Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman  

You're listening to The Nocturnists Conversations. I'm Emily Silverman. We are living in an era of medical breakthroughs, curative treatment for hepatitis C, the sweeping impact of GLP-1 drugs, groundbreaking cancer therapy. But beneath the surface, there's a different story. The healthcare system is more expensive, inefficient and impersonal than ever, driven largely by misaligned incentives and a tangled web of businesses that extract wealth while consuming an ever growing share of our nation's GDP. Physician, health policy expert and New Yorker writer, Dhruv Khullar calls this the Gilded Age of medicine, an era where dazzling innovation masks a deep dysfunction and mounting frustration among the general public. In his latest piece, the Gilded Age of medicine is here, he unpacks how private equity, Medicare Advantage and consolidation are reshaping healthcare and why frontline clinicians must stay engaged in the health policy debate. Dr Khullar is a physician and Associate Professor of Health Policy and Economics at Weill Cornell Medical College. He serves as director of the physicians Foundation Center for the Study of physician practice and leadership, and Associate Director of the Cornell Health Policy Center. His research, published in Jana and the New England Journal, focuses on value based care, health disparities and medical innovation. In my conversation with drove we talk about how private equity is buying up hospital systems, leading to cost cutting, er staffing shortages and even hospital closures, the dark side of Medicare Advantage and the financial incentives that drive up coding, why hospitals, especially non profit ones, aren't always the heroes they appear to be, and how data has become the oil of healthcare, powering Innovation, driving profits and creating new vulnerabilities, like the 2024 cyber attack that crippled hospitals, disrupted patient care and forced United Health to pay a $22 million ransom drove has a rare talent for making complex health policy accessible to the public, so much so that I could easily see him running for office one day. I hope you learn as much from this conversation as I did, but first, take a listen to Dhruv reading from his latest article in The New Yorker "The Gilded Age of Medicine is Here."

Dhruv Khullar  

2024 was arguably the year that the mortal dangers of corporate medicine finally became undeniable and inescapable. A study published in Jana found that after hospitals were acquired by private equity firms, Medicare patients were more likely to suffer falls and contract bloodstream infections. Another study found that if private equity acquired a nursing home, its residents became 11% more likely to die, although private equity firms often argue that they infuse hospitals with capital, a recent analysis found that hospital assets tend to decrease after acquisition. Yet PE now oversees nearly a third of staffing in US emergency departments and owns more than 450 hospitals in some of them, patients were forced to sleep in hallways, and doctors who spoke out were threatened with termination, according to Jonathan Jones, a former president of the American Academy of Emergency Medicine, Aaron fusi Brown, a professor at the Brown University School of Public Health, told me that private equity firms have learned that they don't have to make things better or make them more efficient. You can just change one small thing and make a ton more money. They are hardly the only corporations to learn this lesson. Increasingly, health insurers, private hospitals and even nonprofits are behaving as though they aim first to extract revenue and only second to care for people, patients are often viewed less as humans in need of care than consumers who generate profit in 1873 Mark Twain co wrote the novel The Gilded Age, a tale of today, which satirized an era that was marked by inequality, greed and moral decay, but was painted in a veneer of abundance and progress. Industrialists made fortunes in oil, steel and shipping, even as millions suffered poverty and exploitation. Today, healthcare is where the money is. New technologies and treatments sustain the impression that patients have never been healthier. But corporations and conglomerates wield immense power at the expense of the people they're meant to serve. Welcome to the Gilded Age of medicine. 

Emily Silverman  

I am sitting here with Dhruv Khullar. Dhruv, thanks so much for coming on the show. Thanks for having me so. Dhruv, you are a practicing physician in New York City, and you're also a writer. You've written for the New Yorker for years. Now, I've been following your work and was wondering if you could start by talking to us about your hybrid life as a clinician, but also as a writer.

