MTT #111: Why are patients paying more before they get care?

0:11Dr. Robert Pearl: Hello and welcome to Medicine the Truth, one of the four weekly podcasts in our Fixing Healthcare podcast series. I'm Jeremy Corr, host of Popular Books and Medicine podcast and CEO of Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert led the Permanente Group, the nation's largest physician group. He's a healthcare contributor at Forbes, a best-selling author, and a professor at both the Stanford University School of Medicine and Business. His most recent book, ChatGPTMD, How AI-Empowered Patients and Doctors Can Take Back Control of American Medicine, on the impact generative AI will have in healthcare remains a bestseller.

0:41Dr. Robert Pearl: Information on a broad range of medical topics can be found on his website, robertperlmd.com. Robbie, a listener said that her out-of-pocket costs seem to be increasing every year. She wanted to know, is this happening for everyone?

0:54Jeremy Corr: Jeremy, the answer is that our experience increasingly is the rule, not the exception. As the cost of coverage soars, not only are workers being required to pay more, but as a percentage, their out-of-pocket requirements are going up faster than their wages and at a higher rate than total medical inflation. Already total costs per employee, and we're including both the premium and the out-of-pocket expectations. On the average, it's over$20 ,000 a year, with about a quarter of that being the obligation of the individual. And with projections for next year indicating a rise of between 9 % and 11%, you can see the magnitude of the added burden workers are likely to pay.

1:35Jeremy Corr: But higher out-of-pocket costs aren't the only new and worrisome burden enrollers are carrying in response to these ever greater costs. In addition, providers, both doctors and hospitals, are now demanding payment of the out-of-pocket deductibles in advance for all but emergency admissions and procedures. As hard as it would have been to imagine a few years ago, 92 % of U.S. healthcare providers either strongly encouraged patients to pay in advance or are now requiring it. One year ago, that number, 81%. Let's say you need a hernia repair or your gallbladder removed due to chronic pain. If your deductible is$3 ,000, it's likely that the doctor in the hospital would expect you to pay that before you could have your procedure scheduled, since performing the surgery wouldn't be an emergency.

2:22Jeremy Corr: And the fact that you are limited in your activities and suffering discomfort, that wouldn't make a difference. Depending upon your circumstances, paying that much might require you to take out a loan or a second mortgage in your home. The reason providers are doing this reflects the reality that many individuals default on their payments. And when doctors try to collect the dollars that are owed, increasingly patients are declaring bankruptcy with the physician left unable to collect anything. According to a survey from Java Forum last year, half of all doctor bills that patients were expected to pay under their insurance plan remained unpaid after one year.

2:59Jeremy Corr: Similarly, hospitals are requiring prepayment before patients can schedule a surgery or procedure. Under HIPAA, they are prohibited from requiring payment for emergency care, but the definition of an emergency, that's very subjective. Most people wouldn't consider heart surgery for mild chest pain that wasn't a heart attack or repair a torn ACL with knee instability elective. But that's how both doctors and hospitals are increasingly defining each. For providers demanding prepayment, it's not a patasea. In fact, from a purely financial perspective, it often backfires. Since faced with this demand, patients are deciding not to have the procedure at all.

3:40Jeremy Corr: This means that the provider never gets to bill the insurance. It reduces the physician's overall income. Do the operation and procedure without prepayment? Maybe you'll never end up getting the dollars you're owed from the individual, but demand it and you may get nothing. We're also seeing providers becoming more aggressive in collecting these fees. To get a sense of the magnitude of what's happening, consider Roger Marshall. He's a senator from Kansas. He's a candidate for re-election. He's also an OBGYN physician. He has sued 700 patients for unpaid medical bills, ranging from as little as$100 to several thousand.

4:15Jeremy Corr: And he charges 18 % interest in the interim until the dollars are paid. 81 of the women he treated and he pressed charges ended up in jail as a result of being unable to pay his fee.

