Mitesh Rao: Democratizing Healthcare Data

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

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Mitesh Rao. But first, we like to check in on current or hot topics in health and healthcare. And when we spoke yesterday, Harlan, I don’t think you had this nailed down, so you’re going to surprise me today. What do you have on your mind?

Harlan Krumholz: Well, there’s always so much going on, Howie. So I wanted to point you to a paper that recently came out in Health Affairs Scholar called “The Business Case for Quality: Estimating Lives Saved and Harms Avoided in Value-Based Purchasing Model,” that has come out of the National Quality Forum in Stanford. And one of the authors is Peter V. Lee. This is different than the Peter Lee at Microsoft who’s running all the AI stuff. But Peter V. Lee is an interesting guy. Do you know him?

Howard Forman: I do not.

Harlan Krumholz: He worked a lot with Zeke Emanuel and others on Obamacare. He’s a senior scholar at Stanford in their Clinical Excellence Research Center and was the founding executive director of Covered California, where he was involved in the largest state-run individual marketplace.

Howard Forman: Oh, I did. I actually met him a year or two ago, now that you mention it. I’ve met him through Bob Galvin, I think, or someone like that.

Harlan Krumholz: He helped establish the Center for Medicare/Medicaid Innovation Center. And anyway, he’s been a lot—involved in healthcare for a long time. And so I think he and others came together in this article. And what they were doing was trying to estimate the number of lives saved if we could improve quality. You know I’ve been interested in quality for a long time. And have the strong belief that we can use transparency and measurement of our performance as both a catalyst to improve as well as an indicator for accountability so that we can actually be accountable for this. And by the way, Elizabeth Dry is on this paper, who worked with—

Howard Forman: Who worked for you.

Harlan Krumholz: And one of the things that Peter points out is that he believes, and this group believes, based on their simulations, which were actually pretty conservative, that a little bit more than 350,000 lives could be saved over 10 years in the area of colorectal screening and hypertension control if health plans around the nation were able to get to the level of the best 10% of health plans.

So sometimes people call these achievable benchmarks, that is, they’re not setting a standard that no one has achieved. But they’re saying, if you look at the large number of people—actually, the paper was even more conservative. They said, “How many lives can you save if people get above the 66th percentile?” And that’s because these are what are called HEDIS measures. They’re measures that health plans around the country submit and are subjected to. And if you’re above that, if you’re in that top third, you’re not subject to any penalties. So they were using that in their article. But Peter, in a blast email he sent to many of us, was making the point, why do you care about being in the top third? If they got to the level that the top 10% were achieving, what would you achieve? And he’s saying it’s a large, large number of lives that would be saved.

And what they’re doing is pointing out this uncomfortable fact, this inconvenient truth that around the control of hypertension and in the screening for colorectal cancer, our nation performs really poorly. They perform poorly in health plans, they perform poorly in health systems, in individual practices. You almost can’t find a place. Kaiser is an exception. Kaiser has had exceptional hypertension care and colorectal screening in a bunch of different areas, but that’s a very specialized health system. And somehow the rest of the country has been unable to replicate that exceptional experience. I’ve called them positive deviators. They’re within the system, and they figure out ways to excel.

But one of the problems, Howie, is just the headwinds for people. I think I’ve told you, maybe I’m revealing a little bit too much, but my wife’s up for her colonoscopy, for her colorectal screening. She can’t even get an appointment for a year in New Haven. It becomes almost impossible. On the hypertension side, the number of people, we’ve got thousands and thousands of people in our healthcare system whose blood pressure is a systolic above 160 and even thousands above 180. Five measures that we’re not creating any sort of concierge care to do for them. And one of the things I wanted to pose to you is that one of the problems is, where is the return? I Even in a value-based purchasing system, it’s like somehow we’re not configured as a system to really value the return on lives saved. And that’s different than value-based purchasing, where we’re trying to decrease healthcare utilization. But actually we’re talking about “we can save lives, but no one’s getting rewarded for saving lives.” How do we change these incentives? What are we going to do about it?

Howard Forman: This is going to continue to come up because, as you’ve talked about many times, Ozempic and Mounjaro and Wegovy and Zepbound are very, very costly but presumably have a huge return both in terms of some health savings as well as productivity for those individuals. And they will likely live longer. And the way our system works right now, when you do something that lets somebody live longer, it does not result in net savings to the system because we don’t bank that. We don’t ever consider quality of life or improvements to be a savings to the system. And I think until we are able to wrap our head around cost-effectiveness and actually explicitly talking about cost-effectiveness, I think that it’s going to be very, very difficult for us to move the country forward in ways that would otherwise seem immensely logical.