Dhruv Khullar  

I spent a significant part of my time seeing patients. And I split my time in a few ways. And so I see patients. I do clinical work. The second part of what I do is actually health services research. And so my primary appointment is as an associate professor in the Department of Population Health Sciences at Weill cornene. And then the third thing I do is right, and I think each of those things blends into the other thing. I think that seeing patients informs the research that I do, the writing that I do, the research is always sparking new ideas for some of the more popular press writing that I do, and kind of informs how I think about the system around the care that doctors can deliver to patients. And so I feel really fortunate to be able to do these three things and to have each of them, inform and reinforce the other things.

Emily Silverman  

Talk to us about your writing. The writing you do tends to be more focused on systems, more focused on policy. I don't know if you'd consider yourself a journalist, or if you would consider yourself inspired by the writing of Atul Gawande. He's somebody who I'm sure you hear yourself compared to a lot talk to us about the kind of writing you do.

Dhruv Khullar  

I think of my writing as partly informed by my clinical and my research interests. And so as a researcher, I'm very interested in systems of care. I'm very interested in the healthcare environment that allows high quality care, and often not so high quality care. And so I bring that kind of lens to what I do as a writer as well. And I think of the writing is a really fun way to think about really complex topics, to talk to experts in various fields and try to synthesize that for a lay reader, who might be interested in healthcare, might be interested in the practice of medicine, but may not have the expertise of someone who's actually practicing medicine, and a lot of what I'm doing is trying to find narrative ways to tell an interesting story about a complex topic, and so I never want my pieces to read like a textbook or an academic peer reviewed article, although a lot of the work that I do is informed by those types of articles. I wanted to read like a story, and so I try to find the right characters, I try to find the right experts, I try to draw my own experience as a clinician, to try to tell a story about what's happening that's informed by research and that's informed by analysis of the public policy space.

Emily Silverman  

Tell us about getting the gig at the New Yorker. It's such a cool gig, and I'm curious how that came about.

Dhruv Khullar  

I was mostly freelancing throughout residency mostly, and then a couple years after residency as well. And so my primary work was as a health services researcher and as a doctor. And occasionally I would see something that either my own clinical practice that I thought deserved broader recognition, or something was happening in the public policy space, something with the Affordable Care Act. Affordable Care Act might be changing, or I came across an interesting body of research, and so I'd write that up, usually as an op ed and submit it to various newspapers. During the pandemic, I was caring for patients in the epicenter of the first wave in New York City as a hospitalist, and so it was really in the thick of it, in a way, and got connected to an editor at the New Yorker at that point, and basically started doing dispatches from the hospital. And so I'd see patients all day. I'd come home in the evenings, try to eat something, and then write for a couple hours almost in a diary. And those became the basis of series of dispatches that I did for the New Yorker early in the pandemic. And for the next year or two at least, I was covering primarily, if not exclusively, various parts of the Coronavirus pandemic, a new variant, or the release of vaccines. And then as the pandemic started to Wade and I really had the opportunity to expand a little bit into other areas, which I've really enjoyed, it's been pretty varied in that way. Might be a piece on climate change. I'm writing a piece right now about Ultra processed foods and what they do to our bodies. And so it started as primarily focused on the pandemic, but over time, it's really expanded into other areas as well.

Emily Silverman  

So I want to focus on this most recent piece of yours, the Gilded Age of medicine is here. I've heard some people talk about. The Golden Age of medicine. I've heard it referred to as 1940s to 1970s there was this era where we got antibiotics, we got vaccines, we got contraception, organ transplants started to become a thing. And dialysis, yeah, dialysis. There was this golden age of innovation, golden age of advancement. And let's say that ended in the 70s. Here we are many decades later, and I haven't really thought of us as having been in a new age. I like the idea of thinking about medicine as coming in ages or eras. And so was wondering if you could talk a bit about this idea of the Gilded Age of medicine. You talked about the Twain quote. Where did that idea come from? And then how would you characterize this gilded age?

