Shivan Mehta: Designing Better Healthcare Decisions

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Shivan Mehta, but first we like to check in on current hot topics in health and healthcare. What do you have today, Harlan?

Harlan Krumholz: Well, Howie, I’ve got a question for you. Do you think that if you happen to go to a conference and talk with a Chinese colleague, that that represents a collaboration, and that kind of collaboration could put you at risk for your federal funding?

Howard Forman: I wouldn’t think so, but I think you’re going to tell me otherwise.

Harlan Krumholz: Well, I’m going to tell you that things are changing. Right now, if I talk with a Chinese colleague in the hallway at a scientific meeting, I don’t know whether that’s going to qualify for something that may provide a sanction by the U.S. government. What if we discuss a published paper? What if we write a review together? Analyze data independently for the same paper or advise the same student? Right now, nobody seems to know.

The National Science Foundation has just announced a forthcoming policy prohibiting NSF-funded researchers from collaborating with institutions on several federal restricted party lists, or even with employees of those institutions. The national security concern I get. It’s legitimate. Sure. In some fields, some scientific work is sensitive. Intellectual property can be stolen. Data can be misused. Research can have military/commercial applications. But in healthcare, mostly we’re working in common ground, fighting common enemies, disease, trying to promote health.

And in this NSF letter, it’s telling researchers what is prohibited without clearly defining what collaboration means. Now on that list are groups, countries you would expect: North Korea, Iran. But China’s also on that list. And Science has reported that universities are asking about the rule, wondering about the rule. And I know at Yale, we’re not really sure exactly about it.

And that ambiguity is not a minor administrative problem. The consequences are serious when the boundaries are unclear. Institutions will not interpret them narrowly because they’re worried in this kind of environment that funding will be cut off. So we’re already starting to see researchers avoiding conversations, declining authorship. The meetings that I go to in China have far fewer Americans than I’ve ever seen before.

And so what we’re seeing is this great uncoupling. And I think that matters. It matters in health and medicine because China in particular is not at the periphery of global science. In the 1900s, I mean, going way back, China had a very undeveloped scientific community. And as you got through to Deng Xiaoping, and as China began to open up, it began to grow.

But I can tell you that in the last 10 years, in the last two years, in the last six months, we’re seeing remarkable breakthroughs in the Chinese science that we’ve never seen before. If you look at the number, percentage worldwide of clinical trials, early clinical trials that are being produced, by 2025, the American share had fallen to 18%, from about 26% just 10 years earlier. And the Chinese share had risen to 17%, essentially at equity. So the gap between the two countries and what they’re producing just in the clinical trial side has basically just gone away.

Now look, Chinese science, like American science, sometimes has genuine problems. Uneven research qualities, serious concerns about research integrity. We’ve seen it in both countries. They have a history and a reputation that I think is antiquated at this point. The very best scientists over there are doing extraordinary work.

And I’ll tell you, this uncoupling will not stop Chinese science. At a time when we’re pulling back funding on U.S. science, they’re doubling down and investing more in it. So scientists will build relationships elsewhere there. Companies will find other partners. Talented students, we’re already seeing the flow of Chinese students to the United States is in great decline. These were, in many cases, extraordinarily talented individuals who added importantly to the labs and research groups here. They’re missing in action now.

A sensible policy would draw bright lines around what is classified, what should be dual-use technologies, what’s sensitive personal data, and undisclosed financial relationships. But then create safe harbors where we can work together, where research can be shared, data can be shared, and we can advance together. This idea of zero contact, it’s a prescription for actually U.S. science falling behind. Sure, we should compete vigorously, invest confidently, protect what genuinely requires protection, but we need to cooperate when patients can benefit.

And I can tell you that there are good people of good will who want to do good work together in both countries. And the more that we restrict that, the more we penalize advancing global health broadly. So I’m going to ask this about America. Can a country remain the world’s scientific leader if its researchers are no longer sure who they’re allowed to talk to? This is something we got to fix. We’ve got to make sure that it’s not an overcorrection, one that will harm the U.S. and harm worldwide science.