Harlan Krumholz: Howie, you’re just raising this point, and we should put a link in our references around the South Park cartoon. Have you seen it?

Howard Forman: I did, yes.

Harlan Krumholz: Unfortunately this cartoon, which is funny, but is poignant because it is actually an experience where they have a patient going to the insurer, then going to the provider, then going to the health system and being bounced around the system round and round and round trying to get prior approval for the use of a drug that clearly has remarkable health benefits, in this case Ozempic or Wegovy. And it can be maddening. I know of patients who have ended up spending six hours on the phone through a process of, the insurer said, “Well, we don’t have all the data.” They go back to the provider. “Well, we sent all the data.” It’s just this back and forth. And I think the amount of persistence it takes, whether it’s about getting a colonoscopy or getting the right prescriptions for many people within the system are just so monumental.

Howard Forman: It does not seem like it’s driven by getting better outcomes. It does legitimately seem like it’s driven by holding down costs without any regard for benefit.

Harlan Krumholz: Yeah, this is something I think we should continue to think about, challenge our guests about. Look, if it’s just health returns that are left on the table, that could happen if people got in a room and said, “How are we going to solve this problem?” And anyway, I just think this isn’t about technology, by the way. It’s simply about organizations and how they’re configured. So anyway, I just wanted to share. I thought that article was thoughtful about the return for if we could improve quality. I think the frontier for us is to figure out how to do it. Let’s get to our guest, Mitesh Rao, former student. He started a company. The company’s doing great. It’s not a startup anymore. Let’s move to the interview.

Howard Forman: Dr. Mitesh Rao is an emergency medicine physician, a hospital executive and founder of OMNY Health, a company dedicated to unifying data streams across the healthcare sector. He currently works both as CEO of OMNY Health and retains an adjunct faculty appointment at Stanford University School of Medicine. Throughout his career, he has focused on how to create data-driven systems that maximize patient outcomes and safety. Before founding OMNY Health, Dr. Rao was heavily involved in healthcare leadership and academia. He led the Stanford Center for Advancing Patient Safety, or CAPS, as director and oversaw patient safety, quality, and system redesign for Stanford Healthcare as Chief Patient Safety Officer. Before coming to Stanford, Dr. Rao had similar leadership positions at Northwestern University and Northwestern Memorial Hospital in Chicago, including as Director of the Health Services Evaluation and Policy Research and Head of Integration for the Healthcare Innovation program, respectively. He received his MD from Thomas Jefferson University and went on to complete both his residency and master’s in health services at Yale University, where he was also a Robert Wood Johnson Clinical Scholar.

And so this is somebody that Harlan and I have both had the incredible experience to work with in many ways, and I got to work with you as a resident in the emergency room as well. And we followed you as your career has progressed and as you’ve developed this company, which I think is now about six years in. And what I would love to understand better is, how does our audience understand what OMNY Health does? When I look at the website, it reaches out to the consumers and the hospitals and the companies. But I just want to know, what does a consumer like me understand about OMNY Health?

Mitesh Rao: Yeah, absolutely. First off, Howie, Harlan, thank you for having me on this. As you both know, I don’t think I’d be anywhere that I am today without the mentorship, the guidance, and having been exposed to the two of you. So I really owe you a lot.

OMNY was built out of my frustration on the provider side, where I would consistently see that our data had powerful opportunities for both research, advancing healthcare, but getting that data out at scale, being able to build those partnerships was a constant struggle. And I remember this from my RWJ days where I remember one time I walked into Harlan’s office and I talked about the data that I had finally got my hands on for the first research that I was going to do. And I was complaining about how messy it was and how difficult it was to use and how difficult it was to even just get my hands on it. And Harlan was like, “Hey, welcome to the real world.”

And that was the real challenge that I kept seeing consistently, even when I went on to the healthcare administration side is we knew there was tons of value and power in the data, but how do you enable it at scale? And that missing piece that I couldn’t find was effectively that missing infrastructure. We had the MRs [medical records], we had organizations that were trying to aggregate data, but nobody was building those proverbial pipes that would allow this data to flow regardless of an underlying infrastructure.

