The Cost Curve, Flu, and Other News

Transcript

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

Howard Forman: And I’m Howie Forman. And we are physicians and professors at Yale University trying to get closer to the truth about health and healthcare. And we’re in the studio today.

Harlan Krumholz: We’re in the studio today.

Howard Forman: I know.

Harlan Krumholz: I love this.

Howard Forman: And it’s a lot of fun. And to give our listeners a sense, we usually talk in advance about what we’re covering today, but because we’re taping earlier this week in advance of your travel, we haven’t done that, so this is a little shocking, like each of us is going to cover topics that we don’t know we’re covering.

Harlan Krumholz: I’m going back to China. Howie was nice enough to schedule this a little bit early.

Howard Forman: I’m going back to my office.

Harlan Krumholz: You’re going back to your office?

Howard Forman: But no, it should be good. And there is a lot of news. It’s funny, when we’re doing only one segment a week, I have trouble figuring out what’s the most important one and then when we do these segments, I have trouble getting it down to just three or four topics for me.

Harlan Krumholz: There are so much going on, but I thought we’d have a little bit of fun today. So I have a question for you.

Howard Forman: Go for it.

Harlan Krumholz: All right, so look, we’re here together. I want you to do some predictions for me.

Howard Forman: I’m terrible at predictions.

Harlan Krumholz: No. How do you know? Depends how far out you’re going to predict.

Howard Forman: Yeah, right.

Harlan Krumholz: So here, do this. Give me a prediction that you have 90% confidence will be true in five years.

Howard Forman: I will be five years older.

Harlan Krumholz: Okay, that’s a good one. Okay, let me ask you another one. In healthcare and medicine.

Howard Forman: I think we will continue to have rising healthcare costs that will be outstripping inflation and we will continue to think this is a crisis.

Harlan Krumholz: So we’re not going to make any progress on this?

Howard Forman: We will make progress, but it’ll be slow and it’ll be hard to measure because costs will go up, but quality will continue to go up.

Harlan Krumholz: I show this slide in a lot of my talks. This inexorable rise where... let me just start back for people’s context. So around 1970, we were spending about the same amount as other developed countries on health care, and we were—

Howard Forman: Per capita, yeah.

Harlan Krumholz: ...and we were getting about, per capita, and we were getting about the same outcome. Meaning if you just said life expectancy or anything else you want to measure that’s global like that, we were hand in hand, maybe a little bit behind. We were close, very close, and on the cost very close.

You start to get to the mid-’70s, the ’80s, the lines diverge. But on the side of the life expectancy, if anything, we flattened. The other countries continue to improve incrementally. In the past couple of years, we’ve actually declined somewhat, but our costs continue to rise. So when you look at us on the figure, the other countries still track together largely. And I’m talking about in the European countries, of course Japan spends a lot less, but developed economies are spending roughly about the same.

There’s some variation and they’re getting about the same back. We spend much more and get a lot less back, if you consider life expectancy.

Howard Forman: A hundred percent. On every metric.

Harlan Krumholz: And you don’t think that’s going to change?

Howard Forman: I don’t think it’s going to change materially over this time. And I will point, there’s a fantastic debate that I just watched today between Farzad Mostashari, our former guest and hopefully future guest.

Harlan Krumholz: CEO of Aledade and former head of ONC, the Office of the National Coordinator for electronic health records and so forth.

Howard Forman: The head of the Leonard Davis Institute moderates it. That’s [Rachel] Warner. And then—

Harlan Krumholz: At UPenn.

Howard Forman: At UPenn.

Harlan Krumholz: That’s a large economic sort of think tank within—

Howard Forman: And Farzad debates this guy from Brown, whose name is Ryan, and I don’t know his last name, but he debates him and it is a vigorous, sometimes aggressive debate.

Harlan Krumholz: What is the debate?

Howard Forman: About whether ACOs are saving us money or whether we should be moving back to fee-for-service.

Harlan Krumholz: Accountable care organizations.

Howard Forman: Basically.

Harlan Krumholz: These ideas of the value-based purchasing approach.

Howard Forman: That’s right. That’s right. And really, you have two people who are polar opposites on this, and it’s the first time in a long time I’ve heard anybody defend going back to fee-for-service medicine.

Harlan Krumholz: Farzad thinks they’re working.

Howard Forman: Farzad is convinced that some parts of them are working extremely well and other parts will work and this is absolutely the right direction.

Harlan Krumholz: The guy from Brown is saying—

Howard Forman: “Absolutely not.”