Howard Forman: It does seem like such an odd thing to try to regulate when in fact so many Chinese students come here, as you mentioned, even if it’s going down, it’s still a large number, to do undergraduate, graduate, and then even postdoc programs here. I don’t know how you regulate that when these individuals, when do they stop being your postdoc and start being your colleague, and how do you communicate with them once they leave here? It just seems almost impossible to build these big walls that they seem to want to build.

Harlan Krumholz: And what I’m seeing is that there’s a fear that’s manifesting in American scientists that is leading them to wonder whether they will get in trouble by talking and collaborating. And I will tell you, just another quick vignette is I have a colleague at UT Southwestern who’s had vigorous collaborations in China over the years. The governor there, Governor Abbott—UT Southwestern’s a public institution. It’s part of the state’s network of health centers. They are not allowed to travel to China. They’re not allowed to travel to China. So it’s a prohibition that he told me about. So there are various ways that it’s manifesting, but it’s unfortunate because there’s a lot that we can do together, and separating us I don’t think is going to be a good path.

Howard Forman: It does seem shortsighted. Thanks for telling us about that.

Harlan Krumholz: Thanks. Hey, let’s get to our guest.

Howard Forman: Dr. Shivan Mehta is the associate chief innovation officer at the University of Pennsylvania Health System, director of the Population Health Lab, and associate professor of Medicine and Health Policy at the Perelman School of Medicine. He is also a clinical gastroenterologist and co-director of quality for Penn Medicine’s gastroenterology division.

At Penn Medicine, he heads a team leveraging behavioral science and technology to improve population health outcomes. He has led over 30 pragmatic trials of healthcare delivery innovation that incorporate behavioral economics, technology, and care redesign. He received his bachelor’s degree in economics from Yale University, which is when I first met him, his medical degree and master’s degree in health policy research from the University of Pennsylvania, and his MBA in healthcare management from the Wharton School. He completed residency in internal medicine at New York Presbyterian Hospital, and his fellowship in gastroenterology back at Penn Medicine, where he is now.

And so first I just want to welcome you to the podcast. It’s great to have you on. You recently published in the last few weeks an editorial with a colleague, I believe, who had gone through a pregnancy, and you reflected on the fact that she was getting overwhelmed with text messages after the pregnancy. What are the big lessons that you could give health systems about how to best use text messaging in that type of setting?

Shivan Mehta: Yeah. And I think it’s a good lesson about contextual inquiry or putting yourself in the patient’s shoes. So both Kim and I, Kim Waddell and I, we’ve done a lot of studies showing that text messaging can improve outcomes. They can save lives, they can mitigate disparities, and we’ve implemented them across our health system.

But when you see it from the patient perspective, it’s quite different. And from her perspective, she was getting a lot of different text messages. Some of them coordinated, some of them not. Some of them more evidence-based and some of them not. And I think that’s a lesson in just, whenever we come up with these things, you have to do that design thinking, do that contextual inquiry, understand from the perspective of the users what things might be frustrating. So even though it might actually improve cancer screening rates or improve show rates, if it irritates the patient so much that they don’t want to come back or they want to complain, you’ve kind of missed the mark there.

And we experience this in our lives. We get text messaging every day, particularly around political campaign seasons, and we just sort of ignore them and get frustrated by them. And so I think we just have to see it as, we have the limited bandwidth of patients, but we need to take advantage of it, and say that this is a sort of tragedy of the commons issue where we only have limited bandwidth for our patients. We want to take advantage of it to do the things that we think are the most impactful for their health, things that will make them better.

And so the key lessons that we’ve learned is text messaging can be very useful, and it can mitigate disparities and it’s more accessible for patients than let’s say the patient portal. We’ve found that over and over again. But you have to do it with responsibility. If you’re a health system, you have to coordinate it across all the different programs. You have to think about bundling. And then importantly, you have to think about evaluating it to make sure it’s actually accomplished the thing that you want it to accomplish.

Harlan Krumholz: It’s terrific to have you on the show, and it’s always terrific to have people who are inspired by Howie. There are legions of them. And so we can never quite fill the program with them. And the work you’re doing is so relevant. How can we engage patients? How can we help them to make choices that are in their best interest?