And so we set out, out of my frustration, to build OMNY Health, which now serves as a foundational data layer, a common language of data for health systems, provider groups, specialty networks, AMCs [academic medical centers] all over the country, uniting effectively today about the data from one in five Americans and by end of year it’ll be one in three. And what we’ve effectively done is created a common language of data now that exists beyond that diverse IT infrastructure where you have consistent regulatory-grade, research-grade data that is now connected across the country and can be used to power rare disease research, the next generation of therapeutics, safety and efficacy research, so all of this mission-centric patient-driven work that requires that powerful data behind it.

Howard Forman: Does this ever come close to the UK Biobank? Does this ever come close to data systems that are much more inclusive of all data? Are you able to get to that level of population-level data?

Mitesh Rao: That is absolutely the vision of where we’re growing. So now we’re starting to bring imaging data, we’ll grow into genomic data in pretty short order. And the idea is to create a democratized data layer where not only is there a value that’s shared across the organizations, everybody benefits, but it’s not tied to any subsystem. It frees us from the shackles of what is effectively an inherently closed-off ecosystem that we’ve built across healthcare. And I wanted to do this in a way that wasn’t going to disrupt, that was going to actually enable organizations all over the country to start to step forward in that data-driven world. But yes, the vision is effectively creating a national data layer that will soon encompass every aspect of data, not just the structured and unstructured elements that traditionally come out of seeing EMR, but we’re already across lab data, we’re across imaging data, genomics will be the next forefront. And really being able to tie genomic and phenomic data together to create a truly deep layer of information that can empower personalized medicine.

Harlan Krumholz: Tell me a little bit about that. The moment where maybe you were in discussions with your wife and your family, you say, “I think I’m going to try something risky.” How did that go for you? Because when I knew you, it wasn’t quite on your mind that you were going to do that, meaning when you were a student. You were always creative and thoughtful, but this is a big leap. And can you just tell us a little bit of a story of what were those days like, and how did you come to that decision?

Mitesh Rao: I remember I was sitting in a VC office, and they had asked me for advice and diligence on a company they were looking at to invest in. And we did the session, and then afterwards we were just sitting there talking, and they said, “Hey, you’re at the front lines of healthcare, any interesting ideas you have?” And in that spur of the moment, I went to the whiteboard and I drew out a framework for what would eventually become OMNY. And I said, “Well, this is something I think is a missing piece in our larger.... No one’s built those rails for data. No one’s built those pipes. Everyone’s talking about integration points, but no one’s thinking about it from a sustained perspective of being agnostic of the inline architecture.” And I remember, on the spot, the VCs were like, “Hey, we should back this.”

And I laughed and I said, “I never want to start a company. I’m comfortable in my job. I’m happy where I am. I make a good salary as a physician executive. I am not really interested.” But I remember I came home, and I was talking to my wife. And my wife, Meghna, she’s incredible, we just celebrated our 17th anniversary. And she looked at me and she said, “If you don’t do this, who’s going to do it, and who’s going to do it in the way that you want it to be done?” And I couldn’t answer that question. She said, “Take the risk.” She said, “Dive into the deep end to do this.” She’s like, “I’ll support you. We’ll support you. We’ll figure out a way.” And I remember for the first couple years I took no salary, really. We managed. It was not easy. We lived paycheck to paycheck. We tried to figure it out. We dipped into savings, but there was a belief that we were building towards something strong.

That risk is not easy. You need to have a strong risk appetite. A lot of people stand at that precipice and they opt not to. I chose to dive in. Harlan, it was in the back of my head, “Oh, you’ve got a backup.” Remember my mom, she’s an OB-GYN. She told me, she was like, “Oh, you’ve got to get a backup. You could always go back to practicing.” I told her, “That’s a fallacy. If you’re going to dive in, you have to dive in wholeheartedly, and you have to really believe in what you’re going for.” Not “I’m going to step a toe in, but I could always back up to this.” So we use that phrase of “burn the ships” and wade into the forest. I burned the proverbial ships in my head, and I said, “I’m not going back. I’m going forward, and we’re going to do this.” And it hasn’t been easy, but I have been lucky enough to have support structures around me and people who believe in me. Even when times are tough, I reach out and ask, and I get that support.

