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Episode 65
Duration 34:58

Leora Horwitz: Toward a Continuously Learning Healthcare System


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

Howard Forman: And I’m Howard Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week we’ll be speaking with Dr. Leora Horwitz. But first I wanted to ask you, Harlan, you published yet another paper in JAMA this week, two weeks in a row in fact, and this one is about timing of hospital blood draw, something I have a lot of familiarity about as being a patient. What was the point of this study, and what did you find?

Harlan Krumholz: Yeah, there’s some studies that you just want to do. It’s not like you’re necessarily building a career around but that you think are important for the profession. And one of the ones that has really motivated me over time is the experience of patients and how we can help them be in a position to succeed, to recover, to heal. What are we doing to put them in a better position so that everything else we’re doing to try to help them can fulfill its promise and that people can live long and healthy lives? One of these areas—I know it’s just a really small area—but is sleep in the hospital. And I really think if we believe that sleep is important to health, we ought to believe that it’s critical in the hospital, in the healthcare setting, and yet we routinely ignore it. We ignore its beneficial properties. We ignore its preeminence of importance.

We don’t prescribe it. We don’t say, “Hey, we really need to make sure this patient gets a good night’s sleep. We need to write in the chart, ‘Seven hours of sleep for this person, make sure that they’re uninterrupted,’” and so forth. But we just proceed on, and with noises and beeps. But one of the things is this idea of drawing blood. So people, when they finally maybe do get into a deep sleep around four or five in the morning, often someone comes into their room and sticks them with a needle for the routine and traditional blood draws so that the results are ready for the morning rounds. By the way, our morning rounds, they could be at 7, they could be at 8, by the way, they could be at 10. We could be getting around to that patient at noon. But there’s just a way of doing things.

So we wanted to look and see what was the state of this? And there are some places that have said that they’re working on this issue of trying to let people rest more in the hospital. So we just said, “Well, what if we just look over a couple years at our own experience and see what happened?” And we were able to look at over nine million blood draws in almost 100,000 hospitalized patients, and we saw that about almost 40% of the blood draws were occurring between 4:00 a.m. and 7:00 a.m., time when many people like to get some rest.

But more than that, a good percentage of them were actually occurring between 4 and 5, and 5 and 6, very early in the morning. And again, for I think people who are anxious and stressed in the hospital, it’s not like you can have someone come in, turn on the lights, stick you with a needle, obtain the specimen, that you can just go right back to sleep. I mean usually people are wired. And so this is about trying to sensitize us as a profession to say, “Maybe it’s time to really think about the therapeutic properties of rest and sleep and really incorporate that into our orders and try to make sure that people can get that rest in the hospital.” So I tweeted it. I almost never gotten so much response to a tweet. A lot of patients chiming in about their experience. And so maybe now we can get some attention to it.

Howard Forman: And you’ve written about, you’ve in fact coined the phrase, “post-hospital syndrome.” What is your feeling about how do we actually effect change? Rather than... You’ve now identified a problem. How do we effectuate change?

Harlan Krumholz: Well, let me just first say this post-hospital syndrome idea came because, as a group, we were studying readmissions. So we were very interested in this issue that a very high percentage of people, maybe one in four, one in five, once discharged from the hospital, end up coming back in within 30 days. Within 30 days, that many people end up getting so sick that they need to be hospitalized. And if you include emergency department visits, it starts to go up to almost one in three. And the question was really, well, what accounts for this? And if you look at the reasons people come back, only a minority of them are for the reason that they were initially admitted. And if you think deeply about it, you start to realize that people, when they leave the hospital, are highly vulnerable to a wide range of medical problems. And you say, “Why? Why would that be?” They were sick, of course, but also there’re so many different things they’re vulnerable to.

