Perverse Incentives in Healthcare and Other News

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

Howard Forman: And I’m Howie Forman. We are physician and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. First, happy new year to our listeners and to you, Harlan.‌

Harlan Krumholz: Thank you, Howie.‌

Howard Forman: It’s great to be back.‌

Harlan Krumholz: Happy new year to you.‌

Howard Forman: We’re back in the studio, which is always fun.‌

Harlan Krumholz: It’s always good to see you. I haven’t seen you in a while.‌

Howard Forman: Oh, it’s been fun. It’s good to see you in person. Ordinarily, obviously we have a guest several times each month, but at least once a month we’ve been trying to do one of these. There is a lot of news that we can cover.‌

Harlan Krumholz: Yeah. The big news is a big deal, man. You’re going to Washington tomorrow for some big event. What are you doing?‌

Howard Forman: I know. We’re taping this on Tuesday late afternoon because I do not like to travel, as you know.‌

Harlan Krumholz: You do not like to travel.‌

Howard Forman: For me to get on a train for 11 hours tomorrow, there and back to Washington, to see Vivek Murthy, our surgeon general, is a celebratory event that will summarize the accomplishments of the Office of the Surgeon General that they’re putting on tomorrow. A lot of people I know will be there. It’ll be nice to see. I’m hoping the event goes well. It’s a very quick trip, but I want to do it. I’ll report back next week on how that goes.‌

But what do you have on your mind? Tell me what’s a hot topic for you right now.‌

Harlan Krumholz: Well, I don’t know about a hot topic, but I thought I might start off with, you may have seen this Gallup poll that came out about how people view the U.S. healthcare system.‌

Howard Forman: Yeah.‌

Harlan Krumholz: Did you see it?‌

Howard Forman: Not good.‌

Harlan Krumholz: Well, it’s interesting to me. Only about 44% of Americans rate U.S. healthcare as excellent or good. That compares to about 64% in 2001. I think it’s this general trend about how people feel about institutions.‌

Howard Forman: Yes, yes.‌

Harlan Krumholz: But coverage fares even worse, with just only about a quarter, about 28%, rating it positively. Far below the high of 41%. But yeah, 41%. Less than half of people feel that coverage is good. You and I haven’t spent very much time talking about this, what is it, an assassination that occurred in New York?‌

Howard Forman: Yeah.‌

Harlan Krumholz: We’ve talked a little bit. In this outcry, there was no sympathy at all for the family or the person ... I don’t want to say “no.” What I’m just saying is that we saw a lot of people just focusing on anger at United Healthcare in particular, but also just the general industry.‌

I think this poll represents some of that, but it simmers even more. I just saw so many things on social media, not the crazy stuff on social media, but actually people that you wouldn’t expect to be saying things that were disrespectful—‌

Howard Forman: No question.‌

Harlan Krumholz: ... when this kind of thing happens. I don’t know. How did you internalize? What did you think about all of that?‌

Howard Forman: I was most offended by the people inside the industry who were attacking the health insurance industry at large without acknowledging that we all play a role in this. I’m going to hit on a couple of those issues today. There are real problems in healthcare. Healthcare is too expensive in the United States, particularly for out-of-pocket payments for the middle class. If you’re wealthy in America, you’re getting good access to healthcare, and you can afford it. If you’re very poor, you’re getting pretty good healthcare, but certainly not the level of coverage that wealthy people get. But there’s this vast middle. You have studied this in a scholarly way with talking about financial toxicity, and the exposures that people have not to disease, but to actually financial harm from their own healthcare. I think that’s a topic that is resonant with most people. Everybody has some bad experience with how our health insurers pay for things.‌

Harlan Krumholz: Yeah. Here’s how I thought about it. By the way, the poll also said that 71% of people think the quality of the healthcare they receive is excellent or good. It’s like Congress, they hate Congress but they continue to reelect their own person. It’s like the people love to hate healthcare, but they still like the healthcare they’re getting. You’d like to see it higher than 71%, but still, pretty high.‌

I just didn’t understand why people couldn’t separate this more. Because this is obviously, in my view, someone who’s mentally ill.‌

Howard Forman: Right.‌

Harlan Krumholz: This is a troubled individual who did a heinous act. There’s no way we should be discussing anything connected to that as being a reasonable issue.‌

