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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Doctor.
Rob Lott:Friends, welcome to another episode of A Health Podyssey. I'm your host, Rob Lott, and I'm excited because today is another one of those special episodes where we take a quick break from talking with health affairs authors about recent research papers and instead take a step back and sit down with a luminary from the fields of health and health policy. Today, that person is Doctor. Dhruv Khullar, a practicing physician and associate professor at Weill Cornell Medical College, where he serves as an associate director of the Cornell Health Policy Center. Doctor.
Rob Lott:Khullar is also a contributing writer at a little known general interest magazine, called The New Yorker. I'm delighted to chat with him here today and we're going to start, by talking about one of Dhruv's recent articles for The New Yorker and then we'll take a quick tour of some of the other work that continues to keep him, very, very busy. Doctor. Dhruv Khullar, welcome to A Health Podyssey.
Dhruv Khullar:So good to be with you.
Rob Lott:Well, let's dive in. And as I said, I'm hoping we can talk about a number of your various professional roles and how you navigate those different categories of work on a day to day basis. But first, I wanted to start with the subject of one of your recent articles, which ran with a question for a headline: How prepared are we for a public health emergency? This was, presented in the context of hantavirus and Ebola, and I might add to the mix, cyclospora, which broke out, after your article ran. And I think it's as good a question, as good a place to start as any.
Rob Lott:How prepared are we? Well, the first
Dhruv Khullar:thing I would recommend is not adding cyclospora to any mix, because that that'll give you explosive diarrhea. Fair enough. You know, the unfortunate answer to your question really is that we are not real nearly prepared enough and not nearly as prepared as we could be. So you might think that after going through the deadliest pandemic in a century, we would be taking every opportunity to ensure that, we do better than last time. And instead, we seem to be moving in the opposite direction.
Dhruv Khullar:So as you know, so much of public health, is about surveillance and coordination. You need to be able to identify emerging threats. You need to bring together the rights of actors to address them. But just think about what we've done in the last eighteen months. The coordination side, The US left the WHO.
Dhruv Khullar:It left the World Health Organization. That makes it harder for the WHO to maintain adequate funding. It makes it harder for us to coordinate with our partners abroad. The federal government dismantled USAID. That is estimated to already have led to hundreds of thousands of avoidable deaths around the world.
Dhruv Khullar:It's expected to lead to millions more, and that is a tragedy in its own right, but it also threatens the health of Americans. You know, remember that just because a pathogen starts abroad doesn't mean that it's gonna stay abroad. That's true of Ebola, hantavirus, and bird flu, and any number of other diseases. And then domestically, look what we've done. We've we've the federal government has fired thousands of employees across health agencies, including the CDC.
Dhruv Khullar:That includes initiatives that are related to HIV and tuberculosis, but also initiatives that are ostensibly the administration's priorities, like offices of environmental health and chronic disease. We're now, as you mentioned, in the middle of a cyclospora outbreak. Last year, the administration cut a food program called FoodNet, which coordinates the surveillance of foodborne illnesses. And FoodNet used to collect data on something like eight pathogens, and now it collects data on just two. And guess what?
Dhruv Khullar:Cyclospora did not make the cut there. So that's on the coordination side. And then there's the biomedical side. So last year, HHS cut $600,000,000 in funding for mRNA vaccines. I mean, this is an incredible technology.
Dhruv Khullar:It's the reason that we were able to have a COVID vaccine within less than a year after that pandemic started. So it's our best bet at, creating new vaccines if new pathogens emerge. There's also been a lot of counterproductive messaging on other vaccines. So take the measles vaccine. We're currently in the largest measles outbreak in decades.
Dhruv Khullar:This was a disease that was eliminated in the year 2000 or thought to be eliminated in two thousand in The United States. And now we have had more measles cases in the last eighteen months than in the prior twenty five years combined. So just think about that. This is a totally avoidable failure. And still, the administration is trying to cut funding to the NIH and National Science Foundation.
Dhruv Khullar:Both of these are keys to innovation. And this is the time that we're confronting the potential for not just natural threats, but man or even machine made threats. So AI is making it easier potentially to build bioweapons than ever before, and we should be investing more in biosecurity. So I guess that's all to say that I'm very concerned that we are moving in the wrong direction when it comes to public health preparedness.
Rob Lott:I'm wondering if I could ask you to sort of put on a historian's hat here, and I'm curious how exceptional you think this moment is. Is this lack of preparedness new, or has The US sort of always had a reactionary stance when it comes to these kinds of public health emergencies?