Harlan Krumholz: “Let’s go back to fee-for-service.”

Howard Forman: “…fee-for-service.” That the problem is the prices and the problem is how we use fee-for-service, not whether we should be putting money in the hands of corporate interests who may have other priorities than just healthcare. And they both make good points. You could tell in their voices that they’re angry at times and getting riled up. It’s fascinating. We’ll put it in the show notes.

Harlan Krumholz: Is it on video, or—?

Howard Forman: It’s on video. Yeah. I mean I was listening to most of the audio in the background while I was doing some other things, but it’s on video, but it really was striking to me because you don’t often hear very smart people that you respect take such polar opposites.

Harlan Krumholz: All right, let me ask you this. I’m just going to do one follow-up on you. So if you have that dire prediction that the costs are going to keep rising, where does it stop? I mean, where does it get to the point where the nation, is it 30%? Is it 35% of GDP? I mean, where does it get to the point where the country says no más?

Howard Forman: So we’ve had a reasonable plateau in the last few years where it hasn’t gone as fast as people thought it would be. We’re actually a few percent behind where we thought we’d be. It is still rising over time and rising against inflation.

Harlan Krumholz: So it’s taking a larger chunk of the GDP every year.

Howard Forman: Correct. We’re almost certainly going to cross through 20% in the next decade. And that’s my prediction. What I hope is that quality will improve enough that people will start to see the fruits of their labor. Because I think we underestimate how much progress we are making because what we’re seeing is superimposed on it. The obesity epidemic, the opioid epidemic. We’re seeing a lot of bad things happening in the background that make us look horrible on the healthcare front where we’re spending the money. I think we are making progress.

Harlan Krumholz: So if you decompose this, what percent or just largely, roughly, of this as a result of the aging population in U.S., that is, it was to be expected that we’re going to spend? I hear what you’re saying about opioid and obesity, but also we have an aging population. So it’s to be expected that a higher percent of GDP is going to go to healthcare if a larger percentage of your population is older. Somebody must have done the analysis to say, age-adjusted, how are we doing?

Howard Forman: Look, other nations are aging faster than us, and we’re still tracking faster in spending than us. So I think that gives you a big chunk of the answer. Remember, I think one thing to remember, this is a podcast sponsored by a school of public health and a school of management.

Harlan Krumholz: What a creative idea.

Howard Forman: I know. One of the things that I think our listeners and most people don’t realize is most of our gains in life expectancy have come from public health interventions and social determinants...

Harlan Krumholz: That’s right.

Howard Forman: ...and not from healthcare interventions.

Harlan Krumholz: That’s right. Clean water.

Howard Forman: Clean water. Vaccination programs. Not the—

Harlan Krumholz: Clean air. Clean air.

Howard Forman: Clean air. Education. I mean you look at the numbers I saw published today that just shows that if you are educated with a job, in a stable relationship, your outcomes are just, and your children’s outcomes are just much better than if you’re—

Harlan Krumholz: A healthy economy.

Howard Forman: That’s it. So we’ve got to invest in that.

Harlan Krumholz: All right, well.

Howard Forman: So let me pivot to something that’s a little related to that in that today, if you didn’t know, is World Prematurity Day.

Harlan Krumholz: World Prematurity Day.

Howard Forman: Yes. In 2022, the World Health Assembly officially added World Prematurity Day to the World Health Organization’s international health calendar, recognizing its pivotal importance for improving child survival and well-being. Going forward, it’s going to be celebrated on November 15th, but in this inaugural year, it’s being celebrated today, November 17th, and we’re taping this on a Monday this week.

Around 1 in 10 babies worldwide is preterm, born before 37 weeks of pregnancy. Without effective care, they’re at high risk of life-threatening health conditions like respiratory distress, infections, hypothermia, and this leads to hundreds of thousands of preventable deaths each year. And the WHO, the World Health Organization, has many great items to highlight on this day. We’re going to link those, the major ones in the show notes, but a few from their release.

One, in the poorest countries, very preterm, meaning less than 32 weeks gestation, babies generally die within days. In developed nations, we now do extremely well with them, and the vast majority of them live. There are many effective interventions that generally are cost-effective. Things like skin-to-skin contact, respiratory support, early breastfeeding, infection prevention, and family-centered care. And they very much emphasize two issues, family-centered care involving the family, and they also highlight the critical nature of maternal care and particularly ongoing prenatal care to ensure the health and well-being of the fetus.