Dhruv Khullar  

One of the things about a gilded age the idea is that there's a thin veneer on top of the age that sustains the impression that everything is going really well, but underneath there's some real substantial, often structural problems, and that's what I was trying to get at in this piece. In a way, some of the incredible advancements that you talked about from the 1940s to the 1970s we still have incredible, incredible advances, innovations in medicine. You think about the GLP one, drugs like ozempic, those are turning out to be, I think really game changers in the space of chronic disease and obesity. You think about hepatitis C drugs, we basically had very poor treatments, very difficult treatments that weren't curative for hepatitis C for decades, and about a decade ago, we now have curative treatments for hepatitis C. We have all sorts of new non invasive procedures, people who used to have open heart surgery now can go in and have a stent placed and be out of the hospital in a day. And so there are incredible advances. And so I don't want to gloss over the fact that we still are in a place where the innovations that we're seeing are truly incredible and breathtaking. In some ways, what I'm trying to get at with the idea of the Gilded Age is underneath those treatments, those advances, those innovations, there is a tremendous amount of inequity. There's a tremendous amount of frustration with how care is being administered in the United States. There's a tremendous amount of resentment at the way that people have to try to navigate this thicket of what we call a healthcare system, and that has real consequences for people. And so while we do have new advances, new treatments that isn't always easily accessible, it isn't accessible to everyone. The cost that we pay for it is tremendous. And because healthcare has become such a business, such an enormous industry. I mean, you think about more than 17% of the US GDP, the world's largest economy, goes to healthcare, four and a half trillion dollars. There's not a lot of countries in the world that have a GDP of four and a half trillion dollars that has attracted a lot of private sector activity. A lot of that activity is good. I don't want to dismiss that. There's a lot of innovation that we get from that, but it's also created a system that often is focused on revenue generation, that's often focused on profit and not focused on caring for the person and caring for families.

Emily Silverman  

Your article opens up talking about private equity. I'm a newcomer to some of these more economic forces in healthcare, learning about them, understanding the vocabulary people talk a lot about consolidation and verticalization. These are all terms that I've been slowly learning what they mean. But let's start with private equity, because that seems like it's a pretty big one for people who may not know what private equity is and does. Can you explain what is private equity? Why is it interested in healthcare, and what is it coming in and doing to these hospitals, nursing homes, facilities?

Dhruv Khullar  

Sure. So private equity just means that the capital that's being used to invest in something is private capital is to distinguish it from the public markets. These aren't publicly traded companies or publicly traded firms. And so private equity firms, they come in all sorts of shapes and sizes. And so in a way, we shouldn't lump every one together, but there has been a lot more private equity activity in healthcare generally over the past one or two decades. And so private equity firms have increasingly bought hospitals, bought nursing homes, bought physician practices, and so it's become a focus of a lot more research as a consequence, and we're starting to learn about some of the effects of private equity acquisitions. In my piece, I detail one private equity firm that bought a hospital chain in Massachusetts and then engaged in some activity that I think allowed them to buy many more hospitals around the country, several dozen. And what they often did was sell the land that those hospitals were on to a real estate investment trust, and so the hospitals then had to pay rent on the land that they previously owned. And there were a lot of under investment in basic. Things that these hospitals needed, and so you might see some understaffing. Lack of needed surgical equipment at some hospitals, even things like elevator repairs or clean linens in the worst cases, weren't available at certain hospitals. And this created all sorts of challenges, as you can imagine, for the clinicians that were working in those hospitals, for patients that were being seen in those hospitals, and ultimately, this chain called Stewart healthcare, earlier this year, went bankrupt, and it closed several hospitals already and in the process of selling dozens of other hospitals. So that's a egregious example, I think, of private equity activity. Not all private equity activity looks like that, but it hints at this idea that when we treat medicine just like a business, like any other, we can end up in situations where people really get hurt in the ideal sense, we need to think of healthcare as different, having dual obligations. Of course, you need to keep the lights on in any institution, but your primary focus should really be on the patients that you're trying to carefor. 

