James Dodington: Protecting Kids from Gun Violence

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

Howard Forman: And 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. Our guest today is Dr. James Dodington. But first, we like to check in on current or hot topics in health and healthcare. What do you got?‌

Harlan Krumholz: Well, I got a couple of quick hits for you today, Howie. First, let me just start with Oscar Health, you know about Oscar Health, right?‌

Howard Forman: I do. I followed it a little bit over the last 15 years now.‌

Harlan Krumholz: So you know they came out, they had a cute campaign, they said that they were going to be really tech-oriented. I think one of the Kushners was involved at the very beginning.‌

Howard Forman: Yeah, let’s just mention where it comes from. It’s sort of, Obamacare passes and this company funded by venture capitalists, including... the other Kushner son is involved in this. And I always forget their names now.‌

Harlan Krumholz: One of those Kushners.‌

Howard Forman: One of the Kushners. But they funded it, and it was originally going to be sort of ACA exchange plans and it kept migrating to things. And I don’t even know exactly what it does now. I think it’s those still plus Medicare Advantage maybe.‌

Harlan Krumholz: Well, it attracted my attention, particularly when they hired Mark Bertolini as the CEO. He was the CEO of Aetna, a very traditional insurance company, and then they brought him in—‌

Howard Forman: Yep.‌

Harlan Krumholz: ... I think as someone with vast experience in this industry to help this company mature. Well anyway, here’s the thing. They had a standout Quarter 1 2025, beating earnings expectations and reporting significant gains in revenue, profit, operational efficiency.‌

They posted earnings per share of 92 cents, outpacing the estimates of 81 cents, reported $3 billion in revenue, a 42% increase year over year. Their net income reached $275 million, a $98 million improvement over the same quarter last year. Membership grew 41% year over year, ending the quarter with 2 million members and reinforcing its position as one of the fastest growing players in the individual insurance market.‌

Now, the CEO, like I told you, Bertolini credited the growth to innovative plan design, digital engagement. I told you that they were tech-first from the very beginning. Scalable technology, including new AI-powered tools and virtual care and case management. And then so the stock surged about 15% in pre-market trading with all this. And I think what’s just really interesting is this sort of focus on aggressive operational efficiency, technology-driven scale, disciplined pricing, membership growth with retention.‌

Anyway, it’s just something to keep an eye on because I know you’re very interested in what’s going on at United and some of the other legacy groups, and are going to talk a little bit about United later. But here’s one that really looks like doing quite well.‌

Howard Forman: Yeah, no, and look, we want to see these firms do well. We want to see them do well for their shareholders, but more importantly for the customers, the beneficiaries. It’s been frustrating ’cause there’s not too many that I have great faith in right now, but Oscar Health’s been out there 15 years. It’s nice to see they’ve migrated to a market where they’re able to make money.‌

Harlan Krumholz: Yep. So here, let me get my next quick hit, which is, we’ve talked about it before, Hims & Hers.‌

Howard Forman: Yes.‌

Harlan Krumholz: So they surged 20% last week after announcing strong Quarter 1 results and unveiling a pretty bold long-term plan. They reported a Q1 revenue up to $586 million. That’s a 111% increase year over year. And they beat their market estimates for EPS. And the biggest story here I think was that their projection for 2030, $6.5 billion in revenue, $1.3 billion in adjusted EBITDA. And I always can’t pronounce it. Howie, what is it?‌

Howard Forman: You’re close. It’s EBITDA.‌

Harlan Krumholz: EBITDA.‌

Howard Forman: I mean lot of people get it wrong. Yep.‌

Harlan Krumholz: Earnings before interest.‌

Howard Forman: Earnings before interest, taxes, depreciation and amortization.‌

Harlan Krumholz: Amortization, yeah.‌

Howard Forman: Yeah.‌

Harlan Krumholz: Thank God, you’re teaching in the business school. Look, I think what’s really interesting to me is they got part of that big bump because they were pushing all of the compounded anti-obesity drugs. But they really are trying to say their strategic levers are this personalized solutions at scale, sort of... They’re going to go to new categories like low testosterone and menopause. They’ve got long-term plays in longevity, sleep, preventive care, convenient precision care, this AI-driven coaching that they’re going to start doing. They’ve got a new deal with Novo Nordisk.‌

So even though they’re out of the compounding business... Remember when these drugs were in shortage, the FDA allowed companies like—‌

Howard Forman: And drove their earnings, right?‌

Harlan Krumholz: ... To do the compounding, but now they’ve got a deal actually with Novo Nordisk to be dealing with the real stuff.‌

