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Episode 89
Duration 36:04
Julius Chapiro

Julius Chapiro: Minimally Invasive Liver Cancer Treatment


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. This week, we’ll be speaking with Dr. Julius Chapiro. But first, we like to check in on current hot topics in health and healthcare. And Harlan, I know there was yet one more paper, a follow-up to something that you and I talked about several months ago. What are your thoughts?

Harlan Krumholz: Yeah, I just wanted to lay this out for you and the listeners. Sometimes the journals really disappoint me. They are touting the value of peer review, but sometimes I think they just fail to get the job done and in really perplexing ways. So here’s an example. A few podcasts ago, as you suggest, I talked about a relatively new cholesterol drug that was being evaluated for its effect on improving outcomes in people who are statin-intolerant, people who had trouble taking statins. In that time we were talking about this drug and I said, “I think there are a lot more people who think they can’t take statins and are actually intolerant, that we can actually coach them through it.” Remember we talked about that?

Howard Forman: Oh yeah. Look at one of our first episodes, we talked about the nocebo effect, and I think it was about the—

Harlan Krumholz: Yeah, the nocebo effect.

Howard Forman: Yeah.

Harlan Krumholz: So some people have this idea that it causes muscle issues. So anyway, God bless, there’s a company that came, it’s been working on a drug to try to create an alternative to statins, which is good. It’s good to have lots of drugs. It’s going to be hard to beat statins. They’re dirt cheap, and they’re highly effective, and most people can take them. And they’re tried and true, and so many people have been studied. So it’s a difficult thing to accomplish, but they did it. They did a study that was published in The New England Journal of Medicine, one of our best journals, presented at the American College of Cardiology, of about 14,000 patients, and these people were randomized to this bempedoic acid, which is the name of that new drug or placebo. And all these were people who attested to the fact that they had trouble taking statins.

So it was placebo comparison instead of statin comparison, because these are people who couldn’t take statins. They followed them for about 40 months, and they came out in this article that appeared in April—again, it was contemporaneous with a presentation at the major meeting—that said that for these people who took this drug, they lowered their cholesterol, and they had a modest decrease in their risk of cardiovascular disease. It was about a 15% decrease. In the study, in the subgroup analysis, they show... but in all of our trials, we often say, “Okay, but how about men versus women? How about young versus old?” We have a bunch of subgroups to see, is there any group where the drug might be working differently than it is in the other group? And to try to help us understand who might be best suited for the drug. In their subgroup analysis, so-called subgroup analysis, where they looked at different groups, they looked at a group for primary prevention, that is, people who had never had previous established heart disease, and compared it to the people who had had previous heart disease.

People who had previous heart disease are higher-risk. And most of the people in this trial were in that second group, they had had a previous heart problems. But there was a minority of them that had not had it; it was primary prevention. Anyway, what they showed was that most of this benefit was in that primary prevention group. It was a significant benefit there. But in the secondary prevention group, the people who had had heart disease, there was a non-significant difference. And it was almost like no difference at all. And it was, by the way, there are statistical tests to see whether this could have occurred by chance or not. And it was nominally significant, which meant this might be a real signal. So that’s interesting. Published in April.

So then in June, the end of June in JAMA, another top journal, this same investigator group, what they did was they peeled out the secondary prevention group, and they just published that as a standalone article. And so in that article, they’re basically touting the fact, that for this group, I’m sorry, primary prevention, for the primary prevention group, that smaller group, they were touting that there is this effect. Well, I mean, that’s the same result they just published in New England Journal of Medicine, but they’re highlighting it. But what they’re not doing is saying anything about the secondary prevention group, that larger group that didn’t have any effect.

So to summarize, in April they come out with the whole trial. They say, “We’ve got some exploratory secondary analysis, but overall you should accept the overall result of the trial as suggesting this is an effective medication.” And then in June, just two months later, they pull out the group that had the more impressive result, and they publish that in JAMA, again, touting that, “Hey, this is especially effective in this group.” But they don’t say, if you’re going to buy that, then you should also buy that. It’s not very effective in most of the people who were in the trial. And either you go one way or the other, but the reason I didn’t like it was they’re presenting half the story and it’s pretty redundant with what they already presented. So it’s just an echo.