Lastly, while many preterm births occur without known risk factors, there are some steps women can take to reduce risks, including healthy nutrition, maintaining healthy weight, avoiding tobacco and alcohol use, attending all prenatal checks, and seeking immediate medical attention if there are any warning signs of early labor. And finally, shout-out to the most important former preterm infant in my life, my mother. She turned 90 yesterday—

Harlan Krumholz: Oh, happy birthday.

Howard Forman: —thank you—and is a great example of the greatness and goodness that can come in the world from efforts to protect and help our preterm infants.

Harlan Krumholz: Well, tell us a little bit more. She was born premature?

Howard Forman: She was born premature, I think eight weeks premature. And at that time, when you think 90 years ago, that was a much higher-risk proposition, and she has had, I think, respiratory illnesses over the years that have been worse than would have been if she wasn’t preterm. So it’s not like there’s no manifestations, but in every other way, she’s had a great, fulfilling, loving life for all of us. We’re very thankful.

Harlan Krumholz: Two of the best parents in the world.

Howard Forman: Yes. Thanks.

Harlan Krumholz: That’s amazing.

Howard Forman: Yep.

Harlan Krumholz: The part that kind of disturbed me, though, that you said is, you know, geography is destiny, and if you’re born in the wrong place and you have a premature baby...

Howard Forman: It’s so sad and so much of it, if you read... they go point by point. I didn’t want to go into each of it, but they go point by point about these cost-effective interventions and they’re so cheap. They are really mostly about educational interventions and just having basic antibiotics.

Harlan Krumholz: So you think we could improve the premature survival rates with relatively inexpensive interventions around the world?

Howard Forman: And reduce the preterm deliveries as well. Both of them are—

Harlan Krumholz: Don’t we have to have these high-tech nurseries in order to...

Howard Forman: They’re talking about the 32 and up as being the low-hanging fruit, and we could do so much better with 32 and below. But we’re not talking about, look, you have to accept the fact that in America, in some developed nations, having a normal outcome with a 23-week preterm baby can happen, although rare. We’re not looking for that in the developing world. We’re just looking to save the babies that should be saved easily. There’s so many thousands of them.

Harlan Krumholz: Does this topic in any way intersect with the issue of abortion and the kind of politics around that?

Howard Forman: So I didn’t read into that at all. I imagine that almost everything does to some degree of reproductive justice. But I don’t want to dive into a topic for which I can’t say more about, but I imagine there’s some connection between them. Probably a few.

Harlan Krumholz: I was just going on that topic. I was reading about some debates maybe in the UK or somewhere in Europe. People were talking about sex-selective abortions and whether that’s going to become a thing. People are also talking about... I believe you wanted a prediction for the future. I mean, we are going to have the ability to manipulate the genome of a gamete to such an extent.

Howard Forman: Oh, I see what you mean. Yeah.

Harlan Krumholz: To be able to say, I want intelligent ... the movie Gattaca is like this. It’s like when you look at the movie Her, I’m going to go back to this now. That’s the movie where this artificial intelligence becomes—

Howard Forman: The girlfriend.

Harlan Krumholz: ...this companion to the main protagonist. Scarlett Johansson is the voice of the AI. And it was like 10 or 12 years ago, it seemed just science fiction. Now this seems like really real.

Howard Forman: Oh, yeah.

Harlan Krumholz: Now you see a movie like Gattaca where people can say, “I want an intelligent baby. I want an athletic baby. No, I don’t want a baby that’s got a gene that gives predisposition to asthma,” or so forth. These things are on the horizon and how we’re going to manage that. I know I’m really going afield of your topic. It’s—

Howard Forman: No, you’re not. I mean, there was a separate piece I saw over the weekend where someone said that we need to be investing tens if not hundreds of billions of dollars to counterweight and regulate AI in a way that serves the long interest of society. Otherwise, we could implode. There’s so many downsides to AI as well.

Harlan Krumholz: Well, you’re going jumping on the AI, but I was just jumping on this designer baby thing.

Howard Forman: But it’s related. I mean, technology moves.

Harlan Krumholz: Technology moves.

Howard Forman: And we have to figure out how to regulate it so that we’re not.... We want to see innovation. We want to cure diseases. Just this morning, my father was commenting on your segment last week about CRISPR. He was very enthusiastic about that, and he’s excited about it. But what you’re describing is the flip side of CRISPR, the fact that we can manipulate the genome in ways that may not have the types of intended consequences that people think are all upside.