Howard Forman: Yep.‌

Harlan Krumholz: And they’re going global expansion with the UK. I’m going to get to my last quick hit in a minute, which you’ll see is a big issue with them. But in all of these areas, they don’t want insurance. They want people just paying out of pocket. People apparently are paying out of pocket.‌

Howard Forman: I heard, yep.‌

Harlan Krumholz: And they’re doing stuff like... Take the sexual health stuff. They’re transitioning from on-demand meds, where people just take Viagra on-demand, to actually daily multi-condition treatments, where they’re getting people to take sort of sexual health enhancements daily as part of a regimen.‌

Howard Forman: But a lot of this is not evidence-based. And a lot of this is about the “worried well” in society, and I can’t help but be worried that this is contributing to not helping our overall healthcare system at the moment.‌

Harlan Krumholz: Yeah, certainly not clear that it’s helping people live longer. Is it helping people live better? All I can say is for sure that there are a lot of people who are becoming members of Hims & Hers and are subscribing to these things.‌

Howard Forman: Yeah.‌

Harlan Krumholz: And especially, I think young men. So let me get to that, it’s my last thing, which is one of the areas that they’ve been pushing and I have been sort of surprised to find out is, there are many, many, many men now who are going to Hims & Hers to get finasteride to treat male pattern baldness, or even preempt male pattern baldness. And this is almost becoming like a rite of passage for some people, that they’re trying to stave off baldness. And Howie, you look so beautiful.‌

Howard Forman: With my full hair.‌

Harlan Krumholz: Without hair.‌

Howard Forman: Yep.‌

Harlan Krumholz: I don’t know why anyone would want to be moving in this direction, but in fact—‌

Howard Forman: Yes.‌

Harlan Krumholz: ... many people do. So here is the thing that I thought was interesting. The European Medicines Agency this week concluded, after a comprehensive review of finasteride and dutasteride, confirmed that suicidal ideation is a side effect of finasteride tablets, particularly the one-milligram dose used for male pattern baldness.‌

Howard Forman: Right.‌

Harlan Krumholz: And there’s now going to be an update of product information, a patient alert.‌

Howard Forman: But this is—‌

Harlan Krumholz: Now this is in Europe, their FDA equivalent, which is called the EMA, the European Medicines Agency came out with this. And patients are advised to stop treatment and seek medical advice if they experience mood changes or sexual dysfunction, which also may contribute to this.‌

Now, the numbers of cases they reviewed were in the hundreds, so it’s hard to know what the exact risk is. But there is also these concerns about this post-finasteride syndrome, that includes a whole range of long-lasting effects that people are claiming are associated with the drug, and now suicide cases are among those.‌

So my question was, is everyone who’s on this drug going to receive a notification? How are people going to find out about this? And it’s the European Medicines, it’s not the FDA.‌

Howard Forman: So the FDA does have an alert. The alert went out on—‌

Harlan Krumholz: It’s in the package insert for sure. There is something about sexual dysfunction, there’s things about mood.‌

Howard Forman: April 22nd, our FDA alerted healthcare providers, compounders, and consumers of potential risks associated with compounded topical finasteride products. So the FDA is sort of on top of that aspect of it. They have not acted on the pills at all, but they are aware of side effects of finasteride and have raised it in the last just couple of weeks.‌

So look, I’m with you, but this is my point. There’s not a lot of evidence about a lot of the things they do. We use so many things that are either off-label or on the edge of label—‌

Harlan Krumholz: Yeah, the testosterone thing is going to be a real question here. If they’re going to treat—‌

Howard Forman: Low-T.‌

Harlan Krumholz: ... Low testosterone, what represents low testosterone and who’s going to get treated?‌

Howard Forman: And RFK Jr.! RFK Jr. is like the poster child for the low-testosterone, you-got-to-replace-testosterone movement. And by the way, people with high testosterone levels may be at higher risk for prostate cancer advancement. People need to be informed about all the risks of the things they’re doing, not just how they look in the mirror in the morning.‌

Harlan Krumholz: Yeah, yeah. So anyway, more to come. These are just a couple of quick hits I wanted to get your reaction to.‌

Howard Forman: No, it’s great. Yeah.‌

Harlan Krumholz: All right, let’s get to our guest. This is going to be terrific.‌