Howard Forman: And the other story’s never getting told because nobody has self-interest in telling it.

Harlan Krumholz: Exactly. You’re not going to see a study come out, I don’t think, that’s going to say, “By the way, this is a group that this drug seems ineffective in.” Now, people will argue whether these subgroups should be ignored or actually it’s clinically relevant. It’s a fair thing to say. But if you’re going to publish a study which really highlights the one subgroup, how can you do that without pairing it with what happened to the other group? And it’s like you’re in a promotional mode if you’re going to do this.

Howard Forman: It’s disappointing. And I do think it’s the intersection of probably two things. One, that positive results get a lot of attention. And two, that we have substantial moneyed interests driving healthcare right now. And maybe it’s always been the case, but it just seems worse right now. And if there’s a lot of money behind it, it’s more likely to get press. And if there’s no money behind it, it’s less likely.

Harlan Krumholz: Yeah. And that’s going to be a good foreshadowing for what you’re going to talk about at the end of the podcast. But let’s get to the middle section with Julius Chapiro.

Howard Forman: Yeah, no, this will be great. Dr. Julius Chapiro is a radiologist by training who focuses on treating patients with liver cancer. He’s an associate professor of radiology, digestive diseases, and biomedical engineering at the Yale School of Medicine. And he also serves as a principal investigator at the Yale Interventional Oncology Research Lab. And let me point out that he is among the very rare faculty at Yale who literally went from finishing his residency to being promoted to associate professor at the same time. Usually this can take six to nine years. At Yale, Dr. Chapiro also holds coveted positions as the director of the Center for Minimally Invasive Therapies and the associate director of the Clinical and Translational Core of the Liver Center at Yale. Dr. Chapiro is known for spearheading research on quantitative imaging biomarkers for liver cancer patients. He’s written about the intersection of machine learning and artificial intelligence in treating liver cancer and is passionate about advancing molecular imaging methods to better understand tumors and their biological makeup.

He’s also an expert on minimally invasive liver cancer treatment procedures. So in addition to his positions at Yale, Dr. Chapiro works as a consultant to the Journal of Hepatology and Radiology and is part of the American College of Radiology Liver Imaging Reporting and Data Systems steering committee. He received his MD and PhD from the University of Leipzig, wrote his thesis at the University of Giessen, and went on to complete his training and diagnostic and interventional radiology at Yale New Haven Hospital, where I first came to know him.

And I could say so much more about you. I mean, you’ve got, I think I looked there was like 140 papers on Scopus at this point, which is, most people in their career with numbers that they would aspire to at that level. You’re already there at the beginning. I want to start off for our audience, because I think most people don’t even know what the field of interventional oncology is and what types of modalities you get to use to help treat people and hopefully cure them. So can you give us a little feel for what interventional oncology is?

Julius Chapiro: Yeah. Thank you for this introduction. You said a lot and, in summary, interventional oncology is the application of minimally invasive therapies under image guidance to treat cancer. And for the most part, we focus on cancers that can either not be reached by surgeons or unsafe to be treated by surgeons with open surgery, or we focus on cancers that are extremely responsive to our therapies that we use. And it all started with a guy in Oregon, actually, in the 1960s. His name is Charles Dotter, and he thought about using the natural pathways of the body, the arteries and the veins, to really reach any location in a minimally invasive fashion through the needle. And this is where a specialty started. And as interventional radiology, so the combination of imaging and surgery, as this field evolved, we have developed subspecialties. And interventional oncology is a relatively young subspecialty with a young society. And we are now seeing ourselves as the fourth pillar of cancer care, aside with surgical oncology, medical oncology, and radiation oncology. And so along this line, we offer patients really modern, minimally invasive therapies of their cancers.