Harlan Krumholz: Okay, you’re going to get me talking about AI. I did want to linger on this a second because there’s an article this week that had Yoshua Bengio talking about his concerns about AI. So just to remind you, so Bengio, LeCun, and Hinton were kind of the three—

Howard Forman: Horsemen.

Harlan Krumholz: ... of AI. I mean, they won the Turing Award together. They really generated a lot of the knowledge that served as a foundation for what we’re seeing today. I look back up in 2019, Bengio was in an interview in Nature talking about “the dangers of abuse are very real” with AI. It is 2019, and talking about the Montreal Declaration, which was bringing together people in the social sciences and the humanities as well as in AI that tried to articulate some principles about what’s the most ethical way to proceed.

But at that time still, we don’t have what we had now. And it still blows my mind that you start talking about November 2022, when ChatGPT comes out.

Howard Forman: It’s hard to believe it’s just three years, right?

Harlan Krumholz: In 2023, May 2023, Hinton started giving a lot of interviews about his concern sounding the alarm. And at that time ... he’s in his mid-70s now, and he had a widely discussed interview at The New York Times where he said generative AI could spread misinformation and eventually threaten humanity.

When someone of this stature, not an alarmist, someone who was actually there at the beginning and did some of the fundamental work. It is a Manhattan Project sort of moment where people who are saying, “Gee, we’re just physicists, and we’re just learning how to split atoms as a way to understand nature. And now what we’ve done is unleashed a capability that we’re not sure humans can manage.” And it started to raise a lot of questions about what could happen.

The issue is that Bengio now is coming out. LeCun, by the way, was at Meta, left Meta. He’s going to start his own company. But when these people are coming together and raising issues, then it really concerns me. And now Bengio, I’ll just say, it’s in the November 12 issue of Nature. “It Keeps Me Awake at Night.” And he talks about ... again, now this is of the three, now two of them are really—

Howard Forman: Afraid.

Harlan Krumholz: ... saying things that are quite concerning about the threat to humanity. And many of us are like, “Gosh, really, it’s so much fun to use ChatGPT. It’s really interesting to explore it.” I’m enjoying OpenEvidence, which is helping me find—

Howard Forman: OpenEvidence is probably the one area where I have a lot of confidence. All the others—

Harlan Krumholz: OpenEvidence is an application available to doctors to help them search the literature and get answers to questions.

Howard Forman: And it’s seemingly replacing things like UpToDate, the previous sources that so many people relied on. But the others, ChatGPT and the other LMMs scare me because I’ve seen so many examples where depending on who’s asking the question and what the questions they asked before were, you’re going to get different answers and there can’t be different truths.

Harlan Krumholz: Well, so I just want to read this quote from him in the article. “When ChatGPT came out in November 2022, it took me two or three months to realize we’re on the path that could be extremely dangerous. And although I was initially pleased to see the deep learning,” and he was largely responsible with many others, but that’s what he won the Turing Award, “developing deep learning had finally reached that milestone, I realized because of the nature of these systems, we didn’t know how to make sure they would behave in ways that we want. I started thinking about my grandchild and I thought in 20 years, he’s going to be 22. Will he have a life? Will he live in a democracy? Who will control very advanced AIs in the future will have huge power.”

And so I’m bringing this up on a health show because sometimes it’s worth lingering on existential threats. We talk a lot about individual threats to health and so forth, but this is a very big disruption. You and I are both seeing today that companies are rationally adopting AI and reducing workforce. And there’s a lot of people talking about, what’s the job market look like in the future?

Howard Forman: Oh my god, yeah.

Harlan Krumholz: What does this do for a lot of jobs for a lot of people?

Howard Forman: Oh yeah. I mean, look, the fact that the market has gone this high is to some degree anticipating just massive reduction in force for lots of jobs. And a lot of these jobs are the entry-level jobs that people count on out of college, out of graduate school. So there is a lot of disruptions ahead and we hope that we manage them well.

Harlan Krumholz: Let me just finish this sub-segment by saying, he was asked, do you wish AI had never been invented? It just reminded me the kind of question you might have asked somebody, do you wish that we had never understood nuclear fission and so forth? But his answer was, “It’s a difficult question. I wish we had collectively more foresight about the catastrophic possibilities so that we would have moved more carefully into where we are now.”

I only just say these are not radical individuals. These are scientists who were at there at the beginning whose work became foundational for what we’re seeing today who are sounding an alarm about what we’re seeing.