Howard Forman: Dr. James Dodington is an associate professor of Pediatric Emergency Medicine at the Yale School of Medicine, and works clinically in the Pediatric Emergency Department at Yale New Haven Hospital, where he also serves as the medical director of the Center for Injury and Violence Prevention. His research focuses on injury and violence prevention using community-based participatory research to develop violence intervention programs.‌

He’s an executive leader of the Connecticut Hospital Violence Intervention Program collaborative and serves as a member of the executive committee of the American Academy of Pediatrics Council on Injury, Violence, and Poison Prevention. He received his bachelor’s degree from Vassar College in Science, Technology, and Society, his MD degree from the Perelman School of Medicine at the University of Pennsylvania, and then completed a pediatrics residency at the Children’s Hospital of Philadelphia, before coming to Yale for a Pediatric Emergency Medicine fellowship, after which time he joined our faculty.‌

So first of all, thank you very much for joining us today. This is an incredibly important topic. We’ve heard from Joe Sakran before. We’ve heard from Megan Ranney before about gun violence. You’re specifically addressing pediatric gun violence, which in some ways is similar to adult gun violence, but in other ways, ties into so many other social ills in society, and so many things that are outside the control of the children themselves.‌

Can you give us some statistics to give us the magnitude of the problem that we’re facing, even in a state like Connecticut where gun violence is less than some other places?‌

James Dodington: Howie, to answer your question, I think we often say in this work that gun violence, firearm injuries are the leading cause of death for children and adolescents in the United States. Full stop.‌

Howard Forman: Crazy.‌

James Dodington: The Surgeon General of course put out a report on this, which has now subsequently been removed, but just referencing that great work. Something on the order, 2022 numbers, 4,600 deaths, age one to 19. That is a lot of deaths—again, from what we believe is a preventable cause. And really importantly, I think, Howie, getting to your key points here. When you look at one to 17, where many people really consider pediatrics, and then up to kind of one to 19, the drivers of those numbers are really stark.‌

One of those key drivers is firearm homicide. So for Black or African-American individuals age one to 17, those rates of firearm homicide are nearly 11 in a hundred thousand, versus those identified as White, that just barely approach one per hundred thousand.‌

Howard Forman: Wow.‌

James Dodington: So you have stark disparities and major numbers in terms of what’s driving both suicides and homicides in the United States for children and adolescents.‌

Howard Forman: And also you talk about the rural-urban divide and those exposures. What are the other risk factors for gun violence, besides race?‌

James Dodington: Yeah, so you’re exactly right. We see reflected in the pediatric and adolescent numbers, that sense that folks in the rural communities are very much at risk, higher numbers in suicide. We have seen some changes over the last few years that are rather startling. A piece published by one of my primary mentors, Dr. Lois Lee up at Boston Children’s Hospital, recently looked at rising numbers of suicides for African-American or Black females, which has been an interesting piece that has been underdescribed in the literature.‌

And then importantly, I think what we all say in this field, is that a lot of the potential solutions are known about firearm safety and securing firearms in the home, and focusing a lot on the potential community interventions and other tactics that we can use. But again, there is just very little research, there’s very little investment in this space. We are so lucky at Yale to have the arrival of Dean Megan Ranney at the School of Public Health; I’m working very closely with her in these initiatives. But again, just not enough folks involved.‌

Harlan Krumholz: I was so impressed to see this hospital-based violence intervention program that you’ve set up. And it’s really, as I understand it, an attempt to kind of bring together mental health services, case management, job assistance, housing support. Howie and I have talked about this a lot on the show, where if you really want to make an intervention in health, you have to think more broadly about the context of people’s lives and the challenges that they face. It’s not just about telling them what to do.‌

I wonder if you could just talk a little bit about where did the idea come from, how hard was it to get started? And then the one thing I noticed in the BMJ paper that was put out, was still it seemed like a low participation rate, around 12% at least, was quoted. Why can’t we get more people to avail themselves of the kind of services that you’re trying to pull together?‌

James Dodington: Participation is really hard. Those are honest numbers, but we hope that we are continuing to improve. We’ve expanded our services to look at domestic violence, intimate partner violence, which is slightly different. But it is really hard to get ahold of folks. They’re seen in our emergency department. They might have a radiograph read by Dr. Forman, but then they’re discharged and they’re back in their community, and we’re not always able to get folks to have trust in our group, to be clear, and then to come back in.‌

Howard Forman: Can you touch on the ramifications of violence beyond the victims? Because I think that’s under-discussed. I think it did come out in Dr. Murthy’s report, but just a little bit about what you see from your community-based approach as the ripple effects of violence.‌

