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David Nash, dean of the Jefferson College of Population Health, Thomas Jefferson University, Philadelphia. (Photo: Marshall Clarke)
The January 2015 announcement by Sylvia Burwell, secretary of the U.S. Department of Health and Human Services, might be framed as a timed test for America’s healthcare providers.
By the end of 2018, Medicare intends to make 50 percent of its payments through alternative payment models such as accountable care organizations and bundled- payment arrangements. In announcing the target date, Burwell gave health systems, physicians, and other providers three years to figure out how to succeed when they are financially at risk for the quality and cost of the care they provide.
Of course, many organizations have been tiptoeing into this new era of accountability. But knowing that the nation’s biggest payer sees 2018 as the payment reform tipping point makes the clock tick more loudly.
Alternative payment models have many success factors, but none is more important than the ability to manage patient health at the population level.
“So if you think of it as a three-year journey, we’re about one-third of the way there,” says David Nash, MD, MBA, dean of the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia. “I would say we’re making good progress toward population health.”
His comment was based on recent visits to some of the largest national and regional health systems, where he found population health initiatives that appear poised to pay off. For example, Mercy Health Partners in Cincinnati hired nurse care coordinators to give one-on-one attention to patients with chronic conditions; for patients who had been in care coordination for six months, admissions per 1,000 patients, emergency department visits per 1,000 patients, and inpatient days per 1,000 patients all fell by more than 20 percent on an annualized basis.
That said, not all provider organizations are reading from the same study guide.
“It goes from independent community hospitals that really are hoping this will all go away to national systems like Trinity and Ascension that are devoting millions of dollars in new resources to population health,” he says. “The range is pretty remarkable.”
Nash has been focused on the intersection of payment reform and population health management for years. When the Affordable Care Act became law in 2010, he summarized it in four words—”no outcome, no income”—and the phrase has since become his mantra.
Trained as an internist, Nash received a master’s degree in business from the Wharton School at the University of Pennsylvania in 1986, long before the MD and MBA credentials became a popular combination. He started the Department of Health Policy at Jefferson Medical College in 2003, and five years later he became the founding dean of the College of Population Health.
Currently serving just under 300 students, the first-of-its-kind school offers master’s degrees and certificate programs in population health, health policy, and healthcare quality and safety, among other disciplines. The average age of students is 45, and most are already credentialed as nurses, pharmacists, radiation technologists, or other healthcare professionals. About 70 students are physicians.
“These are folks who are mid- career, working online with us—weekends, early morning, late at night—on a career trajectory to become leaders in the change from volume to value,” Nash says.
In an interview with Healthcare Executive last year, Nash recommended several strategies that healthcare leaders should use to advance population health management. Almost every item has been on the work plan of forward-thinking provider organizations. But that doesn’t mean all of the recommendations are being successfully applied throughout the industry. Nash offered this progress report:
Begin population health management efforts with the employee population. “We are doing a terrible job with this because, regrettably, our whole industry has not placed sufficient interest and resources in the health of their own employees,” Nash says. “I would give us a C grade.”
Employers in other industries are way ahead. He encourages healthcare executives to follow the example of manufacturers, supermarket chains, and other companies that recognize the economic benefit of encouraging workers to adopt healthy habits, get recommended screenings, and avoid inappropriate imaging and other wasteful services.
“Your employees are your captive at-risk population, although most delivery systems have not viewed their own employees in that way,” he says. “And then we wonder why our benefits continue to increase in cost.”
Provide appropriate guidance for those who will lead patient-centered medical homes. A good clinician may not have the skills and attributes needed to proactively manage a population of patients. “There is a false assumption, in my view, that physicians should automatically become capable leaders of patient-centered medical homes,” Nash says. “My point is they need additional training, resources, and support.”
Increase the use of patient registries. Nash is waiting for the day he can walk into his office, open his laptop, and click on the “How am I doing?” icon.
“That’s what I want the icon to be called,” he says. “And when I click on it, up comes an amazing registry, with several categories. One category shows all of my patients who have insulin-dependent diabetes, or chronic obstructive lung disease, or stable angina, the bread-and-butter diagnoses of primary care practices.
“And in that registry, it also shows how I’m doing with regard to key population-based measures. Am I doing the right screening tests? Have I made the appropriate referrals? Am I ordering the appropriate generic drugs? And then that registry is also going to compare my performance with local, regional, and perhaps even national benchmarks.”
Although patient registries have been in use for many years, they are not yet standard practice for organizing a physician’s work. Until they are, Nash says, physicians are working without all the information they need to provide optimum care.
“When we have that kind of robust, agile registry, then I think we’ll really be practicing population-based medicine,” he says. “Right now, the folks who know more about our patients than we do are the payers.”
Partner with retail clinics. The clinics embedded in drug and grocery stores can support population health management in at least two ways: reducing use of high-cost emergency department visits for simple conditions such as strep throat and increasing access for patients with chronic conditions.