Dhruv Khullar:Well, it's not unprecedented. So remember that after the nineteen eighteen flu pandemic, the country basically also just wanted to move on. The US suffered a collective trauma at that point, and no one really wanted to talk about it. The difference now, of course, is that there's genuinely a lot more that we can do on these fronts, and there's a lot more that we should do because of that. And right now, I think generally, we are in a moment of, I would say, public health pessimism.
Dhruv Khullar:So it feels like everyone is kind of on the defensive, and I think it's kind of all the more important for that reason that we tell stories of, the many successes of American public health, the ways in which it has actually not just been reactive but proactive in confronting major health threats. So you think about, polio. You know? The the The US public health infrastructure beat back polio. It helped eradicate smallpox.
Dhruv Khullar:It took smoking rates from nearly fifty percent, fifty percent of American adults smoking to around ten percent. That is an enormous decline. It has saved countless lives. I think about something more recently, something like the, the HIV, epidemic, of course. The HIV was a death sentence, and now it's basically a chronic disease.
Dhruv Khullar:Someone who is on antiviral medications, has HIV, has essentially the same life expectancy as someone who doesn't. And so in all these ways and more, public health in The United States has a lot to be proud of when it acts proactively. We know that it can save lives, and, and that's the case that I think we need to be making loudly and clearly.
Rob Lott:I'm curious if you can sort of put all of this in the context of chronic disease. I think there's this sort of temptation to look at chronic disease and infectious disease as two completely separate things. And indeed, you know, secretary Kennedy has sort of declared his priority to be confronting chronic disease while sort of dialing back the resources and support for infectious disease surveillance that you described just a moment ago. Where do you sort of see the intersection of these two subjects in this moment, chronic disease and infectious disease? And I'm curious if you feel like our system is equipped to capture maybe any potential synergy, if you will, among the the two of them.
Dhruv Khullar:I think it's a mistake to draw too sharp a distinction between the two, actually. So it's true that a lot of the top killers in The United States are chronic diseases, but it's also true that there's often an interplay between the two. So if you take something like Alzheimer's disease, for example, that's a neurodegenerative condition. It's a chronic condition. But one of the things that can happen with Alzheimer's disease is that people develop difficulty swallowing, and that increases the risk of pneumonia, which is, of course, an infectious disease.
Dhruv Khullar:Or if you take something like hepatitis C, so that's a virus. It's an infectious disease. But if you get it and it goes untreated, it can cause cirrhosis, which is a chronic disease. So I think the the goal that we should have as a biomedical infrastructure, as a public health infrastructure, is to help people live long and healthy lives. And I think that achieving that goal requires progress on both fronts.
Rob Lott:Let's take a quick step back, and, maybe you can tell us a little bit about your day to day work as a physician and an academic. Where do you practice? What kind of patients do you see on a regular basis? And, how does that connect to your academic work?
Dhruv Khullar:I love my job. And I probably shouldn't say this, but I would basically do exactly what I'm doing even if no one paid me to do it. So my work really has three parts to it. The first is as a physician, and that probably is the thing that motivates everything else that I do. I get to care for patients in the hospital.
Dhruv Khullar:I'm often working with residents and medical students, so I love the education component of my work. And it is something that gives me, of course, a lot of meaning, being able to care for people, but also informs the other two parts of what I do. And so the second part is, as a health services researcher, I work with a fantastic group of health economists and epidemiologists and AI researchers at Weill Cornell in the Department of Population Health Sciences. My own focus is on a few areas. The first is value based payment programs, things like accountable care organizations, for instance.
Dhruv Khullar:The second is on, health care consolidation. So what happens when, for instance, private equity firms or hospitals acquire physician practices? What happens to to patients' health outcomes in those cases? And the third is a growing area of Medicare, which is Medicare Advantage. So many people probably know at this point that more than half of all Medicare beneficiaries get their coverage not through the government or the traditional Medicare program, but through the privately administrated Medicare Advantage program.
Dhruv Khullar:And then the third part of what I do is I write, and I write for The New Yorker. And so I think of it a little bit is if the research part of what I'm doing is telling stories with data, at The New Yorker, what I get to do is tell stories through characters and through scenes. And there, I get to tackle a really broad range of topics, everything from GLP-one drugs to artificial intelligence. And it's something that I enjoy because I get to look deeply into these topics, but also because I get to talk to and interview some of the most interesting people in the country.
Rob Lott:Before we talk about your work as a journalist, so let's circle back to your role as a researcher and that some of the topics you highlighted obviously are bread and butter for health affairs and health affairs readers. What research are you working on right now that most excited about that you want to kind of shout out to the world about perhaps some of your findings or some of the questions that you're excited to answer?