James Dodington: Yeah, no, this is really important. I think we are just beginning to kind of peel the onion of the impacts of firearm injury. So to your point, I think one of the most important pieces that’s happened here at the Yale School of Public Health is the founding of this, FIPI, as I call it, the Firearm Injury Prevention Initiative. And I bring this forward mostly because the person I think of most, Howie, in this question is Nelba Márquez-Greene.‌

Dean Megan Ranney was able to hire Nelba Márquez-Greene, who is really a survivor-centric advocate. Nelba lost her daughter tragically in the Sandy Hook shooting, and she’s dedicated her life to doing work on behalf of survivors. And Megan, in bringing her into our initiative and work, has really centered this question, which is, what do we know about... in my case, I focus very specifically on the survivors of violent injury, but then what about their families? What about their brothers and sisters? What about those who are merely exposed? And I say “merely,” but of course it’s important, those in the neighborhood who hear gunshots at night or kids that are in schools that are experiencing lockdown drills.‌

We’re finally starting to kind of peel back that onion, as I said, to focus on those impacts. And I have to say I don’t have top-line readout in terms of what we know, but clearly the mental health impacts, and as Nelba often brings forward to me and has really helped shift my perspective, so rarely in the healthcare space are we really looking outside of that bubble of the individual patient and thinking about the impacts of the entire community. And so it’s wonderful to have the Public Health School deeply involved in this.‌

Harlan Krumholz: One thing that you’ve been part of that is, I think, really novel, and I’m curious how it has panned out, is this cash aid as a tool for recovery. And this unrestricted cash assistance, where you can try to meet people’s basic needs, housing, childcare, missed wages. I mean it’s an understanding, again, of what these people’s lives are like typically, among those who are in this situation, those who are missing it, and you’ve said, quote, “We’ve seen it help survivors meet their basic needs while supporting their psychological and emotional recovery.”‌

I wonder if you could just expand a little bit on this. Where did this idea come from? How is it being evaluated?‌

James Dodington: Yeah. Thank you so much, Harlan. That is a new passion of mine. The finance side of healthcare has not been my focus, but suddenly it was classic story. A Yale medical student, Chris Schenck, came to me during the pandemic and said, “They’re doing this cash assistance work in the pandemic.” And he brought to me an example of an organization, 4-CT is the name of the organization that was doing this. And we applied as our violence intervention program, to start a little bit of a pilot.‌

It has really grown from there, in that I would say if my team were speaking, they consider this work to be really foundational to how we approach victims of violence. It is a not large sum of money. This is often $500 that’s transferred. It is very much a transfer. We don’t touch, at the hospital, any portion of these funds. They come directly from the organization to the victim of violence. And myself and some colleagues down at Penn and those are connected to the Penn Center for Universal Basic Income and some of the folks that have really looked into this area have started to draw and help bring out some of the data they have from other, the mayor’s study that’s been done, to look at this case scenario of victims of violence, particularly domestic violence and intimate partner violence.‌

It’s been studied a little bit better, that if we meet the basic emergency financial needs of those who have been victimized, we often can allow them the bandwidth to participate in these programs. One of my colleagues, Ruth Abaya in Philadelphia, commonly says, “You can have the best program in the world and you can have all these bells and whistles and you can have art therapy and music therapy, but if those folks you’re trying to seek can’t meet their immediate needs, their ability to come to you and seek those services is so limited.”‌

And a very final point, I’d say, is that the impact on the staff providing the programmatic interventions has been incredible. And that’s a piece that we’re trying to bring forward in the qualitative work and better evaluation, is that those providing the cash assistance also feel a sense of agency, that I don’t think we really were able to describe before. To your bigger question, Harlan, the ability to evaluate this is very tough. Lots of conversations going on at a high level. There have been some RCTs [randomized controlled trials] in the utilization space, of if you give folks dollars, are they using less healthcare in certain ways? In the specific kind of thought case around victimization and emergency financial assistance, we’re trying to drill down on a way of doing this.‌

Of course, one of the big questions is ethically doing this in an RCT format, with folks who are experiencing these traumas. So looking at ways to build this into a multi-site dimension so that we can better understand the impact. I look to incredible folks at Yale. Emily Wang has done some of this work in the reentry population. There are others that are in this space. I’m excited to see more people enter, and I hope that that story of a medical student–inspired concept that becomes a core of your program really carries forward.‌

Harlan Krumholz: And just to be clear, what qualifies you for it? I mean, because you see a lot of people with gun violence. I mean which individuals... what is the criteria by which you apply?‌