“I’d like to see the nurse practitioners in these retail clinics working more closely with, as an example, the faculty of Jefferson Medical College,” Nash says. “There’s a big opportunity here, especially with regard to patient education, given how often patients are in these retail settings versus how often they see their doctor.”
Partner with managed care plans. By “partner,” Nash does not mean “acquire.” “I cringe a little bit when I hear providers say ‘We’re going to start our own insurance plan,’” he says. “My first question is ‘How many actuaries do you employ?’”
Nash, who serves on the Humana board of directors, thinks insurers have two capabilities that providers typically lack: the actuarial expertise to assess and spread financial risk and the infrastructure to handle care coordination.
He is encouraged to see local and regional health plans working with providers on population health initiatives. “It would be great if we could bump this up to a national strategy,” he says. “I can envision a world where the Humanas, Aetnas, Cignas, etc., will have a large number of partnerships with providers in different geographies across the country.”
Provide funding for physician leadership training. “Am I pleased with what we see here? Definitely not,” Nash says.
Physician leaders need training in quality and safety, a systems approach to healthcare delivery, the application of Lean principles, and other competencies that are not taught in medical school.
In his view, health system CEOs recognize the importance of physician leadership but generally have not allocated resources to adequately train physicians for the bigger roles they are playing. “Therefore, the board needs to be asking: How are we training the physician leaders of tomorrow? It’s so important that this is a governance responsibility,” Nash says.
Nash acknowledges that his CEO to-do list will expand as population health management gains momentum. One of the biggest challenges: establishing and executing an action plan to address factors that, until recently, seemed far beyond a healthcare provider’s purview.
“Leaders are recognizing how inextricably intertwined social determinants are with the health of the population,” he says. “Medical care is 20 percent of the story. The real story is poverty—that’s the critical, most important predictor of health—and other subsidiary issues related to that, including crime and access to food and all the rest.”
That list includes personal behaviors—many of which are tightly related to socioeconomic status—that health systems cannot afford to ignore when they become financially accountable for the health of a population.
Tax-exempt hospitals, required by the Affordable Care Act to conduct a community health needs assessment, are coming to see that this is not just busywork to comply with a regulation. “Last year’s hypertension-screening day in the public park is going to seem pretty rudimentary very soon,” Nash says. “Leaders are hiring all kinds of new people to assess the situation, and they are going to learn pretty quickly how to address these challenges—and it’s going to be complicated.”
Nash serves on a National Quality Forum task force that is creating measures of hospital engagement with communities and will issue a report this fall. “There are many members of the task force who are adamant that hospitals should grow crops to feed the poor,” he says. “That may work in some places. Growing crops at Jefferson would be a big problem.”
As the healthcare industry remakes itself to succeed in the value movement, the roles and responsibilities of its leaders are changing—starting at the top.
Nash sees a dramatic change underway in board structure as clinically integrated networks move to competency-based governance. “We’re going to move from today’s typical hospital board, which may not have a single content expert, to boards with very specific competencies,” he says.
One example: Integris Health, the largest health system in Oklahoma, recently recruited Mark Werner, MD, a Minnesotan who has served as chief clinical integration officer for Fairview Health Services, president of Carilion Clinic Physicians, chief innovation officer for Medica Health Plans, and board chair for the American Association of Physician Leadership.
Moving from a volume-oriented business model to one that rewards value—and penalizes organizations that cannot deliver it—means that a board comprised of local civic leaders with no healthcare experience is no longer sufficient. The senior leadership team needs a new degree of support from board members who have a big-picture perspective on the value journey.
“Recruiters are getting overwhelmed with requests from not-for-profit hospital chains to find board members at the national level,” Nash says. “These big systems know that they have to look nationally to find the board member of the future.”
The roles of healthcare CEOs and CFOs also are changing along with the health system business model. “The blue-and-white hospital sign of the future is going to stand for health and healing, not acute and emergent care,” Nash says. “That’s going to determine the kinds of leaders we are going to need, and they will have a different skill set, for sure.”
As payment reform gains momentum, healthcare organizations will succeed only if their top executives embrace and implement the competencies needed to achieve the Triple Aim, Nash says.
“Improve the health of the population? That involves all the population health management skills, which means formal training in epidemiology and health risk assessment,” he says. “Reduce per capita cost? That’s all the systems thinking about efficiency, reducing unexplained variation. And of course the third part of the Triple Aim is to improve the individual experience of care. That requires understanding behavioral economics and related fields.”
The rest of the healthcare workforce also is redefining roles. The American College of Nurse Executives is developing its own list of population health competencies in recognition of how nurse responsibilities are increasing. Patient navigators, community health workers, and other emerging positions will become ever more important as health systems learn to proactively support a population of patients.
It adds up to the cultural change to which Nash has devoted his career.
“This change management is going to require tremendous leadership,” he says, “So are we training the right kinds of leaders? To me, the rate-limiting step—like in a chemistry equation—is leadership training. Without that, none of the other things can be done.”
Lola Butcher writes about healthcare business and policy topics for several HFMA publications.
Interviewed for this article:
David Nash, MD, MBA, dean, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia.
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