Now we should be discussing healthcare all the time because our healthcare system has got so many flaws, and we should be addressing them and think about systemic solutions. But to pair the discussion, it was as if it’s no wonder that this happened. No, no. This is not any sort of rational response to something that happened. This is a mentally ill individual who took an unforgivable act. There’s something wrong with this kid.‌

Howard Forman: Right.‌

Harlan Krumholz: Anyway, that’s how I felt about it. That we shouldn’t have been mixing these issues. We should be talking about them separately. What do we do when people have access to guns, they’re mentally ill, they’re pursuing a course like this? That was what that discussion should have been about.‌

This other discussion should say that it’s not like he had a point. He doesn’t have a point!‌

Howard Forman: No.‌

Harlan Krumholz: He just assassinated someone.‌

Howard Forman: And the insurance system, we’ve talked about this many times on the podcast. There’s actual fraud, there’s actual bad behavior. That occurs in almost any industry. Put that aside because we’re not going to excuse that. But much of the behavior that people hate about health insurance companies are things that have been thrust upon them by employers and by Medicare Advantage plans that set the rules up.‌

Harlan Krumholz: The structure of our system creates perverse incentives—‌

Howard Forman: The best way of saying it.‌

Harlan Krumholz: ... which has ultimately stripped our profession of its mission, because now it’s become just so businesslike.‌

Howard Forman: That’s right.‌

Harlan Krumholz: We’re going to pay the price for that for a long time.‌

Howard Forman: But again, there are real reasons why those things were introduced. Spending on healthcare has been very expensive. Companies have tried to figure out affordable ways. Individuals are choosing Medicare Advantage plans. There’s a lot there.‌

Harlan Krumholz: Yeah. We’ll take this up in other shows.‌

Howard Forman: Yeah.‌

Harlan Krumholz: I just wanted to—‌

Howard Forman: I’m glad you brought it back up.‌

Harlan Krumholz: ... to bring that up. Okay, what’s on your mind?‌

Howard Forman: Yes. I’m going to do bird flu again, and I know—‌

Harlan Krumholz: Oh no, somebody just died, right?‌

Howard Forman: I know, exactly. I wanted to start off with that. There’s 66 human infections in the current outbreak, 129—‌

Harlan Krumholz: Can I ask you this question?‌

Howard Forman: Yeah.‌

Harlan Krumholz: When people say that, there are lots of people who have been sick.‌

Howard Forman: Yeah.‌

Harlan Krumholz: I was sick for a while, I didn’t get tested. How do they identify these people?‌

Howard Forman: Yeah.‌

Harlan Krumholz: Because I always wondered, who’s showing up to have the surveillance done?‌

Howard Forman: That’s correct. Sixty-three of them, if I’m getting this right because I don’t have the data in front of me, I believe 63 of them were people on farms, that developed symptoms that were relevant enough that they went ahead and tested them. It’s not a prevalence testing.‌

Harlan Krumholz: The public health authorities are looking at a place where they’re concerned—‌

Howard Forman: Correct.‌

Harlan Krumholz: ... and they’re saying, “Let’s test these people.”‌

Howard Forman: Right. The people are presenting to emergency rooms with conjunctivitis, so they’re testing those. Three people, if I got the number correct, in the United States have been detected on the prevalent screening test that they do for flu in a certain subpopulation. If I get this right, one in California, one in Missouri, one in Louisiana.‌

The case in Louisiana is the one that you’re talking about. Unfortunately, a woman over 65 with comorbidities died. It is not surprising, if you talk to people, that H5N1, bird flu, would kill people, particularly those at very high risk. It’s also not surprising that the farm workers who are generally much younger and are not always getting a pulmonary infection but getting a more mucosal infection of their eyes, are not dying of it so far. But this makes people worry.‌

Harlan Krumholz: She died of pulmonary?‌

Howard Forman: Complications. Complications of this, that’s how they’re describing it.‌

Harlan Krumholz: Yeah.‌

Howard Forman: She and the case in Canada, which is not included in my 66. Which was in a 13-year-old, I think girl, who was what you have taught me is Class II obesity now. That young woman not only survived but recovered fully, but she had had a severe case as well. In that case and the Louisiana case, mutations were found in the testing that showed that the virus had attained the ability to infect pulmonary cells.‌

The good news is, it does not appear that that mutation was obtained when they were infected. It was obtained as it mutated inside their own body. But it does worry epidemiologists and pulmonologists that we now are seeing a path that the virus can take to start to become more infectious in humans and lead to more lethality. That’s why people are more worried about those two cases. It’s raising red flags. On the other hand, there’s no evidence of human-to-human spread at this point.‌

