Peter Hotez: Mapping the Anti-Science Machine

Transcript

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. Peter Hotez. First, we always check in on hot topics in health and healthcare. What do you have today, Harlan?

Harlan Krumholz: Well, we want to save a lot of time for Peter today because he’s got a new book and there’s plenty to talk about. But I just wanted to share with you this article that came out of JAMA Network Open this week that I thought was pretty interesting around social media and youth mental health. There’s been a lot of discussion about this. We’re in this mental health crisis moment, especially among the youth and rising uses of social media and how all this stuff comes together. Well, this group enrolled 373 young adults aged 18 to 24, and followed them for two weeks of baseline tracking. Then, 295 of them chose to try a one-week social media detox.

Their phone data showed that they cut their use from just under about two hours a day to about 30 minutes. It wasn’t a complete detox, it wasn’t completely off, but they really cut down their use. What was interesting about this, I’ll just get to the punch line, what happened to the symptoms. On average, anxiety fell by 16%, depression by about 25%, insomnia by 15%. These changes were seen over a very short period, about seven days. They were strongest among the participants who had the most severe symptoms at the start. There was one little nuance here, which was loneliness didn’t change. I guess you could say that abandoning social media make them feel loneli-er.

You could have thought that might have happened if they felt more isolated. In fact, that might have also been a positive finding as opposed to a negative one. But like all studies, this has a lot of limitations. It wasn’t randomized. People volunteered for the detox. There’s lots more to validate, but it just makes you think, is social media today like cigarettes or alcohol or other toxic substances? But this one’s virtual and digital, but is it actually producing negative effects, and if you can move away from it that actually you can recover? What was fascinating about this to me was within a very short timeframe people had improved symptoms.

Again, lots to validate, to replicate, to reproduce, see if this thing really works. But I think it could have lessons for how we start to think about this and what we need to do to improve people’s mental health.

Howard Forman: Yeah. No, I think it’s really important and I think we’re going to keep coming back to this. This goes back to the Surgeon General’s report and so many other people that have raised concerns about this over time.

Harlan Krumholz: Yeah, we’ve introduced into our lives this thing, and if it really is something that is causing harm, we ought to be able to characterize it better, understand it better. Then, the question is, what do parents of young kids do? Let alone, this was a little bit older, 18 to 24, but you start thinking about kids who are just entering adolescence or they get phones. It’s a very powerful potential negative influence on them. How are we going to manage that? Anyway, that was an interesting paper. Again, people should consider it a bit preliminary but provocative and interesting and thought-provoking. All right, let’s get to Peter, because... plenty to talk about.

Howard Forman: Yes. Dr. Peter Hotez is a world-renowned pediatrician, scientist who specializes in vaccine development and neglected tropical diseases. A widely respected public intellectual, Dr. Hotez serves as the dean of the National School of Tropical Medicine at Baylor College of Medicine, co-directs the Texas Children’s Center for Vaccine Development, and holds the Texas Children’s Hospital Endowed Chair of Tropical Pediatrics. He is renowned for leading the development of vaccines for infectious diseases, including two low-cost COVID vaccines administered to over 100 million children and adults in India and Indonesia.

A relentless advocate for science and vaccine access, Dr. Hotez regularly testifies before Congress, is a frequent presence on national TV networks, and served as U.S. science envoy in the Obama administration.

Harlan Krumholz: You know, Howie, I told you not to invite Hotez again because just when I’m feeling good about myself... you know, when I think that I’ve accomplished a little bit in life.

Peter Hotez: Well, actually, you forgot the most important part, Howie—

Howard Forman: I’m getting to it!

Peter Hotez: ...which I was a Yale College undergraduate.

Howard Forman: We’re getting to it! But the thing is, I said, even before I started this, I mentioned that nothing I say will actually capture how great he really is, but let me continue.

Harlan Krumholz: He is a great guy. He’s a great guy.

Howard Forman: He has written several books most recently, Science Under Siege: How to Fight the Five Most Powerful Forces That Threaten Our World. Dr. Hotez—

Harlan Krumholz: Wait a minute, you mean he’s written another book?

Howard Forman: He has written another book—co-written another book—and we’re going to get to that.

Harlan Krumholz: All right.