Howard Forman: And you are able to thread a catheter into the liver. Is that a way you do it? Do you go in through the groin, for instance? How do you do a procedure like this?

Julius Chapiro: So all of our patients basically are done as outpatient procedures because of the minimally invasive character of these procedures. They present to our outpatient ward, and these patients then get screened and seen by us and are brought into a procedure room, where we place them on a surgical table that is surrounded by very advanced imaging equipment. And what happens there is that we select the right artery, mostly it is in the groin or we use an artery in the wrist, and then we access that artery with a tiny little needle, not much bigger than the needle that you use to place an IV. And through that, we thread a little metal wire.

It’s really, really, so tiny it’s slightly thicker than a hair, and we thread it under view, under image guidance, slightly higher and then upsize our axis to a workable diameter. And then through that, we advance plastic catheters and navigate our ways through the large arteries in the body, the aorta, all the way to a small, tiny little feeding vessel that supplies the tumor with all the nutrients, and that’s the tumor-feeding artery. And we place the catheter directly, then we simulate the injection, and then we can inject a variety of different agents to treat that cancer.

Howard Forman: And just before I hand it off to Harlan, you say a variety of different agents. How do you try to get the tumor to shrink? Are you always using chemotherapy, for instance, or are there other ways that you can reduce the size?

Julius Chapiro: So it all started with very early attempts in the 1970s, actually. The first attempts were just to occlude the artery just to block off the blood flow. And that would induce a ischemic insult, something that basically cuts the tumor off the blood supply, and that reduces the oxygen supply of the tumor and the tumors would shrink by themselves. That was very early on. And later, as we compare different outcomes and different possibilities of injecting a variety of agents, we came up with a different type of cocktail of medications and drugs, and now even radiation, that we can inject.

So nowadays what we do, we can either inject a combination of an oil that functions as a carrier for chemotherapeutics, and then we occlude the blood vessel with tiny little plastic beads, and therefore, deposit the chemotherapy in the tumor saturated very selectively without harming the surrounding liver, while at the same time cutting off the blood supply in the back. Or more recently, we started experimenting and actually now it got the FDA approved, we can deliver small little glass or resin beads that are saturated with highly active radiation. We can deposit that into the tumor and deliver internal radiation to the cancer.

Howard Forman: That’s amazing.

Julius Chapiro: And so—

Harlan Krumholz: Yeah, that’s really terrific.

Julius Chapiro: And now we’re at this interface where we have developed these techniques, but still not all of our patients respond. We still have a lot of patients that don’t really have good outcomes. And so we keep thinking of how to improve all that. So as the field has evolved from being just proceduralists that are able to inject certain things with mastery of the art into the liver tumors, we now have entered the space of molecular science, molecular imaging, where we are trying to really profile those tumors, understand the tumor microenvironments, all the contributors in the liver and in the tissue that contribute to a tumor being receptive or non-receptive, now even the immune system response. So it’s an amazing field with a lot of recent breakthroughs.

Harlan Krumholz: Truly breakthroughs. And we’re also very fortunate, Yale, Howie, we’ve got just such a terrific group of interventional radiologists. And we had a chief of radiology, Bob White, who was also a pioneer in the field. But I think what’s interesting about what Julius is saying is just the wide range of modalities and strategies that they’re able to employ. This isn’t just simply about technical skill, but it’s also about pioneering these new methodologies. But I want to move off of, for a second, the technical wonderment that is occurring around these procedures and go a little bit to these digital biomarkers that you’ve been working on, which I think are so interesting.

I mean, the fact that you’re being able to take images.... So you’re a radiologist, you take images as you always have. And the traditional thing is that a person views this, and then they identify patterns, and then they make diagnoses and produce reports that may have information about prognosis, certainly about the existence of structural abnormalities and so forth. But you’re taking this to the next level with machine learning and AI and really trying to identify things that we’re not able to see but that the machine learning and advanced analytics can help us to extract from the images. And I just wonder if you can just talk a little bit about this field, because to me, this is a really exciting field that’s going to extend the abilities of radiologists and be able to extract more actionable insights out of these images than we’ve ever done before. So can you talk a little bit about that?