4:29Dr. Robert Pearl: Robbie, in a previous Medicine the Truth episode, you talked about a potential candidate to replace Marty Macri's head of the FDA. What's happened since then?

4:37Jeremy Corr: Sure, as we predicted, President Trump nominated Dr. Heidi Overton for the position, although it's likely that her nomination will be debated and voted on after the midterm election, not before. However, that hasn't kept her out of the news. She recently made headlines, although not in a positive way, when Trump announced his executive order to reduce the number of vaccinations that children are expected to receive and the number required to begin elementary school, she was at his side. The Republican chair of the Senate Health Committee, that's Dr. Bill Cassidy, he wrote that her stance on this issue, quote, alone is almost disqualifying.

5:16Jeremy Corr: Rather than supporting the scientific research, or at least highlighting where she felt the recommendations were wrong, she said that she would work with states where the actual authority is to implement these scaled back expectations. Moreover, in her comments, she failed to provide any explanation for why she was deviating from the recommendations of pediatric medical experts or why what the president said was more valid than what infectious disease experts have concluded. In the past, she's been a vocal opponent of women having control of whether to terminate a pregnancy, and she's called for major restrictions on the availability of the pills used to accomplish it.

5:55Jeremy Corr: Already, the FDA, along with other regulatory agencies, has seen a massive number of skilled and highly respected staff quit in protest over undue political pressure on what should be scientific research and data-driven decisions. These departures culminated in Marty's resigning from his role after the agencies implemented easing of restrictions on major vaping and tobacco companies. Critics of the decision point to the fact that the final approval came after Trump had a golf course lunch with tobacco executives. Dr. Overton's nomination is unlikely to be considered, as we said, until after the midterms.

6:32Jeremy Corr: But remember that although the voting is held the first week in November, and a shift in control of the House and the Senate could happen at that time, the actual seating of the new members of Congress, that doesn't happen until January 3rd of 2027.

6:48Dr. Robert Pearl: Robbie, it seems like this political versus science battle is growing. What else is new in this area?

6:54Jeremy Corr: Jeremy, you're very right. Almost all the decisions and even the appointments reflect the political desire for a particular outcome, one that's often at odds with the overwhelming scientific data. A recent example was the hiring of an Army doctor. This is Lieutenant Colonel Teresa Long from the Department of Health and Human Services under the leadership of Robert F. Kennedy Jr., and she was hired to investigate unsubstantiated claims that 2 ,500 U.S. service members had died after receiving the COVID vaccine. She doesn't have any specialized training on viruses or vaccines. There's little, if any, evidence that this actually happened.

7:31Jeremy Corr: In fact, two Pentagon reports, one released in March and one in July, found no deaths from the vaccines. And the lack of any evidence that the deaths resulted from vaccination comes after over 95 % of service members have been vaccinated prior to the current administration deciding that mandatory vaccination wasn't appropriate. For comparison, a study of approximately 7 million patients given the COVID vaccine early in the pandemic, found that 30 days after administration, only one in 300 ,000 recipients had died from any cause. And as we've noted in the past, the overall mortality rate from COVID among the unvaccinated was exponentially greater than among those vaccinated.

8:16Assuming those numbers are correct, it's statistically just

8:20Jeremy Corr: about impossible that the claim number by the nominee could be anywhere close to reality.

8:27Dr. Robert Pearl: Robbie, the new vaccine against melanoma made headlines when it was found to extend life in individuals who had complete resection of the cancer and no known metastatic spread, but who are at risk for recurrence due to this cancerous cells themselves or their depth of invasion. Can you tell listeners about the vaccine and your predictions for the future about its use?