Howard Forman: Dr. Hotez received his undergraduate degree in Molecular Biophysics and Biochemistry from Yale University in 1980. Followed by a PhD in Biochemistry from the Rockefeller University and an MD from Weill Cornell Medical College. He did his infectious disease fellowship at Yale, followed by nine more years on the faculty. I could spend the next half hour just talking about the many accolades and honors he has received, but we’ll just highlight that Megan Ranney, our current dean, awarded him the School of Public Health’s highest honor, the C.E.A. Winslow Award earlier this year. We are so excited to have you on the podcast and have you back. I really sincerely consider you a leading light at a time of great darkness, and I wanted to start off with the book.

Peter Hotez: By the way, I was thrilled to come back to Yale and see you guys and spend time with you.

Howard Forman: It was great. It really was great.

Peter Hotez: What you’re doing is just extraordinary.

Howard Forman: By the way, you had been here not much before giving Pediatric Grand Rounds. You’ve been here, and you continue to contribute. I want to start off with your book.

Peter Hotez: I try to stay tethered to Mother Yale.

Howard Forman: Well, and Mother Yale does have two things that I think we are well known for now, and that is our work on climate change and climate science, and our work on public health and healthcare. You have partnered with Michael Mann on this book, which really brings those two issues together. You talk about the five P’s: plutocrats, pros, petro-states, phonies, and the press, making up this complex super web of malevolence. It is a great line. It’s a great opening. Can you just talk briefly about how you come to work with a climate scientist at this time?

Peter Hotez: I had been getting attacked for my views on vaccines for years, and that started a long time ago when the NIH asked me to speak to our good friend Robert F. Kennedy Jr. I was in my office and my assistant said, “Hey, Dr. Hotez, I have these two gentlemen on the phone.” She’s reading it, “One is named Dr. Anthony Fauci and the other one is named Dr. Francis Collins. Can you speak to them?” I was saying, “Yeah, I think so.” They said, “Peter, you have a daughter with autism. You could explain to Bobby why vaccines don’t cause autism.” A year of discussions with them, and that’s what led to my writing an earlier book called Vaccines Did Not Cause Rachel’s Autism, which wound up making me a big public target from anti-vaccine groups.

But I had to look up everything, and I wound up becoming an expert, not only on the vaccine science and making vaccines, but the vaccine anti-science. But there was a pretty steady drumbeat of attacks, and it resurfaced when Mr. Kennedy was running for president in 2023, and there was this big pile-on on social media from Joe Rogan and Elon Musk and Kennedy for me to debate him in public, on The Joe Rogan Show, which I said I didn’t want to do because I think that it would send the wrong message of how we do science. It’s not done through public debate, especially with people who have no background in science. Also, I didn’t want to legitimize his presidency.

But there was this massive assault that came on from all of these techbros and billionaires and even New York Times columnist Ross Douthat that said, “Why aren’t you debating him in this kind of stuff?” I say, “Where the heck is this coming from?” Then, I think that’s when either Michael reached out to me or I reached out to Michael and said, “Hey. Been there, done that.” Because he had endured a similar attack as a climate scientist maybe a decade before. We started comparing notes and realized that there was a lot of crossover between the attacks on climate science and biomedicine. If you think of them as two circles of the Venn diagram, they don’t totally overlap, but there’s significant overlap.

Before we know it, we had a book that could really show that this is a whole organized anti-science ecosystem, that it’s not just some random junk out there on the internet. It was organized. It was deliberate. It was politically motivated and financially motivated. A lot of it coming from the wellness influencer industry. I thought we had an important message to tell and to explain to people how this is organized even though it is a dark book. Our thinking was, “Well, if you can’t even describe it, how can you hope to chip away at it?” That’s what this tries to do.

Harlan Krumholz: If a young scientist came to you and said, “How do I engage with bad faith criticize without amplifying it?” How do you manage that? What advice would you give to others as they think about, yeah, I want to get involved, but then all it can do is escalate the platform.

