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Episode 128
Duration 34:29
Harlan Krumholz and Howard Forman

The Primary Care Crisis and Other News

Howie and Harlan discuss health and healthcare headlines. From flatlining telehealth to Walmart closing retail clinics to months-long waits for healthcare appointments, they try to untangle the challenges in delivering healthcare. Also considered, H5N1 bird flu increasing the risks of drinking unpasteurized milk, promising research on open-source moderation of misinformation on social media.


Yale Repertory Theater | The Far Country

CDC | H5N1

“US bird flu outbreak spreads to chickens, cattle, raises concerns over human infections”

“Raw Milk Is Being Legalized in More States. Is It Safe?”

Recipe for a Healthy Gut: Intake of Unpasteurised Milk Is Associated with Increased Lactobacillus Abundance in the Human Gut Microbiome

“Long-time Teladoc leader departs as virtual care provider struggles with post-COVID tumble”

“Teladoc sinks $13.7B loss in 2022 tied to plummeting value of Livongo acquisition”

“Optum layoffs: naviHealth CEO out; Virtual care business shuttered”

Connecticut | Certificate of Needs

Characteristics of X (Formerly Twitter) Community Notes Addressing COVID-19 Vaccine Misinformation

“Walmart is closing down its health centers. What’s that mean for Amazon, Walgreens and CVS?”

“Walgreens narrows profit outlook for 2024, takes $6B hit in Q2 from VillageMD investment”

“Why It Takes Forever to Get a Doctor’s Appointment”

Yale Innovation Summit 2024

Link for the Health & Veritas Livestream at the Yale Innovation Summit

Learn more about the MBA for Executives program at Yale SOM.

Email Howie and Harlan comments or questions.


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. Today, we don’t have a guest; we have a great opportunity to talk about any number of topics, and there is a lot in the news right now. What’s on your mind, to start off with?

Harlan Krumholz: Well, let me just start away from the news a little bit. I went to a play last night at the Yale Rep.

Howard Forman: I love the Yale Rep. I don’t go there often enough.

Harlan Krumholz: The Yale Rep is incredible. Yeah, yeah, yeah. So there’s a play there by the name of The Far Country, and it really focuses on the experience of Chinese in the United States from around the turn of the last century. As you know, in 1882 Chester Arthur signed the Chinese Exclusion Act, which was the first time in America we prohibited the immigration of certain people.

Howard Forman: I would not have even been able to tell you which president or what year, but I did know that. That’s incredible.

Harlan Krumholz: This play takes place during a period where Teddy Roosevelt is president and people are trying to get in from China. Actually, it turns out the people who could claim that they were born here could be insulated from that because they’re American citizens. But this takes place looking in San Francisco and after the earthquake, many of the records were destroyed. And so people were in difficult situations, but they follow a young man who ends up on Angel Island, which you can think about Ellis Island being where the Europeans came into the country.

Howard Forman: Oh, yeah. Is that off of San Francisco?

Harlan Krumholz: It’s off of San Francisco but has a very different experience. So many people were being held there for months and months and months trying to prove why are they coming here. Do they have rights to come into the United States? Anyway, it was a remarkable play because it really portrayed the difficulty, the challenges, the way in which Chinese were treated in this country. I’ll just say one quick thing about it that I thought was very interesting. So people were held there for months and months and months. Many of them began writing poems on the walls. The authorities there began to cover up the poems, they put plaster over, and they shellacked them. But over periods of time, the poems actually emerged; because of the heat and the light, they came out again. And so this play is built on this idea that people’s identity perseveres over the authorities trying to push them down and make them something that they’re not, so...

Howard Forman: It’s amazing that for a nation that is fundamentally a nation of immigrants, notwithstanding the Original Sin of slavery and the basic devastation to the Native Americans, but a nation of immigrants, and we don’t treat immigrants well, not at any time in our history, if we are particularly….

Harlan Krumholz: So we’re really a nation of perseverance.

Howard Forman: Yeah.

Harlan Krumholz: The people who came here persevered, and so many people despite... anyway, I just wanted to share that, it was a remarkable play. Anybody that hears about it, once they get a chance to see it, they should.

Howard Forman: That’s great.

Harlan Krumholz: What’s on your mind this week?

Howard Forman: Yeah, so look, I’ve been wondering when we’re going to talk about this H5N1 bird flu, which every time you hear about these things, and it’s been for over two decades that we’ve actively talked about bird flu, you wonder, is this overhyping or what? But bird flu is currently afflicting cows in multiple states in our country right now. And I just wanted to mention a few points that I think are worth highlighting here. First of all, there’s only one afflicted human being from this bird flu—

Harlan Krumholz: Someone with conjunctivitis or something, right?