Harlan Krumholz: It does seem like this isn’t when we were in early COVID, where people were ... we’re not seeing that.‌

Howard Forman: We’re not there at all yet.‌

Harlan Krumholz: We’re not seeing that.‌

Howard Forman: No.‌

Harlan Krumholz: There’s some reports, like the New England Journal I believe, talking about people not being hospitalized.‌

Howard Forman: That’s right.‌

Harlan Krumholz: Largely.‌

Howard Forman: Largely. I think 40, or roughly 40 of the 63 farm workers are dairy farmers, and it’s mostly probably milk being squirted in their face. The poultry workers, I’m not familiar with that work, and I don’t think you are either. But apparently when they’re slaughtering the birds after an outbreak occurs, they’re working through these birds really quickly and getting rid of, I don’t know exactly, and that’s the exposure happening there. It’s not shocking that the farm workers are getting it.‌

I think what I wanted to raise, though, as a final point on this, is that the Biden administration has identified a few hundred million more dollars now to the H5N1 outbreak for testing, for building up the vaccines and stockpiles. What they need to be doing more of, and what is coming out more and more, is we need to figure out how to give the farmers incentives to identify their herds and their workers. It’s complicated by the fact that a majority of their workers are undocumented. They’re not as keen to be entered into the healthcare system.‌

Harlan Krumholz: Especially right now.‌

Howard Forman: Right now, exactly. There are big problems going on at this moment.‌

The last point I’ll make is that there are several people that we know who we respect, including Scott Gottlieb, our former FDA commissioner, who have really gone on the record more and more in the last couple of weeks to say that we’ve got to be doing more. I agree with them, I’m just not sure politically it’s as easy as they think. The farm bill that just got approved two weeks ago could have included a billion dollars just for H5N1. I don’t think either party was eager to push that on there right now.‌

Harlan Krumholz: Yeah, I can see that. Just to be clear, you’ve heard about this virus in China now. There’s a virus that’s circulating. That’s different than this.‌

Howard Forman: That’s right.‌

Harlan Krumholz: It does seem like it’s also people get sick, but people aren’t dying as a result of it. They are closing some schools, I heard, to try to slow the spread of this. They’re going to be in the same position trying to figure out what they want to do. But it’s not COVID.‌

Howard Forman: No, that’s right.‌

Harlan Krumholz: Meaning that obviously the virus is different, but it’s not that kind of situation.‌

I only say that because I saw on social media, there were some inflammatory things being written about, “And there’s this new virus in China.” By the way, that’s not a new virus. It’s a virus that’s circulated before. These things are going to happen. It’s not one that’s eliciting the same kind of concerns for example, I think, that the bird flu might, if it really jumps to humans.‌

Howard Forman: Look, if people are really concerned, be concerned about the United States right now, where we have pretty bad outbreaks of RSV, COVID is getting worse again, and the flu.‌

Harlan Krumholz: Flu.‌

Howard Forman: The general flu. We’re seeing so many cases in the ER.‌

Harlan Krumholz: By the way, lots of people very sick right now.‌

Howard Forman: I’ve never seen, in a short period of time other than COVID, as many chest X-rays with positive findings as I’ve been seeing in the last couple of weeks.‌

Harlan Krumholz: Yeah. And heard from a lot of people that they’ve been sick.‌

Howard Forman: Yeah.‌

Harlan Krumholz: I told you, I was sick.‌

Howard Forman: Yeah.‌

Harlan Krumholz: Let’s jump a little bit, since you’re going to go see the surgeon general tomorrow. He came out, as his final salvo, with this report about alcohol and cancer warnings. There were a couple things that interested me about this.‌

This is a report that’s laying out the risk of cancer associated with alcohol, and saying how it’s tied to 100,000 cancer cases and 20,000 cancer-related deaths in the U.S. annually. Something I think we pretty much know and accept.‌

Howard Forman: It’s in the literature.‌

Harlan Krumholz: It’s in the literature. I have felt for some time that there is this growing momentum, appreciation of the toxicity of alcohol. Of course, we’ve always known this. There’s so many ways that alcohol causes harm. It causes harm in overt ways for people who are at the far end of the spectrum of being alcoholic, and we see diseases, so many diseases associated with it.‌