8:47Jeremy Corr: Jeremy, let's start with what makes this personalized vaccine so exciting against cancer. Although mRNA vaccines garnered the big headlines during COVID-19, the original research looked for ways to use the technology to actually treat cancer, not infectious disease. The reason is that traditional chemotherapy attacks all living cells, and that includes the cancer, but also the patient's normal cells. Of course, the chemotherapy is designed to attack the cancer to a greater extent than the normal tissue, and that happens because malignant cells divide faster than regular ones. But the side effect of these chemotherapeutic drugs, they can be horrific.

9:25Jeremy Corr: This customized mRNA vaccine is different from traditional chemotherapy. The vaccine trains the immune system to recognize and attack cancer cells while avoiding the patient's normal cells. What manufacturers of the mRNA vaccine do is first do genetic testing of the cancer and identify more than two dozen tumor-specific proteins in the resected tissue. Often they use AIA to help accomplish this. Then knowing the protein structure, they work backwards to calculate the underlying specific genetic composition responsible, and they design the messenger RNA to instruct the patient's ribosomes to manufacture these tumor-specific proteins.

10:05Jeremy Corr: For analogy, you can think of the DNA as the brains of the architect, the mRNA as the blueprints created, and the ribosomes as the workers at the building construction site who translate the instructions into physical structures. For analogy, you can think of the DNA as the brains of the architect, the mRNA as the blueprints created, and the ribosomes as the workers at the building site who translate the instructions into physical structures. When the vaccine's injected, similar to the COVID vaccine. The patient's body manufactures the proteins that are specified by the mRNA blueprint. These proteins themselves aren't harmful to people when they're not attached to the cancer, but they still generate an immune response from the recipient's body that perceives them as foreign.

11:00Jeremy Corr: In response, the person's immune system activates T cells capable of attacking and destroying the cancer cells that contain the same mutated protein. That specificity is why side effects are relatively low and the success rate higher than with chemotherapy. The key to this whole vaccine-driven immunity approach is finding proteins which are vital to the cancer cell but absent the normal human organs. As I mentioned, the mechanism is identical to what researchers did to create immunity from COVID-19. Rabbi, what were the

11:32Dr. Robert Pearl: results of the melanoma trial?

11:35Jeremy Corr: Jeremy, in this case, Moderna, the company that makes one of the COVID vaccines, partnered with another company, Merck, to test this type of mRNA-produced cytotoxic T-cell response to the cancer. The combination of the mRNA vaccine plus Merck's drug, Kiruta, produced lower rates of recurrence in patients with high-risk advanced melanoma compared to the Merck-manufactured drug alone. The data, however, has not been published, so the exact results and drug effectiveness remain unknown. The partnership with Merck was included to allow patients to get a drug called QRuda that Merck manufactures. Unlike the mRNA vaccine, this drug is not specific to the individual patient, but it was included in the protocol since cancers often suppress T cell function, and QRuda blocks that from happening, allowing the maximal immunological response to follow.

12:29Dr. Robert Pearl: Probably from a business perspective, what do you see for this mRNA cancer vaccine?

12:34Jeremy Corr: Of all the cancers, melanoma is considered to be the most likely malignancy to respond to a cancer-specific mRNA vaccine. Compared to most other malignancies, it tends to have one of the highest number of genetic mutations, since high-intensity sunlight is a well-recognized source for DNA mutations. And almost always the melanoma is found on skin. Moreover, this particular malignancy is highly responsive to cytotoxic T cells. Furthermore, the protocol was designed to maximize the likelihood of success. To qualify for the study, there had to be complete removal of the pigmented lesion, leaving only microscopic disease, and there couldn't yet be metastatic spread.

13:15Jeremy Corr: For these reasons, the number of patients who would meet the study's criteria for treatment would be relatively small. And finally, as I mentioned, the actual data has not been presented and details on survival have yet to be provided. As such, what sounds like a major success can prove not to match the hype when more impartial statisticians and oncologists review the study's protocols and data. But these limitations didn't prevent the drug manufacturers who would be expected to benefit greatly in terms of stock prices for this type of preliminary announcement. And of course, the expected cost per patient, that's estimated to be approximately half a million dollars.