And one of the ideas was that it’s really the stress of the hospital, the “allostatic load,” we call it. This sort of new people, new names, malnutrition, sleep deprivation, the disturbances, all the things that happen in the hospital that stress people out. And it turns out that there’s a long literature here of how that can perturb even healthy people, and there’s whole big studies of animals, where if you put them in that kind of position, all of a sudden their metabolic and neurologic and cardiovascular, all their systems go haywire.

And so the idea was that maybe we ought to be thinking about a way to soothe people, to help it become a more healing environment. So I’ve actually, we’ve coined it, we’ve written about it. We wrote one paper that said, “Why can’t adult hospitals be more like pediatric hospitals where bright colors and they’re quiet at night and when they collect blood, they collect the bare minimum. They want to disturb people the least.” But as adults, we don’t pay attention to it. But I don’t know how we’ve had trouble spreading this, and I think it’s because hospitals are sort of set in their ways, and I don’t know, do you have thoughts about how we can get this greater awareness and bring about change?

Howard Forman: I mean, I think part of it is the conflict that exists with hospitals where on the one hand, they’re trying to be more efficient. They’re trying to do CAT scans as early as they can, trying to get the blood draws done as early enough so that clinicians will have the information in the morning. But as you point out, that ends up being in conflict with the actual core mission. So I think we need to rethink what are the priorities, and as you said, maybe we need to rethink whether we need all the blood draws we do, and maybe we need to do more point-of-care testing if we need it instantaneously as opposed to waiting a few hours. But one way or the other, I think we can do much better.

Harlan Krumholz: I think if we think about this as being toxic, that in fact we’re doing harm by having people leave so strung out. I mean, you’ve had this experience. I mean, it’s just... right? I mean, it’s like anyone who’s been in the hospital’s had this kind of experience where it really isn’t centered on making sure that you get rest, and I think that we need to think about how to change that.

Howard Forman: I agree.

Harlan Krumholz: All right. Well, let’s get onto Leora. She’s a terrific guest today, and so glad that she’s taking the time to be with us.

Howard Forman: Dr. Leora Horwitz is a tenured Professor of Population Health and Medicine at NYU Langone Health, and a practicing hospitalist. She is the founding director of the Center for Healthcare Innovation and Delivery Science and the Division of Healthcare Delivery Science in the Department of Population Health. Dr. Horwitz studies how to improve the safety and quality of healthcare delivery through a learning healthcare system and healthcare redesign. She leads the Rapid Randomized Controlled Trial (RCT) Laboratory, which aims to identify strategies to improve healthcare practice. Her research is federally funded and focuses on the value of healthcare, for example, in developing quality measures for the Centers for Medicare and Medicaid services. She’s been named an emerging leader by the National Academy of Medicine and is an elected fellow of the American Society of Clinical Investigation.

Dr. Horwitz received her bachelor’s and medical degree at Harvard University, completed her residency in internal medicine at Mount Sinai Hospital, and then came to Yale, where we met her, and she received a master’s degree in health services as a Robert Wood Johnson Clinical Scholar. She subsequently spent seven years on our faculty at Yale before moving to her current job. So first of all, I want to welcome you, and we really appreciate that you’re joining us today. And I want to start off... to be thematic about it, I was diagnosed with COVID last night by a rapid antigen test, first time I’ve ever had it, but you were at the epicenter of the pandemic right from the beginning. I remember this really well because you were suiting up to provide hospitalist care on the COVID floors right when New York was effectively Ground Zero. And then soon as you finished that, you pivoted to doing observational and randomized trials around COVID and have really made major contributions to this area. Can you tell us a little about what that experience was like right from the beginning?

Leora Horwitz: It was pretty crazy. I will remember it forever. I was actually scheduled to be on the pulmonary ward anyway, coincidentally, and it turned out that I ended up being the sole physician in charge of a COVID unit, at that time, one of 11, where the week before we had had 2 and the week after we had 15. I’m making up these numbers, but it was just so fast. It just exploded so fast. As a kid, I used to read all these books all the time about people discovering new diseases and learning about coal miner lung and things like this. I thought that was so glamorous and so exotic. And then I suddenly found myself confronted with a brand-new disease that no one had ever seen before. It was really... it was remarkable.