I was glad to see him come out with this. I think it’s a good trend if people start paying attention, at least recognize. Our culture is so, so oriented towards alcohol and social behavior, you can’t go out to dinner without people talking about offering a drink. At least people need to know what they’re signing up for with this. Even a small amount of alcohol can increase risk.‌

There was one part I was just going to talk about for a minute. Which is there still is this, I’ll call it a myth, a persistent belief that a small amount of alcohol can be cardio-protective. People introduce this idea because there was this French paradox. People were drinking alcohol in France, and they have lower-than-average cardiovascular risk. People were wondering if this is this. A lot of epidemiologic studies have been conducted where it seemed like there was this, what they call a J-curve.‌

Howard Forman: Right.‌

Harlan Krumholz: It’s even flatter than that. It’s not even going up at low. It jumps down at one or two drinks, and then it starts to go back up.‌

For many of us, and I’ll just speak for myself, I’ve often felt that it’s very hard in these studies, just as it is in these food studies, to disentangle the potential confounding who has a drink or two a day. A lot of times people who drink nothing historically were people who had trouble with alcohol or had trouble with health.‌

Howard Forman: Right.‌

Harlan Krumholz: So they gave up alcohol because there were health issues. When you start looking at this, it was hard to disentangle that. There was a series of studies that really intrigued me. You know, Howie, that there is this gene that can cause flushing if you drink alcohol.‌

Howard Forman: Yes.‌

Harlan Krumholz: The alcohol dehydrogenates.‌

Howard Forman: More common in Asians, I think.‌

Harlan Krumholz: More common in Asians. But there are people who have this gene who essentially are intolerant to alcohol.‌

Howard Forman: Right.‌

Harlan Krumholz: They have this unfortunate ... I don’t have to say “unfortunate,” maybe it’s fortunate.‌

Howard Forman: Maybe it’s fortunate, yeah.‌

Harlan Krumholz: Yeah, they have an adverse affect to alcohol that they vasodilate because they don’t metabolize it correctly. If you look at this on average, people with this don’t drink. They don’t drink very much because they have a negative reaction to it.‌

They’ve done studies, they call these Mendelian randomization studies, where they look at people who’ve got these genes. Then they can follow them over time, believing that they probably have had less exposure to alcohol than those who don’t have the gene. When you do these studies, when you’re basically saying, “This is a marker for alcohol consumption,” and so forth, you don’t see this piece where people aren’t drinking, who are drinking a little bit maybe, are having a protective effect. Because they can see a certain dose response, in terms of how much of a reaction you might have with this.‌

I don’t know what the answer is. I will say this. No one’s proven that two drinks a day are good. I wouldn’t tell a patient to drink two drinks a day to be protective. If somebody wants to drink, they can drink, but I don’t think they should drink because they think it’s heart-healthy.‌

I have a question. Do you drink alcohol?‌

Howard Forman: I don’t. As you know, I think you know, I stopped during an illness 14 years ago, 15 years ago almost now. And starting about two or three years ago, I started having nonalcoholic beers. I’ve wondered if there’s any data about nonalcoholic.‌

Harlan Krumholz: Because you like the taste, or for you it reminds you of?‌

Howard Forman: I’ve come to love the taste. It’s funny, because I don’t know about your experience, but the first time I ever tasted beer I thought it was horrible. But by the time I quit drinking, I enjoyed having a Guinness every night.‌

Harlan Krumholz: That’s interesting.‌

Howard Forman: Now I have a nonalcoholic beer, more often than not, every evening.‌

Harlan Krumholz: That’s interesting. Yeah. I think you know that it’s not that I wouldn’t take a drink, but I actually basically don’t drink anymore. Part of it is this idea of cognitive function, aging.‌

Howard Forman: Yeah.‌

Harlan Krumholz: I just don’t think I don’t need it, I don’t miss it. I think if I’m trying to do everything I can to maintain my health—‌

Howard Forman: Oh, I agree.‌

Harlan Krumholz: ... and to maintain my sharpness, then I just don’t need it.‌

Howard Forman: Yeah. I do want to give just the magnitude of the effect in his report to our listeners. Because in women, drinking two drinks a day would result in five extra cancer cases per 100 people. And in men, it’s three extra cancer cases. That’s not insubstantial. Accumulative effects matter.‌

Harlan Krumholz: Yeah. I think if we didn’t have alcohol in the society, think about cancer of the esophagus.‌