Dhruv Khullar:Well, I'll highlight two programs. One is focused on, hospital acquisitions of physician practices. So you might think that we actually have a great sense of all the health systems in the country, but it's actually a very difficult thing to know when a physician group is affiliated or employed by hospitals, and how that varies across geographies, different types of, health systems, and importantly, most importantly, what happens to patients' health after, a hospital acquires the primary care practice, for instance, in which they are being seen. And so right now, we are working on putting together a compendium of more than a decade's worth of hospital acquisitions of physician practices. And the next step this fall, I hope, is to start analyzing the outcomes for Medicare patients who are in those practices that were acquired.
Dhruv Khullar:The second project I'll highlight is focused on Medicare Advantage, and so it's focused on a part of Medicare Advantage that people may be familiar with, the star ratings program, or the quality bonus program. This is how, the primary way in which, health, insurers and plans are evaluated in the Medicare Advantage program. And, there are a number of concerns, that policymakers and researchers have raised with the structure of that program. One of the things that we are trying to understand in our group is, do the star ratings that, Medicare Advantage contracts have, let's say it's a four star or four and a half star contract, does that actually mean that they have better outcomes for their patients compared to a two and a half or a three or a three and a half star, contract? So, again, stay tuned, for the results of that body of work as well.
Rob Lott:Alright. Stay tuned perhaps, to the pages of Health Affairs and other, August journals out there that I'm sure would be excited to evaluate that really, really interesting research. I want to ask you a little more about your work as a journalist, but first let's take a quick break. And we're back. Thanks for listening everyone.
Rob Lott:We're here with Doctor. Dhruv Khullar, a practicing physician, professor at Weill Cornell Medical College, and a contributing writer at The New Yorker. And, you mentioned a little bit, of sort of the gamut of topics that you cover. And I'm curious if you can tell us a little bit about sort of how you navigate your beat as it were. How do you choose what to write about?
Rob Lott:Are you pitching to your editor? Are they giving you ideas? And what does that dynamic look like?
Dhruv Khullar:It's pretty bidirectional. So, you know, each of the pieces that I end up pursuing is a conversation with the editors at The New Yorker. And sometimes it's something that is in the news that they, you know, would like me to cover. Sometimes it's something that I've been following that I really wanna bring to them. Sometimes it's, I think, important, but just too dry for our general audience.
Dhruv Khullar:You know, that has happened too. You can't Not everyone wants to know about the intricacies of risk adjustment, in the Medicare Advantage Program in the way that I do. So I would say there's three general ways in which ideas come to me. The first, and I think most rewarding and important, is just something that I see in the hospital. So if patients are increasingly asking me about a particular medication or procedure, or I see them struggling with some aspect of the healthcare system, whether it's care denials or something else, or if people are, let's say, socially isolated or lonely.
Dhruv Khullar:You know, I might have a patient who needs a colonoscopy but doesn't have a single person who can pick them up after that procedure. And so a lot of my ideas come from just the work that I'm doing in the hospital. The second is kind of reviewing the the policy landscape, understanding what's happening, what what policymakers are trying to do, what they're moving towards. Sometimes there's a new policy or program that's been announced or being considered, something that I might want to to to start tackling. And the third is, following a body of research that seems to be emerging in some way.
Dhruv Khullar:So that might be, gene therapies that were initially just in preclinical trials, but now, are showing real promise in people, or, you know, artificial intelligence agents that are, able to do things that they weren't able to do just a few months or years ago. So those are the types of things I'm constantly following. And if it seems like there's something new or different to say about a topic, I'll, I'll take it to the editors.
Rob Lott:Well, so one of the pieces that you recently published, I imagine, came out of perhaps some of your work around private equity and consolidation. And that was the article that run under the headline, The Gilded Age of Medicine is Here, in which you suggest, quote, that health care 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. And I'm curious if maybe you can kind of walk us through how you went perhaps from your sort of academic research in this space to what ultimately became a New Yorker article and sort of what that experience was like getting from step a to step b.
Dhruv Khullar:Absolutely. I mean, that that piece was something that had been rattling around in my head for a long time. And what was kind of gratifying about it is that it it was an instance in which a lot of what made its way in that piece was were things that I had been thinking about on the academic side of my job. And it's a piece that I think resonated as much or more than almost anything else I've I've written. I think it taps into this feeling that a lot of people have that they're hearing about all these amazing innovations in health care, whether it's artificial intelligence or new cancer drugs or GLP ones or gene therapies, which are all genuinely amazing advances.
Dhruv Khullar:And at the same time, health care just feels so broken. It feels like it's too expensive. It's too inconvenient. People are getting, the right care at the right time, in the way that they deserve. And so it was trying to bring these two ideas, into juxtaposition.
