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Episode 99
Duration 32:45

Marc Auerbach: Getting Emergency Departments Kid-Ready

Howie and Harlan are joined by Marc Auerbach, a professor of pediatric emergency medicine at Yale, to discuss his work using standards and simulation to improve the treatment of children in emergency departments throughout the United States. Harlan reflects on the importance of simple, well-designed clinical trials to make rapid improvements to care; Howie reports on a congressional study asking whether the Centers for Medicare and Medicaid Innovation Center has succeeded in lowering costs and increasing quality.


Timely Clinical Trials

“Dexamethasone in Hospitalized Patients with Covid-19”

“Now is the time to fix the evidence generation system”

“The Clinical Trials Enterprise in the United States: A Call for Disruptive Innovation”

The Yale Paxlovid for Long COVID (PAX LC) Trial

Pediatric Emergency Medicine

CDC: Emergency Department Visits Among Children Aged 0–17 by Selected Characteristics: United States, 2019–2020

“Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care”

“The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physician”

Connecticut Emergency Medical Services for Children: Innovation and Improvement Center

Centers for Medicare and Medicaid Innovation Center

CMS: About the CMS Innovation Center

“Accelerating Care Delivery Transformation—The CMS Innovation Center’s Role in the Next Decade”

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.


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. We’re excited to welcome Dr. Marc Auerbach today. But first, we always like to check in on current hot topics in health and healthcare. Why don’t you just start us off, Harlan?

Harlan Krumholz: Yeah. I’m finding it a hard week, Howie, just given the events in Israel, the savagery, the loss of life. This terrorist attack is just... anyway, I just wanted to pause at the beginning of our show and just reflect that and solidarity with all people in the world who believe in good over evil.

Howard Forman: I obviously agree with you, the terrorist attack starting the weekend, and then all of the loss of innocent life that has been revealed since then has just been...

Harlan Krumholz: In the peril that we sit in the world right now. Given all of these events, just I feel it’s something we should all be thinking about.

Howard Forman: Yes.

Harlan Krumholz: I wanted to share, I had the privilege of attending a conference at JAMA, one of our leading medical journals, who convened a bunch of people to talk about how we could improve the clinical trial enterprise in the nation. And I just wanted share that with you, Howie. There were a lot of good ideas that were put out there, but the primary thing is everyone sort of focused on the fact that why was it in the UK that they could rapidly deploy a large number of clinical trials, which answered really important questions at the beginning of the pandemic in a very timely way and actually affected practice. And you juxtapose that to, first of all, our lack of performance in that area. We could not do that in the United States. We did not. We did a good job with vaccines, but I’m just talking about the treatment of people who were affected at the beginning of the pandemic with COVID.

And then we are doing so many kinds of trials that never translate into clinical practice. Some of them deserve to be translated in clinical practice, and then we failed to actually make the connection, and others actually weren’t well designed in the beginning and aren’t answering questions that are important. So there was a lot of discussion about how do we both improve the efficiency, agility, speed, the integration with clinical care. And the one thing about these trials—Martin Landry is a friend of mine, he’s at this meeting. He was one of the leaders of this group that was able to deploy these within the UK. But one of the things was, they answered the questions, very simple designs and the answers. Everyone was avid for them. And we all changed our practice as a result. So when it came out that steroid treatment for, early treatment for worked, you know what? We didn’t have to spend the next month convincing people to do it. Like every hospital in the nation said, “Great trial. We need the information, let’s act on it.” And in the same way they did a real service by showing hydroxychloroquine in Ivermectin didn’t work. Well, we’ve gotten a lot of studies around that. But anyway, what are your thoughts about this? How can we really improve the nature of this?

Howard Forman: And let’s just point out that when trials are done poorly, or even more so when you don’t have a trial and you’re using sort of a retrospective analysis of data and making inferences from it, observational studies, and when you do it poorly, it adds to the potential for misinformation. And I do think if you look at what we’ve watched with hydroxychloroquine, with other drugs out there, we have perpetuated the belief that some things work when the weight of the evidence says they don’t. But there are always going to be people who say there’s 10 or 20 studies that say it works and it contaminates the pool of information.