Howard Forman: Yeah.‌

Harlan Krumholz: There are lots of different kinds of cancers that would probably be a lot lower. Yeah.‌

Howard Forman: If it’s okay, I think I’ll pivot to another topic around cancer, just really briefly, and that’s survivorship. This is just a quick comment.‌

In the Journal of the National Cancer Institute just two months ago, I just noticed it though, they talked about just how many people have survived cancer now. There’s an estimated 18.1 million U.S. cancer survivors, expected to increase to 26 million by 2040. Seventy percent have lived five or more years after diagnosis, and 11% have lived 25 or more years after diagnosis, my brother-in-law being a good example of that. They go on and they give us more statistics.‌

The bottom line is that this is a growing population, big numbers. We have had two guests on in the last couple of years, Hil Moss and Tara Sanft, Dr. Tara Sanft, who have talked about survivorship and survivorship clinics. How do you provide services to them?‌

But I want to mention again and ask you what you think, in terms of the evolution of medicine. How are we doing in serving these populations? Because my sense, partly from my brother-in-law, partly from talking to other patients, is that there’s a rare number of physicians who are really skilled at coordinating the type of healthcare that people who are far out from cancer survivorship but have complications related to their chemotherapy, their radiation therapy, or general surveillance that they still need for other cancers and their original cancer.‌

Harlan Krumholz: Well, you know I’m a big fan of thinking about the entire trajectory of people’s interactions with illness. We were raised, I was raised as a resident, someone came in the hospital, they left the hospital, you declared victory, and they went off on their own.‌

Howard Forman: Right.‌

Harlan Krumholz: In the outpatient world, in the wild, people are, “Can you get an appointment? Whose going to see who’s coordinating things?” It’s not very good. That’s why I started looking at readmission intently.‌

I hope we’re moving to an era where we’re recognizing the illness from the perspective of the patient. We have often had the perspective of the healthcare system, so we look at these junctures of care. They show up in an office; they are hospitalized. But for a patient, that journey is a very different journey. It’s a journey of, yeah, I’m going to different venues, but it’s a longitudinal journey, one in which there’s a need for intense coordination. Cancer highlights it, but you’re seeing this in lots of different areas. Autism.‌

I was talking to someone even about someone who’s had a cardiac arrest. If somebody has a cardiac arrest, they get resuscitated, they leave the hospital. Everyone says, “That was a great save.” Maybe they get a diagnosis of what caused it, something’s addressed. Maybe they get a defibrillator. But what we’re learning is that people have intense psychological effects after having one of these—‌

Howard Forman: I believe it.‌

Harlan Krumholz: ... near-death experiences. It’s not just one-and-done.‌

Howard Forman: Right.‌

Harlan Krumholz: It’s about well, what’s the trajectory of their struggle with this illness? Even if you address the heart, you’ve got think holistically about this person’s journey. They have PTSD after having one of these events.‌

Howard Forman: Without a doubt.‌

Harlan Krumholz: Then I’m just going to broaden it to all the caregivers around this person. The impact of the illness is one that has ripple effects out beyond the individual. I’m hopeful that these kind of things that are cropping up will address it. What I’m worried about is that we continue to micro-segment healthcare.‌

Howard Forman: That’s the problem.‌

Harlan Krumholz: If I’ve got three different problems, now here’s the group handling the cancer. Here’s the group handling the heart failure.‌

Howard Forman: Right.‌

Harlan Krumholz: Here’s the group handling my mental issues. Where we need this holistic approach.‌

Howard Forman: By the way, we got a nice comment from one of our listeners who is a family practitioner, and who made the point after a comment I made on a prior episode that there are family practitioners who do a great job—‌

Harlan Krumholz: Yeah, that’s right.‌

Howard Forman: ... of coordinating care. But what I would say about cancer survivorship is that’s a whole different kettle of fish. You go through sometimes years of intense follow-up with your oncologist just dealing with the major problem and maybe a couple of comorbidities. And then you’re discharged as cured, but you still have a lot of things that need to be attended to.‌

Harlan Krumholz: There are risks that accrue because of what you’ve just been through.‌

Howard Forman: Exactly. Exactly. The chemotherapy, the radiation, the stress, everything.‌

Harlan Krumholz: Secondary cancers, heart disease. It depends what you’ve been through. And then I’m just bringing up, the mental health issues don’t end.‌