Emily Silverman  

Got it so private equity companies who do things like this, maybe they cut costs. Like you say, let's not wash the linens as often, or let's cut half the janitorial staff. Or, I don't know what it is that they're doing to cut costs. And then the idea is that they're just making a ton of money. Do they then flip it and resell it to another private equity company?

Dhruv Khullar  

It depends on the entity. Again, I don't want to paint with a super broad brush. I mean, there may be some private equity companies that are appropriately investing in care, but often what happens, for instance, let's take a physician specialty. And so in some parts of the country, a single specialty in an area, more than half the physicians in that specialty, their practices, may be owned by the same private equity firm. And so you can imagine often what happens is they buy a large practice in an area, and then they buy other smaller practices, and they add those on to the primary practice, and so it becomes a bigger and bigger entity. And that may create some efficiencies. You can envision that leading to some economies of scale, where you can have the same billers or coders that do work across several practices, as opposed to each practice having its own staff in that way. But it can also lead to issues where now prices go up because they're, in a way, the only game in town, and so they can negotiate for higher prices. What has been shown in the research is that sometimes physicians are then replaced with other types of clinicians who may have less training, there's all sorts of different ways in which private sector activity in this way in the healthcare space can change care. Some of that may be for the good. Often it may not be.

Emily Silverman  

You want to talk about Medicare Advantage, because in your piece, you talked about how one doctor you spoke to, he takes care of a lot of patients who have afib, atrial fibrillation, and suddenly he noticed a lot of his patients were having new coding terms on their charts. So for example, instead of just afib, it would say AFib and hypercoagulable state, which I guess you could argue is somewhat accurate, depending on how you think about what that means. But the idea being that people were upcoding these patients so that insurance could get more money. Can you talk about that? And how do you think about the exploitation of business in the corner of the health insurance industry and Medicare Advantage? 

Dhruv Khullar  

It might be helpful just to step back and talk about what Medicare Advantage is, people probably realize that everyone who turned 65 is eligible for Medicare, but these private Medicare Advantage plans have grown tremendously, particularly in the past decade, and so now more than half of all beneficiaries who are eligible for Medicare actually opt for Medicare Advantage plans, not for traditional Medicare, and these are plans that are run by private insurers. So you could think about United Healthcare, or Aetna or humana. And one of the advantages of these types of plans, and the one reason that people may choose them, is because often they provide additional benefits that are not covered by Medicare, traditional Medicare, so vision, dental, prescription drug coverage. There are also brokers who help people who turn 65 choose a plan, and some of those brokers push people towards private plans as opposed to traditional Medicare, because they get higher commissions based on that. There's all sorts of reasons that the Medicare Advantage program has grown. One of the challenges with the program is that insurers are paid partly based on how sick the patients are that they're providing coverage for, and that makes intuitive sense. You don't want insurers to run away from sick patients, because those are the patients that need coverage and they need care, and they are going to cost more money. So you would want to risk adjust the payment based partly on how. Sick patients are. But one of the challenges has become that there's been a kind of race to code patients. The insurers would say, appropriately, we're going to capture every diagnosis for every patient. This isn't Frau and other programs aren't coding people enough. But I think there's been a lot of concern on the part of the government and researchers that there's a lot of up coding going on, meaning that someone who has a diagnosis that is clinically meaningful, you want that there, but if it's not clinically meaningful, it's not going to change management in any way. Those are also added, and that increases the risk profile of the population that you're caring for, and that garners higher payments from the government. And so it's been estimated that the government will pay $80 billion more in 2024 than it would if those same patients had just enrolled in traditional Medicare. And so there's a tremendous amount of money that is at stake, and that is being made. And there's been some investigations over the past year by stat news and other outlets that have found that there's been a lot of pretty dubious practices to try to get doctors and practices to code as many diagnoses as possible in each patient.