Harlan Krumholz: Right. So we need to be able to identify where is strong evidence coming from. We need to be able to generate the evidence, then we need to be able to make sure that people understand. And just for listeners, not everyone here has got experience in research. I mean, one of the things we’re trying to figure out is, is one thing better than another? Is one strategy better than another. And the most powerful tool that we have to do that is randomization, where we basically, people come in and we don’t know what’s best and we just flip a coin essentially and say, you got heads, so you’re going to get this, and you got tails, so you got this.

And at the end of the day, after flipping a coin enough times, we’ve got two groups that are fairly well matched by all characteristics except for the treatment that we tried. And when they did this in COVID, what they did was, people came into the ICU and immediately, as part of the care plan, the teams called up a central center and said, should this patient get A or B? And they said, this one’s A, this one’s B. And then across the country, they had enough people in A and B groups, I’m just talking about different treatments.

And then they were able to compare how they did and come up with answers that were really important. And so we want to be able to apply this as much as we can. By the way, this is just the most powerful way to reduce bias in these kinds of studies. And yet we don’t use it enough the way we do it. We make the studies too complex and too expensive and too slow. And Howie, don’t you think a lot of the incentives within the academic centers, people are so busy, clinicians are busy, it’s hard to oral patients?

Howard Forman: No, look, I think back to our episode with Leora Horwitz, where she was doing rapid cycle randomized trials, but those were a lot about process improvements and short-term interventions. We really do need this on a mammoth scale. We’re five times the size of the UK in population, and even more than that in terms of economic heft. And we actually are, I think, sit in the shadow of them in terms of our ability to create this type of evidence.

Harlan Krumholz: And I’ll just say finally, I think that this is really an imperative for redesign. Right now. Maybe 1% to 2% of people in the country have ever participated in a clinical trial. I don’t know the exact numbers, but I know it’s really low, and we should be getting to the point where everyone’s generating evidence for the next person. I always think, it’s like this is the pay it forward. Like my experience, I’m participating in studies and we create the studies that are low burden for people, people enjoy being part of, we honor and respect their participation. We actually pay them for their time, and we help them understand how they’re helping other people. And we’re just not doing that well now. But that’s my hope.

Howard Forman: Yeah, no, and it’s great that you’re participating in that. And I mean for our listeners, there are very few people that are as expert as you are on understanding the landscape of the type of research that needs to be done. It is not like every physician can run a clinical trial. It’s not like every physician can understand the methodology of these things. And we do need to create incentives for that as well. We can’t just be creating scholars who do wet lab research. We need to have people who are entrusted with doing this type of work in an ongoing and generative way.

Harlan Krumholz: Oh, you’re always too kind to me. But I just say just as a promo, and as you know, we’re doing a trial. I’m doing a trial with Akiko Iwasaki in long COVID, 15 days of Paxlovid. And we’re trying to pioneer a new approach using digital transmission of data, really trying to engage people as partners in this process. And then it’s decentralized. We’re enrolling from the entire United States. We didn’t have to make contracts with other sites. We basically direct to consumer, essentially let’s get people—

Howard Forman: Which is rare, really rare.

Harlan Krumholz: So we’re trying to pioneer some new approaches, which probably is one of the reasons I was invited to this. But anyway, yeah, more to come on this topic, but I just wanted to share some reflections from the meeting. Hey, let’s get to, I guess we have a terrific person coming today. Marc Auerbach.