13:52Jeremy Corr: And that's a hefty price to pay if the mortality rate is identical between patients treated with the drug and those who were not. Prove that it works for breast or lung cancer and show that it extends life, not just reducing recurrence, and you have a block breast of drug. But despite the median investor hype, we don't currently know for sure what the outcome will be. Robbie, any other cancer news? Jeremy, yes. The Food and Drug Administration, the FDA, approved a new drug for patients with advanced pancreatic cancer. Pancreatic cancer has been a challenging malignancy to diagnose and treat. As such, this is encouraging to the oncologists who treat the problem and the patients who have it.

14:33Jeremy Corr: The medication is made by Revolution Medicines. It's approved for patients who have already failed chemotherapy for pancreatic cancer. When the data leading to the FDA approval was presented at a recent oncology conference, the audience applauded. On average, the drug extended life for 13 months, while chemotherapy led to only an additional seven months. The cost is expected to be$480 ,000 a year, and that's for the two pills that the patient takes daily, with the company expecting that insurance will pay most of the expense. Excitement among oncologists come from the reality that pancreatic cancer is one of the most difficult malignancies to manage.

15:11Jeremy Corr: Across the United States, pancreatic cancer kills over 50 ,000 Americans a year, with only 3 % of patients living for five years after the tumor has spread. Unlike the melanoma drug, this one isn't personalized. It works by helping to block a mutated cellular protein called KRAS. The normal protein serves as a shutoff valve for cell growth. But the abnormal protein derived from the mutated gene allows cell replication to go unfettered and facilitates the cancer thriving. By binding to and blocking KRAS, the cells don't reproduce and die. Researchers have recognized the possibility of creating antibodies to this protein, but they couldn't figure out how to get this immunological agent to penetrate the smooth surface of the cell.

15:58Jeremy Corr: This new medication glues two cells together and provides a perch from which drugs can grab and shut down KRAS. However, because the drug blocks both the abnormal and normal KRAS, this medication in many patients has devastating side effects, including severe rash, fatigue, nausea, and diarrhea. But given the lethality of the cancer, most individuals are willing to accept the risk and the discomfort if the treatment extends life successfully. As such, patients, even if they haven't failed chemotherapy, are likely to demand treatment with this new antibody. And since this mutated KRAS protein is found in multiple malignancies, there's the potential for this approach to have broader applicability than for melanoma.

16:40Dr. Robert Pearl: Robbie, the price tag for these drugs seems exorbitant. How do the pharmaceutical companies justify it?

16:46Jeremy Corr: Jeremy, you are correct. Most of the newly released drugs cost more than$300 ,000, with some in the millions. And in many cases where the impact is massive or the R &D expense exorbitant,

17:02Jeremy Corr: and in the cases where the impact is massive or the R &D costs exorbitant, a high price makes sense. However, defending the exorbitant price in the drug industry changes its story depending on the argument that seems most pervasive at the time. Specific to these cancers, the pharmaceutical companies that manufacture them defend the pricing on a cost-value basis. When a different new drug proves no better than a currently far lower-priced medication, they blame it on how many other drugs fail and the R &D costs involved for the company's total portfolio. Never do these companies provide details on the actual R &D expense, which is reported to be less than most companies' annual marketing spend.

17:46Jeremy Corr: And the industry also tries to justify the massive cost by threatening that patients will die because the drug pipeline will dry up if profits decline. However, when unbiased statisticians examine the data, they conclude that the total number of effective medications would be diminished by a tiny number and the publicly traded pharmaceutical companies would still have large profit margins. As an example, according to researchers at Yale University, GLP-1 medications could be manufactured for$5 a month. Even if we add, let's say,$15 for marketing and distribution at a price of$200 a month, rather than the current retail price of over$1 ,000, the pharmaceutical companies could sell their drugs at 20 % of today's retail price, flatten the medical inflation trend, save tens of thousands of lives each year, and still make a massive profit.