Howard Forman: Exactly, conjunctivitis. And the disease was otherwise completely self-limited. For now, there is zero evidence of respiratory illness in humans. And the cows, because we should worry about them too, are also not terribly affected. Most of them recover pretty quickly. There is under-reporting of this disease, which should not be that surprising because farmers are accustomed to knowing that if authorities would know that your cows are infected—

Harlan Krumholz: They’re going to kill them, probably.

Howard Forman: Either kill them or at least take them out of circulation for milking. And so they’re afraid of that, because that’s their livelihood. And what was interesting to me is, I love this TV show, All Creatures Great and Small. It’s the third—

Harlan Krumholz: Yeah, sure. It’s about that vet.

Howard Forman: Yeah. And it’s the third generation of this show. It’s been on PBS last few seasons.

Harlan Krumholz: I didn’t know it was still on.

Howard Forman: Yeah, it’s a new one. And one of the episodes is about exactly this, how farmers were afraid to reveal that a cow might have tuberculosis because it would—

Harlan Krumholz: Well, you know what, with the chickens or the pigs, in China, they killed millions and millions of pigs.

Howard Forman: Same thing, right? But this is an issue that we should come back to at some point because this is the problem with mandatory reporting, or how do you get here—

Harlan Krumholz: How about those minks, remember the minks had COVID in—

Howard Forman: During COVID, right.

Harlan Krumholz: What was it—in Denmark, [CE1] Netherlands, or somewhere?

Howard Forman: I don’t want to make—

Harlan Krumholz: I’m mixing it up, probably.

Howard Forman: No, no. But it’s a real issue about, how do we get people to report without harming them? In many cases, the way to handle it is hold somebody harmless. Make sure that you’re made whole if something happens to your herd. But anyway, it’s another point to raise. There’s still too little information about this outbreak, but all indications are that it’s actually pretty large and that it’s spread primarily through the mammary glands or the udders of the cows.

Harlan Krumholz: Should we stop calling it bird flu?

Howard Forman: Yeah, I know. Well, it’s a good question. It’s H5N1—

Harlan Krumholz: It’s zoonotic at this point.

Howard Forman: We should just say H5N1, I mean really, and get people acclimated to the fact that it is an influenza virus; it’s H5N1.

Harlan Krumholz: But Howie, look, people are listening now, and should people be worried about this?

Howard Forman: So here’s the thing to worry about. The cows are a bigger and bigger reservoir, meaning that there’s more and more infected cows, and the virus replicates inside the cows. The more it replicates, the more it mutates, and the more the virus mutates, the more likely that at some point it will infect another animal. And once it’s already in a mammal, it went from the birds and out to the mammals, the likelihood of it eventually leaping to humans gets greater and greater. So that’s one thing.

Harlan Krumholz: So is the idea that they’re an incubator, and so...

Howard Forman: At some point it turns the wrong way. And so we do need to figure out how to get a hold on this for the cows right now. We are tracking wastewater as well, and the wastewater samples in some regions of the country are trending higher. So we think it’s getting worse at this point, but we really should be tracking it. We should be testing for—

Harlan Krumholz: What do you think, that wastewater is just from the cows? Is that...

Howard Forman: That’s what they’re implicating at this point. It’s in farming areas, and it’s in specific cities where a large number of cattle are.

Harlan Krumholz: Just wondered if people could be asymptomatically infected?

Howard Forman: So we don’t have evidence of that yet. We do have tests. So there are ways to test for it. And there’s no evidence of asymptomatic tests, but it is—

Harlan Krumholz: Asymptomatic positive tests.

Howard Forman: Correct. Yes. Sorry. But it is an issue that it is in the udders. It is an issue that it is the mammary glands of these cows. Because what they have started to find is that the virus particles are showing up in pasteurized milk. Now, it is not the full virus, not a living virus, not a culturable virus, in the pasteurized milk.

Harlan Krumholz: You mean milk that we could be buying in the store right now has these viral fragments?

Howard Forman: Correct.

Harlan Krumholz: Interesting.

Howard Forman: And so that’s where people are starting to get concerned. Now, there’s still no evidence of anybody having any ill effects from that. And as you know, pasteurization is a highly, highly effective process to remove infectious particles from our milk. And it makes it possible for us to eat and healthy for us to eat, or drink, rather. And by the way, it’s also cheese, so it is “eating,” but in this case, we are seeing the particles. So this brings me to the next topic—and you can guess what this is—is, what about unpasteurized milk?