Howard Forman: That’s right.‌

Harlan Krumholz: They don’t end. You still worry, there’s lots of things.‌

Howard Forman: I hope we can do a better job with that. I do think it’s challenging, and I think it’s a challenge for all of medicine, not just for one specialty.‌

Harlan Krumholz: Yeah, yeah. I was going to just raise one thing to you. Again, this will be a quick hit. One thing I’m keeping my eye on is this issue about the ultra-processed foods.‌

Howard Forman: Yeah.‌

Harlan Krumholz: I say that because there’s some possibility that Robert Kennedy Jr. will be the next person who leads HHS, and this is a big area for him. Even though I did see him, what did he do, he deep-fried his turkey in tallow. Did you see this?‌

Howard Forman: No, I hadn’t seen this.‌

Harlan Krumholz: For Thanksgiving? No, I don’t know. But maybe that’s okay because it’s not ultra-processed from his point of view. There’s continuing research and a drumbeat about the harm from metabolic dysfunction, systemic inflammation, a whole range of things. It crept up on us that so much of the food that’s eaten by so many people in this country ends up being this ultra-processed food. That we were worried for a while just about the salt content, but it’s not just the salt content.‌

Howard Forman: Oh, my God, yeah. Look, I was just saying before we got on the podcast, Miranda, our producer, is here with us virtually. I was just saying to her probably the worst thing I eat are my protein bars. Most of the protein bars I eat have all these chemicals in it.‌

Harlan Krumholz: When you look at the ingredients, you don’t recognize most of the stuff that’s in them.‌

Howard Forman: Exactly. It’s terrible.‌

Harlan Krumholz: Yeah. I’m just keeping an eye on that. I’m just wondering. Because the one thing about this ultra-processed food... here’s a story I’ll tell you. I was talking to someone from PepsiCo, my friend George Mensah, who was working there for a while. They were taking trans fats out of the Doritos. They were saying in the U.S., we got all this stuff. Then he was telling me, “But you know in different countries, they have different rules.”‌

I happen to have been traveling to Egypt for a healthcare project at the time. I said, “Well, what about Egypt, for example?” He goes, “Oh yeah, yeah. It’s full of trans fats.” He goes, “I was there and I tasted one.” I’m going, “Well, what did it taste like?” He goes, “It was delicious.”‌

Howard Forman: I believe it. I believe it.‌

Harlan Krumholz: That’s the problem. I’m curious to see how the politicians are going to be able to address this when a large segment of America’s hooked on this stuff.‌

Howard Forman: As a beginning, it would be great if we could figure out how to do the proper studies to figure out what the harm is because we don’t really have answers to that. It is really hard to test these things. It’s hard to do a purely randomized trial on them. It would be great if we had more answers to that.‌

Harlan Krumholz: Yeah. They took the trans fat out of New York. They have done some studies, but it’s still hard to tell how many people were saved as a result of that change.‌

Howard Forman: We’ve talked about the erythritol issue.‌

Harlan Krumholz: That’s right.‌

Howard Forman: And the other sugar alcohols.‌

Harlan Krumholz: That’s right.‌

Howard Forman: Look, I want to go back. We started off talking about what happened with United Healthcare, and the health insurance industry has been vilified, and they deserve some of the opprobrium. But I did want to talk about some other bad behavior. The Department of Justice announced a $17.7 million settlement against cardiology groups in 12 states about overbilling of Medicare.‌

Harlan Krumholz: I was going to bring up that thing in radiology. You see that thing in Florida?‌

Howard Forman: I’m coming to that second.‌

Harlan Krumholz: Oh, you are going to?‌

Howard Forman: Yeah.‌

Harlan Krumholz: I was going to say, if you were going—‌

Howard Forman: I’m giving equal time, equal time.‌

Harlan Krumholz: If you’re going after radiologists, I just wanted to be sure.‌

Howard Forman: Yeah, yeah. Equal time.‌

I’ve no doubt that some overbilling occurs without fraud or deceit. People make mistakes, okay? But when one of the settling groups was a single cardiologist led group with $6.7 million, and he is actually settling with the Department of Justice, you know that there’s bad behavior going on there.‌

Like I said, I just wanted to give equal time to radiology. Aetna has accused ... this is not the Department of Justice, but Aetna has accused a very, very large radiology group owned by private equity investors of grossly inflating their billing to both collect more money and use the federal No Surprises Act to their advantage.‌