You get to work with Kevin Volpp, one of my favorites, real pioneer in the field. Someone who got his PhD in economics and then went into this behavioral economic angle, David Asch. I mean, you’ve got so many good people there, and I’m leaving off so many. There’s so many good people.

One question is that occurs to me. You’re chief of innovation. So where does academics find its best place? So a lot of what you’re talking about is product development. So there are a lot of companies out there that are very incented to sort of figure this out, how we don’t bother the patient. And whether it’s Epic themselves, or one of the hundred thousand startups that are trying to move into this space and provide the kind of services to patients. And Howie, you’ve seen these companies, some of our former students put together these companies, this sort of pre-op about getting people ready for pre-op, like Rob did—yeah, Rob Stavert—and sold that company.

So where’s the special place for academia? I mean, I talk about this all the time on the AI side because obviously those companies have gazillions of dollars, they have big data centers, they have infinite resources. Where do academics tack in this era where they can make the best contribution and recognize that they’re doing something different than what all the companies are going to do?

Shivan Mehta: Yeah, that’s a really great question, and it’s something that I’ve spent the last decade trying to figure out. I’ve been fortunate to be unique where I have a role where I get research funding and do kind of scientific research similar to any type of research that happens at our institution, but also an operational role where I’m accountable for improving outcomes, like colorectal cancer screening. So I understand areas where there’s overlap but also areas where it diverges. If you want to increase colon cancer screening, as we had it as a goal for our health system, you can’t run a bunch of RCTs and expect to get the results three, four years later. You have to do things quickly and learn from it, even with limited evidence.

But I think we found some areas where there are great overlap. So one is that just the evaluation, just rigorous evaluation. So there’s a lot of startups, there’s a lot of technology companies, Epic, one of them, even our own health system... they want to get things out there. They invest in sales teams. And the evidence they have is limited at best, in a lot of circumstances. In some cases, it’s really just what makes the chief information officer happy. What allows for more billing.

And I think it’s our role to say, how can these things benefit society and how can we think about more rigorous evaluations to complement that? It doesn’t mean that they have to go through the turnstile of academics where you have to do an RCT or you have to do a paper to roll it out. You can do that, but you can do the research in parallel.

And so the areas where I found it to be useful, one is, areas where the health system, it’s not on the time horizon for the health system. So the health system, or let’s say a company wants to invest in something, they need to get that product out quickly, in a year or two years. They need to prove to their investors or we need to show an ROI to it very quickly. They don’t have the time to invest in things that might work, let’s say, three, five years down the road.

And that’s where getting research funding, doing research and development, bringing in things from other disciplines, AI is obviously, there’s going to be a huge space there, is really valuable to think about that longer time horizon where academics do have the appetite to do that. And that holds true for basic science research. A lot of the things that didn’t have a business model at the time, but we still invested in it because we got NIH funding or we felt that it was important to advance the science. So I think that’s one area is the time horizon is one piece.

The second is objective evaluation. So a lot of these companies, they have self-interest. We all have self-interest. Just to be perfectly frank, if I’m rolling out a program, I’m invested in showing that that program works because it helps me from a reputational standpoint and helps to advance things in different ways. And so having someone to collaborate with to independently investigate that I think is really valuable. And I think that it lends credibility to it. If you look at a lot of the startups and companies, the ones that have rigorous trials, rigorous evaluations, are really useful.

And the other things I’ve seen is just in my own world of all the things related to healthcare delivery, things that may see—pre-post analyses, particularly for technology. When you look at the people that use a technology and how well they do compared to the people that don’t, often it has a lot more to do with the fact that they’re able to download the app and they have the kind of wherewithal to do that. That’s also been a useful space.

And then I guess the last one I’d say is just bringing in sort of interdisciplinary learning, bringing in insights from.... We’re fortunate here at Penn, and Yale is the same way, that we have lots of different schools, lots of students, lots of trainees. I think that’s a really great avenue. People with fresh ways of thinking, new ways of thinking, lots of exciting ideas. So that’s another area that I think academia can be useful, the multidisciplinary, interdisciplinary learning and bringing in different mindsets and different ways of thinking.

