Drug Pricing, Broken Incentives, and the 340b program Fixes Washington Won't Touch

Drug Pricing, Broken Incentives, and the 340b program Fixes Washington Won't Touch

Episode Summary Ryan Long — former senior policy advisor to Speaker Kevin McCarthy and current non-resident senior scholar at the USC Schaefer Institute — joins Drs. Koka and DiGiorgio for a deep dive into the structural failures driving American drug pricing. The conversation covers the list-to-net price bubble and why patients pay cost-sharing on a fictitious number, how the IRA's price-setting mechanism disincentivizes both new drug development and subsequent indications, and why the 340B program — sold politically as a lifeline for safety net hospitals — systematically funnels the most money to wealthy health systems with high commercial payer mixes. Long argues the fix isn't tweaking the formula; it's scrapping the drug arbitrage mechanism entirely and replacing it with a direct, transparent grant program that actually reaches the hospitals that need it. Chapter Markers 00:00 Introduction — Ryan Long's 25 Years in Health Policy 02:08 Drug Pricing 101: List Price vs. Net Price and Why It Matters 06:39 GLP-1s as a Case Study: Insurance Pullback and the Price War That Followed 11:17 The Medicare Bridge Program and Government Price Setting for GLP-1s 14:11 Why Drug Companies Set List Prices High at Launch 16:10 The Inflation Reduction Act: Price Controls, Rebate Penalties, and Innovation Risk 20:57 Brand-to-Brand Competition and the FDA's Role 28:52 GLP-1s Under Medicare: Is the $50/Month Bridge Program Good Policy? 36:50 The Medicaid Drug Rebate Program and the Best Price Provision 38:08 The Origins of 340B: What the Program Was Actually Designed to Do 42:24 Qui Bono — How 340B Revenue Is Really Generated 50:17 Contract Pharmacies and the For-Profit Middlemen in 340B 56:31 The Humira Biosimilar Case and the Rebate Trap 1:02:58 The 1987 Supreme Court Case That Supercharged the Rebate Structure 1:05:26 Broad Reform Proposals: From 340B Overhaul to Consolidation 1:09:19 Closing Thoughts and Where to Find Ryan's Work Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

Dr. Sanjay Dhall on Trauma, Medical Training, and the County Hospital That Doesn’t Bill

Episode Summary This week, Drs. DiGiorgio and Koka are joined by returning guest Dr. Sanat Dixit and special guest Dr. Sanjay Dhall, chief of neurosurgery at Harbor-UCLA and a leading spinal cord injury researcher. Dr. Dhall traces his path from a "commando shift" in a Houston trauma bay as a pre-med student to running solo trauma call at Grady Hospital as a young attending, then discusses the strange reality of his current institution: a major county hospital that doesn't bill professional fees or for implants, leaving millions on the table. The conversation moves through hospital alignment under for-profit versus non-profit models, the Christopher Duntsch case and what it reveals about resident training and the GME system, Dr. Dhall's controversial Wall Street Journal letter on NIH indirect costs, and a guideline fight over early surgery for spinal cord injury that got him removed from a neurosurgery executive committee. The episode closes with a wide-ranging discussion on AI and robotics in surgery — what they might realistically take off physicians' plates, and what they almost certainly can't replace. Chapter Markers 00:00 Welcome and introducing Dr. Sanjay Dhall 01:49 From a Houston "commando shift" to a trauma bug 05:10 Running Grady's trauma service solo as the only neurosurgeon 09:25 The unsupervised resident era and its billing aftershocks 14:03 Harbor-UCLA doesn't bill for neurosurgery profies — or implants 19:44 How county hospitals account for six-figure implant write-offs 24:30 Fiduciary duty, taxpayers, and the case for billing aggressively 28:00 Drug rep economics at county hospitals 31:10 Comparing Cleveland Clinic, Mayo, and the county model 34:29 The "color-coded sticker" idea and the bureaucratic mindset 37:59 For-profit alignment vs. "non-profits functioning as for-profits" 43:24 The Devi Shetty suture story and physician-driven cost control 44:13 Physician ownership, conflicts of interest, and carve-out hospitals 46:00 Jefferson's neuro hospital and the private anesthesia advantage 48:45 The Christopher Duntsch case and a failure of training oversight 52:10 How does an incompetent surgeon make it through residency? 56:04 Troubled personalities in neurosurgery training 1:00:04 Work-hour restrictions and the self-selection of old-school neurosurgery 1:02:29 Is dissent tolerated in academic medicine anymore? 1:06:31 Inside NIH indirect costs — where 40-60% of grant money goes 1:10:19 The spinal cord injury guideline fight and getting removed from committee 1:13:44 Burnout, call coverage, and the safety net argument 1:20:27 Will robots ever do neurosurgery? 1:23:11 AI for administrative burden vs. AI in the OR 1:28:34 The pilot analogy, a ruptured aneurysm story, and the limits of automation Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

The Atom Bomb Speaks: Tracy Høeg on COVID, Myocarditis, and the FDA From the Inside