Emily Silverman  

There are a lot of people out there who call for Medicare for all. There's other people out there who say, No, I want choice. There's other people out there, including Dr Oz, who may become the leader of the Center for Medicare and Medicaid Services, who wrote an op ed in 2020 arguing Medicare Advantage for all, and made a case for that, and actually that was co authored by a former CEO of Kaiser Permanente. So I'm wondering what you think about all of this. Is it a matter of fixing a broken system or just picking a thing and then giving that to everyone? Or how do you think we can untangle this tangle?

Dhruv Khullar  

One thing that I think we need to keep in mind is that the healthcare system and the policies that we have need to be responsive to the culture and the preferences of a country. And so just because a single payer system, let's say, works in Canada or works in the United Kingdom, it may not work the same way in the United States, and there may be a backlash against that. And so my view is that any of these types of systems could, in theory, work if they're structured in their own way. You could envision a system that is Medicare for all. You could envision a system that's Medicaid for all. You could envision a system that is Medicare Advantage for all. You can envision a system that's just a different version of our current system, where we fix the challenges in Medicare and Medicaid, we expand the marketplaces, we make sure that everyone is covered, and we simplify things for consumers. I'm not strongly wedded to any of these approaches. I think the main thing is that we want people to have accessible care at a reasonable price. We don't want a system that bankrupts people just because they have an unexpected illness. We want a system that feels fair and easily navigable. Any of these approaches could, in theory, work, but the status quo seems unattainable given some of the challenges that we've been talking about.

Emily Silverman  

I have a friend who has worked pretty high up in healthcare, in healthcare business, for several years, and he said something to me once that I haven't forgotten, and it's that he's been in a lot of high level rooms, and he's seen a lot of the dysfunction of health insurance but he said, on some level, he feels like the health insurance companies get more of the anger and rage and, I guess, flak, you could say, than some of the other parties. So for example, he was saying actually hospital systems and hospitals are just as bad, if not worse, the ways in which they jack up prices and they negotiate with the insurance companies, and they're just as much a part of this web of businesses that are contributing to the dysfunction. It's just not as easy to criticize them because they're hospitals. You think of a hospital, of a place that you might donate to or go to a fundraiser for. There's sort of this halo of goodwill around hospitals and hospital systems. Many of them are nonprofits, even though the nonprofits pull in billions of dollars as well. So I was wondering if you could speak to that. Do you feel that hospitals and hospital systems need to be under the microscope as much as health insurance companies are? 

Dhruv Khullar  

I think what you're hinting at is that there's plenty of blame to go around, which is something that I agree with. It's hard to find a player in the healthcare industry that's totally blameless, and there have been some activity on the part of hospitals, including nonprofit hospitals, that has been in some ways unacceptable in the piece I talk about health system called Providence, which the New York Times reported, engage in some pretty egregious practices. They benefited from enormous tax breaks, like other nonprofits, but they would put debt collectors on poor patients. Who were entitled to free care. There's another non profit that was covered by the times as well, that was called Alina health in Minnesota, and that was reportedly denying care to patients who had unpaid medical bills, including children whose parents didn't pay weren't able to pay their medical bills. So I think we need to get back to a place where we hold these institutions to higher standards, that they are places that are supposed to try to care for people, regardless of who those people are, whether they come from a certain place or they have a certain income level. That's part of what it means to be a hospital, to be an anchor institution within a community, and that's a standard that I think we should really be trying to hold these hospitals to as well.

Emily Silverman  

Do you think that the people in these systems, you know, people working in health insurance and hospital systems and pharmacy benefit managers and all of these big players government even? Do you think that they're all doing their best and that the dysfunction is an emergent property, or Do you think that there are actually nefarious players and nefarious intent?