18:39Jeremy Corr: But don't hold your breath for these pharmaceutical companies to do so voluntarily.

18:45Dr. Robert Pearl: Robert, we've talked about ticks on previous Medicine the Truth episodes. How did the season progress?

18:51Jeremy Corr: Jeremy, the biggest shift was in the rise, not in the traditional deer tick, which is, as you know, the cause of Lyme disease, an infection that can be treated once the diagnosis is made. Instead, it was from the Lone Star tick, which derives its name from the white splotch found on the back of the female, a tick that's been prevalent in the southeastern U.S., but is now spreading to New England and upper Midwest. And rather than taking 24 hours between landing on a person and releasing the bacterium responsible for Lyme's disease, the Lone Star Tick almost immediately releases a molecule called alphagel, which is found in the tick's saliva and produces a dangerous allergic reaction any time the person eats red meat.

19:34Jeremy Corr: Unless the person has an EpiPen, there's nothing they can do once a crisis begins. In August, the number of ER visits in the first 18 days of the month were higher than for any August in the past for the full month. And the season is far from over. Moreover, unlike the deer tick, which lays 2 ,000 to 3 ,000 eggs, with the tick becoming quiescent during the fall, the lone star tick, it lays 5 ,000 eggs, and the eggs are just beginning to hatch at the end of the summer. The tick problem is becoming so bad that multiple drug companies are already working on vaccines and drugs to prevent and treat it.

20:14Jeremy Corr: Currently, Moderna is developing an mRNA vaccine against Lyme disease, while Pfizer is developing an alternative vaccine to prevent the problem. While ticks are proliferating and posing ever greater threats, a much bigger fear, if the current weather challenges increase, could be mosquitoes that carry diseases like malaria and illness that kills almost 600 ,000 people around the globe annually. We haven't talked about measles in a while. What's new there? The number of cases that are record-setting pace with the preventable deaths continuing. Already in 2026, more cases have been reported than in any year since 2000, a time when measles was declared eliminated.

20:57Jeremy Corr: Following two deaths in infants, the state of Pennsylvania has reported two more, one in a 40-year-old woman and one in an 18-year-old, from a neurologic complication of the infection. In each of the four cases, the patient wasn't vaccinated. And in all four individuals, scientists identified and documented the measles virus. Already there have been around 3 ,300 measles cases in 2026. That's 1 ,000 more than last year in total. And that had been the previous high year this century. Last year, there were three deaths from measles, two involving infants, the first death from measles in over a decade.

21:33Jeremy Corr: The biggest tragedy is that two doses of the MMR, that's the measles and mumps rubella vaccine, would have been 97 % effective at completely preventing the disease. Had these children been vaccinated, the tragedies almost certainly would have been avoided. As we discussed the medicine of the truth in the past, the United States is at risk of losing its measles elimination status, which actually isn't a measure of complete eradication, but just recognition that there weren't continuous measles cases across the entire year. But given the spread of the virus to new and ever wider U.S. geographies, we haven't seen the last of this infection in 2026.

22:12Jeremy Corr: From perspective on the relative risk of vaccination, a recent analysis published in The Lancet estimated that there have been 154 million lives saved in children since 1974 as a result of vaccines. Measles is a major threat because of how contagious the virus is. It lasts in rooms for up to an estimated two hours after people leave. And on average, a single individual spreads it to 15 to 17 people if there's no immunity from previous infection or vaccination. For this reason, when vaccination rates are above 95 percent, outbreaks rarely occur because there are so few susceptible individuals. But as the immunization rate falls, the dangers grow rapidly, and the likelihood of most unvaccinated individuals encountering someone with the infection and becoming sick rapidly escalates.

23:03Jeremy Corr: Once the 95 % threshold is passed in the downward direction, it's just a statistical calculation to determine how many people will die.

