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Healthcare is Broken... and Funny: Part 1

Written by Andrew Le, MD

PublishedNovember 13, 2021

Welcome to the CEO Corner, where Buoy CEO and Cofounder Andrew Le, MD sits down with industry leaders to chat about the provocative topics of healthcare today. Andrew recently spoke with Nikhil Krishnan, the founder of Out-Of-Pocket. Nikhil started Out-Of-Pocket to make the business of healthcare accessible, entertaining, and understandable. He talks about why memes can distill key issues in any industry, how he would fix healthcare, and shares his secret for creating over 41,000 tweets.

This interview has been edited and condensed for clarity.

Andrew Le, MD: Nikhil, I'm a huge fan. I read all your tweets and posts. One of my favorites is Healthcare Should NOT Be Local. I send it to new leaders here at Buoy. Your opinions and analyses are well thought out. And your memes are hilarious.

Nikhil Krishnan: I think every scientific or economics paper, instead of an abstract, should have three memes that explain the basic idea. Memes are obviously for fun, but they help people take away key points.

"I think every scientific or economics paper, instead of an abstract, should have three memes that explain the basic idea."

Nikhil Krishnan, founder of Out-Of-Pocket

Andrew: If you can't distill it into a meme, maybe the point is too complex. I'm going to steal that one. How did you get to where you are today?

Nikhil: After graduating college, I helped build the research team at CB Insights, market research company. At first, I was forced into healthcare because the first two analysts claimed FinTech and something called Frontier Tech, which was everything else that was cool. I got stuck with chemicals, agriculture, construction, healthcare, and autonomous vehicles. That was doubly hilarious because I don't have my driver's license.

As the team grew, I decided to specialize in healthcare. It was by far the hardest industry to understand, so I saw the biggest opportunity to make it accessible. There weren't a ton of experts at the intersection of software and healthcare. I carved a niche out there.

A lot of people have personal stories for why they get into healthcare. I don't. My parents are both doctors. And I enjoy the intellectual challenge of trying to explain the economics of healthcare. It is f****d up. Take cancer drugs, for example. They’re basically a Giffen good, which is supposed to be theoretical. Because doctors get a percentage of the drug’s list price, they're incentivized to prescribe more. So, somehow demand increases as the price increases while the consumers aren’t luxury shoppers. That’s just one anecdote to describe how financial incentives upstream in healthcare lead to certain behaviors downstream and don’t make any sense in traditional economic models.

Now I am running something called Out-Of-Pocket. I’m teaching people how the business of healthcare works. There’s a newsletter that has memes, as well as analysis. I’m also selling novelty products like a children's book about how clinical trials work and a card game about avoiding medical bankruptcy. Soon I’m going to offer healthcare 101 courses.

Andrew: In developing Out-Of-Pocket, what's been most surprising to you?

Nikhil Krishnan: At a personal level, it's surprising how many things from a full-time job I miss. Ironically, that includes health insurance. I also miss having coworkers.

From a business perspective, I’m surprised by how deeply this information is resonating with people in very different professional circles. I hear from people new to healthcare technology. I have subscribers in some of the biggest healthcare hubs in the U.S., and there are people who have their own personal healthcare story. Maybe because of COVID they've been exposed to how messed up the whole system is. It’s rarer, but I also hear from physicians who are interested in building new care models using software tools.

From all these different vantage points, there’s genuine excitement around how software can rewrite parts of our healthcare system. And that's awesome.

"...there’s genuine excitement around how software can rewrite parts of our healthcare system."

Nikhil Krishnan, founder of Out-Of-Pocket

Andrew: How would you fix healthcare?

Nikhil: We can go in one of two directions. One is Medicare for All. That's a top-down approach. There are tradeoffs with that system. It's government-heavy. It dictates what we should be prescribing, charging, and allowing.

Another route is a consumer-oriented, market-based system that has a public option as a stop gap. Most developed countries have figured this out. They have both a public insurance system as well as a public healthcare system that acts as the safety net for people who need it. And they have a private system that lives on top of that for people who can pay for more.

Which way is better? I'm not totally sure. I lean toward the latter, but my mind changes every day.

Andrew: One of the things I admire about you is how prolific you are. You have 41,000 tweets...

Nikhil: Oh, what have I done with my life?

Andrew: Can you walk me through your process for generating that many ideas on such a frequent basis?

Nikhil: It's a combination of two things. One, my mind is really f****d up. A lot of different ideas come naturally to me, and I fire them off in a tweet. I don’t have many filters.

The other thing is, it’s my whole job to read about trends and data. I take notes and stitch together concepts from different industries, both inside and outside of healthcare. That’s harder to do when you have meetings from 9:00 AM to 5:00 PM. When I left the office to start Out-Of-Pocket, my calendar had no meetings whatsoever. Eliminating all those meetings was one of the most gratifying experiences of my life.

In Part 2 of the conversation, Nikhil talks about his unconventional approach to research and his favorite meme (so far). He also discusses how he would make industry conferences more enjoyable and meaningful.

About the participants:

Nikhil Krishnanis the founder of Out-Of-Pocket, which helps people learn about the business of healthcare in plain English and memes.

Andrew Le, MD, is the CEO and cofounder of Buoy Health.