Peter Hotez: Well, I think first of all, we clearly need more physicians and scientists and physician-scientists out there in the public domain. Because I think too often we’re invisible, and I think part of the problem there is the heads of the academic health centers don’t necessarily like their docs and scientists out there because they’re obsessed about controlling the brand of the institution. It’s become more perilous. One of the things that I say is, if you really want to do public engagement, really think about what your goals are. You don’t want to, as Churchill warned, if you stop to shy a stone at every dog who barks, you’ll never get to the end of your journey.

You really want to be fairly strategic on how you do your public engagement. When people ask me about public engagement, especially young people, they think I’m going to start talking to them about social media. One of the things that I explained to them, “Well, actually, no. Social media is probably the least rewarding, for me, the least rewarding aspect of public engagement.” Especially on Twitter or X right now, which becomes such a cesspool. So that if you’re going to want to have a presence out there and aspire to talk to a wider audience, really think carefully about what you want to do. For instance, for me, I don’t do podcasts, but I could see that being a very rewarding and impactful thing to do.

But in my case, I put my energy into writing books and opinion articles. For me, that’s the most meaningful part. The social media, I think of Lady Gaga’s immortal words, “social media is the toilet of the internet.” I think she’s probably right. I still do it because for legacy reasons I have a lot of followers. I have 400,000 followers on Twitter or X, and keep that going even though Elon is now, I understand, switching up algorithms to make me less visible or make other scientists less visible. But I think that’s the message. Think about how broad you want to make your lane become. I try to still stay pretty focused on the things that I’m passionate about, which are vaccines, infectious diseases, neglected diseases, climate health, things going on in Texas.

That’s about it. What impresses me about the two of you is how you’ve been able to broaden your lane and really are willing to engage in just about any health topic. There are very few people who do that well, and unless you really hone your craft, I recommend not trying to do that. Two of you are among the exceptions who do this exceedingly well. In fact, I was just talking to Jon LaPook recently from CBS News, who’s another person who does that well, or Sanjay Gupta, and your dean of your school of public health is quite good at that too. She also can talk about multiple different topics and do it in an authoritative yet show humility as well, that she’s not trying to be the expert on every topic, so it’s a balancing act. My hat’s off to both of you how you’ve been able to do that.

Harlan Krumholz: Well, I’m going to put that on a commercial.

Howard Forman: No, I think that’s a key point, though. It’s the humility. I do think that we know the narrow areas where we’re actually experts and we’re willing to concede that other things we’re always open to learning more.

Harlan Krumholz: Let me just do a quick follow-up because you mentioned that Churchill quote, so that’s an interesting one, which is, what do you get distracted with? What’s worth your time? Where are you going to engage? Recently, the CDC has changed their guidance because the Secretary of HHS has decided that there would be a statement that led to more ambiguity about the relationship between autism and vaccinations. Did you engage with that?

Peter Hotez: That one I did because that one was right down the center of the lane. That’s how I got involved with public engagement, is having a year of discussions with Bobby Kennedy, explained to him why vaccines don’t cause autism, because I have a daughter—

Harlan Krumholz: What did you do? What did you do?

Peter Hotez: Well, what I did was went back on TV, first of all. I keep on hoping my TV career winds down, but as COVID begins to wane a bit, Mr. Kennedy seems determined to take me out of retirement. I did multiple interviews, BBC and elsewhere, and then went into the cesspool X and spelled out why this is—

Harlan Krumholz: What was your central message? What did you say?

Peter Hotez: There’s two parts of the central message. One is, other than this is total bullshit, the two parts of the central message were, one, a massive body of evidence showing that vaccines don’t cause autism. Reminding people that the anti-vaccine playbook is to keep moving the goalpost so you can’t keep up with them. First, they said it was the measles, mumps, rubella vaccine, and that came out of the Wakefield paper in 1998. Then, Mr. Kennedy came on the scene at 2005 and wrote in Rolling Stone magazine, it was thimerosal preservative. That was also debunked through large cohort studies. Then, it was spacing vaccines, too close together. It was Hilleman vaccines. This was yet another iteration of that.

Each time the scientific community makes a good-faith effort to show, to look into it, investigate it and show it’s not the case. But the other really important piece to this that not enough people talk about is the lack of plausibility. You got to have something there there to talk about. Autism begins in early fetal brain development, through the action of autism genes, all working on expressing proteins involved in neuronal connections, synaptic connections. The first major paper on this came out from the Broad Institute at Harvard MIT in 2020, and a paper in Cell looking at more than a hundred autism genes all involved in early fetal brain development.