Dhruv Khullar  

I think for the most part, people are not nefarious. People go into the healthcare industry, I think to do the right thing. And there are incentives that are set up along the way that create a system that no one is really happy with. I do think that it's become too easy to relinquish the mission of any of these organizations in favor of profit or in favor of revenue. Part of it is changing incentives, and there are policy levers that we may be able to pull, but part of it is having, I think, counter narratives to the pervasive sense that what we're here to do is make money. That's only one part of what we need to be doing in healthcare. We also need to be creating a system that's equitable and effective and high quality, and we can't relinquish that mission. That's something that needs to be the North Star always.

Emily Silverman  

Do you think making those moral arguments works, or do you think it's really more about making the business argument? And the reason I'm asking this is I have a colleague at SF general who did this amazing research study about dialysis for undocumented immigrants, and what ended up happening is undocumented immigrants were showing up the emergency room. They needed dialysis, they didn't have insurance or what have you, and they would just get dialyzed in the emergency room, and it was just bad. It was just a bad situation. And the argument was, let's put the moral case aside here. Forget about morals. Let's make the business case for dialyzing These people on a regular basis so that we're not doing rescue dialysis on them, and they did the whole cost analysis and everything to show that it was actually in everyone's best interests, including the hospitals and businesses, to treat these people humanely, that in this particular scenario, the business interests and the moral interests were aligned. We can shout into the wind, and I feel like people have been shouting into the wind for a long time about the immorality of the system as it's set up now, people are taking even more drastic actions, as we've seen by the very horrible murder of the CEO of United Healthcare in the news that everybody's been following. We do not want to resort to that. That is not the way, that is not the path. But then how do we bang on that moral drum and get people to listen? It feels like otherwise it can just get overlooked.

Dhruv Khullar  

I think the strongest case is always going to be when you're able to marry the moral case and the economic case. When there are opportunities to do that. We should always lead with both. It's wonderful when the right thing to do is also the cost effective thing to do. I do think that a lot of medicine and healthcare, more generally, is a kind of apprenticeship. People learn what it means to be a medical professional or someone working in this industry, often because they have a mentor, or they're watching people who are few years ahead of them, or maybe many years ahead of them, doing whatever it is that they want to be doing. And so I do think there's a powerful case for modeling the type of behavior and the type of decision making that we want to see in the next generation. And so I think the moral case is incredibly effective. I also think, as you're alluding to, there are often cases in which the right thing to do is also the economically sound thing to do, and that is most true in the case of preventive care. One of the challenges becomes, is the institution or the organization that is investing in preventive care isn't always the one that's going to reap the benefits of that preventive care. So people don't often stay on their health insurance for years or decades. They may turn out of one insurance to another, or they may move from one place to another. And so one of the challenges that we overcome is trying to figure out a way to link the investment in preventive care to. Realizing the economic benefit on the other side of things, but I think it can be done, and that's something that we should be looking towards.

Emily Silverman  

Yeah, it seems to me like incentives are really important. And I'm curious what your thoughts are on these next four years. We have a new administration coming in. We've got some scary stuff with vaccines. We definitely don't want to get rid of vaccines. Vaccines save lives. But there are also some interesting conversations coming up, having to do with preventative medicine, having to do with let's look at our food systems. Do you see the next five to 10 years? Let's say optimistically. Do you think we can move towards some of these different ways of approaching healthcare in the United States? 

Dhruv Khullar  

I hope so. I often think that politics is about principles, but also about priorities, and it matters what set of things our leaders prioritize. And so if you think about someone like RFK Jr, who may be the next head of the Department of Health and Human Services, there are some claims that are unfounded about vaccines and other matters, but there are things that we can make common cause with him, things like ultra processed food, things like remoting exercise. There are ways in which we can think about what are the best places to engage how do we try to get our leaders to push forward the issues that we care about? And so I think it'd be a real mistake to write off the next administration, or any administration, really, because some aspects of what they're talking about are not aligned with your values or priorities. We really need to focus on, how do we find the areas that we can agree on, particularly in health? I think there are a lot of places where we can actually agree. And everyone wants healthy children. Everyone wants their parents as they're getting older, to have high quality care, dignified care, and so the more that we can make the argument to focus on those types of issues, I think the better off. We'll all be foreign.