Harlan Krumholz: Yeah. Well, many people drink unpasteurized milk.

Howard Forman: So I have never known anybody who had unpasteurized milk.

Harlan Krumholz: Actually, I think you can buy it at Bishop’s Orchards in Guilford. I think I’ve seen it.

Howard Forman: It’s possible. I don’t know. It’s legal. I don’t know if it’s possible. What I—

Harlan Krumholz: People like it, because they think it’s the freshest possible milk, I think, and this isn’t to say anything bad about my very favorite grocery store in Guilford.

Howard Forman: It’s true, Bishop’s Orchards. So here’s what I know. I spent time looking at this. What drew me into this is, randomly I came across I think a TikTok or a Reel on Facebook where somebody is saying, “If you’re having irritable bowel symptoms, the problem is you’ve got to get rid of processed food and you got to start drinking raw milk.” Raw milk, which is the unpasteurized milk straight from the cow. So I started looking into this, and there’s this tiny, tiny bit of information about raw milk that suggests it has benefits. It seems like most of the benefits line up with farm living. And so it’s hard to know, is it the milk or is it other things related to farm living that have made these people have a lower incidence—

Harlan Krumholz: Do you drink milk?

Howard Forman: Very little. Cheese mostly, almost no milk. Eczema—

Harlan Krumholz: They had that whole campaign about you “Got Milk?” I’m just talking about milk in general. But there were a lot of people that were raising the thing. Maybe it’s not that much of a health product, honestly, that was really all about a campaign that people should be drinking milk. But really when you look at...

Howard Forman: We’ve got a big dairy industry in this country, it would not surprise you.

Harlan Krumholz: The sugar and it’s... it’s not necessarily the healthiest beverage.

Howard Forman: But to the raw milk thing, I started looking into this because I started—

Harlan Krumholz: And I don’t want hate mail from the dairy industry. I’m saying what I’ve heard.

Howard Forman: No, it’s interesting. But it turns out raw milk is prohibited by the FDA. So the FDA prohibits raw milk, but as we’ve talked about before, they can only prohibit it insofar as interstate….

Harlan Krumholz: I’m confused. What’s the difference between raw milk and unpasteurized milk?

Howard Forman: Same thing.

Harlan Krumholz: Okay.

Howard Forman: Same thing. There are—

Harlan Krumholz: The FDA prohibits it, but people sell it.

Howard Forman: Correct. Because the FDA prohibits interstate sale.

Harlan Krumholz: I see.

Howard Forman: So you can’t cross state lines. You can’t—

Harlan Krumholz: Because that’s where their jurisdiction is.

Howard Forman: Correct. It’s from the Commerce Clause—

Harlan Krumholz: So a state would have to say that they were against it.

Howard Forman: Correct. And so you look at the map—

Harlan Krumholz: That is wild.

Howard Forman: Exactly. So you look at the map, there are a few states that absolutely prohibit it.

Harlan Krumholz: So the federal government says we are prohibiting—

Howard Forman: Interstate sale.

Harlan Krumholz: Unpasteurized milk. We think it’s so bad that we don’t think if you live a mile on one side of a border, you couldn’t take it on the other side of the border.

Howard Forman: Correct.

Harlan Krumholz: But within that border—

Howard Forman: You can do whatever you want.

Harlan Krumholz: Godspeed.

Howard Forman: Same thing with compounding pharmacies. And same thing with the spas. This is the rarest limit of the regulation. So the states do have control of this. State of Connecticut says that you can sell this from a farm, I think. I forget if you’re allowed to sell it to a retail store.

Harlan Krumholz: And I may have been wrong about Bishop’s, but I have seen it on some shelf in some grocery...

Howard Forman: And you’re correct that in Connecticut it is legal to sell. I just forget, there’s various versions of it about whether you’re able to sell it to a retail store or whether you have to sell it from a farm. But the various states all look like that.

Harlan Krumholz: That’s interesting.

Howard Forman: Everybody’s different.

Harlan Krumholz: And what does the FDA say? Do they give a justification?

Howard Forman: Yeah, because we have these enormous numbers of outbreaks from E. coli and salmonella involving raw milk and raw—

Harlan Krumholz: You know, that Louis Pasteur, he was a clever guy.

Howard Forman: I know. You want to give him his due. So it’s insane but I was looking... so we’ve had in just like a 15—

Harlan Krumholz: He’s one of my favorites, by the way, Louis Pasteur. He made major contributions.