Julius Chapiro: Absolutely. What really bothered me always about when I was a medical student and then earlier during my PhD thesis and later as a postdoc, when I was attending all these scientific meetings and I was looking at people presenting their trial results and their studies, and all they did with imaging in this field is just measure the diameter. They would take a simple caliper tool and apply it to the size of the tumor and see whether or not the tumor shrinks. And that was so bothersome to me.

I never understood how this can be the maximum of what we can get out in terms of predicting whether a tumor is responding. And so all that started with a journey to just focus on 3D quantitative biomarkers that we wanted to develop. What we wanted to do is we wanted to take the entire tumor at first and look at its composition, look at how it looks in different types of imaging, look how it reacts to different types of treatments and whether or not we can extract some information from it that would recommend to redo this therapy or recommend not to do this therapy and to identify whether or not a tumor responded.

And that moved then into the sphere of machine learning very quickly. When I arrived at Yale about seven years ago, I quickly understood that image post-processing and advanced image analysis is the way to go because we can extract information from imaging because it provides us with a rich amount of data that we cannot easily interpret with the human eye. And so advanced image analysis can give us the opportunity to interrogate those images for biomarkers, for shapes and forms and patterns that we can extract, that would recommend for us to do and go ahead and apply one of our therapies or not. And these things are what really matter.

And as a matter of fact, in liver cancer patients, it’s really hard to get a tissue sample sometimes. And we understand very little, in general, about the microenvironment of liver cancer. I mean, it’s a complex disease that appears on an underlyingly diseased liver background. So we don’t really know what’s going on in there, and all we can do is just extract the diameter. So over the last seven years, I have focused on creating novel tools, measuring fractions of viable tumor, correlating image appearance with what pathology might be, and then using advanced machine learning to really predict outcomes before we subject the patients to therapy. And this is where the field is going.

Harlan Krumholz: And just to break this down for people who are listening, because some of this is, I think people are just hearing, wow, you guys are doing a lot of stuff. But maybe, just realize a lot of people listening here aren’t really familiar with the field. And so as you think about this, and if you were explaining it to friends not in medicine, what’s the major breakthrough here that’s happened? What’s different now than what we were able to do, say, 10 years ago based on employing these kind of techniques?

Julius Chapiro: Yeah. So in the last 10 years, I think we’ve gone a long way. So we are now able to apply very advanced intraprocedural imaging to target the tumors much more specifically. So we’re able to save the non-affected liver very effectively. Number two, our catheter technology has improved very significantly. We now have very, very effective instruments that are very tiny, track very well. But most importantly, we are approaching a point where we can utilize all of the data from a patient, not just the tumor size, for example, or the diagnosis, but clinical information, subtle markers, lab parameters, and integrate all of the information of his history, cross-reference it with available published data and available history of other patients with similar diseases, and then make a decision on whether or not we should be going ahead and treating this patient with one or another modality to select the personalized, ultimately personalized treatment for each patient.

Harlan Krumholz: Well, this is one last thing, because I know... so this sounds amazing. How many people in America who have liver cancer, for example, actually get access to the kind of things you’ve just described? So it almost sounds like science fiction, what you’re talking about. We’re able to take all this information, process it through computers, be able to get an output that tells us exactly what this person needs, and target that issue for them with regard to their tumor and provide better outcomes. But then I’m just thinking, what percent of the people who could benefit from this actually get access to it?

Julius Chapiro: This is such an important question, and I just want to emphasize that liver cancer is one of the diseases that disproportionately affects underrepresented minorities but also people of low socioeconomic status. So this is a disease that has been abandoned, in a way, and has not had a strong national advocacy group. The history of liver cancer just frequently affects marginalized people that don’t have a very strong advocacy that would improve their screenings and make all these technologies more accessible.