23:13Dr. Robert Pearl: Robbie, in a recent Diving Deep episode, we discussed how affordability is the number one health care issue on the minds of Americans. With 2027 fast approaching, several listeners have asked, what can our nation expect?

23:24Jeremy Corr: Jeremy, as you know, predictions are estimates. But the closer we get to year end, the more accurate they become, because insurance rates become more final. And the projections are disturbing. Overall, a new U.S. survey showed that unless benefits are cut, Businesses will see the largest increase in two decades, likely around 11%, and that even with benefits being cut, the rise will be in the 9 % range. In round numbers, we're looking at medical costs for 160 million Americans under the age of 65, averaging$20 ,000 per worker, with a quarter of the total paid by employees using post-tax dollars through high-deductible out-of-pocket coverage requirements.

24:07Jeremy Corr: A growing number of employers in response to massive rate increases that discontinue in coverage of GLP-1 medications, and they're eliminating coverage for spouses who have other insurance options. One reason for this acceleration in cost are the exorbitantly priced obesity and cancer drugs that we've discussed on this podcast. A second are hospitals and doctors using artificial intelligence tools to increase payments for insurers, and more doctors are refusing to be part of a network, and instead challenging the reimbursement payments they receive through the recently passed consumer protection laws.

24:42Jeremy Corr: These actions by providers to obtain higher payments will likely grow in frequency as governmental reimbursements decline. Increasingly, the medical costs are being treated as a hot potato as the federal government cuts back what it pays, which increases what the state and local jurisdictions must spend, while insurers and self-funded businesses are transferring a disproportionate share of the higher premiums to workers, whether through out-of-pocket expenses or simply reduced benefits. The big question is whether payers and insurers will tinker at the edges or whether they'll take the leap and shift payment entirely to a variety of pay-for-value methodologies, including bundled payments, outcomes-based reimbursements, and full capitation with a single payment directly to providers, both hospitals and doctors.

25:30Jeremy Corr: With these capitated payments, providers are responsible for the totality of the medical care for a population of people. Already in response to rising drug costs, many businesses, especially smaller ones, have moved from one of the three largest pharmacy benefit managers, or PBMs, which still recently provided 80 % of drug cost management, to one of the multiple smaller programs. That includes Mark Cuban's Cost Plus Drugs, which he talked about in detail when he was a recent guest on our Fixing Healthcare podcast.

26:01Dr. Robert Pearl: Robbie, shifting to another topic. With the fall arriving, a listener wants to know how to obtain the most scientific advice on vaccines for her and her family. What can you tell her?

26:11Jeremy Corr: Jeremy, she's wise to have broad distrust of the unscientific recommendations coming from various federal regulatory bodies and on social media. The challenge of obtaining the most up-to-date scientific advice on vaccines, it's being addressed by the leading U.S. medical organizations, including American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetrics and Gynecologists, and the Infectious Disease Societies of America. Most of the recommendations align with those of the past. These societies point out that the recent evidence, if anything, supports the previous guidelines rather than contradicting them.

26:50Jeremy Corr: Although the information they offer is more specific, overall they conclude that nearly all Americans would benefit from getting the COVID and flu vaccines this fall. Published in collaboration with the AMA, they wrote that they had reviewed hundreds of peer-reviewed studies on the safety and effectiveness of immunizations against influenza COVID-19 and RSV, that's respiratory syncytial virus, and they found no new safety concerns. Overall, they found serious adverse events rare, and they know that the benefits were overwhelmingly greater than any risks from these vaccines. More specifically for COVID, the Vaccine Integrity Project, which led the work, recommended shots for all adults, including pregnant women.

27:35Jeremy Corr: It also recommended a vaccine for all kids, 6 to 23 months, and for older children with underlying medical conditions. They noted that vaccination has been shown to result in fewer hospitalizations for adults, a reduced number of ER visits for pregnant women, and young children.