Howard Forman: How do you recover from that and then immediately go into your scholarly work and just pursue it as a scholar and academic does?

Leora Horwitz: Well, I think what was so striking about being on the unit is that we had no idea what to do. Even at the time, it was clear that we were not doing the right thing. I knew we were going to know more, but at the moment, we didn’t know anything. We didn’t know if steroids was a good idea. We didn’t know if intubating people, putting them on ventilators was a good idea. We didn’t know if hydroxychloroquine was a good idea. We didn’t know anything. And I was observing all these characteristics of this new disease and wondering what they meant and wondering how we should use that to treat people. And so it was a very natural pivot as soon as I got off the ward to start pulling our data and looking to see well, what is working and what is happening and what are the characteristics of people who are getting sick and getting better? And because we were at the epicenter, we had more patients than anyone in the entire country, and so we could... because we’d built an infrastructure, we could pull that data really fast.

Harlan Krumholz: It seems to me that other parts of the country never experienced what we did in the Northeast. Those very early days were sort of uniquely experienced by us. When people were gasping for air, they really were struck by a lower respiratory illness. It’s the same illness that we were reading about in Wuhan, and I had a lot of colleagues in Wuhan telling me about what was happening on the ground. They feel just very much the same.

As it spread out throughout the United States, I think that’s when the variants started evolving to the point where it started moving upward in the respiratory tract in terms of what they call its tropism, its affinity, and the disease changed. Not that it still didn’t take lives, and not that it still didn’t cause problems, but if the rest of the country had ever experienced what we did, I think there would’ve been millions and millions and tens of millions of people who had died. And it just struck me that really what we had here were that very early variant and in the manifestation, the disease was rather unique. In Northern Italy, they also experienced it. So there were certain pockets where they were afflicted by that variant, which really caused people to die of a hypoxic death in many cases. But that’s not what spread. Is that how you see this, or do you see it a little bit differently?

Leora Horwitz: Well, I do think that the way that the COVID epidemic has evolved has been really dramatic and largely good in the sense that it has evolved to be less severe. I think we were seeing not only people dying of respiratory death, but seeing people dying of clotting-related deaths and stroke and kidney failure. I was really expecting at the beginning something like pandemic flu, but that’s not what we saw at all. People had these multi-organ dysfunction that was just beyond what we were anticipating. And I agree that that luckily evolved pretty quickly, in part because of the variant, in part because of our wonderful colleagues in the UK who did these randomized trials that taught us very early what treatments were effective for very sick people, in part because of epidemiologic work that our colleagues and others did to try to learn that it was not a good idea to intubate people early and maybe we should be anticoagulating and so on. And so I think it was a combination of evolution of disease and evolution of treatment, and then of course, ultimately vaccines as well.

Harlan Krumholz: Yeah. Yeah, I agree.

Howard Forman: Your work has been centered on a continuously learning healthcare system, and so is Harlan’s, by the way. So I don’t want to... and I think a lot of commonalities in the type of work you do, but that has been a focus of what you do. How do we build off of that and make the entire healthcare system in this country more continuously learning? And why don’t you explain to our listeners a little about what that means, and what are the basic principles and values of a system that’s continuously learning?

Leora Horwitz: Yeah. Well, I’m such a nerd that I actually have this printed up and posted on my board right here, because the National Academy of Medicine created a definition of what they call a learning health system. And I’ll read it to you. It says, “In a learning health system, science, informatics, incentives, and culture are aligned for continuous improvement and innovation with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral byproduct of the delivery experience.” I love that. I literally have it on my wall because that is exactly how we should be functioning in healthcare. We should be learning all the time from the terabytes of data that we’re generating every minute, just like we did with COVID. We should be integrating that reflection and that knowledge into our usual care. We should be making it easy to do the right thing. We should be making it obvious and default to do the right thing. We should be generating new knowledge all the time.

