Population Health Evangelist

Turning a Sick System Into a Health System

David Nash, MD, MBA, hasn’t always been a tireless evangelist for population health, but almost from the start of his career, he’s been trying to figure out what ails healthcare. When he was an internal medicine resident diagnosing and treating patients at Graduate Hospital in Philadelphia, the term “population health” didn’t exist. But he already sensed that something bigger than the maladies afflicting individual patients needed to be fixed.

“I thought I was going to lose my mind because I saw that we were re-admitting the same patients for the same problems all the time,” he says. People came to the hospital with heart failure or out-of-control asthma or in a diabetic crisis. They were rescued by hospital physicians and then sent home, only to return later with the same afflictions but now in even worse shape. It was an alarming puzzle that Nash, a newly minted MD, couldn’t wrap his head around.

“I started to wonder what we were really doing here,” he recalls. “We’re doing a good job on the medical side, but we’re completely ignoring the upstream causes of disease. It had to do with a broken system in the hospital and in the community. I didn’t have words to articulate it at the time, but I had very strong feelings about it.”

It wasn’t until he earned a Wharton MBA right out of residency that he found the words: “human-factors engineering,” “system failure,” “performance improvement.” “My head exploded because here were the answers to the riddle,” he recalls. “It’s about understanding what we’ve come to call the ‘systems nature of care.’”

Not that healthcare is just a business, but it’s more than medicine and bigger than fixing illnesses and injuries in patients. And the “systems” aren’t just hospitals and doctor offices. They bleed across the borders of institutions comprising the $3 trillion industry and into the communities where people live and work and play. They encompass what population-health experts call the “social determinants of health”—all the things we do, and where we do them, that keep us healthy or make us sick.

Nash came to Jefferson in 1990 when he caught the attention of Joseph Gonnella, MD, then dean of the medical college, who took note of his work as a Robert Wood Johnson Foundation Clinical Scholar and his unorthodox, forward-looking ideas about healthcare administration. Gonnella appointed him director of the Office of Health Policy.

“There was no such office at Jefferson at that time,” Nash points out. He had to invent it. “And what was my assignment? Prepare the medical college faculty for all the changes that are coming.”

The new office put together continuing-education lessons—more like grand rounds—for Jefferson’s medical staff on subjects like practice guidelines and cost-effective test ordering. It also carried out research on the most effective use of new and expensive drugs.

“When I came here, hardly anyone understood a word I was saying because I was the first faculty member who had an MD-MBA,” he recalls. “People were suspicious. ‘Are you a real doctor?’ they asked. I got that question all the time.”

Because it was too late to change the entrenched habits and mindset of those already practicing medicine, Nash sought to change the upstream culture, teaching a course called “Introduction to the Healthcare System” to medical students. It covered fundamentals—What is Medicare? What’s an HMO? How does insurance work?—and other need-to-know healthcare basics that tend to be ignored by the mostly clinical curricula of medical education.

After 13 years, he managed to elevate the office into a full-blown academic department, which taught classes and conducted a highly successful research agenda, but it didn’t do clinical care. Nash was the first chair for the new Department of Health Policy.

“Jefferson was one of only a dozen medical schools with a nonclinical department devoted to changes in the healthcare system,” he says. During that period, he was appointed the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy, and he co-chaired a committee that was putting together a strategic plan for Jefferson’s new president, Robert Barchi, MD. The plan called for the creation of a new college at Jefferson focusing on healthcare delivery and public health.

“In October of 2007, I got a phone call from the president’s office,” Nash recounts. “Barchi said, ‘I need to talk to you.’” Nash worried that it wasn’t the dean calling the department chair, which is the usual way of things in academia.

“I go across the street, and Barchi sits me down and says, ‘I’ve decided that you will be the dean of the new college.’ He was a visionary man of few words. And I’m like, ‘Well, Bob, I’m happy being a department chair. I have tenure, and I’m at the top of where I thought I’d be. I’m not sure I really want to do something totally new and risky.’

“Barchi looked at his watch and said, ‘Well, you know, David, you have 10 minutes to decide.’ I said, ‘What do you mean?’ And he said, ‘If you don’t say yes to me in the next 10 minutes, I’ll find another person to be the dean.’ So I said, ‘I’m your man.’”

Nash went back across the street, somewhat dazed, and told colleagues, “I’m not sure what just happened, but I think we have to build a new college.”

He wrote up a business plan, which included absorbing the unaccredited Master of Public Health program inside Jefferson’s College of Graduate Studies, and secured approval from the trustees. They called the new entity the College of Population Health so that the accrediting body for public health would only need to certify the public-health program but not the whole college, a move that left the inaugural dean free to build programming for healthcare quality and safety, health economics and outcomes, health policy, and population health data analytics, as well as public health.