Howard Forman: Dr. Marc Auerbach is a professor of pediatric emergency medicine at the Yale School of Medicine and the director of pediatric simulation at the Yale Center for Medical Simulation. With his focus on quality improvement and emergency readiness, Dr. Auerbach has held leadership roles at the state and national levels, including as the principal investigator for the Collaborative National Impact Study and as the Connecticut Center director with the Emergency Medicine Services for Children Innovation and Improvement Center. His current research centers on pediatric readiness and reducing disparities in pediatric care. He was the founding co-chair of INSPIRE, the world’s largest simulation-based research network. He holds an MD from the University of Buffalo and completed both his residency and a master of science degree at the New York University. He also completed his fellowship at NYU with the Bellevue Hospital Center. And so first, welcome to the Health & Veritas podcast. And I want to point out that I work with you.

I come and visit you when you’re on clinical service. And one of the striking things, differences that I see in pediatric emergency medicine from adult emergency medicine is on the adult side, there are big procedures being performed in high volumes on patients all the time. People are being intubated, tubes put down their throat, people are having central lines put in all the time. And pediatrics, thankfully, the severity of cases looks very different. People are not at the end of life. And so the practice of pediatric emergency medicine does not really look the same as adult emergency medicine. Do you want to just comment on some of those differences and why it’s so important to be able to make sure that we have centers of excellence for this?

Marc Auerbach: Absolutely. And thank you so much for having me today. First time guest, but longtime listener. So children are a quarter of the 140 million U.S. ED visits every year. And I think that number is pretty astounding, but what I think is even more astounding is that 92% of those children are cared for in emergency departments across this country that see less than 15 children per day, but see a whole lot of adults. So I think that children have different conditions, different treatments, but I would actually come back at you, Howie, that there is no such thing as an adult emergency physician. Every emergency physician that I train takes care of both children and adults.

Harlan Krumholz: Good point.

Marc Auerbach: Some like me are fortunate enough only to care for children every day. But the preponderance of care is provided by general emergency physicians across the country. And again, seeing 10, 15 kids per day, it’s a different dilemma than the hundreds or even sometimes thousands of adults coming into many EDs each day.

Harlan Krumholz: Great to have you on. And I understand that there’s some personal experiences you’ve had in your life that really drew you to emergency medicine, but also this notion of the importance of thinking about centers of excellence and where are standards being met for the care of kids. I don’t know if you’d be willing to talk a little bit about that, both from I guess your childhood but also in your family and things that seemed to be pretty important.

Marc Auerbach: Yeah, absolutely. I can speak to that. So as a young child, I actually had a partial amputation to one of my fingers and was in a rural hospital in upstate New York. And our family has a place up in the Lake George area, one of the most beautiful places in the world in my mind. And then many years later, actually about two years ago, was at that same cabin with my own son who was having very severe respiratory distress and was thinking back as I pulled out of the driveway, do I take a right and travel farther to an urban center that might be an hour’s or multiple hours’ drive, or do I travel 10 to 15 minutes to that rural hospital that was right near me, where unfortunately I did have some significant complications from my own experience as a child. And—

Harlan Krumholz: And just to say, was it your sense that from your childhood you go to this sort of more community hospital, that some of those complications were related to the expertise and the lack of a pediatric emergency medicine specialist there was that?

Marc Auerbach: Yeah, I don’t think the lack of a specialist, but I think a lack of a pediatric lens to how they cared for patients. So one of the things that I think was striking to me was, this surgeon and emergency physician who are much more accustomed to take care of adults. I still remember to this day that they wouldn’t take my sutures out until I stopped crying or moving. And just to think about that these days and why I got an infection is pretty clear to me now looking back as a physician. But I would say that that system of care was really built as many EDs were, to take care of adults, and every system gets exactly the results it was designed for, as Edward Deming says. And that system was designed to take care of adults based on sort of how emergency medicine was born in the United States.

Harlan Krumholz: And just fast-forward, I kind of cut you off as you were going on to the end of the story. So when you were deciding to turn right or left, how’d you make the decision and how did it turn out?