Howard Forman: What’s the obstacle? Why is it so hard to actually do that?

Leora Horwitz: Well, we’ve designed IT systems that are not for knowledge but are for other purposes, and then made it really hard to get to those data. We have not made use of our colleagues in computer science and elsewhere who have made phenomenal strides in learning from big data. We don’t do that well enough. We don’t learn from our own patients. We don’t have any closed-loop systems to find out from them what’s important and what their experience is like so we can learn what makes it better. And most importantly, we don’t test things. We just do stuff, and we think it works, but we don’t really know that. And if you don’t test things, you cannot improve them.

Harlan Krumholz: I want to just take a second then to beat the drum of the work that you’ve been doing about these rapid randomized trials. I really consider you a leader in this area. Just before I do, do you want to just define for people what you mean by closed-loop systems?

Leora Horwitz: We don’t have good ways of finding out how our interventions change outcomes, except for some outcomes that are kind of easy to capture through blood tests and things like this. But we don’t have good ways of understanding people’s physical function, their quality of life, their experience, things like that. We have a super fragmented system where people will go elsewhere and then we never know what happens to them. We have, in every possible way, we have fragmented our care, such that we cannot put a whole picture together and really understand what’s happening.

Harlan Krumholz: And just for people listening too, I think a classic closed system would be like a Google search. So it gives you an answer and then Google can see what you click on and whether or not the order of the responses they gave you or what did you choose? And then it can get smarter that way. In medicine, because we don’t often have the outcome in front of us, we don’t get the feedback to determine, especially in real time, exactly what happened and should we improve and what should happen? So people make assumptions about how good we are, but we don’t necessarily have that closed loop. So can you just say a little bit about these rapid randomized trials, your idea about it, because I think you’re the leading proponent of this idea, of bringing this kind of testing into medicine. So what is this rapid randomized trials idea?

Leora Horwitz: Well, people have been doing randomized trials for clinical medicine since the 1950s when they were testing streptomycin for tuberculosis in the UK, and that has revolutionized our care for so many things, for childhood cancer, for heart attacks, for all kinds of things. We test “Is drug A better than drug B?” and we randomize that across people and then we figure out which drug is better, and that’s what we use. But 90-something percent of healthcare is not really about drug A versus drug B. It’s about do we get drug A, which we know to be better, to the right people at the right time, in the right format, in a patient-centered fashion? Do we get people the mammograms that we know they need? And so on and so forth. And the healthcare system, which delivers these treatments to people, organizes these treatments, we just do that stuff.

We don’t think about how we’re organizing care in the same rigorous way as we think about what care we actually should be giving. And it turns out that that’s like 90% of the problem. We might know that aspirin is the right care for heart attack, but if we’re not getting aspirin to people, then it’s not any good to know that. So what we do here at NYU is we try really hard to actually test the way in which we try to get people the care we already know to be the right thing. How should we contact a patient about their mammogram? Should we call them? Should we send them a MyChart message? Should we send them a text? What should we say in that text message? What should we write in our letter to them? What should we say on the phone call? How should we organize our electronic health record to let doctors do the right thing? What messaging should there be? What timing should there be? How do we organize it?

All of that stuff that most people just do, we actually test one versus another. One approach versus another. We call at night, we call during the daytime, we send a text, we send a message, and we learn all the time that what we think is effective turns out not effective at all, or not as resource-efficient as it could be, or so on. And so we can improve the way that we deliver care really fast that way. And we run these trials one month, two month, three months. We don’t need more than that because we have so many patients and so many interactions. We can run them quickly and we can iterate. And that’s what we’ve been doing for years. We’ve been iterating and iterating and iterating what we do in a rigorous way.