Just to give you a reference number, per capita mortality, each liver cancer patient gets only 1/20 of what, for example, a prostate cancer, lung cancer, or breast cancer patient would get in terms of funding from the NIH to explore these things. So we’re talking about it, already, a severely underprivileged and disadvantaged minority of patients. And unfortunately, right now, all of these technologies are rapidly evolving. And of course, they are available at top national centers such as Yale and Memorial Sloan Kettering Cancer Center and MD Anderson [Cancer Center], and we are able to do really miraculous stuff and extend patient lives almost to twice as long as it used to be 10 years ago. But unfortunately, due to just the essence of the healthcare system and the presence of this disease in underserved areas and underserved populations, we’re unable to deliver it to a large number of patients.

Howard Forman: Can you give us a little sense, I mean, liver cancer is something that very few people really understand. I think the general public understands the idea of lung cancer; they understand the idea of colon cancer; they may know about pancreatic cancer. Very often when you hear people talk about liver cancer, they very often talk about metastatic disease. But liver cancer is caused by, as I understand it—the two most common mechanisms leading to it at least are cirrhosis due to infectious causes and cirrhosis due to non-infectious causes. And so the numbers have been increasing over time, as I understand it, even as we treat hepatitis. When you are looking at an average patient, are you seeing them to the end of life or are you curing them? What does the typical path occur once you find these patients?

Julius Chapiro: So first of all, I want to say liver cancer is, depending on the year of the stats, the second or the third most common cancer in the world, at least in terms of mortality. So it’s a very common disease. It is much more common in Asia, where hepatitis B is much more rampant. And it is also very common in sub-Saharan Africa, where we can’t get reliable numbers. But when you go there, with our exchange programs, you’ll see that every third cancer is probably a liver cancer patient. It suffers from poor screening. But the essence that makes liver cancer so complex, it’s essentially a disease two in one. So you have the underlying diseased liver, as you outlined, and in the United States, the two primary causes, historically, were viral infections, hepatitis C, but also alcoholic cirrhosis and increasingly now non-alcoholic steatohepatitis and fatty liver disease, and just obesity is contributing to the numbers as we’re able to handle the hepatitis.

But globally, primarily it’s hepatitis B as the driver. And when we see our patients, our therapies have now, I mean, they started off being palliative care and more advanced patients that are non-surgical and only amenable to local regional therapies because these patients are at the end of the line. That was 10 years ago. So now we are seeing these patients coming off screening and being diagnosed with tiny little lesions in the liver, tiny little tumors, and our local therapies have become a safe surgery in some aspects. And so we are seeing these patients from the beginning of the first diagnosis, essentially on their first day, and as we are able to control their cancer, and sometimes with some of the approaches that we go directly through the skin, we’re able to cure them.

But over time, some of these patients tend to recur. They tend to develop cancer again, and then we see them again and again. And so these relationships between us and the patients are almost throughout the course of their disease until they go to hospice sometimes. And because we’ve begun to be really good at prolonging their life, these relationships have become pretty extensive and now lead many years. So we really participate in the cancer journey of liver cancer patients, almost from the diagnosis to the very end. And nowadays, it can be sometimes 5 to 10 years.

Harlan Krumholz: Now, I wanted to ask you, I see that you’ve received some patents for some of the work that you’ve been doing. And this is a thing now, when academics produce breakthroughs there’s often now an idea about how to commercialize and really use it as a means to scale and see their application. I wonder if you could just talk about one or two of them that you think could make a significant difference in the field?

Julius Chapiro: Yeah, absolutely. So one of the first things that we did, and I learned this early on, is that when you work on a clinical issue and you want your solution or whatever proposed solution you have to reach a broad variety of people, you need to have a product that is being able to be commercialized. And so we started early on, I was very fortunate when I was working still at Johns Hopkins over a decade ago to begin a partnership with Philips, which is an imaging company that is, essentially, one of the chief vendors for our MRIs and our x-ray machines that help us deliver these therapies. So when I started working with Philips, what happened was that we understood that the tools that are available to measure tumor response really are not sufficient and not enough. So the first thing that we started developing together is a 3D quantitative tumor response instrument that is based in the picture archiving system of a radiologist and is very well integrated into the tumor board.