Howard Forman: You basically do colonoscopies, you’re a gastroenterologist, you’re involved with patients with a full spectrum of gastroenterology diseases. Do you feel like we’re making progress in that specific domain, since you know it the best? And what have been the interventions that get greatest compliance with regular colonoscopy or other type of screening?

Shivan Mehta: Yeah, colorectal cancer, reducing the burden of colorectal cancer is something that I spend a lot of time thinking about, mostly from a delivery science perspective. So we know things work, but how do you actually get patients to do it and clinicians to order it and how can you think about adoption across different health systems?

And I’d say it’s one of the few success stories I’d say with cancer screening. There’s not a lot of screening tests out there. There’s some multi-cancer detection tests, but the evidence really isn’t there yet. But for colorectal cancer screening specifically, there’s no doubt that it reduces the burden of colorectal cancer. We’ve implemented it across lots of different sites. There’s evidence that it can mitigate disparities. That it can eliminate disparities for minority groups.

But I think the thing that people sometimes forget is that it’s not just screening that reduces the burden of disease and it’s not just treatment. It’s you have to identify when people have symptoms early on, you have to make sure that those people actually come in and get care. The 35-year-old that has rectal bleeding or symptoms, they shouldn’t be screened and they wouldn’t be screened unless they have a family history. So you have to think about ways to detect that. So early detection for people with symptoms, identifying people with family history, average risk screening, and then follow up with people that have follow-up tests. So that whole spectrum is actually where we need to really be thinking about it. And I think a lot of the thinking has really just been focused on average risk screening. We used to screen people at age 50, now we screen them age 45. So I think that kind of holistic aspect of it is really important.

And then finally, when they get diagnosed with colon cancer, making sure they go to an evidence-based place, someone that knows what they’re doing. A surgeon that has a lot of experience with it, someone that knows the latest chemotherapies and radiation therapy that’s effective for that. So I’ve seen colorectal cancer as a microcosm for lots of different cancers and other population health interventions.

But the biggest limitation now is that there’s a lot of things that we know work. And let’s say at our own health system, and let’s say Kaiser and other places, they have, let’s say, 75%, 80% screening rates, and they have programs looking across the continuum. But a lot of places don’t. And some of it gets to a business model.

So we know that mailing out just low-cost fecal immunochemical testing kits, not the Cologuard that you see on TV, just a twenty- or thirty-dollar test works. It’s very effective. Yet we don’t do it because health systems have competing interests. They get paid for colonoscopy, but they don’t get paid the ten dollars it takes to mail it out. So some of it does get back to organizational incentives, payment, and just kind of cultural differences across different systems.

Harlan Krumholz: Since you mentioned Cologuard, a lot of listeners will have seen the commercials on TV and wondered about that. I assume you’ve really dug into this. So you’re suggesting that just sending out people who take a sample of their stool and see if there’s any evidence of blood in it is good enough.

Can you, just as a public service announcement on our show, help people understand the difference between colonoscopy, Cologuard that they’re seeing on TV, and what you’re describing, which is just even a simpler thing. People used to talk about guaiac testing. It’s like just taking a little bit of the stool and seeing if there’s any evidence of blood in it. Can you compare and contrast those methods, and what should people be thinking about for themselves? Because a lot of people I think are curious about Cologuard when they see these ads on TV.

Shivan Mehta: Yeah, I think we’re fortunate that there’s so many different tests out there, and now there’s actually blood testing out there too that can be reasonably effective. It’s not as effective as other tests. And so I think we’ve been fortunate about having different tests and there’s been a lot of research and development. And clearly the fact that Cologuard has all these advertisements out there means that there’s a big business model for them. They just got bought by Abbott. And so there’s no doubt that you can tell if there’s a good business model for it when you start to see ads during the World Cup about it.

So I think we’ve been fortunate that we have a lot of different tests. But I think the worry, particularly from a behavioral standpoint, is choice overload. How do you choose different tests? Clinicians can’t even make those decisions. I talked to my primary care colleagues, even gastroenterologists, they may not be aware of all the nuances of it. And then of course, if they can’t understand it fully, then how can patients understand it, the differences?