Howard Forman: I think I wrote a paper about him in first or second grade. My father probably still has it, or my mother does. E. coli in four states involving 10 people, including four hospitalizations. And one person with hemolytic uremic syndrome reported two months ago.

Harlan Krumholz: Wow.

Howard Forman: That’s just recently. And there are hundreds of cases that are directly related to raw milk. Now remember, raw milk is a relatively small industry, but it is fast-growing. And so right now the bottom line for all of our listeners is, no raw milk. Not right now. Even if you are willing to take all the other risks, we don’t know enough about H5N1 coming from the cows. Just cut it out of your diet until we learn more.

Harlan Krumholz: Okay, I’m going to go on record saying, right now I’m not that worried about H5N1, but I would just wonder if I’ll be shown wrong. I mean, a lot of things have to happen for this to actually be a threat to humans.

Howard Forman: I agree.

Harlan Krumholz: And it doesn’t even look like it’s a big threat to cows right now.

Howard Forman: Correct. So here’s the weird part of it is the cows are presumably getting it when they’re being milked. They’re not getting it by eating anything.

Harlan Krumholz: So I even wonder if it’s got a tropism for the udders or whether it’s just about the skin and these things are being transmitted because of—

Howard Forman: But because it’s coming from the udders now, the concentration of H5N1 in the milk is apparently off the charts.

Harlan Krumholz: But couldn’t we just start monitoring for this?

Howard Forman: We should be. I mean this is part of the thing we learned—

Harlan Krumholz: But this was the thing. The pasteurization is thought to inactivate the virus, even if there’s some remnants.

Howard Forman: Correct.

Harlan Krumholz: Right.

Howard Forman: So, highly effective at it.... It seems there are no culturable viral particles found there.

Harlan Krumholz: So let me say the reason why, just to support why I said that I’m not that worried yet. I’m going to be worried when I hear that there’s airborne transmission.

Howard Forman: Oh, yeah.

Harlan Krumholz: But I’m just saying, in the absence of the airborne transmission, it seems like this is actually somehow surface-to-surface to the udders.

Howard Forman: So, I agree with you. But the conjunctivitis case, by the way, you know how we think it was transmitted?

Harlan Krumholz: How?

Howard Forman: Because the person was milking the cow, and it squirted in the eye. It’s such high concentration that even an organ that isn’t usually infected by a respiratory virus got infected because it’s in such a high concentration. So I would just... the only reason I’m saying caution, I’m not saying people should run around with their head cut off. I’m just saying—

Harlan Krumholz: You’re a cautious guy.

Howard Forman: I’m a cautious guy.

Harlan Krumholz: Yeah, I know. And I’m not not being concerned, but I got so many other things to worry about in this world right now.

Howard Forman: I hear you.

Harlan Krumholz: I’m putting it on the side.

Howard Forman: I know.

Harlan Krumholz: Until it’s more actionable for... let me get onto to another thing now I wanted to talk to you about.

Howard Forman: Yeah, let’s do it.

Harlan Krumholz: So you remember telehealth?

Howard Forman: Yes.

Harlan Krumholz: That was an exciting era, right?

Howard Forman: It’s over.

Harlan Krumholz: Well, wait a minute. It was going to change everything forever. Forever, right? I mean, seriously, it was like the pandemic accelerated our movement towards being able to implement a system that was going to be much more convenient for patients, we’re going to be able to do—

Howard Forman: And it is very active, and we are using it a lot more. It’s not like it’s gone away, it’s just the industry that’s—

Harlan Krumholz: So, it’s just so interesting. So this Teladoc, which I’ve been watching very closely, you know that they sort of got rid of their CEO with an abrupt departure. This guy had been there for 15 years. He grew the company from practically nothing. A guy by the name of Jason Gorevic. And then they basically, “We’re going in a different direction.”. Right now they actually have an acting CEO. I mean, it wasn’t like they—

Howard Forman: They weren’t ready for a search.

Harlan Krumholz: No, they weren’t. They didn’t make a transition. They basically said thanks very much for 15 years of service. And I’m sure he’s done very well, but they wanting to say tremendous legacy and blah, blah, blah. But they’re having trouble. Their stock’s down 40% year to date. And there’s a lot of questions about the overall performance. Just to remind, the stock’s at about 13 bucks today.

Howard Forman: What was its highest? Do you remember?

Harlan Krumholz: About $300. Yeah, about $300.

Howard Forman: Just incredible.

Harlan Krumholz: Yeah. So their market cap now is about $2 billion. That’s nothing to sniff at. I mean, you build a company, $2 billion, that’s a success. But it was a lot higher.