James Dodington: Right. So for our smaller-sized program, you have to be a victim of violence. So you are, in a sense, one of our higher-acuity trauma patients. You have been a victim of a gunshot wound or a stabbing or high-acuity assault that’s in our program, that then allows you to get this emergency financial assistance.‌

Harlan Krumholz: Would this be like an innocent bystander? I mean, if two people were shooting at each other and they both got injured, are they qualified for this assistance?‌

James Dodington: Ah, interesting. So yes, there are some key points of how we intervene to do our work. We tend to see victims of violence that cross our threshold at the hospital and enroll as many of those as we can. To your point, there is sometimes a difficulty if those who are shooting and getting shot are kind of in the same situation. And we work very carefully with a lot of city partners to try to sort that out. And we are funded by the Victims of Crime Act dollars for our violence intervention program. And that does have a caveat that we really can’t intervene for folks that are currently incarcerated or in custody.‌

Harlan Krumholz: One other quick follow-up. Sorry, Howie, this is so interesting. I can imagine that a patient could become the family members of the person who may have become deceased through this process, and that these kind of transfers can help them manage a situation. So further pathology doesn’t grow from... I mean obviously they’re mourning, but they also are in need of assistance.‌

James Dodington: Yeah. So actually, that is a key point. One of the only other groups that we primarily serve are the next of kin of victims of homicide.‌

Harlan Krumholz: Yeah.‌

James Dodington: That has been one of the most impactful parts of this work. I have to reference my primary motivator in all this work, Mr. Pepe Vega, he leads our outreach. He was a victim of violence in our hospital, two episodes, and now has really dedicated his life and work to doing this. And so he is really—‌

Harlan Krumholz: In the hospital, somebody...?‌

James Dodington: Oh no, sorry. He was a victim who arrived to our hospital.‌

Harlan Krumholz: At the hospital. Okay, yeah.‌

James Dodington: He was treated in the hospital.‌

Howard Forman: But twice, and had a horrible interaction, even though innocent bystander it sounds, twice and was never treated appropriately. I mean we’ll put that in the show notes, but it’s a very compelling and sad story, and yet he has risen up to be an active participant in helping fix this.‌

James Dodington: Absolutely.‌

Howard Forman: I wanted to quickly also mention, you’ve not just been involved in this from a scholarly point of view and in trying to intervene, you’ve also been a great mentor to so many students. And one in particular, you and I had in common with a project that won a case competition and ultimately made some progress in the state of Connecticut, Operation Healthy Homefront.‌

Can you speak just briefly about how that it’s... I don’t know. For me, at least, it’s so special to be in a place where you have students, you have passions, and those things come together. Do you want to speak briefly about that?‌

James Dodington: Absolutely. That’s a great story, Howie. So you referenced three wonderful Yale undergraduate students, Abe, Allie, and Patryk. They came to me and Howie I think kind of jointly to work on a health policy project about combining the incredible opportunity of having veterans involved in firearm injury prevention, and they won a health policy scholars competition. And I think in my understanding of how I was as a medical student... or excuse me, an undergraduate. I assumed after that that maybe we’d be kind of done and I couldn’t have been further from the truth.‌

They came home to New Haven and dove into community partnership and advocacy. Abe, Allie, and Patryk joined with me and really helped work with one of our key community partners in this space. So the Urban Community Alliance in New Haven had already formed a program called the V.E.T.T.S. program, that was utilizing veterans in the Westville area where they were based to help do mentoring to young people. And Abe and Allie and Patryk not only dove into understanding that program and how their kind of work in health policy, their connection could assist in improving that program. But got on up to the capital, gave testimony before the Veterans Committee on behalf of funding and support for this kind of work.‌

And I’ve told them many times, distal to that, we’ve had great partnership and improvements and connection to that organization and that work. I think it’s always this testament to the incredible power you get from mentorship and support from students. They have all come back multiple times to check on things and see how things are going. And I would say in sometimes these darker times, it’s really what keeps me moving.‌

Howard Forman: And I’ll just say a brief thing, two things. One, I had nothing to do with it, other than mentioning the case competition in class, so I don’t want to take any credit for what they did. But two, they’re all graduating this week from Yale and going on to really great things. And I know that this experience for all three of them was one of the most important ones during their four years here.‌

