Population Health, Failures of Leadership, Promises of Technology

Brian Urban: [00:00:22]
Yes, this is the Healthcare Rethink podcast. I am your host, Brian Urban. And today we have joining our show, the Father of Population Health. That's right, Doctor David B Nash of Jefferson College, Population Health of Thomas Jefferson University. And today we're going to be talking about. That's right. Where is it? His newest book. That's right. I was just skimming through it this past week here. So excited to talk to you about this. Dr. Nash, You covered everything in this from I'm talking population health failures of leadership, our culture in the US, and the promises of technology that hopefully won't fail us, but maybe challenging to get through some adoption and some growth. So, so excited to have you on the show.

David Nash: [00:01:10]
Well, thank you. Thanks, Brian. Great to be here. I'm wearing my soccer shirt in recognition of the World Cup yesterday and I was rooting for Argentina. So go messy and outstanding. Thanks again for having me. Thanks for reading the book. And it's been a labor of love during the pandemic. Special thanks to my amazing co author, Charles Wolf forth, who's so awesome. And I appreciate your interest in the book. The book has sold out two printings and is back at the printer in suburban Maryland. So it's been an amazing since September 15, have been amazing couple of months. And of course, we're donating every nickel of the proceeds back to the College of Population Health. So this is a win win for everybody.

Brian Urban: [00:01:59]
I'm glad that you said that, because that was one of the first things I was going to say about really the humanitarian side of this and the giving side of it and and even to the book's dedication to all of the health care workers across the world and for us for giving so much, so amazing. Amazing. So let's let's just get right into it with all of our conversations on our show here. We'd love to get our guests a little bit more familiar with our audience and vice versa there. So we have audience from across the whole health care ecosystem, tech, data research, and of course, the actual actual workers in health systems as well. So for for you, can you please tell us who David Nash's before the MD, how you got this this great title of the population for Father of population health and really just tell us how you.

David Nash: [00:02:56]
Great. Well, Brian, thanks so much. So a little bit of this is, if you would, you know, Revenge of the Nerds, I guess. But so I've been a pretty focused individual. I've been on the faculty at Jefferson now for 32 years. I didn't train at Jefferson. I got recruited there 32 years ago next month. But so before the M.D., I was I grew up on a suburban Long Island, New York. I went off to Vassar College. I was in the second fully co-educational class. So that's a story in and of itself, in a polite way in those days applying to medical school. So I was born in 1955, the zenith year in history for the number of applications to American medical schools. So as a zenith boomer, I applied with more than any other group to medical school, was very lucky to get into a bunch of schools, went to the University of Rochester School of Medicine after Vassar. But what was out of the ordinary, not only going to Vassar, but I was an undergraduate economics major. So I did graduate, fulfilled all the requirements for Phi Beta Kappa undergraduate economics, and I did the minimum number of pre-medical courses to satisfy the application process. Was very lucky to be able to go to Rochester, a top ten med school.

David Nash: [00:04:34]
The challenge when I got there was I didn't know how to turn the microscope on, other than that it was just great. So your year one and two were a little bit of a problem for me. I barely passed by the time I got to year three and four was a totally different story also while in high school. As we relate the story in the book because it's a little out of the ordinary. While in high school, I found a mentor at the University of Pennsylvania by the name of Samuel P martin, MD, who was a giant and had created a special program nationally for physicians interested in leadership training. And to make a very long story short, this all coalesced around my getting accepted to the Robert Wood Johnson Clinical Scholars program after residency training, where in I then got an academic scholarship to go to Wharton. So to summarize Vassar. Rochester residency Wharton nonstop. So unlike my grown millennial children, who all had a junior year abroad travel, the world did all of this great stuff. I did none of that. Back then, if you got into medical school, you got your sorry, but they're as fast as possible because they were going to give your seat away. Also great. In medical school, I met my future wife at a medical school convention.