Howard Forman: Fifty billion dollars or something, right?

Harlan Krumholz: And you know how I rail about this Livongo acquisition?

Howard Forman: Yeah. You taught me about that.

Harlan Krumholz: I just have to say it again. Livongo was a company that basically had outpatient chronic care services for people with diabetes. And they were going into people with hypertension, and they had created a continuous glucose monitor, which I thought was a little clunky. And they had revenues of about $245 million. That’s good. They were losing $45 million a year. So, $45 million a year. Teladoc bought Livongo for...

Howard Forman: It’s like $15 billion or something.

Harlan Krumholz: Eighteen billion dollars. They’ve already written off a lot of that. And that was in the heyday when their stock was so high. Some of it was stock, but some of it was straight-out cash. Everyone at Livongo I think did really well, but just nuts. So currently Teladoc brings in about $600 million in revenue. They had also bought this mental health group, BetterHelp. So it’s all telemedicine stuff, but they’re having a little bit of trouble. Their net loss in the first quarter went up to $82 million, and their EBITDA increased 20%, $60 million. So they got cash flow coming in. But there’s a lot of concerns about the company. Of course, the company’s saying, “Don’t worry, things are great.” But it’s just so fascinating to me that this juggernaut of telehealth…and then you may have read it also, Optum discontinued their telehealth. Did you see that, Howie?

Howard Forman: I did not see that. You mentioned that you were going to talk about telehealth, and I honestly should have looked that up. I did not.

Harlan Krumholz: No. So they had a thing called Optum Virtual Care. So Optum, which is an arm of United Healthcare—

Howard Forman: Which is a huge primary care practice—

Harlan Krumholz: It’s throwing tons of money into reforming healthcare. How does Optum, which has large-scale clinics and has taken care... they are taking care of patients, let alone selling services to others. Fascinating. They discontinued their telehealth company.

Howard Forman: I mean, the market’s being tremendously disrupted right now. I mean when you look out there, Walgreens shut down their primary care practices or shut down the... What was it called? VillageMD. I mean, the market’s—

Harlan Krumholz: Well, I’m going to talk about that next.

Howard Forman: Okay. The market’s being disrupted right now. And what you said before is worth hearing for our listeners a little more. When you have an inflated stock price, you can make everything look great. Because I can buy your company for $14 billion with paper. I’m using my stock that’s inflated to buy something. It makes it look great. Everybody looks richer. On the back end, it goes the other way.

Harlan Krumholz: So I sometimes tell you this, “Riddle me this, Howie.” This is one thing I don’t understand. So at the same time that telehealth is sort of imploding... like you said, it’s still going. I mean it’s growing, but it’s not transforming medicine like it was. And the capital’s not quite where...

Howard Forman: And it may turn out to be something that are just built into health systems.

Harlan Krumholz: So meanwhile, try to get an appointment here at Yale. I think I told you I needed an eye appointment and I called up, it wasn’t urgent, but I would like to be seen. And they said, “Okay, we’ll see you next January or February.” I just want to remind you it’s May. It’s the beginning of May. And that’s true in cardiology. You know this in radiology. You need an elective MRI. How long have you got to wait?

Howard Forman: I think we’re like... it depends on what type, but it could be as many as several months.

Harlan Krumholz: My wife is getting her routine colonoscopy. She’s been good. That’s what the recommendation is. She wants to stay with the guidelines, eight months, six to eight months to get a colonoscopy. Here we want the population to be caught up, but we’re making it difficult. So some of these things are procedures, MRIs and such and such. But take cardiology, where it’ll take six months to get an appointment. Why aren’t we ramping up at least to be able to filter who really needs to be seen in person, who doesn’t need to be seen?

Howard Forman: I couldn’t agree with you more, and I wish I could explain why we’re not able to fill this void faster.

Harlan Krumholz: And how does the hospital lose... say they’re on track to lose $300 million a year and a lot of high-margin things that they do, you can’t get done because...

Howard Forman: So there, I think the problem is that we are... when you see the hierarchy of where we put resources, we can’t tell the ER to schedule people for six months. And we can’t tell patients on the inpatient floor that you can’t get an MRI if you need an MRI. So there are certain patients that automatically jump the queue because of the acuity of the problem.

Harlan Krumholz: And I know I’m pivoting to this topic about... so I was talking about telehealth, but now I’m just talking about supply and demand, just even to see patients. So the need for another system is there. And then what I don’t get is, you’re all about incentives. You teach a class, everything in healthcare is about the incentives. MRIs are good business.