Howard Forman: NYU Langone is uniquely geographically situated with a Veterans Administration hospital on one side and a city hospital on the other. I may have it backwards, but it’s somewhat like that, with a lot of common faculty, but also specific faculty assigned to different institutions. And for our listeners, Bellevue Hospital is a part of the Health and Hospitals Corporation of New York, which is a city hospital system, a public, basically a public hospital system. And the VAS people know as part of our Veterans Administration Services. Does the work that you are doing within NYU Langone translate? How fast does it translate? Is the care equal across those three institutions?

Leora Horwitz: Yeah, I think our biggest challenge has been translation, not even just within our own five-block radius, but nationally too. And I have gotten dozens and dozens of calls from people from other places asking, “How can we do what you’re doing?” And some of that involves having an IT infrastructure and a leadership infrastructure that supports this idea of testing and supports the data production for it. And some institutions are set up better for that than others. So the city hospital system, which is a very large hospital system, dozen or so hospitals, big IT set, it’s harder to do something at just one of those hospitals than we have it here at NYU where we control our own organization. But we’ve been doing lots of partnerships with public hospitals and safety net hospitals and academic hospitals and others around the country to try to just spread the concept, to teach the skills, to think... We have a toolkit to help people think through what are some of the common barriers and challenges working with IRBs [institutional review boards] around the country. So I think it’s starting, but it’s slow.

Harlan Krumholz: I wanted to reflect on a... I know we’re kind of jumping around here, but I wanted to make sure we cover a couple things that you’ve done I think are interesting. You wrote a paper, qualitative paper—of course, you have skills both in quantitative and qualitative methods—and you said, “I’m not the same as I was before qualitative analysis of COVID-19 survivors.” And I thought it was so important because you really were able to channel the experiences and continued challenges that people are facing who’ve had relatively severe COVID. These are people who required oxygen supplementation, so they were fairly sick individuals. But in medicine we tend to think, “Okay, great, you got over your illness, move on, you’re all better.” And this is a really, I think, important paper that just again, is telling us a story about how people process that experience. By the way, I don’t think it’s exclusive to COVID-19, but it was a good opportunity. What did you learn most in the course of doing that paper?

Leora Horwitz: We started the work in May of 2020. We had just discharged our first patients with COVID and nobody was talking about long COVID yet. We didn’t know that was a thing. But we were curious. We wanted to know what happened to these people that we were so amazed that they survived and we sent them home. We called them up after a month, and then we called them up after six months. And we were really preoccupied by how their breathing was. That’s what we were really focused on. But we asked them to tell us also how they were feeling. And they told us all kinds of things well beyond that. And one of the most striking things that many people said is that their whole sense of self changed. They were exposed to this life-threatening disease, and they didn’t have confidence in their own body anymore. They felt vulnerable and uncertain in a way that they had never experienced before. And that was very moving for us. It wasn’t something that we thought about initially. That’s not what we were asking, but that’s what they told us.

Harlan Krumholz: Yeah, no, I think it’s so important that you did that. I want to reflect on another paper that we did together about a decade ago, and I continue to reflect on. Saying it’s one of the most important papers I think I’ve been involved in. You led this, was your idea to really look at the difference between what patients perceive... it was really about the quality of discharge instructions and information. I mean, we looked at the discharge summaries and said that most of it was in language laypeople couldn’t really understand.

But one of the more important things about that paper was trying to understand what did patients think just happened to them and what they were supposed to be doing, and what did the doctors and all the notes say had just happened to them? And the discordance, I don’t know if you could just reflect a minute about that paper because I keep coming back to it, because we don’t do enough of that kind of research to say where we’re sort of not really communicating properly. And it should be no surprise that when people go home, they have problems because there’s a lot of confusion on both sides.