David Nash: [00:06:16]
That's a separate altogether. And we've been married for 42 years, so it's a great story. Incredibly grateful to be able to be at Jefferson for so long. And the book is the product of my friendship with Charles Wolff forth, who I actually met pre-pandemic, a great writer at a medical conference, and we became fast pals. And May June of 20, so called it three or four months into the pandemic. I'm sitting home zooming, trying to do my work, and I get a call from Charles, and punchline of that conversation was his amazing insight that he could give a. Prose to my voice and that together we could make a contribution to battling the COVID pandemic. So I owe a lot to Charles, who basically said, We need to do this. And it was a very personal decision, Brian. My wife and I, both doctors, as I noted, we have three children, one of whom is a frontline physician attending hospitalist who was battling COVID like everybody else at the bedside. So I thought if she could risk her life literally at the bedside, I can devote some time to writing a book about COVID. So that's how all this came full circle. During 2020 and 2021.

Brian Urban: [00:07:53]
A great, great little journey. And I think that gives our audience a good perspective on this is a part of life and this is an output within the story. And really you open up the book, I think in a great way. It's it's kind of a high up and then getting down into an investigation around the pandemic globally and then in particular COVID 19, the impacts economically into our health care system infrastructure in the US. And you have probably so many great shoutouts that we can give throughout the book. I'll start off with one big fan of of former CEO and president of Jefferson Health, Dr. Steven Glasgow. He had the foreword to your book and he actually ended that forward with a really interesting perspective that I hope we can open up on and get a little bit more into. He had mentioned kind of building out the preparedness of of the future of health care and touching on some really big pillars. He mentioned social determinants of health. You've written several business case and studies on in terms of investment and addressing predictive analytics, population health of course, and payment models, medical education in particular, that that stood out pretty, pretty high for me in terms of the medical humanities that's come through in a lot of the really successful places, hospitals in the US when dealing with the height of the pandemic. So in health care now how do we prioritize all those things Sdoh analytics, pop health and contracting models. But where do we start? Where do you put all your chips and how do we start to shift the model of care? Maybe that's.

David Nash: [00:09:36]
Well, let's try to unpack some of that. Let's start with Steve Glasgow and then we could try to unpack your great question. So look, we I owe a lot to Steve Glasgow. We were pals before he came to Jefferson. He was a transformative leader. Over eight years we went from two or three hospitals to 18 hospitals. We purchased a payer organization, Health Partners Plan and Medicaid Managed Care Plan. We built an ACO. I mean, Steve was a totally transformative leader in every respect and is super supportive of our college of population health. I mean, I wish every university president and system president like Steve was would be equally supportive. Without him, there would be no college. So he told everybody whenever he had a chance that our college was the first such school of its kind in the country. True, when we opened the doors in 2009, I mean, Brian, there wasn't a single textbook of population health at that time. So not only were we the first college, we had to write the first textbook and and I'm still the editor in chief of the only scholarly journal called the Population Health Management. So Steve was ultra supportive of all of this. So now to try to unpack your question, look, here's here it is in a nutshell. I spent from 2009 to 2010. That's Obamacare, 2011, 2012, let's call it three or four years on our own campus every darn day trying to explain what's population health, why it's different from public health. And, you know, it was a slugfest to build a brand new school from scratch, make it all online, asynchronous learning. I had never been a dean before.

David Nash: [00:11:43]
I was a med school department chair. So all of that's in the rearview mirror. What was really astounding was at the very beginning of the pandemic, let's call it March of 20, April, May, June, the summer of 20. I mean, I was home like lots of other very privileged folk doing my work. And it is fair to say that my email exploded globally of people coming to me saying, you know, that population health stuff you've been talking about for ten years seems like it might be the pretty important now. I mean, it applies essentially. That's what happened. And my colleagues and I and our associate dean at the time and our faculty, it wasn't just me, certainly not. But our team had been focused on these issues literally for a decade. But to see them become front page news and shining a spotlight on the social determinants. And if you just look at Philadelphia, let me give you just a quick sort of vignette of. Why it was so. The pathos of it all. So Philadelphia, home of five medical schools, including the two largest private med schools in the country, Jefferson and Drexel. Our county, Philadelphia County, pre-COVID was the least healthy county in the state of Pennsylvania. So one more time. Five med schools, our county pre-COVID the least healthy. So what's the cause? Well, you described a little bit of it. It's the social determinants or what Don Berwick calls the moral determinants and others call the drivers of health, whatever you want to call it. It has nothing to do with Jefferson or Temple or Penn or anything. It has all to do with crime, poverty, racism, lack of education, all the things that America doesn't like to talk about.