So generally the biggest tests we have are colonoscopy, which can both identify precancerous polyps and identify early stages of the disease, and non-invasive tests that are usually good for finding early stages of cancer but not as good for finding polyps. So historically the guaiac stool-based test looks for traces amounts of blood in the stool. Then there’s a fecal immunochemical test [FIT], which is a slightly better test.

And then Cologuard, most of the operating characteristics from Cologuard actually comes from the FIT test that I just mentioned. They add stool DNA, but it adds a very, very modest amount of it. It adds a lot more cost to it. I still think it’s reasonable. If somebody wants to get Cologuard, I think that’s great. There’s nothing wrong with that. I think the best test is the one that you do that’s evidence-based. So if you get a stool test, the simple FIT stool test, great. If you get a Cologuard, that’s great. If you get a colonoscopy, that’s great.

But what we have to start to think about is the cost of it, because I think all of our premiums are going up, that Medicare and Medicaid has to pay for a lot of this stuff. So we have to balance that from a societal perspective. But also from just a choice perspective because we don’t want to confuse patients so much that they end up not pursuing any of these tests.

Harlan Krumholz: Well, just in the spirit of clarity then, who are you recommending get Cologuard versus colonoscopy? Because I could see some people saying, “Why should I get a colonoscopy?” And as I’ve seen it, it’s a matter of the sensitivity and specificity. It’s a matter of the false negatives and false positives from it. I just know because you’re deep into it. So who are you recommending for what?

Shivan Mehta: Yeah. And so colonoscopy is more sensitive and more specific for identifying polyps and cancer. But the bigger benefit of it, I think from an implementation standpoint, is that if you get a colonoscopy and it’s negative, you don’t have to go back and do something every year. You can come back in 10 years, and maybe even more, based on evidence that we have.

The biggest challenge with FIT or Cologuard is that you do it once and you may not necessarily do it again. And so just doing when your doctor hands you a FIT kit or orders a Cologuard, and it’s not part of a program where they keep reaching out to you every year, or every three years or every two years, then it’s actually not that effective. People that have family history, high risk features, symptoms, they should obviously get colonoscopy.

But if you’re average risk, if you are a little bit averse to getting the more invasive procedure, and you’re happy to hold off on it, it’s not unreasonable to go with a Cologuard or a FIT test. But the key thing is that we can’t trust that the primary care docs and the patients are going to remember every year. We have data to show that. Getting a random Cologuard once, they’re not going to get it for 10 years.

Harlan Krumholz: I mean, first of all, I think this is a really important point. People don’t think of these as complex interventions. Complex interventions are ones where it’s not just about the test, but it’s the context in which it’s provided. The kind of support, follow-up, all the things you’re mentioning. I think it’s so important because people hear about these, and they just sort of think of them as standalones, but really their effectiveness depends on the context in which they’re provided.

But it does seem like if this option’s available and it’s something we want people to be using, it’s up to us to build within our health systems the means to ensure that there’s follow-up. I mean, there’s so many people who fall through the cracks in our healthcare systems, not just because of colorectal cancer screening but for a wide variety of other conditions that they really do need to follow up and they’re not getting it. So it’s a really good point you’re making.

Shivan Mehta: Yeah, I’ll give you some examples. So Kaiser Permanente, Northern California, they do a FIT first, a stool testing approach first, but they mail it out every year to patients. They follow up on the positive ones to make sure they follow through. And they found that they reduced the incidence of colorectal cancer, and they’ve eliminated disparities between Black patients and non-Black patients. So they have great evidence to show that they’re doing good by patients. That’s perfectly acceptable. But if you get a FIT test in some primary care clinic where they’re not having that same program, then that’s actually not the same thing. Then they’re getting subpar care, I’d say, compared to if that person just ordered a colonoscopy.

So I think you’re absolutely right. And what we’re starting to see is that there’s actually a lot of similarities with breast cancer screening and a lot of other cancer screenings. It’s the same. You have to think about the same principles. And so that’s where we’ve moved from individual interventions for just colorectal cancer to programmatic interventions. Just like I said, about text messaging, you shouldn’t get five different text messages. You probably shouldn’t get five different messages, one for cervical cancer this week, another for colon cancer next week. What if you could bundle them together so people can see, “Oh, these are the three or four things I need to get done” and leverage the same infrastructure to not just help colorectal cancer but help lots of different cancers and other preventive ailments.