Howard Forman: That’s right. I want to pivot to a public health topic that we have come back to many times. Bird flu, to start with.

Harlan Krumholz: By the way, I’ve heard there’s a lot of flu in China.

Howard Forman: We’re going to come to that separately. So that’s the influenza outbreak. I want to cover those two both quickly if I can. We recently touched on bird flu on the podcast, and I was mentioning that there hadn’t been any human cases in a long while. And that’s partially true right now because we have still have not had another H5N1 bird flu case in over nine months, but for the first time since February, there is a human case of bird flu in Washington state. The kicker is, it’s not H5N1, which is what we’ve been talking about for three years now. It’s H5N5. And it is the first time H5N5 has been identified in a human being.

It does appear that it arrived through backyard poultry, probably wild bird comes down, droppings spreads to the backyard, poultry then spreads to this elderly man. That elderly adult’s severely ill since early November with this new strain that has not been previously identified, just to be clear. There is no indication that it can be transmitted to humans, but it’s just a reminder that we still need to be cautious about these ongoing cases and hoping that as we develop therapies and vaccines, and we talked just a few weeks ago about a potential treatment and vaccine being developed and other preventive measures because we want to be able to get to those before it does eventually reach the ability to transmit between humans.

Harlan Krumholz: Just for the audience (and maybe for me).

Howard Forman: And me, probably.

Harlan Krumholz: So when you talk about bird flu, how should people think about that different than influenza because they both have Hs and Ns?

Howard Forman: That’s right. So these are the influenza viruses that have been documented as transmitting between birds. And so we describe them as “avian”—

Harlan Krumholz: Why do people care about that as opposed to flu that comes from mutation within humans?

Howard Forman: Right. So we assume that most viruses will naturally progress from birds to nonhuman animals to mammals and eventually to humans. That’s the natural progression. One of the issues that we faced with H5N1 is we watched it literally go from just birds to eventually cows and pigs. Cats we’ve seen, and I think dogs, so we know it’s working its way through other mammals.

We worry that if there are additional mutations that humans will eventually be able to get it. And we’ve seen the cases. We’ve seen, I think, 70 cases in humans, but still not human-to-human transmission, we have not seen. The issue going forward is will it eventually reach the ability to spread between humans? And that’s what we’re trying to prevent.

Harlan Krumholz: And is it also that if it hasn’t been in humans before, we’re just not prepared for it?

Howard Forman: Right. We don’t have the immunity. Exactly right.

Harlan Krumholz: All right. Well, tell me what I need to know about flu in China.

Howard Forman: Okay, so it turns out that we’ve actually had quite a bad flu season so far. Australia just had the worst season, I think, in history. Japan is having a very bad season. China, I think, is ...

Harlan Krumholz: Their cases are growing.

Howard Forman: ... growing. I don’t think they’re as bad as Australia or even Japan, but they’re growing. The UK looks like they’re having one of their worst seasons.

Harlan Krumholz: And when you say “worst,” there’s about spread, but there’s also about severity.

Howard Forman: Right.

Harlan Krumholz: So is it both?

Howard Forman: So the numbers I’m looking at are just spread. I’m not talking hospitalizations or deaths at this point, but the way the Australia outbreak has been described is it has been described as the worst. So I think it’s also acuity, but the absolute numbers in Australia were quite huge considering past years that have been tracked.

And here’s the kicker about it that’s concerning is, we do include in our trivalent vaccine, we have H3N2, which is the strain that is circulating worldwide right now. There have been, I think, seven separate mutations that have occurred between the time that our flu vaccine was created and the current circulating strain that we’re seeing. So unfortunately, our vaccine is going to be less effective this year than it otherwise could have been.

Now, that doesn’t mean you shouldn’t get it. It’s still the single best—

Harlan Krumholz: You’re bumming me out.

Howard Forman: I know. And it’s the single best strategy.

Harlan Krumholz: Have you gotten yours?

Howard Forman: I did.

Harlan Krumholz: Yeah. I got mine.

Howard Forman: Right. It’s the single best strategy to push back on the flu, but it does mean that we’re likely to have a less effective vaccine this year than—

Harlan Krumholz: Why can’t they figure this out?

Howard Forman: It’s so hard, because it moves.... The flu, more than COVID, more than any other virus that we’ve seen, changes so rapidly that you’re always several steps behind. In this case, seven steps behind.

Harlan Krumholz: Do you have any side effects when you got it?

Howard Forman: None. Not even ... maybe the tiniest arm pain, but I—

Harlan Krumholz: You’re a Superman.