David Nash: [00:13:55]
Hungry children mean. So all of that existed and COVID was essentially a12 knockout punch to a town where one out of four people lives in poverty. What did people think was going to happen? No primary care doctors, super subspecialists at most of the medical schools. And look, I'm inside the belly of the beast and have been for more than three decades. I get it. So Philadelphia is the poster child for what the heck went wrong. And the book, How COVID Crashed the System is all about. Well, what are we going to do now? You know, I mean, the first half of the book is Johnny Downer. You know, poverty, crime, racism, misguided education, misaligned incentives. That's why the plane crashed, if you would. And Charles, my coauthor and I, where the National Transportation Safety Board investigators, we have those black baseball hats on. Everybody has seen them. And we're crawling around the smoldering wreckage at the airport. And there's still smoke and there's bodies everywhere. We're searching for the black box. But here's the punchline, Brian, As you well know, we knew exactly what was in that darn black box, Right? All those social determinants, the poverty, the racism, the disconnection, the no primary care doctors, the misalignment. Oh, and then finally, American culture, which we describe in detail in the book, three themes. Very quickly, American individualism. We are going to figure this out our own way. Don't worry. American exceptionalism. Who cares what's happening anywhere else? And American federalism, where the president at the time said, Hey, all you governors, you're on your own. Good luck. So. Wow.

David Nash: [00:15:54]
Now. Yeah. And I love that you went into how American culture, United States American culture had created this vulnerability and and it challenged us. It highlighted a lot of access to care, health equity gaps across the country. And you mentioned something really interesting going into kind of the provider side of your book here. And I want to move geographically, West, Midwest specifically. So at the height of the pandemic, there was about 11% of the deaths of COVID 19 attributed to the African American African American race. And I think it was interesting you mention Rush University Medical Center in Chicago. A quick shout out to recently named CEO Omar Latif, but yet you interviewed Dr..

David Nash: [00:16:54]
David Ansel, one of my heroes. Yes.

Brian Urban: [00:16:57]
Yeah. And there's such an awesome excerpts from there. You talked about how there was community links as a part of their equity strategy, and they accepted so many transcripts from different hospital safety net hospitals around the area and further out outside the time zone. And they took a loss in terms of reimbursement and the cost of care they hit. But Dr. Insel mentioned how many lives that they saved, and that echoed, I think, greatly throughout the health care economy and through other partners in the area. So I want to talk about your conversation with with Dr. Metzl. So, first of all, very cool guy and the insights that he was sharing. Can you talk a little bit about maybe what that's done as a positive ripple effect in health care?

David Nash: [00:17:47]
So let's let's set the stage and thanks for mentioning David Ansel and Omar Latif, two amazing doctors, by the way. Omar Latif, who's a really young guy, super dynamic of color. And David Ansel is older than yours truly, which is pretty awesome. But Ansel's 2017 New York Times bestseller, The Death Gap, was all about the social determinants in Chicago and why, if you lived in certain neighborhoods in Chicago, your life expectancy was two thirds, that of folks born in different zip codes. So Ansel was talking about zip code as destiny. Zip code more important than your genetic code way before it was popular, we had David Ansel come to Jefferson during one of our annual Population Health Colloquium to discuss his book, The Death Gap. I had the privilege of meeting Omar Latif because he was a mentee of Steve Lasko. So Omar came to our campus with his leadership team. So Rush had a decades long commitment to the neighborhood, hiring people from the hood, working with companies. The Board of Trustees of Rush was committed to tackling the social determinants before it was popular and way before the pandemic of March of 20. So they're not a Johnny come lately to this story. They could serve as a great role model for organizations like the 155 academic medical centers in the United States.