EPISODE SUMMARY Dr. Tracy Høeg — physician, epidemiologist, and former Acting Director of the FDA's Center for Drug Evaluation and Research — joins Drs. Koka and DiGiorgio for her first interview since being fired from the agency in May 2025. She traces her unusual path from ophthalmology dropout to professional ultramarathoner to one of the most consequential and contested researchers of the COVID era, walking through her school transmission studies, the myocarditis preprint that detonated on social media, and what she actually found when she got inside the FDA: career scientists who were sharp, collegial, and largely aligned with her — not the entrenched bureaucratic resistance she expected. She also gives the most detailed account yet of how her firing went down, why she refused to resign, and what she thinks it signals about pharmaceutical industry influence over the agency. CHAPTER MARKERS 00:00 Introduction and Tracy's bio 02:19 Origin story: French major, med school, ophthalmology dropout 07:42 Seven years in Denmark: PhD, clinical work, ultra marathon racing 10:55 Back to the US: PM&R, interventional spine, and the start of COVID research 13:43 Funding research outside the NIH pipeline 17:18 How government funding crowds out independent science 20:59 Evidence-based medicine, spine, and the N-of-one problem 25:35 The Wisconsin school transmission study 28:32 If masks were a drug, would they pass FDA approval? 30:04 Testifying before Congress three times 32:46 The myocarditis preprint: origins, backlash, and vindication 38:34 Post-vaccine myocarditis: what the data actually showed 43:01 Regulatory failure, COVID vaccine risk-benefit, and the pediatric question 45:09 How Europe and Scandinavia got it right earlier 47:58 Cancel culture in academia and the chilling effect on scientific questions 51:18 Joining the FDA: how it happened and what she expected 53:50 What the FDA looks like from the inside vs. the outside 56:38 Where real philosophical disagreements lived within the agency 58:58 Reducing animal testing and CNPV pilot: what actually got done 1:01:45 Leaks to the media: where they came from and what they meant 1:05:17 What the FDA's role should be 1:06:23 Pharmaceutical industry influence and the Wall Street Journal editorial board 1:14:48 The firing: why she refused to resign 1:18:53 The chain of command and who is responsible 1:21:08 What the firing signals about FDA reform 1:27:42 Advice for anyone thinking about taking a leadership role in government Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Resource link: Anish's substack: https://open.substack.com/pub/anishkokamd/p/they-were-fixing-the-fda-then-they?r=6chj5&utm_campaign=post-expanded-share&utm_medium=web [https://open.substack.com/pub/anishkokamd/p/they-were-fixing-the-fda-then-they?r=6chj5&utm_campaign=post-expanded-share&utm_medium=web] SUBSCRIBE LINKS Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

The ER Doc Who Quit the System - and Built His Own

Episode Summary Dr. Noah Kaufman - board-certified emergency physician with 20 years in the ER, seven seasons on American Ninja Warrior, and a new direct acute care practice in Denver - joins Drs. Koka and DiGiorgio to talk about why he walked away from the employed medicine model and built Cough Care, a cash-pay, fully transparent urgent care. The conversation covers the broken economics of emergency billing, why most urgent care is a race to the bottom, how price signals change both patient and physician behavior, and what a parallel direct care system could look like at scale -including the franchise model Kaufman is already planning. Chapter Markers 00:00 Introduction — Meet Dr. Noah Kaufman 02:12 What led to leaving the ER after 20 years 04:53 Becoming the patient — the moment everything clicked 09:33 What is Cough Care and where it sits between urgent care and the ER 13:54 Why he doesn't take insurance 16:30 How ER billing actually works — the 2.6 cm laceration rule 19:49 Can urgent care be shopped? The free market argument 21:17 One month in — what he's actually seeing 41:00 Does cost-consciousness lead to undertreating? 43:39 The culture of over-treatment and the evidence behind it 45:48 Longevity, peptides, and the gray market 54:25 Patient autonomy vs. clinical responsibility 1:01:36 What happens if every burned-out ER doc does this? 1:07:33 The franchise vision — scaling direct acute care nationwide Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

The Cholesterol Debate: What the Keto Influencers Get Right (and Wrong)

Episode Summary Dr. Greg Katz, preventive cardiologist at NYU Langone and co-host of Beyond Journal Club, joins Anish to dissect the online cholesterol debate — specifically the claims made by science communicator Nick Norwitz, who has maintained an LDL over 500 mg/dL on a low-carb diet for seven years with no coronary plaque on CTA. Katz takes the data point seriously, walks through the limitations of coronary CTA and the flawed Keto CTA study, and explains why he still believes the burden of proof lies with those arguing diet-induced hypercholesterolemia is safe — while acknowledging where the cardiology establishment, including the new lipid guidelines, overcorrects. The conversation covers the accountability gap between clinicians and content creators, the failure of risk calculators in young patients, and what a well-designed trial to actually answer this question would look like. Chapter Markers 00:00 Introduction — Dr. Greg Katz, NYU Langone cardiologist and Beyond Journal Club co-host 01:40 What prompted the Substack: patients bringing in Nick Norwitz's content 02:51 Who is Nick Norwitz — LDL of 500, low-carb diet, and the clean CTA 05:38 Why Katz takes the question seriously but disagrees with the framing 08:01 Familial hypercholesterolemia outliers: why some FH patients never have events 10:05 The 50/50 problem — half of high-cholesterol patients have heart disease, half don't 12:27 The Jody Plute story: homozygous FH, Thomas Starzl, and the portacaval shunt experiments 17:37 Seven years of LDL 500 — is that long enough to know anything? 18:21 Limitations of coronary CTA: what it can and can't see 21:00 Why LDL gets put on a pedestal — and the cognitive dissonance of a diet that works 22:05 The conflict of interest argument — and why it cuts both ways 25:43 Burden of proof: mechanisms vs. outcomes data 27:16 Statins and GLP-1 levels — why a mechanistic claim isn't the same as a clinical outcome 31:38 Physician accountability vs. content creator accountability 35:24 The Keto CTA study: what it found, what it didn't, and why the blinding controversy matters 44:40 The new lipid guidelines: where they overcomplicate, where they overprescribe 49:38 GLP-1 deficiency framing and the over-medicalization of well people 55:54 Longevity medicine as "over-medicalization of well people" 57:35 What a well-designed trial would actually look like 1:00:01 Why the debate needs real research, not conjecture 1:02:37 How Katz talks to statin-hesitant patients in clinic 1:07:06 Wrap Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]