And that tool, it’s called Q Easel Quantitative, and we use the European Association for the Study of the Liver guidelines to name the tool Quantitative Easel, or Q Easel. That is a tool that provides you with a very intuitive 3D quantitative feedback on the size and the evolution of a tumor as you treat it. And that tool has been, then later down the road, installed on essentially every workstation of a radiologist that works with Philips. Now, the limitation here was that I have also learned is that if you work with a company, whoever the target group is, has to buy the specific product of that company. And so more recently, what we’ve started doing is we’ve started creating code, machine learning code, that we make freely accessible online and to make sure that hopefully in the future all of our innovations are not limited to just one product of one company. But one of these tools is, again, a quantitative tool to measure the tumor size in a volumetric fashion. And it has been extensively used in my published, I would say the majority of my early work, about 35 papers on that topic.

Harlan Krumholz: That’s great. Well, thank you so much for taking the time to be with us.

Howard Forman: Thanks, Julius. This has been fantastic. And it is just such a joy to know that I met you seven years ago and here you are, an associate professor, and by the way, in the clinician scientist track, which is very rare in radiology, and your trajectory is just amazing. And I look forward to following your career.

Julius Chapiro: Well, I appreciate the mentorship.

Harlan Krumholz: Congratulations.

Julius Chapiro: Thank you.

Harlan Krumholz: Well, that was a terrific interview. And I think it really just shows the power of these advances in oncology and the multidisciplinary approaches. Here’s a radiologist that are actually delivering therapies and pioneering new approaches to cancer. My only concerns, which I asked him about, was that we have all these fancy new tools—we got to be careful that this doesn’t exacerbate disparities. We got to figure out ways to ensure that people can all get access to this. But let’s get to your section now, Howie. I know I’ve already anticipated some of the topic, because I know that you’re interested in how medicine is changing and the role of money in that change. So go ahead. What’s on your mind this week?

Howard Forman: We talked about private equity firms buying physician practices very recently, mostly to highlight that the deals can sometimes go wrong. At the time, I mentioned that there were bankruptcies occurring in the assets acquired by KKR and Blackstone. These are two of the most well-known, well-funded private equity firms in the country, and they had acquired assets that went bankrupt. So put that aside for a minute. This week, a report came out from a group of academics funded by the Arnold Family Foundation highlighting greater concerns about private equity–funded physician practice acquisition. And I’ll be honest, I was very surprised by this.

So I’ll just mention a few of the highlights. One, acquisitions are growing in number and size, and in just over one decade, dramatic increase in the number of metropolitan statistical areas. These are little regions of concentrated populations achieving 30 and even 50 percent market share. So in other words, there are groups now that control 50% or more of the market in some of these areas. And these acquisitions are occurring in most specialties, not narrow anymore. Surprising to me is dermatology, ophthalmology, gastroenterology, to the top of the list. And I say it’s surprising because I talked about emergency medicine, radiology, and anesthesia. They’re not at the top of the list at this point.

There is good evidence, and when we get Zack Cooper on the podcast—and he is scheduled—he’ll talk about this, that when you get concentration at this level, when you get a large concentration owning a market space, you are going to see higher prices. And they found this as well. They make a few recommendations, mostly about regulatory oversight of further mergers and about transparency. But I think everyone is missing the bigger point. And that is that the profit motive that has always been present in physician practices, but mostly in the hands of small providers spread over small and large geographic areas and generally still having an inclination to serve a community, seem paramount over the idea of maximizing income or profit.

But the game’s changed. I don’t think there’s going back. And as I’ve expressed many times, I think that the underinsured, including Medicaid and Medicare, will eventually find themselves losing access to the largest practices. Practices like our own academic physician group at Yale will find it harder to compete with these large groups, at least partly because we’re committed to continuing to serve the underinsured and uninsured. And at some point, the system devolves to a point where it collapses on its own weight. And I’m concerned that we’re really close to this and a lot closer than people are admitting.