Then, we did genomic sequencing on Rachel, my wife Anne and I, and found Rachel’s autism gene, which was similar to, not on the list, but similar to the one that was a neuronal cytoskeleton gene. Going through all of that lack of plausibility, that this is all happening during early fetal brain development. It doesn’t mean that there’s no environmental exposure, but there are environmental exposures that are happening in early fetal brain development. For instance, if you’re pregnant and not aware of it and on an anti-seizure medication called Depakote or valproic acid, also a mood stabilizer. That’s been shown to interact with autism genes and give you an autism phenotype, and remind people, as Mr. Kennedy had no interest in looking into that and others as well.

Telling a completely different narrative that actually made sense to people I think was really important, because it wasn’t enough to just say the evidence that vaccines don’t cause autism because then parents would say, “Okay, doc, now I get it. Vaccines don’t cause autism. Hey, doc, what causes autism?” That’s a very reasonable thing to ask. Going into the science of autism I think was something that was really important to do at that time.

Howard Forman: I want to pivot to the other side of the equation, which is that there’s more and more misinformation about the effectiveness of vaccines—not the safety, now, but the effectiveness. There are people that are out there saying that all of these infectious diseases were going away before we had vaccines to begin with. There’s no question that there have been public health measures and better living and all those things that have allowed a lot of diseases to get better over time. But the evidence of the vaccines’ effectiveness is so high. We have this new evidence right now because unfortunately we have declining vaccination rates all over the country.

I just want to read a few examples of that, but then come back to you and just ask you how do we use this better to inform people? South Carolina, Spartanburg, which is the epicenter of the outbreak, there’s 58 cases in South Carolina. Their vaccination rate is down to 90% from 95% just four years earlier. That’s not a random association. Measles outbreak in West Texas earlier this year occurred in the Mennonite community, where vaccination rate for the county was 82%, but as low as 50% in the school district where the outbreak occurred. There was a type of polio virus spread in the New York metropolitan area in 2022 when a traveler brought the virus into the area. In that area, the vaccination rate for polio was as low as 37%. Luckily, nobody actually developed poliomyelitis from that.

Then, just yesterday, the third whooping cough death was announced in an infant in Kentucky, another area with a huge outbreak. Kentucky’s yet another state with declining vaccination rates. They specifically indicated in the article that I was reading that none of the infants who died had been vaccinated, nor had their mothers. To me, these are such compelling stories and yet it’s not resonating on that side. We’ve got to be able to push back on both issues, the safety as well as the efficacy, and I think we’re losing the battle on both ends.

Peter Hotez: Well, remember, it started with our Health and Human Services Secretary, who just every few days he would put out a piece of vaccine misinformation. Either discrediting the effectiveness of vaccines or discrediting the safety. It started during our measles, terrible measles epidemic where we had a hundred hospitalizations and two needless deaths among unvaccinated kids. He said the hospitalizations were due to quarantine measures, which was absolute BS. Those were sick kids with measles pneumonia and other measles complications. Then, he said, the MMR, measles, mumps, rubella vaccine’s a “leaky” vaccine, whatever that means. It’s not—it’s one of the safest, most effective vaccines we have.

When I aspire to make a vaccine and doing our design of new vaccines, we try to make something—our goal is to make something as good as the MMR vaccine. It’s a gold standard. Then, he says the effectiveness rates decline 4% per year, and you’re scratching your head, where the heck did that come from? Well, I actually went into it. It’s not 4%; it’s 0.04% per year. He was off by a factor of a hundred. Then, he says the MMR vaccine is contaminated with aborted fetal remnants. Absolutely not true. Then, he keeps going from there, so every few days, and then, comes... you know, the difference between Bobby Kennedy when I spoke to him almost a decade ago and now is the way he’s aligning himself with the health wellness influencer industry.

Then he says, “Well, you can either get the MMR vaccine or you can get an infusion of vitamin A, budesonide, and clarithromycin.” You’re like, “Where did that come from?” Then, you realize that he’s aligned himself with the health wellness influencer industry, which is all built on buying up whatever they can in bulk, jacking up the price, and pairing it with a $1,600 telehealth visit. If you ever wondered why are they all always antiparasitic drugs, ivermectin, hydroxychloroquine, fenbendazole, that’s because there’s a bucket of it. You could buy it for cheap. You can then repackage it—

Howard Forman: Repackage it.