Harlan Krumholz: One of the things Howie and I were talking last week, Howie was talking to me about entrepreneurism, and one of the comments I had was, “It’s a lot harder than it might appear on the surface, and it’s not for the faint of heart.” Can you share a little bit about what you found hard about this and unexpectedly challenging? Because there would be people listening to you and going like, “Wow, that’s amazing. I’d like to start getting into this.” But they also need to know the grit it takes in order to get to the point that you’re talking about now. Can you elaborate a little bit on some stories about times where it seemed hard?

Mitesh Rao: Thank you for that. I think there are three pieces that were really awakenings for me going on an entrepreneurship route. The first was, I didn’t know what I didn’t know. There was tons of aspects to running a business that I just wasn’t privy to, either in my prior careers as a physician, as a system executive. Once you’re encompassing the entire spectrum of a business, understanding things like HR, finance, you’re just thrown into the deep end. And I think one of the reasons I encourage physicians to think about entrepreneurship is because I feel like our field pushes us to be able to move very quickly with limited knowledge and challenging environments. We’re used to challenges. We don’t shy away from them. And I think that actually makes us great entrepreneurs. So that gives me a lot of faith in the healthcare industry as a whole, that we can be inventive and we can drive a lot of pieces because I think we have that substrate built into us.

The second thing that was really challenging, which you mentioned grit, but even at our stage of a business when we’re scaling and growing so quickly, it’s still an emotional roller coaster. There are days where everything looks amazing and we’re going to conquer the world and we’re going to change everything. And there are days where it’s just so frustrating that you feel like pulling your hair out. And it never stops. I used to joke that emergency medicine was a lot of work. We do nights, we do weekends, but this job is 24/7. I wake up thinking about the company, I wake up thinking about healthcare data and security and compliance, and sometimes my wife says I mumble in my sleep about compliance and high trust and all these aspects of data security that we constantly think about. And then this guiding principle of we built this company to protect patients and patient rights and to ensure that things like HIPAA were really closely followed, that the identification protocols were done at a national level so that we could really make sure that this data was secure and compliant.

And that’s a piece, that resilience of dealing with those challenges, it’s something that’s nonstop. So I’d say both of those aspects are probably the biggest eye-opening parts, but there’s a lot of good to it. I’ll be honest. My only regret in any of this is I didn’t do it sooner. I think it’s absolutely amazing. It’s a great feeling to be able to start and build something. It requires that resilience. It requires a deep dedication. And I think if you have both those pieces and are willing to stand the test of time, which it takes time for all these companies, not every company is an overnight success. We always dream about, you hear about the successes in the press all the time, but you don’t hear about some of the challenging journeys and the failures, honestly. And I think that’s where we learn a lot in entrepreneurship.

Howard Forman: Last weekend during a reunion for the medical school, one of our MD/MBA students came back, and he’s got a successful, presumably unicorn-level company that he started. And listening to him talk about what fundraising was for that, which again, as you said, to outsiders this always looks so easy. When you hear him describe it, it’s definitely not easy. And I’m just curious if there are any stories you have about how it was to raise funds to get where you are right now.

Mitesh Rao: Yeah, when we first went out, we were a couple of guys, an idea and a slide deck. And fundraising initially was centered around expertise, having come from the industry, being people who actually knew what we were talking about and having had that experience, and also the vision of where we could take the company. It’s never easy to be able to raise capital at any stage of a business because you’re thinking about a lot of different aspects. And this actually goes back to a third element to Harlan’s prior question about what are the challenges and difficulties in entrepreneurship. You gain a lot of responsibility. Today when I wake up, I’m not just thinking about myself and my family. I’m thinking about all the people we employ and their families because it’s a ton of that weight that comes on you.

And when you’re fundraising, you’re thinking about the same thing. You’re trying to do right by the company, you’re trying to do right by your investors. You’re trying to do right by your employees, who are part of the mission, who have decided to take a higher-risk role and dedicate themselves in harder work because they believe in what you’re building and what you’re trying to do to transform healthcare. And getting people to follow the mission, that’s the easy part. Getting them to stay and stay true to that mission and you yourself stay through that mission, that’s the harder part in the entrepreneurship piece. And I think if you have that come through in your conversations with investors, fundraising does tend to follow along well, because you find investors who also believe in your mission. And that’s, I think, one of the most important things that I’ve tried to do as we’ve raised capital.

Howard Forman: And along those lines, do you have a timeline in your head about when you go out for each series of fundraising? For instance, are you able to sustain yourself now and fundraising is only about scaling and scoping the business, or do you require capital to sustain this now?

