By BETSY TAYLOR
Dr. David Nash
When Dr. David Nash became the founding dean of the Jefferson School of Population Health in Philadelphia, he fielded a common question: School of Population Health? What exactly is that?
Fast forward six years to 2014, and in health care circles population health now is "front-page news every day," Nash said. The focus comes at a time when the nation is revamping how it provides health care. "We're going to be practicing a new type of medicine, and that medicine is called population-based care," he said. Population-based care includes the recognition that social determinants of health — factors such as poverty, education, crime, geography and pollution — drive a significant part of society's health outcomes, he said.
That reality, he said, should resonate with many CHA members who know from their work that includes care for the poor and underserved that, "regrettably, the poor are sicker, and they're sicker because they're poor." Population-based care calls for medicine to have a greater impact on a larger number of people than it has in the past. It means that health care systems have to allocate resources differently, with a greater focus on efficiency and evidence-based practice, he said.
Nash will be a keynote speaker at the Catholic Health Assembly from June 22-24 in Chicago. Nash, a M.D. with a M.B.A., is known for his work in outcomes management, medical staff development and quality-of-care improvement. He repeatedly has been named to Modern Healthcare's list of most influential figures in health care. Nash writes a blog and has written more than 100 journal articles and edited 22 books, including the most recent, Demand Better! Revive Our Broken Healthcare System. He is editor-in-chief of four national journals: American Journal of Medical Quality, Population Health Management, P&T and American Health & Drug Benefits. Nash's appointment as dean of the Jefferson School of Population Health caps his 20-year tenure on the faculty of Thomas Jefferson University, where he is the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy.
Putting assets to work
As an example of why population-based care is needed, Nash points to Philadelphia. "We have five medical schools in our town," he said. "Yet, if you looked at the health of the counties in the state of Pennsylvania, if you rank them from healthiest to least healthy, Philadelphia County is least healthy. So how do we reconcile that? … How much longer are we going to tolerate that?"
Nash said the nation is spending nearly18 percent of its gross domestic product on health care; however, despite this high percentage of spending compared to other nations, the Institute of Medicine believes Americans will have poorer health and shorter lives moving forward. Nash said as part of practicing population-based care, health care systems will have to spend money more carefully, and health care administrators and providers are going to need educations that stress resource stewardship, communication, leadership and teamwork to improve the health of populations. Many health care systems are focused on using resources wisely and better coordinating of care among providers and facilities as they work to reform patient care.
Time of transition
But everyone is not on the same page. Nash said there is a lack of consensus in the medical community about what specific factors health systems should be looking at to improve the health of their populations. There's also not shared agreement on how populations should be defined, with systems generally defining populations based on the payer, clinicians often defining populations based on disease, and public health experts commonly defining populations based on geography and demographics. Nash said that in the current evolving health care environment, where more providers are open to risk-sharing contracts with insurance payers, the definition of a population for a health system often is: "who are we economically at risk for?"
There's a change occurring in payment models, away from fee-for-service to population-based payments, through which providers collect a regular, per-person sum to cover expenses for members of a group. Nash said whether these changes happen through bundled payments or accountable care organizations, providers will have the potential to share in savings on health expenditures if these models add value and improve population health. But they also will share in some of the economic risk for larger numbers of people than ever before. Nash said no one knows for sure when payment models for providing health care will experience a broad shift, but he believes the time frame will be "somewhere in the next three to five years."
Population health pioneers
Throughout the nation, there are health care providers that have successfully borne economic risk for decades, such as the Oakland, Calif.-based provider and not-for-profit health plan Kaiser Permanente, he said. He cited a number of multispecialty group practices and health care systems that have done well with at-risk contracts, including The Everett Clinic based in Everett, Wash., and Baylor Scott & White Health in Dallas. "But their whole delivery system is organized in a population health framework. The doctors are employees; the pharmacists are employees; the nursing home is directly connected to the institution itself, or at least economically connected. The typical American community hospital has none of that, and is not organized to practice population-based medicine. It's organized for episodic care of the acute and the chronically ill," he said.
An important aspect of population-based health is working to improve patients' health by getting patients more involved. Nash said technological tools, like apps and electronic messages from health care providers, can help patients better adhere to taking their medications properly. More needs to be done to get patients engaged in their day-to-day health and fitness, he said. Economic disincentives could motivate patients to change unhealthy behaviors, he said. For example, job seekers might be more likely to quit smoking if more employers refused to hire smokers.
Nash said resistance to population-based care persists, from those who work for health care systems and facilities not designed around population-based care to health care providers, including physicians, many of whom trained under a model that placed great emphasis on professional autonomy, sometimes at the expense of communication and teamwork skills.
"I have a pretty provocative view here, so hold onto your seat. Basically, survival is at stake. The status quo is untenable," he said. He added population-based care may not be the only solution to reforming health care in the U.S., but he said there is research to support his position that changing economic incentives and aligning them with the needs of patients will "go a long way to fixing what's broken."