Peter Hotez: ... and sell it with a $1,600 telehealth visit. And then he’s appealing to that. This is a man who’s in charge of health for the United States government. That’s a tough voice to compete with, but we do what we can.

Harlan Krumholz: Peter, let me ask you this. So far the sides have been very antagonistic to each other. Is there a moment for Mamdani.... An embrace of the newly elected socialist mayor of New York was not something people expected to see. You’ve had this escalation of confrontation that yields to a rapprochement where actually there’s a return. If you look at this administration—take this week, where all of a sudden Trump’s for subsidies, then he’s against subsidies again. But there’s a zig and a zag to the administration. Is there a path that you could see where we could actually turn some of this around with the administration?

Because it’s one thing for us to bemoan what’s going on or to... but this administration, like it or not, is here for more than three more years. The question is, is there a path for adversaries to find common ground? I don’t know, have you had any thoughts about that?

Peter Hotez: Yeah. No, this is an important question. Teddy Roosevelt once said, “To complain about something without offering a solution is just whining.” I think that’s absolutely right. One of the reasons why Kennedy can get away with this is because there’s no brakes on him. There’s no feedback loop. He’s not getting anyone, either in the Congress—

Harlan Krumholz: And he is pretty popular—

Peter Hotez: ...or the White House too. What’s that?

Harlan Krumholz: He’s pretty popular.

Peter Hotez: Yeah, he’s not getting—

Harlan Krumholz: He’s more popular than the president. Let me say that.

Peter Hotez: He’s not getting anybody in the White House or Congress really to tamp him down or just say, “Hey, Bobby, put the brakes on this stuff. It’s because it’s so self-defeating for the country and so dangerous for the country.” Look, I’ve offered, and I do talk with members of Congress. I’ve had, you know—

Harlan Krumholz: Do you talk to Cassidy?

Peter Hotez: I talked with Senator Cassidy and he gets it and how empowered he is to do something about it, it’s another question. I’ve offered to come to the White House, and I’ve always had good relations with people in the White House in every administration. Even the first Trump administration. Secretary Azar, who was Health and Human Services secretary, invited me to Geneva to speak at an event at the World Health Assembly on why vaccines don’t cause autism.

Harlan Krumholz: I think the way to this administration is to find someone like Kushner or Witkoff or these people who have influence with Trump to be able to start to change things. I’m really serious. I don’t know if getting you together with Kushner for an afternoon—

Peter Hotez: I would do it in a heartbeat, absolutely. But unfortunately, it’s asymmetric right now. They’re in power, and they haven’t shown a willingness to reach out, and I don’t have access to them.

Harlan Krumholz: Maybe we should talk to Jeff Sonnenfeld, we should talk to Jeff Sonnenfeld, if he can broker this. No, I’m serious, Howie, getting Peter together with Jeff and seeing what kind of ways we can broker the conversation, I think it would be a good idea.

Howard Forman: Yeah, I just don’t get the sense that the administration is really influencing Kennedy that much. I think Kennedy is influencing everything right now.

Harlan Krumholz: The way in is to say that one of his greatest accomplishments was what happened with the mRNA vaccine and Operation Warp Speed. Getting him in the mindset of what actually could be claimed as one of his greatest accomplishments is a way to reorient this a little bit because he really—

Peter Hotez: By the way, Harlan, it would be heartfelt. That’s actually true.

Harlan Krumholz: Yeah, exactly. Anyway, well, hey, we’re going to work on this. We’re going to solve this with you, Peter. We’re going to solve this with you.

Howard Forman: Final question for me is, Harlan last week on the podcast mentioned that we should corral our students and help them push back on misinformation on the various social media platforms, and it is a great idea. I love the idea of it, but there are two things that concern me. One is that it’s putting them in harm’s way to some degree if they become engaged in that way. Number two, it may be, as Harlan and you mentioned earlier, it can draw negative attention as well. It may not necessarily float well if Yale students are the ones that are doing this. You have a lot of students in Texas and all over the country that you’ve come in contact with.