Marc Auerbach: Yeah, I made the decision that if I needed to, fortunately I had a number of those skills and knowledge bases that would be needed for my son’s care. And as I was driving down, realized this was a time-sensitive thing. Unfortunately in that area, the EMS, which we’re not talking about today, but pre-hospital is a big part of this continuum of care. And as I pulled up to the hospital and came inside, I realized that this hospital had transformed, it was truly pediatric-ready. And this was through a partnership with a regional specialty center through a University of Vermont partnership. And really I want to highlight that the centers of excellence in my mind are not where everyone needs to go for emergency care but need to be supporting their communities and their regions in optimizing care.

Howard Forman: And so what is the state of the art right now? A lot of our listeners don’t live right in New Haven or in New York or Vermont. What is the state of the art, and how can people know where they can or shouldn’t go?

Marc Auerbach: Yeah, that’s a really great question, Howie. So I think the state, state of the art from a pediatric emergency care perspective is really following the guidelines of the multi-specialty entities that have come together to say what constitutes a emergency department that’s providing high-quality care to ill and injured children. And I want to make sure to say every clinician—I’ve never met a doctor, a nurse, a nurse practitioner, or a parent that doesn’t think every child deserves the highest-quality emergency care. It’s just where resources are allocated.

So that system really is a way of saying these are the pediatric medication, supplies, equipment; this is the staffing and training—not requiring a pediatric specialist, but this is the staffing and training that the generalist nurse or generalist physicians should have. These are policies, procedures, QI interventions for pediatrics, patient safety for pediatrics. And the biggest challenge and the biggest cost of this work is something I feel very passionately about, that every ED needs to have what we call a pediatric emergency care coordinator or champion. And really that person in the back of the room in a meeting that advocates for, “Hey, I know we’re working on this policy. I know our hospital is stressed out with COVID right now, but what about the kids?”

Howard Forman: How do you measure this, though? How do you make sure that it’s not just a name assigned to a position?

Marc Auerbach: Absolutely. So we have a number of ways of measuring both the pediatric readiness. So we have a hundred-point scale that’s done every 5 to 10 years by the Health Research Service Administration, which is funded by the federal government. And the most recent grade that we were getting, if we go on a hundred-point scale, was unfortunately 69.5 out of 100. And the optimism in me says, “Hey, we improved on everything other than the having that pediatric emergency care coordinator.” But that’s also the most costly element of this work. I will flag that the real compelling argument that I’ve been able to make today that I wasn’t able to make two years ago is really based on health services research and an amazing colleague and friend, Dr. Craig Newgard, has published work showing a 60% reduction in mortality if your child is critically injured and a 76% reduction in mortality if your child’s critically ill, whatever hospital you’re presenting to.

Howard Forman: Wow.

Marc Auerbach: So a hospital that is highly pediatric-ready, rural, seeing very few patients as long as they’re following those guidelines is going to have that high survival rate.

Harlan Krumholz: It really represents a major sea change. I remember when I was in residency, internal medicine residency, my colleagues and I had opportunity to moonlight at Half Moon Bay Hospital that we saw all comers. I mean, I stopped doing that, I actually, because I just didn’t feel comfortable, but they just didn’t have the coverage. But I just think back to that time, I mean there was no preparation for us to really think about kids or how that was going to be managed. And it was kind of a dangerous situation actually, if you really think about it. Just sort of speaking to what you’re saying. I mean there wasn’t any readiness and so forth. How quickly has this happened across the country and what kind of coverage does it have? I mean, what percent of the American population has their closest emergency room now in a position where they can provide that level of care to kids and feel confident that they’re not putting them at risk?

Marc Auerbach: Yeah, that’s a really great question, Harlan. So this work is new, and the evidence to practice gap we know exists everywhere, including in health systems work. So I do want to give a shout-out to Connecticut and our connection. So Senator Lowell Weicker, who died this past summer, is actually the individual that sponsored a bill to create the Emergency Medical Services for Children program, which has now been in existence since 1984. And it’s up for reauthorization this year and his child, or grandchild, I’m sorry—his staffer’s grandchild—was in Hawaii and suffered severe sepsis and had a delayed diagnosis and a bad outcome.