James Dodington: Can I say one last thing to you both is, Howie, I’ve heard you say this before, but I think both of you very much represent this for me and many other folks in the faculty. But the focus on mentoring, Howie, I think your phrase is “basking in the glow of others,” that this concept that we really get so much out of the mentees that we put out in the world, and that has been so inspirational. So thank you both.‌

Howard Forman: Yeah. No, and I also don’t want to let you go without explaining to our listeners what you see day to day in the pediatric emergency room outside of gun violence, ’cause I don’t think we talk about that often enough. And how this subspecialty has evolved into a multi-modality broad-based ability to deliver care into the communities. I don’t know if you’d want to just say a brief word about that field.‌

James Dodington: Yeah, just a tiny moment. I think we in the Pediatric ED are incredibly close to Dr. Forman, because he comes to check in on us and get a little snack every so often.‌

Harlan Krumholz: Absolutely.‌

James Dodington: I don’t know if you know this, Harlan, but Howie is our favorite visitor. When he comes by he always checks—‌

Harlan Krumholz: He’s everyone’s favorite visitor. I don’t know if you know this.‌

James Dodington: He comes and checks on us clinically. It’s very much a clinical check-in, but he also may get a small snack.‌

Howard Forman: It’s the best snacks in the hospital. I’ll just say that now.‌

Harlan Krumholz: What do you entice him with? I’m just wondering, what is it that you’re offering?‌

Howard Forman: Oh, it’s bad. It’s unhealthy food.‌

James Dodington: Yeah.‌

Howard Forman: It’s ultra-processed food.‌

James Dodington: Yes.‌

Howard Forman: Honestly, Harlan, I’m trying to get the food away from the children ’cause it’s not healthy for them.‌

James Dodington: That’s right. That is... it’s a service.‌

Harlan Krumholz: Just give me a little hint. What’s an example of the ultra-processed food?‌

Howard Forman: Cinnamon Toast Crunch, lately.‌

Harlan Krumholz: Okay, there you go.‌

Howard Forman: Not good.‌

James Dodington: We try to save them for Dr. Forman.‌

Howard Forman: Not good.‌

Harlan Krumholz: He’s a hero. He’s a hero, really.‌

James Dodington: So to be clear, the Pediatric ED is really an incredible field that has grown out of some fabulous folks that founded this, now 30-odd years back. But we’re really excited in that we’re now finally seeing that this is disseminating out into the community. So we have operations at Bridgeport Hospital and Greenwich Hospital and really supporting our emergency colleagues. And I think one of our biggest points that you’ve had on Dr. Auerbach, Mark Auerbach, so much of our work is how do we educate the emergency physicians of the country to respond to pediatric emergencies that are generally lower frequency, but often sometimes very high acuity?‌

And for ER providers, we’re constantly thinking about what they face in the overcrowding and in their environment. And so we are so lucky to have a fabulous emergency medicine residency in our pediatrics residency and have great opportunities to do teaching throughout our system. So yes, thank you, Dr. Forman, for always your visits. Dr. Hummel and others, thank you for years of friendship in this work.‌

Harlan Krumholz: It’s a spectacular group that we have and we’re really lucky, and it’s wonderful to see this sort of evolve. I can remember as a resident, we would moonlight in emergency rooms. We would call there. Really there were no departments. These were in smaller hospitals, but I mean even the field of emergency medicine hadn’t really evolved.‌

James Dodington: That’s right.‌

Harlan Krumholz: And then the worst thing that would happen, a kid would come in and people really often weren’t prepared to handle that.‌

James Dodington: Yeah, right.‌

Harlan Krumholz: We have you guys here, it’s amazing. You guys do wonderful work and we want to thank for that. And also just double down on what you said about the mentoring. I think that anyone who’s a mentor knows that the benefits are really more to the mentor. That’s really what it’s all about. But what a pleasure to have you on today, what great work you’re doing, and I wish you the best going forward.‌

James Dodington: Thank you.‌

Howard Forman: Thanks very much, Jim. This was great.‌

Harlan Krumholz: Hey, that was a really great interview.‌

Howard Forman: He’s good.‌

Harlan Krumholz: And I’m glad to hear about the snacks that you take at the emergency—‌

Howard Forman: Nobody should really... It’s a little scary how bad it is.‌

Harlan Krumholz: Yeah.‌

Howard Forman: Yeah.‌

Harlan Krumholz: The more we can find out about you, the better. All right, let’s get to a favorite part of the show for me.‌

Howard Forman: Okay.‌

Harlan Krumholz: What’s on your mind this week?‌

Howard Forman: Yeah, this is a podcast sponsored by a public health school and a management school, co-hosted by two physicians. So it would be derelict for us to not comment on a healthcare company when it loses $280 billion worth of market capitalization over a six-month period. Sixty billion of it this week alone, and it’s facing lawsuits galore while its celebrity CEO mysteriously steps aside. But that’s what’s happened to UnitedHealthCare Group, a company that even after losing all of that market value is still the 22nd largest publicly traded company in the United States, and the third largest in terms of sales.