Is there a role that we could take in bringing together students that are passionate, young, motivated, and social media–savvy to push back on fact-based counter detailing in the anti-vaccine space?

Peter Hotez: The answer is yes, but I would frame it a bit differently, and that is, put less emphasis on social media and more on first getting educated on what the disinformation space looks like. Because just to go right to X, or social media, I think may not be the way to go. As I point out, Michael and I point out in the book Science Under Siege, it’s a very complicated ecosystem. It’s not only social, and by the way, it’s not only X, right? There’s lots of other platforms. You have all the conspiracy podcasters, and you have elements coming from even outside the United States. You have foreign actors now. This was shown by David Broniatowski at George Washington University. He’s a computer scientist. He has looked at the role of Russian influence or North Korean influence.

In their case, they’re filling it up with both anti-vaccine and pro-vaccine bots and trolls because their goal is a little bit different. They see this as one of a half dozen wedge issues which could divide the country. Half the time, or two, three quarters of the time that someone might engage in social media, they’re engaging with a bot coming out of North Korea or Russia or elsewhere. That makes it even more important to be extremely strategic in how you’re going to do your public engagement. I think one of the things that would be equally or more impactful would be not just so much the students, but getting the academic health center, medical school’s offices of communications on board.

Because they’re so concerned about the unwanted attention and protecting the brand of the institution, or what you’ll get from many offices of communications, and Baylor and Texas Children’s are better than most, but they get, “Well, yeah, you’re an academic, you’re free to speak out dot, dot, dot, but don’t screw this up and don’t get the institution in trouble.” You deal with the Damocles over your head. As you both know, that if you do this enough you eventually do screw it up, and you do get the institution in trouble, and you need to know that we have their backing. You know, educating the offices that communicate—many of them were hired decades ago, when social media wasn’t even a thing.

Oftentimes university offices of communications, you know, party like it’s 1999, and they’re still back to very old-school ways of doing things and not understanding. So it’s not just getting the students on board. We have to get the leaders of the academic health centers and particularly office of communications on board with this as well.

Howard Forman: Well, we appreciate you and everything that you’ve done. I want to just remind our listeners, you got the new book, Science Under Siege: How to Fight the Five Most Powerful Forces That Threaten Our World. It’s a great read, and we hope we get you coming back again in person and on the podcast.

Harlan Krumholz: Peter, such a pleasure to talk to you. You’re an American hero. We really appreciate the opportunity.

Peter Hotez: Well, the two of you are my heroes and extraordinary physicians and physician scientists. Thank you for everything you’re doing.

Harlan Krumholz: Thank you.

Howard Forman: Thank you.

Harlan Krumholz: Thank you. Well, that was a tremendous interview.

Howard Forman: He’s amazing. You could have him on every week.

Harlan Krumholz: Peter, like you know, was a classmate of mine in college. We didn’t know each other well. I think I really admire him, and he’s just terrific and amazing. But, okay, let’s get to your piece today. What’s on your mind?

Howard Forman: All right, so this will be quick, but two things coming from the Trump administration, and if the press is right, I’m actually in agreement with the administration on both items. The president was, and I’m using that term specifically, said to be offering a compromise on the enhanced premium tax credits for the ACA exchanges. We’ve talked about this many times over the last several months. Reminder, if Congress and the President don’t act, ACA exchange policies, over 24 million people will increase costs to beneficiaries by a hundred percent or more in many cases, and many will just drop coverage because the cost will be too high, and that’s just not good.

The President appears willing to renew the credits for two years, reducing the group that benefits from them to those under 700% of the federal poverty level, which for our listeners is about $230,000 for a family of four. It would make sure that everyone pays some premium, no more $0 premiums, and would allow for those who choose cheaper policies to redirect some of the subsidy into a health savings account. All these things are reasonable. Of course, the administration is already getting pushback from Congress. All that I have just said is basically rumor because the White House is now disavowing the comments and stepping back from it.