Emily Silverman  

I wanted to ask you about an interesting line in your piece where you wrote "data is the Oil of the healthcare system." Data and computation and AI is going to be such a huge part of our world in general, but that that includes healthcare. You share an anecdote in the piece about how malevolent cyber hackers got into united, and I don't know what they did. They took a bunch of data and they held it ransom, and then United had to pay them $22 million in Bitcoin to get the data back. Like, can you just talk a little bit about data privacy, security, and I guess what you mean when you say that data is the Oil of the healthcare system.

Dhruv Khullar  

That quote actually comes from a professor, Aaron Fauci Brown, who is a public health professor at Brown, and she told me, basically, as you say, data is the Oil of the healthcare system. And she kind of goes on and says, data is the raw material, the critical infrastructure that facilitates the flow of money. If you control the data, you get to say how sick patients are, you get to say how well you're caring for them. You get to control the money. And I think that really speaks, in part, to how big healthcare has gotten. It's no longer this idea that you have a doctor making house calls and you can kind of appreciate how they're caring for you. Or even a small solo practitioner or a small practice that you like to go to often, a lot of the health systems that we interact with now are enormous, and there are some advantages of that. We talked about economies of scale. Maybe they have all the sub specialists that you need in the same place. And there may be technology and equipment that comes with that, but it also means that there's a kind of distancing between, how do you evaluate how good a place is and what the care is that you're receiving and other patients receive, and a lot of that comes down to now reporting and collecting of data. And so there's all sorts of payment programs pay for performance type programs that are out there by both private insurers, but also the government has its own programs, and a lot of it depends on not just how well you care for patients, but how well you're able to collect the data on how well you're caring for patients, and the way in which you structure that data, and how you enter that data and how it's reported. That's what we mean here by the idea that data is the critical infrastructure, the oil, the thing that makes everything move in the healthcare system. If you think about just something as simple as processing a claim, that's really what happened here. The organization that you're talking about was change healthcare, and change healthcare is clearing house for medical claims and enables payments to doctors and hospitals and pharmacies. That company was acquired by United Health a couple years ago, and. And it became embedded in almost every part of the healthcare system. And so then there was this massive cyber attack that pretty much brought the entire healthcare system to a halt in a way. Practices weren't able to meet payroll, they weren't able to enter their claims, patients couldn't get their medications covered. It is a total disaster. 

Emily Silverman  

I feel like this wasn't covered in the news as much as it should have been. 

Dhruv Khullar  

Yeah, I guess it depends on the news that one is reading is covered, definitely in the healthcare space. But I think, as you're pointing out, maybe more could have been done to raise the salience of this issue. But it really showed that in some cases, as we get these enormous conglomerates, there can be a single point of failure for the entire system, and that can really cause a lot of issues and cause a lot of pain, both to doctors, but most importantly, to patients. And

Emily Silverman  

what was the goal of the hackers? Was it I wanna disrupt the American healthcare system? Was it I just wanna take this information hostage and return it and get some money? Or did you see this as the equivalent of robbing a bank? Or is it more akin to a declaration of war on a sovereign nation? Instead of dropping a bomb over a city, for example, you cause like an outage in the entire healthcare system and hurt people that way. Do you have a sense for what exactly was going on there?

Dhruv Khullar  

I'm not sure exactly what their motivation was. My understanding is that it was more of a robbing a bank type situation where they knew that this was a critical aspect of the healthcare system, and that basically there'd be no choice but to pay a ransom payment. There have been other similar ransomware attacks that have attacked critical infrastructure, and so I think the idea here was that when something is large and critical to the functioning of everyday life that's a potentially lucrative target for some of these malevolent actors. 