Harlan Krumholz: Yeah, that’s right.

Howard Forman: While you’re a specialist, a lot of the work you do is really targeted at primary care because getting a colonoscopy or getting another screening is really a decision that very often happens in the primary care doctor’s office. How do you work within a large health system that is very specialty-based to try to change those behaviors when the incentives aren’t always there?

Shivan Mehta: Yeah, that’s a really great question. And I think that that’s what confounds a lot of us in the U.S. healthcare system is that people are kind of operating in their silos. I’ve been fortunate for a couple of things. One is that Penn is an integrated delivery system. So we have a very large primary care network all across the region, across our seven hospitals. So I think that’s one piece is that we have them in-house. We’re not trying to develop relationships with lots of different private groups. So it makes it a little bit easier to do that.

Two is that we have great collaborators and great partners. So Corie Rhodes is a medical director in population health. She’s a primary care doc. She’s been a wonderful collaborator, and we work on lots of things of mutual interest. I come with ideas, and some of those are good ideas, some of those are not-so-good ideas. She comes with problems, areas they want to work on, and we try to tackle those things. So it can’t just be whatever I think is the most exciting thing. It has to be a collaborative thing.

And the last is, incentives matter. So in the past decade, while there’s some mixed evidence about where value-based care has been effective and certain populations it hasn’t worked as well in, but I’d say the biggest positive thing has been in HEDIS measures. I know of course people, there’s concerns about quality metrics for lots of different things, but the fact that there’s a business model for insurance companies and for health systems to increase colorectal cancer screening rates and breast cancer screening rates absolutely allows us to have more leeway to implement things that we think matter and to get limited health system resources to invest in mailing out FIT kits for colorectal cancer screening, something that historically would never make the health system money. In fact, it might lose the health system money if you take people that would’ve gotten a colonoscopy in a limited-demand world, and then now have them get a FIT test, we might actually lose money. Insurance companies and the self-insured employers, they probably make money off of that. And so that’s where it gets to the incentives.

Harlan Krumholz: Just wonder, one of the things I wonder in terms of tracking, these programs are often just tracking utilization. Is there any effort to track the number of people who present in Philadelphia with advanced stage colorectal cancer and to see whether you can bend that curve?

Shivan Mehta: Yeah, that’s a really great question. It’s something that our cancer center is really trying to think about. I’ve worked on a few initiatives where we’ve partnered across the region of Philadelphia to mitigate disparities and reduce the burden of colorectal cancer in the region. And it’s challenging. The data isn’t great. So we’re always relying on the behavioral BRFSS [Behavioral Risk Factor Surveillance System], which is surveys of a small sub-sample of people about whether they’re up-to-date or not. And it’s a few years late, and it doesn’t necessarily reflect our populations.

I think looking at the cancers is really useful, and that’s what Kaiser did. Because they’re sort of a closed system, they’re able to track all the outcomes, and because they’re also a payer for a lot of their patients, they were able to see advanced stages of cancer, incidence of cancer, in a way that many of us can’t because people get their care at different places.

And so I think that is the next step because you’re right, these are process measures. We rely on the studies showing that it reduces mortality, and we rely on people getting cancer screening. So just getting cancer screening alone is not health-beneficial. It’s what happens downstream as a result of that. And so I think it would be a great thing as we get better data, as you get better integration, to start to look at those more distal outcomes that we think are the things that actually matter for patients and for our communities.

Harlan Krumholz: Let me just follow up one quick question, just because I know we’re getting to the end, I want to get this one in. So you really are one of the world’s experts in this issue of engaging and trying to in a way capture the attention. I mean, this is what we’re all trying to do, right? How do you get people’s attention in the right moment so that they get the opportunity to make the right decision for themselves? Not telling them what to do but giving them the opportunity, maybe nudging them toward it if they’re indifferent. But it was sort of like there was some friction that was leading them not to do that.

What have you learned, do you think, is the best way to engage people? I mean, especially in this world of people are getting bombarded in every different direction all the time. I think it makes it more difficult for a healthcare system to try to connect with people. And people are suspicious of things coming across their phone. Or I mean, they can’t even tell, we’re being told all the time with the cybersecurity and the hacking, how do you know it’s real? So how are you thinking now today is the best strategies to actually engage people?