Howard Forman: And I went to the Yale’s flu clinic. I’m just always so impressed by this. They run these clinics where you walk in and 30 seconds later you’re out. It’s so fast.

Harlan Krumholz: Did you get the high dose?

Howard Forman: No. I don’t think I qualify yet. I look like I qualify.

Harlan Krumholz: No. Not at all. Not at all.

Howard Forman: What have you got?

Harlan Krumholz: I wanted to talk to you about this thing that’s happening in cardiology because I’m curious what you think about it. So we’re increasingly applying AI to CT angiograms. So for people who want to know about this—

Howard Forman: I want to know about this topic. I read about this. Yeah.

Harlan Krumholz: Sometimes we talk about CT scans for the heart. There can be these simple fifty-dollar tests that are just looking for any hint of calcium. If you don’t have any calcium, you’re low-risk. If you’ve got some calcium, you’re a little bit higher-risk and the more calcium you have, the higher risk.

Howard Forman: It’s a true screening test.

Harlan Krumholz: Right? It is a screening test and about the radiation of a mammogram. And actually, I find it very useful, especially for people on the border of whether they should start on a statin. But there’s a more advanced level than that, which is called a CT angiogram, much more radiation, a much more involved test, which actually can use a non-invasive test. There’s no going into the heart here. There’s just taking pictures of the heart, but because of the technology now, we can take pictures of the heart and actually see the arteries with pretty good precision.

Howard Forman: That’s right.

Harlan Krumholz: But now what the AI came up with was to quantify and characterize the plaque, what’s actually in the arteries, how much of it’s calcified and even to make inferences or suggestions about its stability. In other words, we can see the arteries, but now can we get more information from those pixels that gives us information about what we might call the vulnerability or the danger of those narrowings.

So not all narrowings are created equal. It could be that you have some narrowings in your arteries, but they’re very stable and they’re not as dangerous as something which might be unstable, could crack plaque, could then form a blood clot and then it could be a heart attack. So these are, this kind of movement towards AI, and it does not involve a radiologist. It’s advanced AI.

So it’s not like the ... we’ve talked about these decision support tools where a radiologist might be told, “Take a look here, this is what this looks like. Make sure you don’t miss anything.” That’s not a decision support tool. It’s basically a processing of the data with a report that suggests that ... indicating what the risk is. And there are several companies now that have emerged that have products that have been through the FDA.

Howard Forman: The thing that struck me about what I was reading this weekend is that Medicare has decided to pay $1,000 just for the AI application added on to the CT angio.

Harlan Krumholz: Yeah. So there’s an article on STAT, but all of us in the field know about this. And the question is, what’s ... first of all, at the margin, do you need this information? Even if it’s better at predicting, it doesn’t lead you to do something different than you would have otherwise. So I can have a test that says I can predict better, but moving you from 15% to 18% or 15% to 25% doesn’t make you do something different.

Howard Forman: So the company claims that in the subselect group for which it’s intended, that it actually saves money by diverting patients away from more expensive interventions and allowing them to proceed with just observation and not having to do further interventions. The problem with that in all of imaging, in my experience, is that you never keep this narrow to the group for which it was intended. It always expands dramatically to far more people than it was intended. And I just think this is another example of where, yes, this will probably have some positive impact and we could argue about how much impact. It’s going to cost a huge amount of money. I was blown away, a thousand dollars for something like this is extraordinary.

I don’t think people realize that within the Medicare realm, a thousand dollars for a non-invasive application is almost unheard of.

Harlan Krumholz: Well, the marginal cost is practically zero.

Howard Forman: Right, to the provider. Yes.

Harlan Krumholz: To the company. I’m just saying, somebody run one more—

Howard Forman: It’s software.

Harlan Krumholz: It’s software. So I’m not making judgment. I’m just saying, in terms of the business model here, it’s really interesting because it did take investment to develop it, but once you’ve developed it, you can deploy it. There’s a big question. Does it in the end help people live longer? Does it reduce heart attacks? My concern about the cost issue is that... so the people who are making decisions with patients are the cardiologists. And if you start reducing their volumes, do they start changing their thresholds, even subconsciously, about what they sent? It’s not clear to me that the cardiologists are going to say, “We’re going to let our volumes drop.”

Howard Forman: But you don’t think the opposite is going to happen, every cardiologist is going to be investing in centers that provide this service? And from what I understand, the margins that you will make from buying the software and having Medicare reimburse you a thousand dollars is going to be positive.