Emily Silverman  

And how do you see that tying into the Gilded Age of medicine? Is it more just another symptom of the consolidation of the system these vulnerabilities?

Dhruv Khullar  

I think it's a matter of basically an increasingly consolidated healthcare industry. And so this idea that while there are potential benefits of consolidation, whether you think about large, horizontally consolidated systems or vertically consolidated systems, they do engender an environment where there can be these single points of failure, and there can be tremendous levels of disruption, because one organization is hit in some way, and so it's more about the too big to fail nature of some of these institutions that have developed over time.

Emily Silverman  

Well I'm glad that you're writing about this. I'm glad that you have your finger on the pulse of this and are continuing to bring these conversations in the public square. It's extremely important. And I'm glad that you have a platform like The New Yorker to get the word out there. I'm wondering about your aspirations and ambitions. Do you have any ambitions to write a book? Do you have any political ambitions? What do you hope for for yourself moving forward so that you can continue to make an impact? 

Dhruv Khullar  

I love what I get to do right now, I feel like I have the perfect blend of the type of career that I want, which is to say, I get to see patients, I get to do health services research that focuses on issues that I feel passionately about, and then I get to communicate about both of those things to a broader audience. And so I love, love what I'm doing right now, and I think I'll have a, hopefully a similar setup for the foreseeable future. I think at some point I'd love to write a book. I don't have an idea just now that is so gripping to me that I want to spend two or three years of my life working on it. But my hope is that at some point that idea or that experience comes along, and at some point I'd love to serve in a role in government, whether that's at the state level or the federal level. I think public service is incredibly important and incredibly impactful, and I'd love to have that as part of my career at some point. I don't know when that will be, but I guess the short answer is, I love what I'm doing now, and if we talk again in a couple years, maybe that'll have shifted a little bit, but no major changes, I think, in the foreseeable future.

Emily Silverman  

And as we round to an end, for people listening who are taking care of patients more front line workers and don't have as much experience interacting with the system at the level that you do? Like really zooming out? Do you have any tips or suggestions for them? Like, to what extent do you see it as a responsibility of clinicians to start getting involved in these conversations, to start educating themselves more about these issues. In medical school, we really do not learn that much about this. I learned a lot in medical school about transcription and translation and cytokine cascades. I don't think I learned anything about Medicare Advantage in medical school. So I think there's a gap there. Just wondering if you have any thoughts like, do we have a responsibility as a profession to fill that gap, but whether that's on an individual basis, like just reading your articles and kind of getting more informed, or do we need to start incorporating this more intentionally into medical education? Or how do you see physicians being connected or disconnected from this conversation?

Dhruv Khullar  

Yeah. I think we have to get involved, because the system increasingly dictates the type of care that we're able to deliver. And if we don't get involved, educate ourselves and help make these decisions, those decisions are going to be made for us. And so I think we don't have a choice but to advocate for what we think is right for the profession, what we think is right for the patients that we care for. And my hope is that some of that happens in medical school, some of that happens throughout medical training, but a lot of that will just happen by trying to be engaged on these issues, that might be reading, that might be talking to people, that might be organizing, that might be writing your congress person, whatever it might be. I think we have such a unique vantage point into not just the healthcare system, but into society. In a way, there's not a ton of professions that are at once relatively highly compensated and highly educated, but on a day to day basis, care for people who are in some of the most dire straits in our society. And so we do have a unique vantage point into some of the challenges that people are facing. And I think that perspective is incredibly valuable. And so we need to learn, we need to get educated, we need to speak out and try to create a system that we feel better serves doctors and patients.

Emily Silverman  

Great. Well. Thank you so much. I have been speaking to Dr Dhruv Khullar, Dhruv is a writer. He's a physician. You can find his work in the New Yorker and elsewhere, and you can check out his most recent piece, the Gilded Age of medicine is here. Dhruv, thank you so much again. 

Dhruv Khullar  

Thanks so much for having me.