back by this.

Harlan Krumholz: It’s really remarkable around that area of the world, at one time, so many Jews, now only about a hundred thousand Jews, about 0.2% of the population. Remarkable that there’s a Jewish president.

And I was disheartened to see that the Russians had either targeted or inadvertently hit the memorial, the Holocaust memorial, at Babi Yar. For many of us growing up, that was an important place to learn about. Where 30,000 Jews were rounded up in a couple days and killed by the Nazis into a ravine. And it was the single probably largest massacre, and not just Jews of course, Roma people, whole range of others who also suffered at the hands of the Nazis in that moment. And to have that be also hit, I mean, I know it’s not people, but the symbolism of that. And especially when Putin’s talking about de-Nazification, it just is terrible.

The one thing I will want to come on and plus-one on you with is, oh my God, what did it make you feel like to see the Congress, where actually everyone stood up? I mean, we’re so used to seeing one half standing up, the other half sitting down, no matter what’s being said, depending on who the leader is at front. And to be able to find common ground where people were unified. I’ve just found that such a touching moment that ... I know this seems silly, it’s such a small thing, but that everyone in Congress could find it within themselves to stand together. And it made me hopeful that maybe this country can find a path forward where we can find points of common ground. Because we certainly will ... we’ll be weaker if all we do is fight. And instead of seeking to find those areas where we can come together. So yeah, I feel for you. And that’s something about your family, Howie, and also the loss. Yeah. Thanks for sharing that.

Howard Forman: Thank you.

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 us on Twitter.

Harlan Krumholz: I’m at H-M-K-Y-A-L-E, that’s hmkyale.

Howard Forman: And I’m @thehowie, that’s @T-H-E-H-O-W-I-E.

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

Howard Forman: Thanks very much, Harlan, talk to you soon.