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Jan. 19, 2021, 9:10 a.m.
Reporting & Production

With Out-of-Pocket, Nikhil Krishnan wants to make the healthcare industry funnier — and easier to understand

“It doesn’t lend itself to a lot of different types of jokes but I’m so in the deep Reddit that at this point, the sadboi existential crisis jokes just come naturally.”

To Nikhil Krishnan, healthcare is kind of an uptight industry.

He finds that people don’t speak clearly or casually about how things work. That lack of clarity causes a lot of problems for the person on the receiving end, who’s left with meaningless words.

While he was an industry analyst for CB Insights, a data company that builds platforms to predict technology trends, the company was leaning into newsletters to get people more interested in their work. Krishnan focused on healthcare because, as he says, the other analysts took all the good industries. As he started researching about the healthcare industry, he was intrigued by how complicated it was.

“It’s just, like, jargon everywhere,” he said. “It’s hard to figure out which players do what. No one is really upfront about their business model. I saw an opportunity to carve my niche out as making healthcare reports that were more accessible.” He leaned into being funny, and it worked. The newsletter, which he ran for 18 months, had more than 90,000 subscribers when he left CB Insights in 2019.

After spending a year working for a biotech company, Krishnan was still thinking about healthcare and comedy, and settled on a Substack newsletter called Out-of-Pocket (“U.S. healthcare is a joke. Let’s make it funny.”) His comedic timing is impeccable: He left his job and launched a newsletter about healthcare at the beginning of a global pandemic. The newsletter is written in the language of the extremely online.

Krishnan covers topics like healthcare disparities in Black communities and how to fix them, how pharmacies actually work, and why video games should be a model for engagement in healthcare. The logo for Out-of-Pocket is a shrug emoticon inside of a caduceus.

In the first issue from February 28, 2020, “Newsletter One + Patient Zero,” there was no way of getting around the issue of coronavirus.

Krishnan writes (I’ve condensed for clarity):

I didn’t want my very first issue to be about this, but here we are. As per usual, instead of listening to actual experts, my friends keep asking if they should be worried about Covid-19. To remind everyone, to the sadness of my parents I am not a doctor or public health person, just a thinkboi. But I figured I would just put this down in a newsletter.

Things I know:

  • I am not an expert on this.
  • You should listen to actual experts on this and not vigilante epidemiologists on Twitter. Spreading misinformation is exactly how sh*t is going to hit the fan and makes it difficult to organize a coordinated response. In fact I would say it’s a history of fear mongering and misinformation around public health issues that’s made the public extremely confused about when they should be very seriously preparing. A true “boy who cried wolf” scenario taking place.

Things I don’t know: […]

  • Why stocks are moving in certain directions. For the drug companies, addressing this situation isn’t good business for them (more on this below). For remote work tools like Zoom, the pricing and utilization likely won’t change post outbreak. All of this seems like pseudo-intellectualized gambling.
  • Why did the CDC put out this absolutely hilarious graphic? Since when did THAT mustache get called a toothbrush??? Why didn’t they just outline where to NOT have facial hair instead of create every permutation of facial hair?

In a March edition of the newsletter, Krishnan found himself in the middle of a Twitter fight between healthcare technology entrepreneurs about the value of randomized control treatment trials between healthcare technology entrepreneurs. He used it as an opportunity to launch a mini-series explaining why randomized control trials are useful, the controversies surrounding them, and where clinical trials are heading.

So how do you make jokes about healthcare during a global pandemic that’s only exacerbated the existing problems in the industry?

“It’s kind of a dark topic. It doesn’t lend itself to a lot of different types of jokes. But I’m so in the deep Reddit that at this point, like, the sadboi existential crisis jokes just come naturally,” Krishnan said. “I also just try to write like I talk.”

But writing the jokes and making the memes aren’t the hardest part of this work, he said.

It’s hard “explaining how money flows through the system, because in a lot of cases it’s not logical,” he said. “Usually as you dig deeper, you start uncovering things and figure out, ‘Oh yeah, that’s why that happens.’ Healthcare is the opposite. It’s like, ‘I don’t understand why both of these parties are getting money.'”

The newsletter, which is free, has 7,500 subscribers. In July, Krishnan won an honorable mention in the Substack Fellowship for Independent Writers and received some “financial support and training.”

Krishnan hosts webinars on how the healthcare industry works. He self-published a book called If You Give A Mouse Metformin (“learn how clinical trials work in a fun, satirical, and kid-friendly way!”) He also hosts a paid Slack community, for $30 a month, that’s designed to make it easier for people to start their own healthcare companies and meet others interested in the field. There, Krishnan has an application process and carefully curates the group. He assigns monthly written assignments and weekly discussion prompts. “I’m self-selecting for people who care about the same things,” he said.

To keep the newsletter free, Krishnan is experimenting with sponsored content. He’s conscious of the subscription fatigue in the newsletter business and believes the barrier to access would only be enforced further by requiring people to pay for the information. In the sponsored content pieces, he tells the stories of healthcare companies that he believes are helping move the industry forward.

“In healthcare, there are a lot of companies that have way more money to spend on this kind of stuff than individual people ever will,” he said. “Also, healthcare companies frankly suck at telling their story. I think this is like a win-win: I can tell the company’s story, I can choose which companies I work with and just pick the ones that I like, I can keep this free for people who are reading and get more new people into healthcare.”

By Nikhil Krishnan

Hanaa' Tameez is a staff writer at Nieman Lab. You can reach her via email ( or Twitter DM (@HanaaTameez).
POSTED     Jan. 19, 2021, 9:10 a.m.
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