Howard Forman: Oh, my God. And for the hospital right now, the margins they make on MRIs and CTs and, for that matter, breast imaging are very, very high.

Harlan Krumholz: But wouldn’t that lead you to try to figure out a system where you could accommodate all the demand?

Howard Forman: So for us, we’re in a unique situation where CONs, certificate of needs, significantly limit our ability to do it. Those particular procedures are not particularly limited by physicians. The breast imaging maybe a little bit, but certainly not the CTs or the MRIs.

Harlan Krumholz: So the state holds us back.

Howard Forman: The state holds us back. We’re constantly applying for and then having to negotiate around certificates of needs.

Harlan Krumholz: But I am hearing this around the country, a lot of other people are having the same problem. I mean it’s not just a Connecticut problem.

Howard Forman: Yeah, no. There’s access problems all across the board. We want to hire people across the board.

Harlan Krumholz: We do. We’re hiring docs.

Howard Forman: I mean I think we’re hiring docs in cardiology as well.

Harlan Krumholz: We’re trying. Yeah.

Howard Forman: So I do think we’re trying our best. I do think the hospital is filled to the gills, and that ties up capacity and it hurts our ability to make money because, quite frankly, our ER and inpatient are where we’re going to lose money.

Harlan Krumholz: And I want to pivot to because I know you’ve got a couple of things you want to talk about, but I’m just saying, is the market failing? Because we often like to say we’ve got a... we know we’ve got problems with our healthcare system, but some people like to say, “But you don’t want to move away from our capitalist system because the market in the end is highly efficient”—we know that this isn’t a real market in healthcare—but they say, “The market will respond, private equity’s coming in,” all these things. And yet somehow the demand for services is not being met.

Howard Forman: We definitely have a lot of regulations, many of which make good sense.

Harlan Krumholz: So you’re attributing it to regulations.

Howard Forman: I think some of it is, it’s not just the CONs, by the way, but some of it is. Wouldn’t it be so much better if doctors could figure out how to see patients according to their need and not according to, how do I code for the maximum amount of money?

Harlan Krumholz: Well, that’s another crazy thing.

Howard Forman: But that’s part of it. We want—

Harlan Krumholz: How about, why are we having any limits on the number of doctors? We have many more qualified people who want to be doctors than we’re… allowed to be doctors—

Howard Forman: Nurse practitioners. I mean we absolutely constrain nurse practitioners. There’s a lot of turf battles between physicians and other practitioners. We could do so much better. We allow regulation to get in our own way.

Harlan Krumholz: All right. Hey, come on, get to your next topic.

Howard Forman: So this is a quickie, but so, you and I have talked about this a lot. Both of us are still on Twitter, X, and both of us sort of have a love-hate relationship with it.

Harlan Krumholz: I may expand my... now that I’m editor of a journal, I feel now an obligation, I actually may dig into this a little bit more after being away from it for a while.

Howard Forman: But I, right away, soon as I was offered the option to participate in Community Notes for Twitter, I got involved in that. So I got involved—

Harlan Krumholz: What’s Community Notes?

Howard Forman: So you can create a note on almost any tweet and say, “This is complete fabrication. This is ridiculous, it’s stupid. Here’s these four papers that prove that what you’re saying here is absolutely wrong.”

Harlan Krumholz: And how do you see that on X? So okay, I’ve just tweeted something you disagree with, and you write a note to say what I’ve written is no good. Where does it appear?

Howard Forman: It doesn’t appear until another... a group of other members of the Community Notes—

Harlan Krumholz: Validate that.

Howard Forman: Validate it. And they fight over it, Harlan. And there’s been times where I’ve been enormously skeptical.

Harlan Krumholz: But do they have to vote for you?

Howard Forman: Effectively. So I’ve been enormously skeptical of this because I’ll go on Community Notes—I see it, you won’t, but I see it—and literally someone will say “Blah, blah, blah.” And then the next note will say, “The person above wrote this. This is absolutely wrong.” And then the person below that says, “NNN,” meaning “No note needed. You guys should be arguing this in the replies. This is not appropriate for Community Notes.” And everybody’s being raided, constantly, in real time, as to how credible they are. And you’ll occasionally get—

Harlan Krumholz: But what if you attract a bunch of, for example, extremists in one direction or the other? Then they’re all kind of endorsing each other and it’s making it seem like there’s voting for it.