And then he collaborated with Daniel Inouye and actually Orrin Hatch to create the Emergency Medical Services for Children program. So that was 1984. The pediatric readiness concept is really only since 2001. So now we are measuring, going back to 2001. I think we’ve only been improving probably since about 2010. So where the closest ED is that’s pediatric-ready, I would urge the listeners to ask that ED, “Did you do your pediatric readiness score? How are you doing? If you are doing poorly, can we help to advocate with your hospital leadership to improve pediatric readiness?” Again, we have a nice recipe for this, and it’s extremely cost-effective. So a paper that’ll be coming out this fall shows that the cost is really in the range of $5 to $50 per child. So not really talking about a high cost intervention.

Howard Forman: Can I ask, a lot of your work does involve technology, and you’ve used simulations for both training but more so even for research. Can you tell us a little about how technology is enabling a center of excellence like Yale to be able to assist other centers? How do you get involved in that, and are there parallels to telestroke, where stroke centers can work with other outlying hospitals?

Marc Auerbach: Absolutely, Howie. So the technology runs the gamut from what I would describe as somewhat complex like telecritical care. And that one is challenging because I’ve seen some health systems that have implemented that for pediatrics, but those high-acuity pediatric patients are so uncommon in these places that those sometimes collect dust and aren’t used as often. But then there’s low-cost, high-value interventions. And I would describe something very elegant and simple, like not doing math. So “math kills” is what I tell any emergency physician. Don’t do math, use an app to calculate the dose of a medication for a child.

And having an app like that readily available is an example that really is extremely low-cost and should be occurring in every ED. I know some of us, going back to med school and thinking about pediatrics rotation, you were getting at Harriet Lane and other books to try to calculate mgs per kg dosing, and this is not something we should ever be doing math for. I would describe that as the abacus of pediatric emergency care; use an app, have that dose readily available, have the equipment readily available in terms of the expertise, Howie, we have not found that access to expertise is as much of a gap as we would expect.

Howard Forman: Interesting. And can you speak very briefly to the simulation piece about how do you test competency in certain procedures that should be critically available?

Marc Auerbach: Yeah, absolutely. So simulation can be used to train and educate people. I think a lot of people are familiar with flight simulators and NASA and healthcare simulation. I would also advocate that in the automotive industry as well as the aviation industry, simulators can be used to test systems.

Howard Forman: Yes.

Marc Auerbach: So we have brought simulators to hundreds of EDs across the country and have been able to look at what were the barriers to high-quality emergency care for resuscitating acutely ill and injured child. And we found that actually the knowledge gap that you are mentioning or the specialty care that we think may be a gap is not as much of a gap. It’s more often finding that equipment, making sure that equipment’s functioning and having all the resources, like I mentioned, of an app and things of that nature.

Howard Forman: I apologize in advance for asking you this question with just a couple of minutes left. Knowing that we can do two full episodes on it, but I would be remiss not to ask you what you’re seeing in the pediatric emergency room with regard to our mental health crisis among youth. And if you could just comment on how different it is now versus the past and what are the things that you’ve observed that are either getting better or worse right now?

Marc Auerbach: Yeah, Howie. So this is a really trying time in pediatric mental health care. I will put a plug in for the Emergency Medical Services for Children Innovation and Improvement Center, which, again, is coming up for reauthorization. There’s a national collaborative that they have put together of community hospital emergency departments who are actually suffering the burden of this quite a bit more than we are at Yale. So I go out to a lot of community hospitals in my work, and we complain when we have children that are boarding for a day or two, which is very sad that children with mental health issues are treated differently than children with medical issues. But some of these hospitals will have six, seven days because EMTALA, which is the Emergency Medical Treatment and Labor Act, these mental health patients are thought about a little differently. And I wanted to give you a somewhat short answer.