Harlan Krumholz: Is it radiology, the one who’s doing this right now at Yale?

Howard Forman: At Yale it’s split. Cardiology and radiology.

Harlan Krumholz: So what does that mean?

Howard Forman: It means that radiologists and cardiologists alternate days, I believe, and who reads the cardiac portion of the study, and the radiologists do back up the cardiologists for the noncardiac portions of the study.

Harlan Krumholz: That’s interesting.

Howard Forman: Yeah, I mean—

Harlan Krumholz: I worry. And why did that happen?

Howard Forman: I think because there was a collaboration between cardiology and radiology early on. They both wanted to have it, and I think that they both—

Harlan Krumholz: But here’s the interesting thing to me. You don’t need to read this. It’s just ordering a potassium.

Howard Forman: So that’s a different step. These are still being read.

Harlan Krumholz: The CT angiograms are being read.

Howard Forman: Right.

Harlan Krumholz: But the AI on top—

Howard Forman: Correct.

Harlan Krumholz: ... is just a test.

Howard Forman: Right. And maybe it’s the hospital that makes the full margin off of this, but I am convinced that one thing will happen from this, is there will be people that will become rich.

Harlan Krumholz: But this gets back to our discussion about the ACOs, which is, if you are responsible for a certain number of patients and you’re making choices about what tests you’re going to apply—

Howard Forman: You would think. I agree.

Harlan Krumholz: ...because you’re trying to get best outcomes at the best cost.

Howard Forman: That’s why you and I have believed in this, that value-based care should make a difference, but I’m going to—

Harlan Krumholz: By the way, the whole point about that article, just to finish it, was that Medicare’s going to start paying for it.

Howard Forman: It’s crazy.

Harlan Krumholz: So that’s—

Howard Forman: It’s a big step and without a lot of evidence. So I want to do this. This is real quick and it’s apropos of last week’s episode. So last week, we had Dr. Jerry Avorn on, and this week, there’s a research letter in JAMA from the University of Chicago, highlights a problem that you touched on in one of your questions: What are the limits of free speech when it comes to drug promotion? The authors reviewed 740 high-engagement social media posts across the typical platforms with 57.5 million views from various formal and informal social media influencers. What they found is both surprising as well as unsurprising and very disturbing, 80% of the posts on social media they reviewed had potential undisclosed promotional contact. Eighty percent.

Harlan Krumholz: Does that mean somebody was paying for it?

Howard Forman: Well, we don’t know.

Harlan Krumholz: Or just that it was promotional?

Howard Forman: That it was promotional. It’s not about legal versus illegal, by the way. It’s just about reality. Let’s assume for the moment that all of these influencers are not receiving any money from anybody. They still make money off of ad revenue and followers and from grabbing attention. And there’s a large segment to the population that just wants to hear about new cures for one thing or another. And in a pro-free-speech society, it’s almost impossible to stop this, or frankly, we shouldn’t want to stop this, but it does beg the question as to whether counter promotion is even attempting to keep pace. And one thing that you and I have committed to do is having more social media influencers who are doing the hard work of pushing back against misinformation—or even countering accurate information but incomplete information.

Harlan Krumholz: I think we should do this, with your army of students. We should start putting together students who are truth tellers.

Howard Forman: Well, I think we’re starting because we have an Instagram account now.

Harlan Krumholz: No, no, but you and I should think about this. We should get students—

Howard Forman: That’s a good idea.

Harlan Krumholz: ... who have referenced what they’re saying, where it comes from, what it is and comes up and tries to be a counter—

Howard Forman: But there are—

Harlan Krumholz: ... for misinformation.

Howard Forman: But there are a lot of people at Yale right now, Perry Wilson is a good example of someone who tries.

Harlan Krumholz: What if we get a bunch of students?

Howard Forman: Look, you and I are going to talk about this offline.

Harlan Krumholz: Okay, we’re going to talk about this. I like this. Okay, I’ve got one more before we end—

Howard Forman: Yeah, go for it.

Harlan Krumholz: ...which is I just need your help understanding this. So there’s a lot of discussion here today about the Obamacare subsidies. That was the whole reason for the shutdown, and there’s a promise for a vote that’s going to come up in the Senate. But I was surprised to learn that Medicare premiums are jumping 10% and that.... So nobody is really talking about this. Now, I know that it may seem like it’s not a huge jump. For example, older people and people with disabilities will pay almost $203 per month in 2026 for their Medicare Part B premium and that’s about 10% higher. So it went up from 185 a month. Some people may sniff at that, but it’s still—

Howard Forman: It’s a lot per month.