Leora Horwitz: Yeah. My interest initially, and still to this day, has always been around this, transitions of care. As we move people through our terribly fragmented system, how do we make that work? This is a topic it’s easy for me to talk about with anybody because the second I say that to a stranger on the street, they’ll say, “Oh, let me tell you about this experience.” And so what we did is we called up people after they went home from the hospital and we just asked a few questions. We said, “Why were you in the hospital? What medicines do you have to change? What follow-up do you have?” And less than half of people could tell us why they were hospitalized, even just what their diagnosis was. A tiny minority could tell us what medications they were supposed to be taking. And this was really important because people focus a lot on the fact that people sometimes go home from the hospital and get sick and then have to come back.

And there was all this talk about, “Well, people who are sick enough to be hospitalized are probably sick enough to come back. It’s not so surprising.” But it turns out that our own structure and our own organization contributes to that. And in the spirit of trainees, sort of mentees always doing better than their mentors, I just want to plug a follow-up paper that is just about to come out also in JAMA Internal Medicine from one of my own mentees, Shreya Trivedi, who’s now at Harvard. She actually did one better than me. She sat in the patient’s room all morning on the day that they were about to be discharged and wrote down everything that people came in and said, and it is phenomenal what she discovered. The ways in which we do not communicate, the ways in which we ignore people’s concerns, the ways in which we just sort of brush them off and send them home. It was just a phenomenal study. So watch for that when it comes out.

Harlan Krumholz: Oh, we can’t wait to see it. And by the way, yeah, you are an example how mentees can outperform their mentors, and I always marvel at all the things that you’re doing and have been privileged to work with you. Let me ask you this last question, since I have Howie here, because I want you to give some advice to Howie. So you wrote a paper that was called “Tweeting into the Void: Effective Use of Social Media for Healthcare Professionals”. Tell me the three ways you think Howie can do better on his Twitter account.

Howard Forman: Yeah, tell me. Tell me.

Leora Horwitz: I’m not going to talk about the politics on your Twitter account.

Howard Forman: Smart move. Smart move.

Leora Horwitz: I think the important thing about Twitter is to always hit pause before you hit send, to be humble about it, to not get dragged down into rabbit holes of engagement, but to be genuine and to be sincere about what you’re saying. I try very hard only to tweet about things that I know something about and that I think I can convey some context for. I try very hard to make my tweets accessible to the general public—not always. Sometimes I’m tweeting about something really technical for a technical audience, but I try not to do that exclusively. I think Twitter’s a wonderful way to have science progress.

Harlan Krumholz: You just have to now keep saying “as of this moment,” because it’s—

Leora Horwitz: I do.

Howard Forman: Well, you are an incredibly generous, empathetic, compassionate physician and scholar, and it is such a joy to have you here and to see you again. And thanks very much for joining us in the Health & Veritas podcast.

Harlan Krumholz: Yeah, thanks, Leora.

Leora Horwitz: It was my pleasure. Thank you for having me.

Harlan Krumholz: It’s great to have you.

Howie, that was a great interview with Leora. Let’s pivot to your section. You and I have talked a lot about Mark Cuban’s low-cost drug company, and yesterday I saw they tweeted about a new Amazon Prime feature for low-cost generic drugs. I mean, a lot of people are calling this a breakthrough. What can you tell our listeners about what’s going on and how important it is?

Howard Forman: It has always shocked me that on the generic drug side of the market, there is still enormous variation in prices, and educated, smart people I know are spending so much money on some drugs that when you search around enough can be a lot less expensive. And so about I think a year ago, Mark Cuban started this Cost Plus Drug company or at least became an investor and a promoter of it. And he covers hundreds and hundreds of drugs at dramatically lower prices than a lot of people had access to. Now, granted, a lot of these people did not have insurance or had poor insurance, but dramatically lower, sometimes 95, 98% lower.

Harlan Krumholz: I just have a quick question for you about this, Howie. How does he do it? How do they... I mean, if it’s possible to sell drugs at that price, why isn’t everyone doing it? How can that company beat the competition?