So I will say that within our emergency department, we are working on upskilling our staff related to mental health, using things like simulation, working to address disparities in how we address these children. Particularly work done by our group here has recognized that the way that we use physical restraints or chemical restraints for minoritized populations is quite different than for White affluent patients. But coming together with the simulation, this is again a skill that during my training, we didn’t really deal too much, even though I was at Bellevue, big psych institution, psych came down and saw those patients. Now I’m needing to deal with this quite a bit more frequently as an emergency physician. And by doing trainings and simulation, we have been able to show that we are able to reduce the use of inappropriate restraints and hopefully improve the equity and use of restraints.

Howard Forman: I’ve known you since the first week you came to Yale, and you are a fantastic clinician. You’re a kind, compassionate person, and you are a subject matter expert, and we are so grateful to have you join us.

Harlan Krumholz: Oh, yeah, thank you so much. What a treat.

Marc Auerbach: Thank you so much. It’s been an honor and thanks for all you guys are doing to support my work and others at Yale. Really a great knowing you and working with you.

Howard Forman: Thanks, Marc.

Harlan Krumholz: Thank you so much.

Howard Forman: So you and I always talk right before the podcast and think about what to talk about. You suggested this topic, which is just awesome. So let me just give a little background to our listeners, and then we’ll talk a little about it. The Congressional Budget Office, which is the nonpartisan budgeting and research arm of Congress, recently issued an update on the budgeting of the Centers for Medicare and Medicaid Innovation Center, known as CMMI, sometimes also called CMI.

CMMI was authorized in the original Affordable Care Act—that’s Obamacare—to test innovative payment and service delivery models in order to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals in the Medicare or Medicaid programs. In other words, they were open to increasing quality as long as it didn’t increase cost, they were open to decreasing cost as long as it didn’t decrease quality or both. The one thing they were not authorized to consider were programs that would increase quality [and increase cost] even if the increase in cost was small. So no matter how cost-effective it might be, if it was increasing cost, if it was increasing cost and quality, that was not in the category, it had to be one without the other in order to satisfy this.

Harlan Krumholz: So Howie, these were really cost containment innovations. That’s what they were trying to do. Yes.

Howard Forman: Yes. The CBO looked at the first 10 years of the program and compared it with the expected costs as enumerated by the CBO at the time. So the initial expectation was that for the first 10 years, which is what we’re measuring now, they would have savings of $2.8 billion. And what actually turned out to be the case, at least by their estimate, is a net cost, not a savings of $5.4 billion. The original expectations for the next 10 years, the second 10 years was predicted to be a net savings of $77.5 billion. That’s an enormous amount. Now it’s expected to be a net cost of 1.3 billion. It is not that there has not been some significant successes; it’s just that these are so far, few and far between and getting lower savings is harder than we thought. It’s hard, and we can’t pretend otherwise. Now, I want to point out for our listeners, you were at least considering briefly being at the head of this organization when it first launched. You have a lot of experience thinking about this. Tell me your thoughts on this.

Harlan Krumholz: Yeah, there’s a whole long story about that other part because careers take different courses and that was a hard decision to not pursue that. But the CMMI, I’m very avid about, look, Congress put into the Affordable Care Act this idea that innovation could exist within Medicare and that they should try new programs. But I think the point you made was the most important, which it turns out to be hard, right? To mount these programs, to really evaluate them. And saving money is challenging even when you, within the context of a very creative program, can try to create incentives that should get people focusing on value in squeezing out the waste in our system. And I don’t know, Howie, do you think it speaks to how deeply entrenched that waste is, both psychologically with the way we practice, but just in terms of the vested interest sort of pushing on us so that it turns out to be very difficult to kind of transform the system because there’s so much inertia in it?

Howard Forman: So I hate to say this too much, because we obviously don’t have a rich literature to back it up, but I think there are a lot of factors, including the ones you mentioned. I think some of it’s culture, I think it’s very hard to change the culture of physicians and other people have practiced medicine in a short time period. So some of the things we may have done now may have long-term positive effects, but it’s not being captured in the current budget situation.