Mitesh Rao: That’s a great question. I think the approach to fundraising that I always try to use is if I’m going to raise a dollar, I want to know where that dollar goes, and I want to know that dollar goes to something that’s going to amplify a part of our business or allow us to do more. And so we’re actually considering going to raise our Series C soon, with the idea that there is a lot as we’re scaling, as we’re building, we’ll go to north of 100 million lives by end of year. We’re bringing on many of the largest IDNs [integrated delivery networks], nonprofits, and AMCs in the country onto the platform. And with that growth requires both a need for more people, but also a need for continuously improving your internal processes.

So those require resources. A lot of what we build, new products we build, the new data we’re growing into requires those resources. And the VC world is well designed to be able to support entrepreneurship in that method because you are painting a forward picture, so you’re getting people to invest in where the company is headed, as opposed to where it’s today. And that’s how I think about fundraising is I want to make sure that I know exactly where those dollars go, never raising for the sake of press releases or to be able to just say the company’s worth X, Y, or Z because at the end of the day, that’s all on paper. What you actually deliver and what people actually get benefit out of is the true value that a company brings to anything in our industry.

Harlan Krumholz: I just want to raise one thing because sometimes people are facing this decision—can I be a founder and stay in my job? As opposed to actually, like you said, burning the ships going forward, leaving what you’ve got behind and jumping in as being in the company. What was that decision like? Because you could have said, “Hey, I’ve got this vision. I’m actually happy as a physician executive doing really well. Maybe we can hire people and I’ll be on the board.” But you actually jumped all the way in. What was that decision like?

Mitesh Rao: And there are plenty of companies that are like that are started by incredible founders who have full-time roles in health systems and academia and they find people to basically drive those parts of those different roles. It was the fact that I believed so strongly in the idea that I was doing that I couldn’t think of anybody else driving that vision forward in the early stage. And in the back of my head, I thought maybe at some point, maybe down the road it’ll be something that I would hire somebody to run.

But at the moment, in that moment sitting there talking with my wife, I agreed with her. I said, “If I’m not there at the helm trying to guide this, is it really going to happen in the vision that I have?” Because I feel like a lot of people have tried to build this capability, but they’ve done it in different ways, some for better, some for worse. And I had a very distinct vision of creating an empowered data layer that democratized that value. And I knew that if I wanted it to happen in the right way, that I’d need to step forward. So I took the plunge and—

Harlan Krumholz: Let me just ask one more question, then, Howie, I’ll let you jump in. Some people listening will have heard this word, “democratize” that layer. Can you just unpack it for people who aren’t tech people, what does it mean to democratize that layer?

Mitesh Rao: We see that in two dimensions. One, it’s freeing it up from any focal part of the architecture. So talking about data sitting within an EMR.

Howard Forman: And just for our audience, EMR means?

Mitesh Rao: Electronic medical record.

Howard Forman: You mentioned VC at one point. We’re talking about venture capitalists, right?

Mitesh Rao: That’s right. Venture capitalists in an aggregated system within even groups that are trying to consolidate data. OMNY was never designed to do that. It was designed to be able to allow data to flow in every direction. So that democratized access is effectively what we’ve built at an infrastructure layer for all of our provider partners. The second piece we talk about when democratizing data is really from the research perspective. A big core of our mission is improving diversity, inclusion, and research. I crack the joke that we don’t need more clinical trials at academic centers. We need them out in the community. We need them out in rural parts of the country. We need the average American to be able to have access to lifesaving clinical trials and advances in medicine.

Simultaneously, we also need their participation when we do safety and efficacy research, that we’re making things across healthcare safer for every American. And so that idea of just a data layer where not only everybody benefits but everybody’s included, and it’s not limited by any aspect of what we’ve built in the healthcare IT stack, that’s what I think about from a democratized data layer. So that’s always been a central vision of how we built OMNY, and it’s never been the easy route. We took the much more challenging route of going health system to health system, provider to provider, doing the hard work of stitching together the data. And it’s been a lot of blood, sweat, and tears. But we got the first few to do it, and then it started to grow. We hit 5 million lives and 10 million lives, and now we’re north of 75. We’ll be north of 100 soon. And at a certain point, you start to be able to build that movement where groups start to have faith, and they believe that you can do this, and they want to be a part of that mission.