David Nash: [00:19:27]
And Omar described how important his personal role is and his incentive compensation tied to measures of improvement of the health of the population. So one more time, let's make sure we set a hammer this home, because I believe so much of this challenge could be certainly ameliorated by realigning the economic incentives, incentives to actually improve health. Brian, we've lost our true north and the way to get back onto the campus of the true north, I believe one definitely important way is to realign the economic incentives of the most senior leaders so that they're held accountable for improving health, reducing disparities, reducing inequality if they were economically rewarded like Omar Latif and others, to improve health in the community, that would go a long way. It's not the only answer, but it's a big part of it. And in the foreword to our book, Steve Glasgow talks about a very similar strategy. We didn't invent this, and David Ansel and Omar Latif didn't invent it, but you've got to give them credit for operationalizing this in some pretty tough, very deprived communities of color, poverty, lack of. Education, crime and Chicago, of course, another poster child for what went wrong and what went right during the pandemic.

Brian Urban: [00:21:07]
I love that that's in the meat of the book and actually provides a really nice transition to. So we're talking about very dense urban African-American population inside Chicago. And you mentioned community health. So actually, I want to take us back to the East Coast time zone here. We're going to go to the center of Pennsylvania. Between the both of us here, you talk to Dr. Ryu in terms of community health. And he made a really interesting comment about Geisinger Health System being at the root of communities. And he talked about how Geisinger was first. Community hospital is really so close to their patients because they wanted to have convenience and access and be a part of the culture of the community. So Geisinger was an amazing player in terms of creating a blueprint for a pivot model at that time, in the height of the pandemic and even going through into 2021. But in terms of a blueprint for better health system going forward.

David Nash: [00:22:13]
So guys are in Danville and Geisinger Commonwealth School of Medicine, where I have the privilege of being a board member is in Scranton. So Danville, Scranton, 75 miles. So Geisinger Commonwealth School of Medicine, Ohm is an amazing medical school where it's unique, in fact, in the country where more than half of the students are the first family members in their family to even go to college, let alone medical school. So they're all about service to the community, which of course, is not shared typically by most allopathic medical schools in the country. That's one piece. Dr. Joanne Rue, the CEO of the entire Enterprise, who came from the Humana Corporation, where he was a senior national medical director, where I first met him when I was a board member for a decade at Humana. So it's all interconnected. Joanne is a transformative leader like Steve Blasko, and Geisinger is a fully integrated provider and payer. They have their own health plan, as most folks know. They're considered one of the best models of a community based tertiary delivery system and connected directly to their own health plan. What does all this mean? They have every economic incentive to keep people healthy. As a matter of fact, I was just in Scranton one week ago for the med school board meeting and a meeting of the Geisinger Fiduciary Board. It's an amazing group of people, a real privilege to be a part of this. Gail Wilensky, Tom Lee, and other big shots like that.

David Nash: [00:24:03]
But the punch line is Geisinger has every economic incentive to do basic stuff, like stay out of the damn hospital. Let me treat your heart failure at home. Well, we can't do that in Philadelphia unless you have great economic risk for keeping people healthy. Everything about American health care is get in, utilize the services will handle this problem at this time, and we're going to get paid for doing it. So if you get paid for doing more and not thinking about the true north of improving health, well, we're going to do more and we're darn good at doing more. And then finally, g com is sort of like if you would play ball to train the residents who will then graduate and go to work inside the Geisinger system. It's very analogous to the Bernard Tyson School of Medicine, of course, at Kaiser Permanente, which took 75 years, if you would, to build an open up because Kaiser kept saying we don't have the right kind of doctor to work in our kind of system. Well, duh. So they had to build their own med school to create the doctor of the future. Look, I'm not saying that every med school should look like Geisinger and Bernie Thyssen. Certainly not. But there's a lot we can learn from. Are we training the right doctor, nurse, pharmacist, social worker for the future? I would argue there's a long way to go here. A lot of opportunity for improvement.