Howard Forman: So that’s what I was worried about, and that’s what this paper made me feel a little better about. So this paper comes out written by a medical student at University of San Diego who have looked at Community Notes around COVID-19 vaccination misinformation. And I thought for sure he was going to say there’s been like no impact. But the overall summary—I’ll read you the summary statement: “A sample of Community Notes added to posts on X containing COVID-19 vaccination misinformation primarily addressed adverse events and conspiracy theories, were accurate, cited moderate and high credibility sources, and were attached to posts viewed hundreds of millions of times.” And so that’s when it gets visible. At a certain point you get enough effective votes from credible people that it becomes visible.

Harlan Krumholz: Well, what’s a “credible person”? That’s someone with a blue check?

Howard Forman: No, somebody who’s gotten enough...

Harlan Krumholz: Oh, who’s been endorsed by the community.

Howard Forman: Exactly. Nobody knows it’s me.

Harlan Krumholz: Has this worked for you? You’ve gone on, put Community Notes, and—

Howard Forman: Then I get a feedback of sometimes a day later, sometimes a week later, that’ll say, “A Community Note that you effectively endorsed has now become visible to the public. Thank you. Your score has gone up.”

Harlan Krumholz: And then when I see the original tweet, will I see your note?

Howard Forman: Not at all. You’ll see my note, but never my name.

Harlan Krumholz: Not your name.

Howard Forman: So if I get a note on there, you’ll never know it was me that wrote it.

Harlan Krumholz: That’s fascinating.

Howard Forman: It is fascinating. And this—

Harlan Krumholz: So you’re a creator now.

Howard Forman: A moderator, I would say. I don’t know—

Harlan Krumholz: But you’re creating Notes.

Howard Forman: I’m helping. I’ll rate Notes, and I create Notes. I create very few. I mostly—

Harlan Krumholz: How many hours do you spend on this a week?

Howard Forman: Maybe an hour. Not more than that.

Harlan Krumholz: That’s good.

Howard Forman: But the point is, JAMA, I forget if it was Network Open or the main JAMA journal had this nice piece, and it gave me hope that maybe there are ways to moderate misinformation. Bottom line, they also said more social media firms should open-source their misinformation countermeasures for evaluation by independent scientists to illuminate, foster public trust and scale the most effective strategies.

Harlan Krumholz: I’m just worried that the loudest voices win or...

Howard Forman: That’s what I was worried about. But that does not seem to be the case.

Harlan Krumholz: So far it’s not been the case. It’s fascinating. Hey, the one other thing I wanted to talk about today was the news that came out, it’ll be a couple of days before this releases, is that Walmart was shutting down their retail health.

Howard Forman: It’s crazy. And they were one of the biggest players.

Harlan Krumholz: So this is wild. I was so excited about this because Walmart is within 10 miles of 90% of the population. And they really do serve so many different—

Howard Forman: And they’re low in cost.

Harlan Krumholz: …people in society. They’re a known brand as value. And many people, how do they afford school supplies? How do they afford clothes for their kids? It’s because they go to Walmart. So it’s a trusted place for them. And so they started this initiative where they said, “We’re going to start building primary care clinics.” And they made a big commitment. They launched it in 2019. They expanded to 51 facilities in five states, but they were talking about having another 75 by the end of this year. Just a few weeks ago, they were telling people about we are having a little bit trouble with some construction, but we’re still on track to be able to do 75 more this year.

Howard Forman: And these are mostly in-store clinics, right?

Harlan Krumholz: Yeah. Well they could be stand-alones or next to the stores. Yeah, they’re brick and mortar. And they were intended to be able to provide this kind of primary care. And wow, they’ve completely discontinued the program. Now this comes on the heels of a lot of other retailers struggling with primary care businesses. This seemed like a good place to go. You may know Walgreens is scaling back its footprint. You mentioned before, VillageMD. They’re shuttering 160 of the VillageMDs. This is interesting that Walgreens in March of ’24 announced that they had lost $6 billion in the second quarter of 2024. They had an impairment charge of $12 billion. You want to tell the folks about impairment charges?

Howard Forman: Yeah. It’s just when you realize that something’s never going to be valued at what you thought it was and you just take a hit to your earnings all at once.

Harlan Krumholz: So they had taken on VillageMD with about a $5.2 billion investment. And then they took on this... you know about this, Summit Health CityMD. It’s another group providing care. They invest $8.9 billion in that and now they seemingly are pulling back, and this is a big deal. And so CVS also has... and Amazon have been expanding the reach in this area, and the question’s sort of going to be how’s that all going to be going? Amazon bought One Medical.

Howard Forman: One Medical is different, though. So One Medical goes after rich people.