Howard Forman: As an outsider, as someone who’s not an entrepreneur, I’m witness to social media communities, physical communities like we had here last week at the Venture Summit for Yale, that there are networks of people that you can meet who can support each other. But I’m curious, for you, where did you find that support? You’re in a part of the country that naturally has more support, but how did you find the right people to help you think, to hire, and so on? And are there specific people or even without using their names, are there specific individuals who played critical roles in that part of the business?

Mitesh Rao: Yeah, I did two things that I think have paid long-term dividends. One, I went out and I found members for my team that were veterans. They had resilience already built in. And so when we early on went through tough times, they weathered the storm with me. They weren’t gun-shy about anything coming at them. They weren’t flighty about any of the risks in the early stages of the business. And so that paid dividends. The second thing is I did tap in broadly to my network to ask for help. I made myself very vulnerable talking to, I’m going to highlight the Clinical Scholars Program because the Robert Johnson Foundation Clinical Scholars Program, people who went through that fellowship with me, people you all taught, people who were at other sites, they formed a backbone of support for me. And I still stay so close to many of them.

When I had tough times, they were there to support. When I had ideas, they were there to be sounding boards. That was incredible. And the fact that I had a group of people across the country who were in healthcare, who were doing different things, changing the world in their own different ways, would take the time to engage with me and support me, that was an incredibly powerful piece. So between those two plus family, I had the support I needed. You crack the joke that it takes a village to build a company, but the truth is it takes a village to support the psychological and emotional burden of entrepreneurship, and you need people behind you.

Harlan Krumholz: I think that’s an amazing point, because you need to project confidence. You need to project it not just for yourself but for all the people around you. But the truth is I think it’s also important to project some vulnerability, because everybody who’s involved in the enterprise also is not standing on firm ground yet as you’re starting out and things are going. And so an acknowledgment of your own vulnerability and the reality of what the psychological stress is of being in that environment, Mitesh, you’re evolved. And I think that’s a good example to many other people. So I know we could talk for a long time. I just want to thank you for coming on the program, for sharing these insights. You know we’re cheering for you. To get to this point, you’ve already beaten the odds. For every company that starts, very few even make it past the first year. You’ve done much more than that. You’ve got a successful enterprise that’s growing, and we’re proud of you, we’re hopeful for you.

Howard Forman: We’re cheering for you.

Harlan Krumholz: And we’re glad to know you.

Mitesh Rao: Thank you.

Howard Forman: Great seeing you.

Mitesh Rao: I’m grateful every day and really grateful for the two of you. Appreciate it.

Howard Forman: Thank you.

Harlan Krumholz: Thank you. Hey, that was a terrific interview. It’s so nice to have people come back. But now I want to get to one of my most favorite parts of the show. Howie—da da da!—what’s on your mind?

Howard Forman: Yeah, so I’ve been thinking about this for several weeks to talk about this, and I’m just going to scratch the surface of the topic. But that’s prompted because the U.S. government, through the Drug Enforcement Agency, is likely to reclassify marijuana from being a Schedule 1, which is in the category of heroin or LSD, to a Schedule 3 drug, which is in the same bucket as ketamine and anabolic steroids, which is to say a controlled substance but now you can legally prescribe it and regulate it and test it and do research on it. This has abundant implications, and it continues to move away from criminalization and possession, which is a good thing. But it is worth examining what’s happened with marijuana or cannabis over the last few years.

It’s been legalized for recreational use now in 24 states and the District of Columbia and for medical use in many more than that. Half of all adults have tried marijuana. One in six have used it in the last month. Daily and near-daily use of marijuana is now more common than similar usage of alcohol, if you can believe that. About 40% of current users of cannabis use it daily or near-daily, and that’s just an astounding frequency. That’s getting closer to thinking of it as tobacco than it is what used to be as a recreational, rarely used drug. Thirty percent, by the way, of 12th graders had used marijuana, and by 12th grade, 6% were using it daily. So these are astonishing figures to me. Maybe it’s because I’m out of touch, but I found that alone interesting.

So here’s what I think drives me to want to talk about it today. The potency of current marijuana products, particularly the leaf products, not even the candies and so on, has increased dramatically. In the 1980s, it was 2% delta-9-tetrahydrocannabinol, which is the active ingredient, THC, in marijuana. So 2% in the ’80s. It was 4% in the ’90s. And now, depending on who you listen to, it’s 12, 17, or 28%. And it varies in parts of the nation and so on. But suffice it to say, even on the lowest end, this is not your grandmother’s marijuana, as they say.