27:53Jeremy Corr: They noted that the vaccination has been shown to result in fewer hospitalizations for adults, a reduced number of ER visits for pregnant women and young children, and diminished ICU admissions and deaths for immunocompromised adults. For influenza, the groups recommended a vaccination for everyone over the age of six months, including the traditional shots for most, a nasal spray for some ages 2 to 49, and a new mRNA vaccine from Merck for individuals over 50. This vaccine has been proven to reduce severe disease, to reduce hospitalizations, and to diminish deaths. It's particularly important for the most vulnerable populations, including young children and older adults with medical issues.

28:34Jeremy Corr: In total, the flu is responsible for around 36 ,000 deaths and hundreds of thousands of hospitalizations each year in the U.S. When it comes to the third vaccine, the one for respiratory syncytial virus, or as we said, RSV, the group recommended one-time vaccination for adults over 75 and for immunocompromised individuals ages 50 to 74. And to protect babies born in the winter and spring, pregnant mothers should be vaccinated, and here are the caveats if they're between 32 and 36 weeks of pregnancy and between the months of September and March. What many people don't know is that prior to the RSV vaccine, this infection was the leading cause of hospitalization for babies, and it carried a 2 % to 3 % risk of severe illness for each infant, with vaccination that no longer is the case.

29:29Dr. Robert Pearl: Robert, we've talked about primary care on this podcast multiple times. A listener wanted to know more about the evidence and efficacy of this specialty relative to cost. What can you provide?

29:44Jeremy Corr: Jeremy, despite a massive amount of theoretical evidence that investments in primary care should lead to improved health and lower expense, the studies for the most part have been borderline encouraging, but not overwhelming. Now a study from Amsterdam provides stronger evidence. published in the Annals of Family Medicine, examined two factors relative to primary care, not just one. First, did the person have a primary care clinician? But second, was it a long-term relationship? They found when the doctor-patient relationship was long-term, then there were fewer ER hospital admissions and lower healthcare costs.

30:25Jeremy Corr: But that positive outcome wasn't the case without longevity. The researchers examined data on 100 ,000 adults, and they found that those patients who had seen the same clinician for 15 to 20 years, they had between a 9 % and 21 % lower odds of an ER to hospital admission compared to those who had a primary care doctor but had not seen the same clinician for more than five years. And that was true even if they saw the short-term clinician multiple times during the interview. Overall, the magnitude of cost reduction with primary care correlated with the length of the relationship, peaking between 10 and 15 years at 39.7 % decrease in medical expense.

31:09Jeremy Corr: Of course, these findings are correlations, and they don't prove causation. But the data makes sense. It takes time for greater prevention and improved chronic disease control to prevent heart attacks, strokes, cancers, and kidney failures. However, once the long-term relationship accomplishes those goals, then other medical problems, ones that can't be avoided, intervene as the person ages. But regardless of the details, a nearly 40 % reduction in cost, that would be massive in the context of our nation's$5.7 trillion spend.

31:43Dr. Robert Pearl: Robbie, one of the most frequent questions we receive from people considering a weight loss medication is which GLP-1 is best? What do you think?

31:51Jeremy Corr: Jeremy, my first response is that the specific one is far less important than the difference between taking any of the currently available ones and taking nothing. But since our listeners want some more comparison, here's data from the journal Clinical Obesity, comparing the two most common GLP-1 medications, terzepatide and semaglutide. And in a split decision, terzepatide wins based on weight loss, but semaglutide wins on safety. The article looked at over 41 ,000 adults who took one or the other for weight loss based on standard drug dosing. The trisepatide led to around a 10-pound greater weight loss and a 0.29 greater reduction in hemoglobin A1c.

32:37Jeremy Corr: But 5.7 % of the patients reported side effects, compared to only 2.9 % of those on semiglutide. As I said, both medications are highly effective, and neither has significant problems. Most individuals who quit a GLP-1, they do so because of cost, not medical issues or side effects.