One example from this filing is the “interpretation” of a chest X-ray, which in the worst-case scenario could take me a minute, in the best-case scenario it could be 10 seconds, they inflated the price from $14.50—what they get reimbursed, $14.50—to $252.12.‌

Harlan Krumholz: Okay. I read a lot about this. Actually, I was going to raise this with you. This is a very interesting thing that happened. I had heard some of the X-rays were $7, some were $77. I didn’t hear the—‌

Howard Forman: $252.12.‌

Harlan Krumholz: ... $14 to $250 that you said. But I understood that happened was that, as you know, depending on your arrangement and negotiation with the payer, there are different rates floating around, correct? Actually, this crazy amount of range that you’re talking about, 10X or more range, you’re talking 20X range of payment. What they did was they were acquiring practices and putting the charges through the group that—‌

Howard Forman: With the highest price.‌

Harlan Krumholz: ... that had negotiated the highest price.‌

Howard Forman: Correct.‌

Harlan Krumholz: But you and I have seen this because there was a similar thing happening all around the country where health systems—‌

Howard Forman: Correct.‌

Harlan Krumholz: ... were purchasing private practices.‌

Howard Forman: Right.‌

Harlan Krumholz: So that they could bill their services under the health system–negotiated costs for, say, an echocardiogram.‌

Howard Forman: Correct.‌

Harlan Krumholz: That was maybe 2X, maybe 5X or 10X. I think we have to come to terms with why isn’t there a standard amount that’s being paid for something? Everybody’s got a different deal. This is, as I read it, more of an arbitrage activity. Which was, somebody has got a higher negotiated payment for this, let’s all come under that tent, and we’ll all do better. That’s what a lot of health systems do.‌

Howard Forman: No question. I think in this case, what they’re doing is not only collecting this enormously inflated number—‌

Harlan Krumholz: Well, why are you calling it “inflated”?‌

Howard Forman: Because Medicare, which is statutorily required to pay cost, would say a chest X-ray is about $9.50, or maybe it’s $10 now.‌

Harlan Krumholz: The interpretation?‌

Howard Forman: Correct. That’s what it is. This is interpretation only.‌

Harlan Krumholz: When you do an interpretation for Medicare, you get paid nine bucks?‌

Howard Forman: About that.‌

Harlan Krumholz: Wow.‌

Howard Forman: Yeah. By the way, you can make money off that. Not a lot, but you can make money off it. Because if you’re reading 40 an hour, which you can do for probably four or five hours in a day, that’s not a terrible ...‌

Harlan Krumholz: Wow.‌

Howard Forman: You can make money off of it.‌

Harlan Krumholz: You were the business guy in radiology.‌

Howard Forman: No question.‌

Harlan Krumholz: So if anybody knows you can make money of it, you can.‌

Howard Forman: Look, I’m not saying anyone wants to be building a practice around chest X-rays. Most radiologists would say it’s probably more fair to get paid $20 or $25, but Medicare can get away with paying $9 or $10; $252.12 for the interpretation is so outside the norm.‌

Harlan Krumholz: It’s not fraud. Someone negotiated that payment.‌

Howard Forman: It’s their fee schedule.‌

Harlan Krumholz: I know, but somebody negotiated it. Somebody could have easily said, “I’m not paying that much to you.” Why did they say yes?‌

Howard Forman: I’m not even sure if it’s actually within network for Aetna.‌

Harlan Krumholz: That was the thing.‌

Howard Forman: Yeah.‌

Harlan Krumholz: They pulled out of the network and they were calling a lot of these out-of-network.‌

Howard Forman: Right.‌

Harlan Krumholz: That was another part of it.‌

Howard Forman: Yeah. All I’m saying is, you want to point fingers at UnitedHealth Group, go right ahead. There’s a lot of bad behavior there. Aetna, all of them have done bad things. But our physician brethren, and sisters I guess as well—‌

Harlan Krumholz: Please. Thank you, Howie.‌

Howard Forman: There’s bad behavior out there.‌

Harlan Krumholz: I don’t want to be getting letters.‌

Howard Forman: No, no. There’s bad behavior out there.‌

Harlan Krumholz: Appropriately getting letters.‌

Howard Forman: Yes, yes.‌

Harlan Krumholz: This is, I think, isn’t this why we hate the fee-for-service system? You know, everything. It reduces everything to transactions. Now we’re fighting over the amount.‌