Dhruv Khullar:And the central idea of the piece was that basically healthcare has become a business. It's become a way to, for many people at least, to extract profit from a medical encounter as opposed to focusing on what healthcare should be about, which is healing, helping people live, you know, longer and better and healthier. And and that kind of profit extraction motive, it's it's true of private equity firms and maybe MA insurers, but it's even true of of nonprofit entities. It's not like there's any part of health care that feels like it's immune to this now. And what we really need is movement that's focused on changing this.
Dhruv Khullar:And I think, you know, if you squint, there are ways in which this is starting to happen. I think something like affordability, which has become kind of a slogan, in politics, I think that's a, it's not the only thing, but it is a good unifying theme, things like affordability and abundance. Like, these ideas that are circulating more broadly, they might be used in in health care, as well. And then when I think about affordability, I think it's important to think not just in terms of cost. Of course, we think immediately of out of pocket costs and premiums, but also in terms of people's time.
Dhruv Khullar:You know, can they afford to take a day off work to see, a doctor for a fifteen minute appointment? Can they afford to, care for a loved one who is going through a really challenging, illness? So I think there's a way in which we can yoke some of the changes that are needed in health care to larger themes that are now circulating in society.
Rob Lott:Well, I want to take a shift back to another piece of your academic work, which is the, Cornell Health Policy Insight Panel, which surveys the nation's top health policy researchers, to provide a timely analysis and perspective on the most pressing issues facing The US health care system. And in fact, rapid response write ups by you and some of your colleagues of these surveys regularly run on health affairs forefront. And that's a collaboration that we've really enjoyed and appreciate. I'm wondering if you can say a little more about sort of how this panel came about, what the sort of theory is behind it, and why you think it's necessary.
Dhruv Khullar:I'm so glad you brought this up because it's something that I'm really excited about. We've been running this insight panel through the Cornell Health Policy Center. And as as as you mentioned, it's been a wonderful collaboration with with health affairs to get that information out in front of people. You know, the basic idea is that sometimes you wanna know what a lot of smart people, who are thoughtful on these issues, think, even in the absence, or maybe especially in the absence of settled science on a subject. So whether that's private equity, whether that's, let's say, most favored nation drug pricing or ACA subsidies, Medicaid work requirements, often we're asking, people, to look forward.
Dhruv Khullar:You know, a a policy has just been passed or a policy is being considered. What are the likely effects of this type of policy? Sometimes there's some research on that. So for instance, with Medicaid work requirements, you might look at what happened in Arkansas, you know, eight or nine years ago, but but we don't really know how it'll play out today. So these are all people who have had distinguished academic careers.
Dhruv Khullar:They are full professors or equivalents at think tanks. We've tried really hard to have ideological diversity on the panel, so as people from all across the political spectrum. And we survey them about a timely health policy issue every six weeks or so, and then release the findings. The goal is to inject some of these ideas into the public discourse at a time frame that's faster than might happen with kind of formal peer reviewed research.
Rob Lott:This is obviously a relatively new project, and I'm curious if sort of going through this process and kind of reflecting both on the survey questions as well as the answers from these experts, how they have sort of informed your thinking, both as a researcher exploring maybe potential new research questions, as well as a journalist? Has it sort of adjusted or affected the way you approach some of these questions?
Dhruv Khullar:I think it has. I mean, part of part of what I mentioned was having people with various perspectives on a particular issue from different ideological viewpoints, I think, is very helpful, particularly in a country that is now as polarized as ours, Getting to hear different voices and perspectives is is important, and and this this panel tries to bring that together. The other part that I would mention here is the speed at which we're able to do these surveys and then release the results. I mean, our goal here really is to inform the public discourse, potentially inform policy discussions. Many of these issues, affect the lives of patients and clinicians and, families, and so, it has the kind of element of, really being relevant to what's happening, in the real world.
Dhruv Khullar:But also, we can get this information out quickly, you know, before, necessarily all the evidence comes in or before the policy, its full effects take a you know, come come into view, we're able to give people some insight into where things might be headed.
Rob Lott:Great. Well, a good plug. And, to all our listeners and readers, they can check out the results, at Health Affairs Forefront as well as, the Cornell Health Policy Center. Doctor. Dhruv Khullar, thank you so much for taking the time to chat with us today.
Rob Lott:Really enjoyed our conversation. I appreciate it. My pleasure. Thanks for having me. And to our listeners, thanks for tuning in.
Rob Lott:If you enjoyed this episode, leave a review, recommend it to a friend, and, of course, tune in next week. Thanks, everyone.