The Gilded Age of Medicine with Dhruv Khullar, MD
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What is the “Gilded Age of Medicine” and why does Dhruv Khullar call today’s healthcare era that?
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You're listening to the Nocturnous Conversations. I'm Emily Silverman. We are living in an era of medical breakthroughs. Curative treatment for hepatitis C, the sweeping impact of GLP1 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 Drev Coulard 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. Coolar 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 JAMA 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 upcoding. Why hospitals, especially nonprofit 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. Dreve 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 Drew reading from his latest article in The New Yorker.
The Gilded Age of Medicine is here.
2024 was arguably the year that the mortal dangers of corporate medicine finally became undeniable and inescapable. A study published in JAMA 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 a private equity acquired a nursing home, its residents became eleven percent 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 Fusey 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 non profits 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.
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Chapters
7 chapters
1
What is the “Gilded Age of Medicine” and why does Dhruv Khullar call today’s healthcare era that?
0:00–11:47
2
How do private‑equity acquisitions affect hospital quality, staffing, and patient safety?
11:47–19:05
3
What are the hidden costs and incentives behind Medicare Advantage’s up‑coding practices?
19:05–24:26
4
Why does Dhruv Khullar describe data as the “oil” of the healthcare system and what are the security risks?
24:26–31:22
5
How did the 2024 ransomware attack on Change Healthcare expose vulnerabilities in a consolidated system?
31:22–38:06
6
What future policy levers could realign incentives to make care more affordable and equitable?
38:06–41:58
7
Why should frontline clinicians become active participants in health‑policy debates?
41:58–42:32