And the other thing they’re not mapping out, which goes back to our last episode or maybe two episodes ago when we talked about the North Carolina project on social determinants of health, is it may be the case that we’re not saving the money in emergency room spending or ambulance spending, but maybe these people are back to work earlier, or maybe these people are living healthier lives in other ways and they’re going to live a year longer because of these programs. And maybe I’m being too optimistic here, but it’s also important for people to realize that budgets matter about which perspective you’re taking. And this one takes a very narrow federal Medicare budget perspective and Medicaid budget perspective.

Harlan Krumholz: First of all, no one should consider that CMI has not been a success. Look, it has engendered a lot of experiments. There’s a lot of new ideas that have been put out there. By the way, a lot of talented individuals have gotten trained through CMMI and are in other areas where they’re innovating in healthcare. I think it’s been a great success. I think it’s a great example of how government can embed this in a way where they can try new things. I mean, my concern is that you’re grafting new approaches on an old infrastructure that’s in a survey. So even when we’ve done some of these things, I think that it’s been a mixed, I have some fee-for-service patients. I have some of these patients in these programs. It doesn’t sort of change the fundamental way that the system’s working.

Howard Forman: Look, so you and I are a little different in this way. I accept how bad our system is and want to make it better and realize that it’s just going to be hard. You are always going to hope that we’re going to get a better system delivered to us. I don’t think we’re that far apart, but I think for me at least, I accept that this is sclerosis, as Zeke Emanuel likes to talk about it. And you don’t get rid of sclerosis all at once. You’re going to work through it. But what I do think is, we are probably not imagining how much impact this is having. We’re just looking at it in a budgetary right now.

Harlan Krumholz: I think it’s a great, great dream. Yeah.

Howard Forman: And look, the one thing I pray that does not happen, and it is always on the table, is that Congress does not defund something like this. Because I agree that this may not be, first of all, it doesn’t cost a lot right now. Even the net cost is still not a lot. In the grand scheme of a trillion-dollar budget, a net cost of maybe $250 million a year is not a lot of money. But I really hope that Congress, particularly with their budgetary austerity right now, does not try to whack this away. That would be a big mistake.

Harlan Krumholz: Liz Fowler’s great. She’s leading it. Our colleague Susanna Bernheim went to go work at CMI that’s, she’s doing great work there. And I just think, again, it’s also, it’s still early. I mean, this is a program that’s still growing and learning, but let’s just end on—I think your point is right on, which is it would be too narrow-minded to think this is a singular metric to say thumbs up, thumbs down on this kind of program. It’s just one of the ways to do it. And thank you so much for talking about it, Howie, and—

Howard Forman: Thanks bringing it up, Harlan.

Harlan Krumholz: Well, you’re one of the world’s experts on this stuff, so it’s really helpful to hear your views.

Howard Forman: Thanks.

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

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find this on, I don’t know, Twitter, Threads, Bluesky, LinkedIn, wherever you want to find us. We’re also at

Harlan Krumholz: I’m thinking very seriously about all this misinformation. And then you have the owner of X sort of promoting sites that are known to—

Howard Forman: Purveyors of misinformation.

Harlan Krumholz: ...antisemitic kind of stuff. Just in this particular episode, but also broadly around a whole range of issues. I will say I’m @HMKYale. But people will see I’m not posting very much anymore. And I have loved the community I have on it, but I just am not sure what to do.

Howard Forman: And I’m @thehowie still, that’s at T-H-E-H-O-W-I-E. Aside from Twitter and the podcast and all the other ways you can reach us, 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 where you can check out our website at

Harlan Krumholz: Health & Veritas is produced of the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Strumpf, and to our producer, Miranda Schafer, week in, week out. Amazing. Thank you. Thank you. Thank you.

Howard Forman: I agree.

Harlan Krumholz: Talk to you soon, Howie.

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