Shivan Mehta: Yeah, it’s something that I have thought about, and something that we’ve seen in a lot of the experiments that we’ve run. And so I’d say there’s probably three principles that I’ve seen repeatedly work, things that work not just in one context but different contexts. And a fourth that I think I’d say is an asterisk.

The first is I think the trust part is important. So social norms matter. So from a patient perspective, having something come from someone they trust absolutely makes a difference. We’ve found that just signing a outreach about getting mammograms from the PCP [primary care provider], putting the PCP name on it versus just the practice name, had about a one- or two-percentage-point increase in participation just by that trust factor. We found that an automatic pended order during a visit for, let’s say, a flu vaccine, had one of the biggest impacts because it fosters the discussion between the primary care doc and the patient.

With vaccines, it’s an interesting one. Forty-five percent of adult population, they get their vaccines every year, and they’re totally fine with it. They get it from their local pharmacy and there’s no problem. Another 40% will probably never get it done, especially in this sort of media environment about it. But there’s that 10, 15% that are, say, persuadable. And they listen to their PCP. The PCP is one of the few people that people absolutely trust. It cuts across great sociodemographic lines and political beliefs and things like that. So that’s one piece.

The second is shifting a lot of prevention from an opt-in approach to an opt-out approach. Giving people a hundred different reasons why they should get colon cancer screening and then asking them what they want to do. In some cases, we want to get their preferences. In some cases, we should just tell them that this is what you’re supposed to do and this is what I’m recommending. And they’re like, “Thank you.” They still have the opportunity to opt out. We’re not forcing anyone to do it, but we basically simplify it for them. That’s the second.

The third is effort reduction. Just think about Amazon. My watch had the battery ran out. I ordered something from Amazon. It came the next day. It took me three or four clicks to figure that out. Think about healthcare. If someone that doesn’t have a primary care doc has to get colon cancer screening, there’s 10, 15 steps of the process. You to get a primary care doc, you have to talk to them, you have to check insurance. So we’re the opposite of Amazon in that way. And what we found is every step of the way, for both clinicians and patients, cutting out extra friction, making it super easy for people to do. Do work for them. That probably has, I’d say, maybe the most effect.

And then I think for financial incentives, I think just having the right incentives for people to get it done from a systematic perspective, that matters to some degree. But I think it’s a little bit less effective if I were to say just, “Why don’t you just pay people to do these things?” It’s actually not as effective, particularly for things like health. Because there’s a lot of intrinsic motivation that we want people to follow through on it, especially if they want to get it done over and over again. And we don’t want to make it a transactional thing.

Howard Forman: I’m so fascinated by the way that you’ve brought together all the things that you’ve always been interested in. You were pre-med, but you’re interested in economics. You’re a specialist in gastroenterology, and you’re doing all of that great work and advancing our understanding of how to deliver care better. And I just really appreciate you, appreciate you coming on the podcast. I learned a lot. Thank you.

Harlan Krumholz: Oh, what a pleasure. What a pleasure to meet you. What a pleasure to have you on. And it’s so nice to know about the connection with Howie.

Shivan Mehta: Yeah. Thanks so much for having me. It was a lot of fun.

Harlan Krumholz: Well, another all-star student of Howie Forman. He’s incredible.

Howard Forman: He makes me so proud. And then to be fair, I just saw him for reunion just a few months ago. So it’s not like I’ve seen him a lot over the years, but it’s just great to see what he’s grown into. He’s quite the scholar.

Harlan Krumholz: No, and it’s great how you keep in touch with people. I’m so glad you brought him on. But let’s get to the part of the podcast I always enjoy, which is Howie Forman, what’s on your mind this week?

Howard Forman: Here you go. We just celebrated our nation’s 250th anniversary. So now we get to celebrate the 50th anniversary of a public health triumph. It’s Philadelphia, it’s 1976, it’s July. We’ve just had our bicentennial celebration. And following that, 2,000 veterans gather at the grand old Bellevue-Stratford Hotel on Broad Street for their state convention of the American Legion.