I have on numerous occasions railed against insurance companies from my personal perspective as a patient and to a lesser degree from my perspective as a physician and an administrator. And I remain very frustrated by so many things that they do. But as you know, I’ve also been outspoken in defending them when there are so many problems that contribute to our inability to efficiently deliver high-value, accessible healthcare.‌

So Andrew Witty, for those that may not know him, he’s the CEO who just stepped down. He’s a relative rockstar among CEOs. He was CEO of GlaxoSmithKline, a very large pharmaceutical company, at the age of 43, having started there as a management trainee at the age of 21. He subsequently became chancellor of the University of Nottingham in his native England, and then moved over to UnitedHealth Group subsidiary Optum in 2018 prior to ascending to the top title at UNH just four years ago.‌

After the assassination of Brian Thompson, who was the CEO of their largest subsidiary, greater and greater attention was drawn to the patterns of behavior by UnitedHealth Group, in denying care at what were described as unusual levels. And at that point, the stock had just had some disappointing earnings news but was still relatively close to its all-time high. The last several months have seen more and more bad news come out for the company and its shareholders. And just last week, shareholders filed a lawsuit against the company.‌

And I just got to read you this quote from the lawsuit directly. “The statement in paragraph 33,” which just referred to their statement about earnings, “was materially false and misleading at the time it was made, because it [had] omitted that the Company was no longer willing (as a result of heightened scrutiny against the Company as well as open hostility against the Company from large swaths of the general public) to use the aggressive anti-consumer tactics that it would need to achieve the $28.15–$28.65 in earnings per share,” and then it has adjusted earnings as well.‌

“As such, the company was deliberately reckless in doubling down on its previously issued guidance.” UNH has also had challenges from lawsuits related to its Medicare Advantage plans, the Change Healthcare hack, and many more. But just pointing out that here is a company that is sued by shareholders for not being aggressive enough—although legal experts would say that the real issue is the misleading guidance—and criticized by Congress for being too aggressive, under attack by the public for doing precisely what employers, Medicare Advantage, and even individual policyholders are asking for, and that is holding down costs of care. Yes, they are enormously profitable, even in bad years, earning tens of billions of dollars.‌

And the last point I’ll make during my shift in the emergency room, I see some of the consequences of this insurance company behavior. It becomes actually easier to pay a larger copay and come to the emergency room to get an MRI or a CT scan, than to go through the lengthy and frustrating process to get it pre-approved by an insurance company. That’s nuts. It’s not helping anyone. We absolutely need to do better, but it’s not about one company. It’s about a completely stinking healthcare system right now.‌

Harlan Krumholz: Okay. I don’t think I could disagree that there are so many different things that need to get better.‌

Howard Forman: I’m just angry, Harlan, I’m angry.‌

Harlan Krumholz: You’re an angry guy. You’re not going to take it anymore.‌

Howard Forman: No.‌

Harlan Krumholz: I think the question is, are these too big to fail? First of all, like you said, they’re still making money hand over fist.‌

Howard Forman: Yes.‌

Harlan Krumholz: I mean, it’s just remarkable, the amount of money, quarter, quarter, quarter, billions and billions of dollars. Of course the money’s coming from different sources. Some from the primary insurance companies, some from Optum itself, some from selling data—‌

Howard Forman: It’s mostly the insurance. I mean, that’s where the money’s made.‌

Harlan Krumholz: Well, but they also own a lot of practices. I mean, it’s a huge, huge ongoing concern. And we talked about Oscar before, which is very much more focused. It’s a small little gnat on the shoulder of a UnitedHealthCare.‌

Howard Forman: Yeah, right.‌

Harlan Krumholz: But they’re doing well. But what’s your concrete suggestion here, ’cause—‌

Howard Forman: Yeah. So I think about that a lot. I mean, I think that number one, we do need to hold these companies much more accountable to bad behavior. And I think the Department of Justice has done just that over the last few years, but it’s slow. The public has held UnitedHealth Group very accountable, and that’s why they’re having these problems right now, because the company is suddenly realizing that the public’s not going to take it anymore. I do have a little hope that it doesn’t have to be Oscar, it could be UnitedHealth Group, can get their act together. They need to...‌