32:58Dr. Robert Pearl: Robbie, any final thoughts?

33:01Jeremy Corr: Jeremy, the time has come for healthcare professionals to stop denying the power of generative AI. That's not to say that there are not huge existential risks that have been in the headlines lately, But the same threats also highlight the huge opportunities to achieve superior clinical outcomes, to save lives, to make care more accessible and affordable. When I published ChatGPTMD, how AI-empowered patients and doctors can take back control of American medicine, everyone talked about the large language models hallucinating or simply predicting next words. Then with each new model, the conversation shifted.

33:42Jeremy Corr: The models became more reliable, far more powerful. And when study after study showed that these LLMs were as good as clinicians, the medical profession acknowledged the positive, but insisted that these Gen.A.I. applications had to be under human oversight. Now, 30 % of people are obtaining medical expertise from one and increasingly finding the information is as good as or better than when they called their doctor's office. If American medicine was achieving excellent outcomes and doing so consistently, maintaining the status quo would make sense. But with 400 ,000 people dying annually from misdiagnoses, another quarter of a million from preventable medical errors, and at least half a million from poor control of chronic diseases, leading to unnecessary heart attacks, strokes, cancers, and kidney failures, the opportunities of Gen.AI are too massive to ignore.

34:39Jeremy Corr: Physicians have accepted that Gen.AI can assist them with administrative tasks and help them enter data during office visits into the electronic health record. I believe the time has arrived to figure out how Gen.AI agents can provide better medical care in the patient's home by being able to monitor and evaluate people on a frequent basis, not just every three to four months in a doctor's office. Jeremy, let's plan to talk in our next Diving Deep episode about the details of how this powerful technology could make a huge difference. But let me just point out that around a third of all Americans already consult a large language model like ChatGPT, Claude or Gemini when they have new symptoms or when they have medical questions.

35:25Jeremy Corr: In the middle of the night, when something arises and the physician's offices closed, a large language model will be the first place people go rather than the ER. When the first available appointment with a primary care specialist doctor is days or weeks away, they're going to do the same. Of course, you can get one of these applications to give a bad answer if you try to trick it, just as you could if you try to trick your clinician by intentionally omitting information or not telling the truth about the problem. But I've experimented multiple times, dozens of times. I've rarely seen my language model recommend something very different from what a doctor would say.

36:06Jeremy Corr: The recent hugging-faced news about hundreds of agents taking independent action to achieve a better answer than they otherwise could, that's a warning that these frontier models are improving faster than even their developers imagine. And hopefully once Congress is back in Washington, D.C., that won't be until after the midterms, but they'll be coming back, the government will put in monitoring experts and find a means of stepping on a break when the danger gets too high. But as worried as some clinicians might be about these existential threats, the truth is the medical profession can't do much to force Open AI and Tropical Google to limit them.

36:43What doctors can do, however, is ask themselves how these agents

36:48Jeremy Corr: could assist patients to better control chronic disease, to identify post-op patients with wound complications, and monitor individuals suffering from chronic heart failure to notify them and their doctors when the compensation is beginning and a crisis is approaching. Done well, the result would be improved chronic disease control, early detection of wound infection, and rapid treatment of patients with chronic heart failure before a life-threatening episode of acute heart failure requires an ICU admission. The hope of some in medicine at these generative AI applications won't provide clinical expertise or give patients advice.

37:26Jeremy Corr: That hope is in the rearview mirror. The only question remaining is whether healthcare professionals will lead the way and maximize the opportunity or whether someone else will seize the moment. As a physician and a patient, I hope it's the former.

37:42Dr. Robert Pearl: as a reminder to listeners this episode is available on our website fixinghealthcarepodcast.com and in all podcast apps including apple podcast and spotify if you like the show please rate it five stars and share it with your friends and family to submit a question or comment to the host please visit the contact page on our website or send us a message on linkedin twitter or facebook thank you for listening and have a great day

38:11Thank you.