Harlan Krumholz: Exactly. Maybe it’s a little different approach. It’s got the sort of high-tech approach. Remember Amazon shuttered, they had another group that was trying to do—

Howard Forman: And they shut it down…

Harlan Krumholz: Primary care, they shut down. CVS picked up this Oak Street Health, which was more focused on seniors, Medicare.

Howard Forman: Medicare Advantage, right?

Harlan Krumholz: Yeah. They bought that for $10.6 billion. And it’s going to really be interesting to see what happens. They also bought this company in 2023, Signify Health, that was focusing on health and technology around care delivery. I don’t know, somebody said to me yesterday, “Well, maybe Walmart found out it’s harder to take care of people than to sell lawn furniture.”

Howard Forman: We had a former president who said, “Healthcare is hard.”

Harlan Krumholz: Well, I can tell you, Walmart’s not naive about this. I mean, you may know that they’ve got 4,600 pharmacies and 3,000 vision centers and they’re a pretty smart group of people in that company.

Howard Forman: And they’ve been planning and doing this for over 15 years. So it’s not new.

Harlan Krumholz: I don’t think it’s a naive group that went in and said they didn’t know what they were doing. I don’t know exactly what triggered it. But here’s the thing, and this’ll finish up with what we were talking about, for try to get a primary care doc in New Haven County right now, or in most places around the country. So I had hope maybe this would decompress this. And also for kids, it’s like a lot of these kids up in the emergency department because simply parents can’t find primary care for their kids. And so we’re going to have to think about other approaches. But the retailers seem like it could work, but maybe always primary care is a loss leader. And the only way it works for the health systems is because it feeds other things. Because we’ve got this crazy system of reimbursement.

Howard Forman: Oh, it’s insane. And look, I am reminded, though, that for the lowest-income individuals, those that are on Medicaid or even uninsured, our federally qualified community health centers are the absolute best safety net around because they have primary care providers.

Harlan Krumholz: And they’ve been great. But there are also, many places are overwhelmed too. And I brought up this issue about I had trouble making appointments. Imagine somebody with very poor insurance or uninsured—

Howard Forman: It’s impossible.

Harlan Krumholz: With no facility to navigate the system. We’ve got a problem.

Howard Forman: We’ve got a problem.

Harlan Krumholz: But the primary care issue is a crisis. And then withdrawing just also says that, okay, this is not going to be the solution.

Howard Forman: There’s been an awful lot of areas where people have moved into healthcare thinking that they’re going to make a mint and then they move out. And I think it is what you said, it’s a lot harder than it looks.

Harlan Krumholz: But they said they were far from profitability. They really just started a couple of years ago. I would’ve thought they would have had a 10-year timeframe to when this thing can really be profitable.

Howard Forman: Businesses map things out and figure out not only when we’ll be profitable, but if we’ll be profitable. They may have figured out that it’s an if, not a when.

Harlan Krumholz: And they have other places to put their capital to get returns for the company. Maybe that was what it was.

Howard Forman: Yep.

Harlan Krumholz: So this is great, Howie. I love talking to you. What a great session.

Howard Forman: This is fun.

Harlan Krumholz: I love the guests we have, but let me just say, these are great sessions for me.

Howard Forman: No, I’m really glad that we get to do this. And we have, as we’re going to mention in just a second, we got the live session at the Innovation Summit coming up. So we’ve got a lot of fun—

Harlan Krumholz: That’ll be something different for us.

Howard Forman: Yeah, that’ll be great. Different environment. Totally.

Harlan Krumholz: Yep. So 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, keep the conversation going, email us at or follow us on LinkedIn, Threads, or Twitter.

Harlan Krumholz: And we very much want to hear your feedback or if you have questions or any suggestions for us. And if you like the podcast, please rate and review us on your favorite app because that helps people find us.

Howard Forman: Absolutely. And we love seeing anything anybody has to tell us. And if you have questions about the MBA for Executives program at the Yale School of Management, reach out via email or look to our website at And as I mentioned, we’re going to be doing this live in just four weeks at the Yale Innovation Summit on May 30th.

Harlan Krumholz: Who knows what we’ll say?

Howard Forman: I know, and we got three guests. We have never met them before. We don’t even know who they are in advance. It’ll be fun. The links are in the show notes today. Come to the Innovation Summit, see us interview some of the greatest health and technology innovators.

Harlan Krumholz: All right. Health & Veritas is produced at the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Amazing people. We so appreciate all their help.

Howard Forman: And they always roll with the changes. We really appreciate it a lot.

Harlan Krumholz: They’re great. Talk to you soon, Howie.

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