Howard Forman: We would be so much better off if we figured out how to get to a more population health-based system. We talked to Jaewon Ryu just a month or so ago about how Geisinger has population health-based delivery. We would be much better off if we got to that type of payment.‌

Harlan Krumholz: Well, this is a great way to kick off the year. It’s so much fun being here with you. I really feel like, gosh, Howie, I have no idea what’s going to happen with this next administration. The leadership, the fights, what are going to be priorities.‌

Howard Forman: There’s a lot to talk about.‌

Harlan Krumholz: This was the administration that wanted to eliminate Obamacare. They seemed to have softened on that now.‌

Howard Forman: They are, without a doubt, looking at Medicaid right now. One in four people in America gets health insurance through Medicaid. I don’t blame them for looking at it, in the sense that if you’re looking for budgetary savings, Medicaid is where you have to look.‌

Harlan Krumholz: The thing that is going to be so interesting, and we’ll have a lot to talk about as things progress is that they’re going to be able to pass a lot of things. Because there’s a sense, in the country, that this wasn’t his first election and more of a split. Whether you believe he got a mandate or not, and there’s controversy about how much he won by and whether he got a mandate, there’s a sense on the Hill that this administration should be allowed to pursue what they want to pursue and see what happens.‌

Howard Forman: His party controls the House, the Senate, and the executive branch. He did get—‌

Harlan Krumholz: Some people would say part of the highest judicial.‌

Howard Forman: That’s right. I think we’re going to see them testing how much of a mandate he has. I do think you’re going to see major legislation passing, and I do think healthcare is going to be part of that. I hope that the best of us are able to protect those who are—‌

Harlan Krumholz: There could be some good things. I brought this up before. This administration, because it was immune to external lobbying, they just did what they wanted to do. I was sitting in the office with Secretary Azar. They were talking about, “We have to make sure people get access to their medical records,” and they were just going to do it.‌

Howard Forman: Yeah.‌

Harlan Krumholz: No matter what kind of resistance there came from the status quo. There is the possibility that there are some good things that can accrue out of an administration that is going—‌

Howard Forman: Take the bull by the horns because they believe it.‌

Harlan Krumholz: Take the bull by the horns.‌

Howard Forman: Look, I am very cautious. I saw him give a talk this morning at a press conference that was very disturbing to me. But I remain of the opinion that I’m not going to worry about what he can do. I want to see good things come out of them. If there are good things, I’ll applaud it. If there are bad things, we must do everything we can to highlight for the public why it’s bad and hope that Congress responds appropriately.‌

Harlan Krumholz: I think that’s what we should be doing with any administration. Which is, we should reflexively say one thing is good or bad, everything should be evaluated in its own right, and we should be able to reason why that is. It’s going to be a very interesting time. We’re on the cusp of this. Next week on our podcast, we’ll be days from the transition. It’s hold on tight.‌

Howard Forman: Absolutely.‌

Harlan Krumholz: We’ll see.‌

Howard Forman: One last thing I’ll say about the presidency though, is on Thursday, the day that this gets released, is Jimmy Carter’s memorial service.‌

Harlan Krumholz: Yeah.‌

Howard Forman: We have talked many times about his legacy.‌

Harlan Krumholz: Oh my gosh. What a contribution to the world’s health.‌

Howard Forman: That’s right. Really, rest in peace, Jimmy Carter.‌

Harlan Krumholz: Yeah. We should always reflect on what he did, yeah.‌

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

Howard Forman: 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, Twitter, or now Bluesky.‌

Harlan Krumholz: And we’re eager for your feedback, so please rate us. That helps people find us. We listen, we often talk about it on the air. We value our listeners and we’re eager to hear from you.‌

Howard Forman: We’ve been getting more and more emails and feedback, and we try to incorporate it into as many episodes as we can.‌

If you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information. Or check out our website at som.yale.edu/emba.‌

Harlan Krumholz: Our podcast is sponsored by the Yale School of Management, the Yale School of Public Health. We’re fortunate to have one of the world’s greatest producers, Miranda Shafer, working with us. And Howie has recruited, from his classes in his networks, some of the most amazing Yale undergrads that we’ve ever seen. Sophia Stumpf, Inès Gilles, Tobias Liu. We’re just so lucky to be working with them.‌

Howard Forman: Yeah. We’re just excited to continue the podcast. Happy new year to everybody. Thank you, Harlan.‌

Harlan Krumholz: Talk to you soon, Howie.‌

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