Number one, denials are appropriate at times, but you got to give people recourse. You can’t tell somebody no and then make them wait a three-month period to adjudicate something that might have been a mistake. And that’s what they do. They delay this way too much, way too often. You also have to be able to hold accountable all the other players in the market, including the physicians, including the drug companies, including the PBMs [pharmacy benefit managers]—‌

Harlan Krumholz: Well, how about the role of the employers? I mean, look—‌

Howard Forman: Exactly.‌

Harlan Krumholz: Here’s the thing, is that in many cases they’re just acting as a fiduciary.‌

Howard Forman: Yes.‌

Harlan Krumholz: I even wonder this with Aetna. Aetna said, we’re not going to be prescribing Zepbound tirzepatide anymore from Lilly.‌

Howard Forman: Yes.‌

Harlan Krumholz: You’re going to force people on Wegovy, which is like Ozempic, which is a semaglutide.‌

Howard Forman: And they get a cheaper price.‌

Harlan Krumholz: And a study just came out that said semaglutide’s less effective than tirzepatide. But they’re kind of forcing people down an avenue and...‌

Howard Forman: But this is... again, that example is great. I almost thought about doing a whole segment on that. Do we owe everybody the best, most expensive option or are we trying to maximize healthcare? Semaglutide is dramatically better than prior anything before it. And as of right now, Zepbound is pricing themselves so much more expensive, that the trade-off is, do we want to commit to an extra thousand dollars a year, for a benefit that might on the margin only be five or 10% better for an individual?‌

And look, I actually applaud Aetna for trying to build in Wegovy into their plan in a cost-effective way. If you start building in Zepbound, Eli Lilly, I think they’re the manufacturer, right?‌

Harlan Krumholz: Lilly, yeah.‌

Howard Forman: Lilly, if they don’t want to play along and come up with a cheaper price, is that the right thing? So everybody has a part to play here.‌

Harlan Krumholz: Yeah. And I think it’s, the question is, is what you’re going to be paying for insurance going to go up, even within employer plans?‌

Howard Forman: Exactly.‌

Harlan Krumholz: But I will just say, about the anti-obesity drugs, at least we know they work.‌

Howard Forman: Yeah.‌

Harlan Krumholz: I mean, there’s so many things being done within the healthcare system that we have really no real clear evidence.‌

Howard Forman: My imaging. A lot of my imaging is of marginal benefit, but very expensive.‌

Harlan Krumholz: Yeah, that’s a good example. 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, email us at health.veritas@yale.edu or follow us on any of social media.‌

Harlan Krumholz: Yeah. And we love to get your feedback. It helps people find us. We always get back to folks who email us.‌

Howard Forman: We do.‌

Harlan Krumholz: So yeah, keep it coming.‌

Howard Forman: And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/emba. And once again, Health & Veritas will be at the Yale Innovation Summit on May 29th, with Yale School of Public Health Dean Megan Ranney subbing in for Harlan.‌

Harlan Krumholz: Subbing in. Subbing in.‌

Howard Forman: I know, who will sadly be on another continent that day. And I say this with sincerity, he will be missed, and I know he misses us as well.‌

Harlan Krumholz: I will miss you.‌

Howard Forman: But we will have a number of surprise guests and a live audience there. So please look at the Innovation Summit and come see us.‌

Harlan Krumholz: Everyone remembers Wally Pipp, right? That was the guy who was sick one day. Lou Gehrig came in and he played another...‌

Howard Forman: Luckily, Megan Ranney is probably the only person I know who’s as busy as you. So I think your job is safe, but—‌

Harlan Krumholz: I knew my job is safe.‌

Howard Forman: We’re thankful.‌

Harlan Krumholz: Health & Veritas is sponsored by the Yale School of Public Health and the Yale School of Management. We’re so fortunate to work with these superstar students like Tobias Liu and Gloria Beck and with our wonderful, remarkable producer, Miranda Shafer. And I’m thrilled and honored to be working with the Howie Forman.‌

Howard Forman: And I love working with all of you. And it’s also a great time, Harlan, to point out, as we did earlier, this is graduation week for Yale, and so many of our graduates are going to walk this next week, and Sophia Stumpf and Inès Gilles will be among them. So congratulations to them.‌

Harlan Krumholz: Way to pronounce their name, Howie. You got it. Talk to you soon, Howie.‌

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