David Nash: [00:25:40]
Let's start with quality and safety, human factors, engineering, epidemiology, understanding the social determinants mean all of that stuff. But educators will push back on me and they have face to face to say, Well, what would you like us to take out of the curriculum? So Bryan, here's the model American medical education, nursing education, all the rest. It's like a barge in the river. And medical education is weighted down by lots of stuff. And you can't put more stuff on the barge unless you take stuff off the barge. So I don't believe in that description, but that is the reality. So to pass an LCM accreditation visit, you got to have certain stuff on the barge. My view would be sink the damn thing and start over. It's not a widely held view. What can I tell you? But we need those 32 years. I'm not going to stop talking about what I care so deeply about. Let's look at the epidemiology today. So here we are right before the holidays. Amazing. 2022. We've been at it for almost three years, right? Crazy. So in America today, the number one cause of death among adults is still heart disease. Number two is cancer. Number three is COVID. And number four is preventable medical mistakes. So heart disease, cancer, COVID, preventable medical mistakes. My question then remains, are we training the right team with the right skills to tackle the epidemiology that we're faced with? That's my question.

Brian Urban: [00:27:36]
And we need those diverse views and we need those hard pressing questions. So obviously, I'm on your side. We've got to keep pushing and challenging sasquatches and moving forward. So you mentioned one thing in terms of social determinants of health. So how important will it be to provide physicians of the future information that's happening outside the clinic?

David Nash: [00:28:00]
All right, so it's a great question. I have two responses. A private sector one and a public sector one. Let's do the private sector first. So it's already happened. Companies like City BLOCK Health and Absolute Care, One medical, Oak Street. Right. So these are mostly private equity backed disruptive models of primary care, where the social determinants are part of the everyday work that these organizations are all about. So let's see how they do. I mean, it's a city block in particular in our market in New York and elsewhere, is all about treating folks who, when I was training, impossible to take care of these people because they're so poor, they're never going to come back. They're poor historians, they're compliant. Well, of course, that was sort of a racist approach, but accepted by everybody, including me, because that was what the training model was like. Instead, their model is we're going to shower and surround these people with services because that's what's determining their lack of health. So that's a private sector response, public sector response. What's the research show? So the research evidence is fascinating. If you give doctors, nurses and pharmacists tools to attack the social determinants, guess what? You reduce burnout. That's fantastic. So it's not like getting a muffin when you walk into work or a yoga mat. I want my hair out.

Brian Urban: [00:29:40]
Yeah.

David Nash: [00:29:41]
They don't need a muffin or a yoga mat. Mean it might be nice. What they need is give me a tool. So when this patient's in front of me and I say, What's in your refrigerator? And they say it's empty, then I could write a prescription for food, for transportation, for legal help, for mental health services. That reduces my burnout as a primary care doctor. That's pretty powerful stuff. So I think there's a private sector approach, there's a public sector approach, but you've got to build this into the curriculum. You know, look, mea culpa. I've been a primary care doctor for 35 years. I finally stopped practicing in March of 2020 because it's a young person's game. But I don't think, honestly, I ever asked a patient, What's in your refrigerator? My doctor daughter. This is a part a core part of her training. It's a totally different world, appropriately so. I'm not saying one is totally wrong or totally right, but look, we've got to keep up with the times. It's the 21st century. I've always seen doctors as social activists. That's really the core issue here. And there's lots of folks who came before me who articulated this model, famous people, Fitzhugh, Mullan and others, Jack. I mean, there's a whole bunch of folks. We've lost that in medicine. So if doctors can't be activists to improve health, well, you know, that's part of what we have a sworn oath to do. So that's why training a different kind of doctor, nurse, pharmacist for the future is a big part of what I've spent 32 years trying to do at Jefferson.