Today, since most of the students who enroll are already healthcare professionals with full-time jobs, nearly all the degree and certificate programs are offered online. “These are folks who are mid-career, working online with us—weekends, early mornings, late at night—on a trajectory to become leaders in the change from volume to value,” says Nash.

Population health isn’t so much a specialty as it is a kind of ubiquity that recognizes the overriding and far-reaching importance of nonmedical factors like social structures and lifestyles in determining whether groups of people spend their lives in sickness or in health. “The punch line for the academic definition of population health is that 80 percent of the well-being of a society has nothing to do with the delivery of medical services,” he says, a stat that has profound implications for how we understand health and how we do healthcare.

Within a big city, life expectancy can differ from neighborhood to neighborhood by as much as 20 years. The fact that someone’s zip code is a better predictor of health than their genetic code suggests there’s much more at play in creating healthier communities than medical interventions, Nash observes. “We know from research that the principal predictors of health are poverty and housing. The most important thing people need to improve health is housing, and the second is access to good food. In Philadelphia, one out of four people lives in poverty, which means they can’t put food on the table. Health has much more to do with reducing income disparity and providing maternity leave, housing, and drug-abuse or mental-health counseling—all the things that sound like social work. The paradox is that to really improve health, we have to improve social services. The answer isn’t to build another hospital.”

Steven Scheinman, MD, president and dean of Geisinger Commonwealth School of Medicine and executive vice president of Geisinger Health, states that “Dr. Nash has been a leading voice in making us all aware that the medical profession’s responsibility goes well beyond managing disease, that social factors play a much larger role in health outcomes than mere healthcare itself does, and that it is our responsibility to address those social factors. He has been a dynamo in articulating these concepts, not only through his energetic leadership of the College of Population Health but also through his public presence in journals, books, and lectures; through his annual National Population Health Colloquium; his presence on boards; and his many other activities.”

Part of the issue for population health, Nash maintains, is that better business equals better health. Healthcare is America’s biggest business: 18 percent of the gross domestic product. “One trillion of that is totally wasteful and probably harmful,” he says, noting also that medical error is the third-leading cause of death in the nation and the average life span for Americans is shortening. For all that we spend, the U.S. isn’t even a top-10 country in terms of having a healthy population. “No other industry has these ridiculous attributes,” he argues. “No for-profit company would tolerate the ROI that we’ve achieved. What other evidence do we need that our current system of healthcare isn’t working?”

“My job is to be the evangelist for population health, and to be at the pulpit, night and day, giving the sermon on why we need to be in the promised land now in the hope that the payment system will catch up to us.”

He preaches often on the advantages of converting healthcare’s payment system from one that reimburses medical procedures and services to one that rewards physicians for outcomes measured in terms of improvements in the health of particular populations. “No outcome; no income” is his catchphrase. The shift in emphasis, backed by remuneration, from the volume of medical procedures to the value of better outcomes will make healthcare providers more transparent and accountable, while reducing costs by reducing waste, and improving patients’ experience of care.

Better outcomes, lower cost, and higher quality—in a word, “value”—is the promised land healthcare is already headed toward, Nash says. “The private payers are all moving toward a value-based payment system because it completely aligns incentives with the beneficiary. Keeping the beneficiary healthy, after all, is the core corporate value. These payers are perfectly aligned with the tenets of population health. Most delivery systems are not because their revenue base is still heads-in-beds, volume reimbursement. I believe the private sector is going to continue to push toward value-based reimbursement.”

On July 1, Nash voluntarily stepped down as dean of the Jefferson College of Population Health. “Leaders have as one of their most important responsibilities to train the leaders of the future,” he explained. “I believe very strongly that you’ve got to give younger people an opportunity. I felt, based on the management literature, that 10 years of running anything, that’s a perfect time to step aside. So I waited 11.”

Nash’s newest Jefferson appointment as special assistant to the chief physician executive—Bruce Meyer, a fellow MD-MBA—gives him a new pulpit from which he can advise, propose, and cajole Jefferson’s leadership on its pilgrimage to a fee-for-value vision and population-health management structures. After nearly three decades on the faculty, he’s still preparing Jefferson for all the changes that are coming.

Brent James, MD, clinical professor at Stanford University School of Medicine and member of the National Academy of Medicine renowned for his work in clinical quality improvement and patient safety, observes that “healthcare delivery in the U.S. is finally moving strongly and consistently from pay for volume to pay for value. This has the potential to dramatically reduce healthcare costs by improving clinical outcomes. Another name for this shift is ‘population health.’ Dr. Nash anticipated it by almost 20 years. He established the nation’s first college of population health; he advanced the science, making a compelling case for pay-for-value as a significantly better approach to care delivery policy, and more than that, Jefferson’s College of Population Health has trained hundreds of people in these theories and methods.

“His vision is finally—at last!—coming into its own.”