Harlan Krumholz: So you’re raising a really good point, but let me ask you about our commitment. So when we decide to build a new clinic, we look off to areas that have high, let me just call it like this, “high-quality insurance.” You’re going to actually be making big margins. So when we build a beautiful facility in Guilford, Connecticut, we didn’t do a needs assessment and say, “That’s where the biggest health need is.” We thought, that would be a good place to sit one because it would make sense in a business model sense. And I really do think that the nonprofits have been in a mode for a long time of facing how to basically create business models of work. And people always talk about, no margin, no mission, right? And that’s a way to cloak the business of healthcare—

Howard Forman: I don’t think it’s cloaking though, because what I think is that that has always been true and we’ve always been.... We own New Haven. We also own a big part of Bridgeport. We own urban areas. No one’s trying to take that away from us.

Harlan Krumholz: Just to be clear, what you’re saying is we own the market because there’s not competition in the market, just so anyone listening knows.

Howard Forman: But we own it because nobody wants the market, in many ways. So we have this market to provide care to underinsured, uninsured, a lot of people, and we will, we continue to go after the commercially insured. And historically, that played to our benefit. And you’re right, we were not going down Dixwell Avenue, which is a poorer area of New Haven. We were going down to Guilford, where richer individuals live, and sometimes to Fairfield County and so on. But I think that we have now seen a structural change over the last decade that may make a system like ours destined to lose money well into the future unless something gives. And I don’t have an easy answer to something giving.

Harlan Krumholz: Yeah, I mean, I don’t disagree. And I didn’t mean to... I’m not quite making a judgment on the strategic decision. I mean, I think putting a clinic in Guilford may have enabled the health system to devote more resources to areas where they weren’t going to make money. But you and I have also seen profit motive driven within nonprofits as well. I think what the difference is that, in a way, it was a little amateurish compared to the people who are just coming in and all they’re concerned about is driving value. So they’re not constrained by having a community board or having community benefits, part of it.

Howard Forman: I agree with you.

Harlan Krumholz: And by the way, I was shocked when I saw the number of cardiovascular practices that are moving into this thing. I think it’s going to be a challenge to the regulatory environment to say, and to us as citizens, what kind of health system do we really want in the end, and how is it going to best provide equity? We have such big income inequality in this country. We have big health inequality too, and it’s getting bigger.

Howard Forman: This can make it worse.

Harlan Krumholz: And the challenge for us is, how do we figure out how to address that? How do we address it?

Howard Forman: I’m worried. I mean, I’m sincerely worried. I’ve never felt this concerned. I always felt like somehow things would work out, the government steps in, competition helps. I’m sincerely worried.

Harlan Krumholz: And let’s just say that, I mean, many of us, I believe that the market doesn’t work well in an environment like this because of the way our health system is structured. The market doesn’t provide solutions because there are many people who are so incompletely insured or uninsured that it just doesn’t work.

Howard Forman: That’s right.

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 @hmkyale. That’s H-M-K Yale. Howie, we should talk about this sometime, Threads and Twitter.

Howard Forman: I know. I joined Threads.

Harlan Krumholz: I’m all confused now.

Howard Forman: I saw. And I’m @theHowie—

Harlan Krumholz: I joined Threads, but I don’t know what to do—

Howard Forman: I know I’m in the same boat.

Harlan Krumholz: No one’s there. Anyway, go ahead. Go ahead. But I’m just saying, I’m confused.

Howard Forman: I’m the same. I’m @TheHowie. That’s @T-H-E-H-O-W-I-E. You can 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 on our website at

Harlan Krumholz:Health & Veritas is produced with Yale School of Management, Yale School of Public Health. Thanks to our researchers, Inez Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. They are absolutely amazing.

Howard Forman: Yes.

Harlan Krumholz: Week in, week out. Talk to you soon, Howie.

Howard Forman:

Thanks very much, Harlan. Talk to you soon.