Brian Urban: [00:31:34]
And I love that response. You gave me both the private side, the care side, and then kind of a little bit of part of your journey comparison to your daughters, which is an excellent kind of evolution of of kind of where we need to be going. And you took us in that direction a little bit later in your book. I believe you're quoting a New York Times article when you had mentioned about 45% of hospitals, US had big time issues with actually matching identities of patients when moving them across care platforms, getting them transferred, etc.. So many other things there. So that kind of goes back to to data sharing in a way, and also data maintenance too. So as as we look into the future, how critical is that going to be? Is hospitals working together and health plans working together?

David Nash: [00:32:31]
Well, look, it's not as easy as just implementing Epic or Cerner, that's for sure. We've learned that that's a baby first step. And my generation, we're the first ones to have experienced this. My daughter's doctor generation is much more fluent with all of this. But you are right, Brian. Just two months ago, the Office of the National Coordinator for Health Information Technology, right. Unchecked, there's national law now to find a way to make these systems talk to each other. I think we're a long ways away from seeing that operationalized. But hey, I'm all for it for sure. Look, Philadelphia, Chicago, we couldn't tell you who was vaccinated and who wasn't. We couldn't tell you who was in which hospital and who was in the other hospital. Back to Omar Latif. He talked all about accepting these terribly sick transfers from rich hospitals of poor people who they knew weren't going to pay. So they went to rush, you know, crazy. But if we could really improve the interconnectivity and there's lots of great companies, both private and public, working on this, it makes for a very exciting future. It will be critically important in the next pandemic that we have the capability to make those connections. I sure hope all those smart software writers and policymakers are working to do it. As best as I could tell, major national leaders, David Blumenthal among them, articulating where oh, and see, it has got to go. I have to hope we're in the right direction.

Brian Urban: [00:34:19]
Yeah, I do as well. I feel that and I hope that because health equity and and disparities by race is a top of mind and coming out of every right now. But I hope it gets back up I hope it gets backed up and and speaking of the future, kind of looking ahead here, what I want to bring us to a compelling close, Dr. Nash, because this has been such a wonderful conversation. I feel a part two episode coming on that might involve some policy conversation as well. But what I would say the top three things, I guess that for me, what what would what would you break down for the US health care system or health care economy across the board that we'd want to consider in preparing for the next or next economic?

David Nash: [00:35:09]
Yeah, well, you know, there's a great question. So there's no future in predicting the future, I'll tell you that. But let me take a stab at it. At least based on the two years that Charles and I devoted to how COVID crashed the system in no particular order. I think there's certainly three things we could start doing after the holidays. One would be to realign the economic incentives and tie compensation for the whole system to improving health. And we could do that in any number of ways, some of which we talked about already. But realign economic incentives, build new relationships between payers and providers. I mean, the kind of antagonism that's existed in Philadelphia is similar in many big cities between payers and providers. Put that aside. Be like Arthur Brooks has counseled in his new book, Love Your Enemy. You know, create the provider model. So one is realign incentives to is create these new collaborative models certainly to a might be get the computers to talk to each other to create these models and three change undergraduate and graduate medical education to include all of these issues and build a cadre of faculty and scholarship in these fields to attract more young people who care about these issues. I'm not saying stop training every cardiologist and other ologists, but America needs a primary care strategy. We're going to need one for the next pandemic. That was pretty clear in our city. So a whole new strategy as it relates to education for all health professions, for the future, if you want to call it a flexner, 2.0 or 3.0, that's okay with me. But I'm all about building a different kind of doctor for the future. And some good places to look might include Bernard Tyson on the West Coast and soem on the east coast.

Brian Urban: [00:37:27]
We got our three. That's what I was hoping to hit. So it's a lot of economic incentives. Support the pay via provider model going forward and start to evolve the education for physicians of the future, whether that includes medical humanities, includes. So everything that we've seen come from the COVID 19. Exactly right. In the world. But this has been amazing. And if you haven't read this, we've talked about it the whole time. It's how COVID crashed the system by Dr. David B Nash, Thank you so much for joining our little show. And for more experts and insights, please visit Thrive dot com.

David Nash: [00:38:12]
Thanks so much. Awesome.