Within days of heading home, they start dying. The first is a retired Air Force captain named Ray Brennan. He was written up as a heart attack. Then another legionnaire, then six more in a single day. They all share the same story. Fatigue, chest pain, high fever, lungs filling up. And the only thread connecting them is that hotel.

By the time it’s over, 182 people have fallen ill, and 29 are dead. A case fatality rate near 16%. And here’s the eerie part. Some of the victims never even set foot inside of the hotel. They simply walked past the Bellevue-Stratford on the sidewalk. The country was terrified. This is the same summer as the swine flu scare. Nobody knew if this was a virus, a poison, sabotage, the start of a pandemic. The Bellevue-Stratford, one of the most storied hotels in America, lost so much business that it closed its doors that November.

And then comes the part I find genuinely heroic. The CDC mounted what was at the time the largest disease investigation in its history. They ran down everything. Swine flu, parrot fever, plague, nickel poisoning, toxic chemicals, and ruled it all out. For six months, nothing. Then the week after Christmas, a microbiologist named Joseph McDade went back to his slides, dropped the antibiotics from his cultures, and finally grew it. A brand new bacterium, never before identified. They named it Legionella pneumophila, “lung loving.” It was hiding in the hotel’s air conditioning cooling system. And once they could see it, old mysteries solved themselves. Unexplained outbreaks going back many years suddenly had a name. That’s the legacy, a disease nobody knew existed, found by people who refused to stop looking.

Harlan Krumholz: Well, this thing going on in New York, Howie, has got me worried. And one of the things that I am wondering about the Legionella outbreak in New York is, why New York? What is it that makes New York the place where this is happening?

Howard Forman: I think it’s because of this very specific type of old-school air cooling towers that are used in these extremely high buildings. And I’ve tried to understand this more about how it works, both the physics of it and why it becomes a breeding ground for Legionella, but it sort of does. And I think it’s the reason why we’re seeing it only in places with tall buildings with water towers on top that are part of their cooling system, and the summertime when they’re obviously in active use and the humidity is higher.

Harlan Krumholz: And I wonder sometimes whether, I know New York’s got a really good public health system, and probably very strong active surveillance. So they also probably pick these things up early, but the other cities around the country, especially those that are... I mean, we’re all under heat waves. So this is all about these air conditioners, and this is something we have to—

Howard Forman: I know. And one of the innovations that I learned about in preparing for this is that the current administration in New York, I believe it’s under Mamdani, has started to keep track of all the air cooling systems because these outbreaks are so frequent that, when the outbreak happens, they know exactly which buildings to go to and start testing.

Harlan Krumholz: Do you have any concerns that, given the issues that are going on with the CDC today, Jeremy Faust writing about this again, leadership, people leaving still, is that going to put us in a difficult position or we don’t really depend on CDC anymore because the local health departments have to step up?

Howard Forman: Yeah, I will say I’m very impressed with New York State and New York City health departments. Very impressed. Because I get a lot of their newsletters and I follow them because I’m from New York originally. Look, I think it helps a lot when we have centralized CDC. We’ll talk more in the future about the cyclosporiasis outbreak that’s leading to thousands of people having debilitating diarrhea. When you have multiple states happening at once, it’s really good to have a central authority taking the lead, and I believe they are. But for the local outbreaks, I think our state departments in New York, in Connecticut, Massachusetts are really good. Pennsylvania, really good. I don’t know if every state is as good.

Harlan Krumholz: That’s great. Thanks, Howie. Thanks for reporting on 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 any of social media.

Harlan Krumholz: And give us your feedback. We always love hearing from you.

Howard Forman: Health & Veritas is produced with the Yale School of Management, the Yale School of Public Health. To learn more about Yale SOM’s MBA for Executives program, visit som.yale.edu/emba. And to learn about the School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/emph.

Harlan Krumholz: And a hat tip to our superstar undergraduates, Gloria Baek’s with us here today. She did a great job. Donovan Brown. To our great producer, Miranda Shafer, and to the best in the business, Howie Forman. It’s great to work with you.

Howard Forman: Thanks, Harlan. Have a great week. Talk to you soon.

Harlan Krumholz: Talk to you soon, huh?