Howard Forman: Yeah, because we have a crazy system that is so distorted by insurance that CVS is used to selling drugs for $400 because they know that the negotiated rate with the insurance company’s going to be $200 and you are going to pay 20% of that, so it’s 40. No big deal. Mark Cuban comes along and says, “I don’t want to deal with insurance at all. What’s the lowest-cost producer of that drug?” And if it’s $20, he gives it to you for $21 or a tiny little margin that he builds into it. And so is this sustainable in the long run? I can’t tell you, but in the short run, he’s making a huge difference in people’s lives. Then Amazon comes along and announces yesterday that if you’re already an Amazon Prime customer, you have to pay only $5 a month more, so $60 a year, and then you can have any one of these 50 generic drugs.

Which by the way, are drugs that you prescribe for your patients that most internists prescribe. A lot of people are on many of these drugs. You get them for free for your $5 a month, and for people that are having trouble affording healthcare expenses, this can make a huge difference. It doesn’t tackle the high cost of brand drugs that are not generic. It doesn’t help us tackle the issues around biotechnology drugs, which can be hundreds of thousands of dollars, if not millions, but it really is impressive, and I’d encourage everybody to at least look at the Amazon press release and all the drugs that are covered because it shocks me what a difference this will make for most people.

Harlan Krumholz: And what are some examples of these drugs?

Howard Forman: So it includes very common drugs like glipizide, like most blood pressure pills, simvastatin, atorvastatin, that’s Zocor and Lipitor. It includes amlodipine. I mean, these are drugs that a lot of people are on, and they’re used to spending $20 a month as a copay, and now you’re getting it for free as long as you pay your $5 a month for the subscription service.

Harlan Krumholz: So what’s the catch, then? I mean, is this entirely a good thing or is there anything offsetting? Is this going to solve the drug pricing puzzle?

Howard Forman: Yeah, there’s a couple of concerns about it. I think one concern first of all is you can’t have this unless you’re already an Amazon Prime customer, and that’s already meaning that you’re spending about $140 a [year]. It already means that you are a generally higher-income individual who’s already highly engaged with Amazon. The bigger question, Harlan, and you and I have seen this with a lot of startups in the last few years is, is it sustainable? Right now, it will save money, and in the deep pockets of Amazon, they can afford to lose hundreds of millions of dollars launching this and pulling more people in. But is it really sustainable, or in the long run, is it going to be like a lot of other things where it’ll eventually become much more expensive? But I do think it’s disruptive, and I do think it’s disruptive in a favorable way in the short run.

Harlan Krumholz: And what about Amazon? Didn’t they just buy this company that provides primary care, One Medical? I mean, what’s the future of a company like Amazon, do you think, in healthcare?

Howard Forman: Yeah. I’m convinced that Amazon is going to keep doing this. They’re going to keep offering add-on subscription benefits that will apply mostly to upper-middle-income and higher-income individuals, which is not bad for those people. I’m not opposed to it, but I don’t know that it solves a real problem of people with multiple chronic comorbid conditions, who may be disabled, who may be on Medicaid or Medicare, and I’m not sure it’s solving that. But I do think they are trying to innovate, and I think they’re hitting a part of the market that has been underserved, that being primary care.

Harlan Krumholz: It’s so interesting. I mean, the company has so dominated the retail space and now is going into the very challenging area of healthcare. We have to keep our eyes on to see what that brings.

Howard Forman: Agreed.

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

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

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

Howard Forman: And 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 out our website at

Harlan Krumholz: Health & Veritas is produced at the Yale School of Management. Thanks to our researcher, Jenny Tan, to our producer, Miranda Shafer, they are absolutely amazing. Talk to you soon, Howie. Please take care and get better soon. Sorry to hear about this COVID.

Howard Forman: Apologize for the raspy voice today.

Harlan Krumholz: Oh man, you are a trooper, baby. You are a trooper.

Howard Forman: I try. Talk to you all soon.