So here’s why I’m concerned. Number one, I’m seeing a lot of cases of what is called cannabinoid hyperemesis syndrome in the emergency room, which is to say people that are using marijuana typically in a chronic way who develop a repetitive nausea and vomiting cycle that is so severe that they come to the emergency room. I’ll be honest with you. I’d never heard of this syndrome a few years ago, and now I see it frequently in patients that I, as a radiologist in imaging for one reason or another. It could be that we’re just diagnosing it more, but I think dosing and frequency of use has a lot to do with it.

There’s also increasing evidence that marijuana is associated with increasing the risk of psychotic disorders and other mental illness. And then finally, there is evidence of actual addiction. We used to say marijuana is not addictive, but there is actual addiction with that. And then add to that the number of unknowns. We don’t know what this does to a developing fetus. We don’t know how it differentially impacts a 13-year-old versus a 20-year-old versus a 25-year-old. We don’t know whether dose matters in those populations as much or more. So I just want to sum up by saying I’m truly in favor of decriminalization and legalization, but more than ever before, even with my usual libertarian impulse, I am for strengthening regulations so that the public’s well-being is protected while we learn more. With THC vaping and ready access to actual cannabis and candies and all sorts of other mechanisms of taking this, we really cannot afford to be complacent.

Harlan Krumholz: So Howie, I take your point, but I just want a benchmark here. So how many people die each year, do you think, from alcohol? And how many people do you think die each year from smoking where there’s no—

Howard Forman: Oh, tens, hundreds of thousands.

Harlan Krumholz: Or more. So we have decided as a society that there are substances that are addictive that can cause considerable harm that we are going to allow to be legal.

Howard Forman: But those are highly regulated. Both of them, highly regulated.

Harlan Krumholz: So you’re saying it’s okay, but we just need to regulate it more.

Howard Forman: Yeah. Look, I know it’s always hard for people to believe because in so many ways, I’m a real progressive. I’m a true libertarian. I really believe the reason why we regulate things is if their externalities that impact other people, and that our goal should be to make sure people know what they’re getting into. But I don’t want to stop you from skydiving. I don’t want to stop you from riding your motorcycle. These are all unsafe things.

Harlan Krumholz: Without a helmet, or you don’t care?

Howard Forman: I do care, because we have externalized their costs onto society.

Harlan Krumholz: So they should wear a helmet if they’re going to going to.

Howard Forman: They should. But again, there are a lot of things that are unsafe, smoking being a big, big one. I would love people to stop smoking, but I don’t necessarily want to ban it. And the same thing for marijuana. I feel like when we ban things, we’ve learned that we don’t do a good job with it, that people figure out how to get ahold of it. I would rather have it be part of the overall economy and regulate it. But in the case of marijuana, unlike alcohol—alcohol and tobacco, as you mentioned—we have huge amounts of data about what it actually is causing. We don’t even know how many deaths are caused by marijuana because we don’t track it.

Harlan Krumholz: Yeah. No, fair enough. I think that’s good. You’ve clarified your position for me. I think that’s right. And by the way, I’m not pro-alcohol, pro-smoking. They cause such harm. But I also just think it’s a question of how do we develop fairness in how we’re thinking about these substances and also enable people to make decisions for themselves. And like you said, prohibition didn’t work. It didn’t work.

Howard Forman: And look, I’m telling you, this cannabinoid hyperemesis syndrome, which again, never heard of four or five years ago, it’s every day I’m in the ER, I’m looking at a chart, and the patient either has it or they suspect it in the patient.

Harlan Krumholz: Well, thanks for sharing that. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on LinkedIn, Threads, or Twitter.

Harlan Krumholz: And we’d love to hear your feedback or any questions or experiences with these topics. Rate us. That’s always good. Helps people to find us. We always appreciate that.

Howard Forman: And let me just amplify that. Both of us, in the last week or so, have gotten some really nice comments from a host of different individuals, some of whom we know, many of whom we don’t know. And getting the feedback helps. It’s nice because we do this as a labor of love, but we also love hearing from you about what you’d like to hear us talk about more. How can we help you and how can we make this better? And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email. For more information, check out our website, som.yale.edu/emda.

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, Sophia Stumpf, and to our producer, Miranda Shafer. They’re wonderful to help us every week. Thank you.

Howard Forman: Grateful for them.

Harlan Krumholz: Talk to you soon, Howie.

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