But if it is true, it is a step in the right direction to providing necessary support to both the individuals and families who need this, as well as the exchanges themselves so they can continue to function. I sincerely hope this works out. It would appear to be politically advantageous to the president, but it is good for the millions of middle- and lower-income individuals who need and deserve this. That’s number one, the second—

Harlan Krumholz: Well, let me just say quickly, this is what I’m talking about when I say that the administration pivots. This was unexpected. By the way, the whole shutdown was about this, and he’s coming in now on this approach.

Howard Forman: But he’s backing away from it already, Harlan, because he’s afraid of—

Harlan Krumholz: He’s been pressured. But the fact that they would even suggest it just tells you that we shouldn’t give up on engagement with the administration.

Howard Forman: I know, but I’m not hopeful about the last thing. The next thing is—

Harlan Krumholz: Yeah. Okay, keep going.

Howard Forman: Yeah. The second related story coming out of the White House and CMS is that they are moving ahead with more efforts at what we call site-neutral payments. We’ve briefly touched on this in the past as well. As a quick recap, Medicare currently pays more for many outpatient services when performed in a hospital-based practice. That includes within the hospital, but also within freestanding hospital-associated practices, more for those than they do for a freestanding physician outpatient practice. In the current case, Medicare is proposing to reduce this discrepant payment. The argument in favor of paying more to hospital practices is that they are seeing sicker patients that require more intensive and costly care. This is true.

The counterargument is that once you establish that hospital-based care is paid more, it creates perverse incentives to send healthier patients to hospital-based practices when they would do just as well in a presumably more convenient, lower-cost physician office. Both things can be true. We do not adequately reward physicians or hospitals for the acuity of these outpatients. We use structural labels, hospital or physician practice, to assign higher payments. We need to fix this. The administration is starting with chemotherapy, but the long-term goal would be to fix this across the board, radiology, cardiology, gastroenterology, et cetera. This is a hugely contentious issue.

I do not mean to say that we could fix this properly and quickly, but we first have to acknowledge there is a problem and then we should address it. If Medicare could properly reimburse for high-acuity patients when they’re cared for in hospital outpatient settings, site-neutral payments would be a lot easier to swallow. For what it’s worth, the savings are in the tens, if not hundreds of billions of dollars over a ten-year budget window. That’s just the savings to the Medicare program. Additional savings would accrue to beneficiaries themselves. I also just want to end here, Harlan, with saying my annual shout out of thanks to my family, to my colleagues, my students, to our listeners, to our team, and especially to you, Harlan.

We are approaching our 200th episode. I’m eternally grateful for this opportunity to work with you, and I wish everybody Happy Thanksgiving.

Harlan Krumholz: Let me just punch in quickly on the comment on your thing about the site-neutral payments, which is, people should just know that this created a tremendous incentive for hospitals to make physicians employees, because the physicians would do the same work and now more could be billed greater margins, and it just escalated costs throughout the entire system. This is not just a trivial thing about you’ve got these parallel systems. It created a tremendous incentive, which has forever transformed the healthcare landscape and made physicians largely employees, because of the way that this worked.

Howard Forman: It’s all true.

Harlan Krumholz: Well, let’s just finish the end, but on the Thanksgiving side, my God, Howie, what a pleasure and joy to be able to work with you every week. We’ve got a terrific team. I was going to do it in a different way with the outro, but we’ll do it here. To our listeners and to the feedback and to the opportunity and privilege of being on this platform, and to Yale School of Public Health and to Yale School of Management for really their sponsorship and belief that there was a need for something like this, and for their continued endorsement and support throughout, we’re grateful. Thanksgiving is such a wonderful holiday for us to be able to show gratitude, and thanks.

Howard Forman: It is.

Harlan Krumholz: Thanks for that.

Howard Forman: We’re always still looking for the feedback, health.veritas@yale.edu, and we still want to tell you about our MBA for Executives program at som.yale.edu/emba, and the School of Public Health’s Executive Master of Public Health program at sph.yale.edu/emph.

Harlan Krumholz: I’m always going to double down on saying our superstar undergrads, Tobias and Gloria, our marvelous producer, Miranda, and me, who gets to work with the best in the business, Howie Forman.

Howard Forman: Right back at you, and a really sincere Happy Thanksgiving to everybody. We’ll be back here next week with another episode.

Harlan Krumholz: Yeah, thanks, Howie. Happy Thanksgiving. Talk to you soon.

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