Harlan Krumholz: Many people are struggling to buy and especially retirees.

Howard Forman: And remember, Social Security is only going up 2.8% this year. So when this is going up 9.7%, it’s eating into your disposable income, whatever, however small that is.

Harlan Krumholz: So then interestingly, the Trump administration was, according to this article, again I pulled one from STAT, but there were other people reporting on this that, saying, “Well, it would have been even higher if it wasn’t for us and we’ve done other things.” But this does seem like, again, a concern, the trend, the idea.

Howard Forman: Oh, my God. Oh, look, this is absolutely—

Harlan Krumholz: And are more people going to just go to Medicare Advantage as a result?

Howard Forman: So that’s generally what people worry about, is that as you make it harder and harder for people to afford this, they’re more inclined to go for Medicare Advantage because it’s cheaper and those have narrower panels. There are some downsides for people, but this does drive that mechanism as well.

Harlan Krumholz: But since you’re someone who thinks that fee-for-service shouldn’t continue, right? Am I correct about that?

Howard Forman: I wouldn’t say that I don’t think it should continue. I’ve been a believer that population health-based payments are the way to go in the long run.

Harlan Krumholz: So then is this okay because it actually is pushing people towards—

Howard Forman: If I thought we were pricing Medicare Advantage properly, I’d have a lot less concern. My concern with Medicare Advantage is I think much of the billions and billions of dollars in profit have been just that. It’s not been a transformation of healthcare. It’s mostly been about financial engineering. I do want to just mention one quick thing related to the Medicare increase. It is, as you mentioned, the Trump administration literally put into this boilerplate memo. They said, “If not for the Trump administration, it would’ve gone up to this, this higher amount.” So I went back and tried to figure out it was—

Harlan Krumholz: There’s something about “skin substitutes.”

Howard Forman: It was because of the skin grafting. They’ve changed the rules about that, which was a good thing. They’ve been overpaying for that. It’s been a scam, billions of dollars.

Harlan Krumholz: My mother got skin grafting…

Howard Forman: Probably this, probably this, right, right. It’s been a scam. You could read about it.

Harlan Krumholz: What?

Howard Forman: Yeah. It’s been overused, let’s say that.

Harlan Krumholz: I think she’s gotten better!

Howard Forman: Well, no. So it can be really valuable. No one’s saying it shouldn’t be done.

Harlan Krumholz: It’s just what they were paying for it.

Howard Forman: And it was doing too many of them, like they were going way too far. But what I wanted to mention is—

Harlan Krumholz: I got to look into this now.

Howard Forman: ... so I went back to try to figure out, did the Biden administration ever mention themselves? You have to go back to 2019 to find a prior memo where it basically mentions the current administration with respective savings. We should not be mixing politics in here.

Harlan Krumholz: Oh, my God, Howie.

Howard Forman: I know. All right.

Harlan Krumholz: All right. I think that’s a good one maybe to end on. So we should not be mixing politics. Anyone listening, take note.

Howard Forman: Take note.

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

Howard Forman: So how did we do? So give us your feedback to keep the conversation going. Email us at health.veritas@yale.edu or follow us on any social media. And we have a special Health & Veritas account on Instagram now, and we are active on it. We’re going to try to post several times a week.

Harlan Krumholz: Yeah, we love your feedback. Let us know how you’re thinking, and we always try to get back to people.

Howard Forman: And Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. To learn more about Yale’s SOM’s MBA for Executives program, visit som.yale.edu/EMBA and to learn about the Yale School of Public Health’s Executive Master of Public Health program, visit sph.yale.edu/EMPH. Well, what I am sure about—

Harlan Krumholz: Is that we have two superstar undergrads who are helping us, Tobias Liu and Gloria Beck. Gloria is with us today in studio.

Howard Forman: Yes.

Harlan Krumholz: We have a remarkable producer, Miranda Shafer. We’re here today with Ryan McEvoy, who’s helping us in studio, who’s also spectacular. And I’m here with the best in the business, Howie Forman.

Howard Forman: And it’s fun to be here and I’m wishing you well on this trip to China, Harlan. I don’t know how you do it. It is exhausting, but—

Harlan Krumholz: I’ll be back next Sunday.

Howard Forman: You’re the best of us.

Harlan Krumholz: I’ll be back for the next podcast. Talk to you soon now, Howie.

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