-PhD candidate Vrushabh Ladage chose The Dartmouth Institute for its mix of methodological rigor and commitment to policy innovation.
In August 2022, President Joe Biden signed into law the Inflation Reduction Act (IRA), setting in motion a dynamic overhaul of Medicare Part D, the federal prescription benefit for people over the age of 65 and some Social Security beneficiaries. The legislation caps the price of insulin and mandates price negotiations by Medicare on behalf of beneficiaries. In 2025, two additional features will go into effect: a $2,000 annual cap for out-of-pocket spending on prescriptions and a “smoothing” option which will allow enrollees to make their payments in monthly installments in line with that annual cap.
When news of the signing reached The Dartmouth Institute PhD candidate Vrushabh Ladage, he was both “ecstatic” and skeptical. “I read through the Medicare Part D provisions numerous times, just to be doubly sure it was all there and real,” he says. “I am overjoyed to say that this section of the law now fixes issues with the previous Medicare Part D design.”
Mr. Ladage has a solid grasp of just how profound the impact could be. For much of the past decade he has investigated the consequences of high prescription prices as a researcher at the University of Pennsylvania. By the time he began his doctoral studies in Health Policy and Clinical Practice at The Dartmouth Institute, Mr. Ladage had coauthored seven peer-reviewed reports on topics such as how out-of-pocket prices affect specialty drug utilization and strategies to nudge physicians to prescribe more affordable, evidence-based medications for their patients. Perhaps most importantly, the work to which Mr. Ladage has contributed shows that among Medicare beneficiaries whose income exceeds the most generous federal subsidies, the variable and unaffordably high out-of-pocket pricing structures characteristic of Part D in the pre-IRA era could substantially affect whether people filled pricey prescriptions for chronic diseases.In multiple studies, Mr. Ladage and coauthors found that in January—when Medicare Part D copays are highest—beneficiaries being treated for cancer and multiple sclerosis who were ineligible for cost-sharing federal subsidies were less likely to fill the prescriptions for specialty drugs to manage their conditions, subjecting them to more severe symptoms and faster disease progression over time.
During his first year as a doctoral student at Dartmouth, Mr. Ladage continued his research at Penn, due to visa processing delays caused by pandemic shut-downs. The online classes and work-from-home regulations prevalent during that same time period eased the burden. His simultaneous engagements proved synergistic when the PAN Foundation, a nonprofit advocacy group that helps people with life-threatening, chronic, and rare diseases get the medications and treatment they need, reached out to Mr. Ladage’s supervisor and mentor Dr. Jalpa Doshi at Penn.
“It’s one thing to write a paper,” says Mr. Ladage, “and another to meaningfully move the needle in the right direction.”
The PAN Foundation wanted help developing materials they could use to lobby members of Congress in support of draft legislation to fix Part D—what would eventually become the IRA. Ladage credits Steven Woloshin, MD, MS, co-director of the Center for Medicine and Media at The Dartmouth Institute, for providing a vital forum in which to refine the materials Mr. Ladage’s supervisor ultimately provided to the PAN Foundation.
Dr. Woloshin conceived of the Professional Development Seminar PH 290 (now PH 105) with his wife—the late internist Dr. Lisa Schwartz—with whom he co-founded the Center for Medicine and Media, and Bob Drake, then a professor of Health Policy and Clinical Practice at The Dartmouth Institute. “We tried to model it on the best research group we had been in,” recalls Dr. Woloshin. “Fellows would take turns, get an hour of the meeting dedicated to them and they could do whatever they thought would be helpful.”
In the seminar, Dr. Woloshin encourages students to request guest speakers and other presentations that would support their goals. Visitors have included grant writers and evaluators, researchers who provide peer review, and journal editors, among others. “In my own professional life, I have a group like this that I work with,” says Dr. Woloshin, “and I encourage students to keep the group going or create their own.”
Mr. Ladage used PH 290 class sessions to workshop synopses of the Penn team’s findings for three distinct audiences. In spring 2021, he co-created a presentation for representatives of the PAN Foundation on how different ways of restructuring the Medicare Part D cost-sharing requirements would affect public health. He also solicited his classmates’ feedback on an academic research poster detailing how those policies would affect out-of-pocket costs and access to specialty drugs. The third project—a two-page synopsis, complete with a case study—was used by the PAN Foundation to educate Congressional staffers on the issue.
Mr. Ladage was in the final year of a bachelor’s degree in biochemistry and molecular biophysics at the University of Arizona when the United States Congress enacted the Affordable Care Act in 2010.
For Mr. Ladage, who was weighing whether to pursue an MD or a PhD, the potential for policy to affect millions of lives was captivating. “I wanted to have impact,” he says.
Beginning in 2012, Mr. Ladage landed a series of health outcomes research posts at Penn. While working full time, he earned a master’s in healthcare innovation from Penn’s Perelman School of Medicine. He also affirmed his desire to earn a PhD.
“I want to be an independent researcher, test questions,” he says. “And I want to transform and innovate in health systems through the solutions I find.” He chose The Dartmouth Institute for its mix of methodological rigor and commitment to policy innovation.
Elliott Fisher, MD, MPH, a Dartmouth Institute and Geisel School of Medicine professor, is one of Ladage’s PhD proposal advisors. “His energy, curiosity, and desire to make a difference were very clear,” says Dr. Fisher, who also taught PH 111, Medical Care Epidemiology, when Mr. Ladage was in the class. In the course, Dr. Fisher invited students to think critically about healthcare systems—the dynamic interplay of hospitals, medical practices, physicians, public health workers, and activists, who produce population health—with a focus on the modifiable factors that might lead to greater health and equity, as well as the potential for unintended consequences.
Mr. Ladage used the final project in PH 111 to synthesize the two Medicare Part D policy recommendations for which he saw the most potential. “There are a lot of skills needed to take a good policy idea and convince legislators to move it forward,” says Dr. Fisher, who was an originator of the concept of accountable care organizations (ACOs) and worked with colleagues to carry out the research that led to their inclusion in the Affordable Care Act. “Vrush took to the work like a fish to water.”
-Written by Sharon Tregaskis
-Photograph by Mark Washburn