As part of Pearl Health’s Drive for Better Care, we recently had a chance to sit down with Dr. David B. Nash, Founding Dean Emeritus at Jefferson College of Population Health and one of Pearl Health’s Top 50 Value-Based Care Thinkers of 2024. A board-certified internist, Dr. Nash is internationally recognized for his work in public accountability for outcomes, physician leadership development, and quality-of-care improvement.
Join us as we discuss the intersection of population health and value-based care, how to improve support for primary care physicians, lessons from COVID-19, innovative breakthroughs on the horizon, and more.
Michael Kopko: I’m very excited and honored to be here with Dr. Nash, one of Pearl Health’s Top 50 Value-Based Care Thinkers, today. We’re here in Philadelphia, at Jefferson. I’m really excited to share with everybody a little bit about your story. You’ve been the dean of Jefferson, you’ve been on many boards, you’ve helped shape many quality programs. I’d like to start with a brief introduction about you and some of the things you’re most proud of that you’ve spent your time and your career on.
Dr. David Nash: Sure, Mike, and great to be here. Thanks for making the trip. We’re sitting three blocks west of the founding of our nation. So Independence Place, Liberty Bell, Constitution Hall, and we’re coming up on a pretty important holiday, right? July 4th. Philadelphia, we like to think, is the founding city of America, and I’ve had the privilege of being here on our campus at Jefferson, at the Center City campus for the last 34 years on the full-time faculty. I’m wearing a pin to recognize the 200th anniversary of Jefferson Medical School. And I’ve been here for about one sixth of the entire time, which is a little crazy. It’s been a fantastic journey. And I did have the privilege to be the founding dean of America’s first college of population health. Not public health, but population health.
We opened the doors to the college on September 9th, 2009, easy to remember. And, at that time, there wasn’t even a textbook available on population health. So, over the last 15 years, we got the school off the ground. We now have a new permanent dean. We got our Scholarly Journal, Population Health Management, which just celebrated its 25th anniversary last year. We have our book, Population Health, Creating a Culture of Wellness, soon to be in its fourth edition. So, look, I’ve really had a ringside seat for all of this, and that’s big, really important to me personally and, you know, selfishly a part of my legacy that I like to think about at Jefferson. But the most important part of all this is all of the students, doctors, nurses, and pharmacists that I’ve had the privilege of teaching and working with.
Let me give you one example. So one of the other things I’m known for nationally is my work with the American Association of Physician Leaders, AAPL. It used to be called the American College of Physician Executives. In any event, I’m the oldest living, working, national faculty member for AAPL. And last summer they created a prize for me, the Inaugural Lifetime Achievement Award. Basically, who’s still around that is working for us. And it was a big deal last summer, going to Chicago and giving a valedictory talk to all of my colleagues. But it turned out, we did a little arithmetic, and here’s the punchline. For AAPL, I taught 6,000 doctors face to face over my 30 years with them. So, I mean, basically, Brent James and Don Berwick got me, but I’m like number three. Which is pretty cool. So, you know, great, great to be here. I believe in the mission of Pearl, and in my post-deanship life, for the last five years, I’m still on the Grandon chairing on policy.
I get to work on the things that I have a lot of passion for, and among those things are still improving quality and safety. That’s still our top job. And the second job is to reduce waste and improve health, most of which we’ve done a pretty terrible job at. So Pearl is part of the solution, and that’s another reason I’m so excited you guys are here.
Michael Kopko: Well, we are as well. We’d love to dig in, starting with population health—why is it so important? What is the core discipline of it? What is it when it’s working well?
Dr. David Nash: Great question. So let me go back to 2008. It’s a long time ago, 16 years ago, right around this time of year. The university, Jefferson, was in the midst of a strategic planning process — like all universities, you get a new president, you gotta have a new plan. So a strategy across the entire campus was implemented and a search to figure out what will be the educational needs of the next 10 to 15 years in our industry. And I gotta give credit to Former President Robert Barchi of our university, the board, who said in 2008: hey, we need a new kind of leader. And we need a new term to describe the scholarship to help create these new leaders. So all of this came together using a term, as it turns out, that we found in the literature from a long time pal of mine, David Kindig, who in 2003 wrote a paper that said: hey, public health is super important, but I, David Kindig, have a new term I want to put out there called population health.
Population health says, essentially, that all of the cornerstone public health issues, clean water, vaccination, reduced pollution, all of that is super important. But, it doesn’t really take into consideration the economics of healthcare, or the quality and safety of healthcare, and most importantly, doesn’t really recognize how important the moral determinants or social determinants of care are. Meaning, it’s all about your own behavior, education, or lack thereof, and poverty. So population health says public health is still at the center of what we do, but we gotta think about what are we doing, what does it cost, and despite our best efforts in a city like Philadelphia, with five medical schools, the health of our population in this county ranks dead last in the state of Pennsylvania.
So what’s population health? It’s figuring out this mess. And explicit recognition that sadly, in our great country, if you’re poor, you’re sick. You have poor health. And the reasons for that are legion, having to do with lack of access, no primary care doctors, structural racism, redlining. I mean, it’s decades worth of stuff that goes into why the poor have poor health. And then finally, only in America, whatever your politics, if you’re in a red state, you’re even less healthy than if you’re in a blue state. So no other Western developed country has all of these issues. Insummary, population health salutes centuries of public health work, which is still critically important. And we add on health economics, health policy, quality, safety, social determinants, all of that stuff. And that’s what the college originally was all about. And under a new dean and new leadership, they’re taking this to the next level.
Michael Kopko: Wonderful. Let’s align on one more term from Michael Porter, and then I want to get into how we drive this better system that you spent your career on. How do we relate population health and value-based care? How do you think about those two different jobs?
Dr. David Nash: Porter is an incredible guy, of course, and I would add in there the triple and quadruple aim from Don Berwick, another great thinker. So, look, here’s some additional sad reality: we’re spending roughly 4 trillion a year on healthcare services. Let me put it in a way that most folks would get their arms around. That comes down to $10,000 per person, including children, on an annual basis. While at the same time, pre-COVID, 2019 dollars, we’re spending $400 per person on the public health infrastructure. $10,000 versus $400. So, no surprise, and we’ll get to it in the book, we talk about how COVID crashed this system. We knew exactly what was going to happen, that it would crash and burn. So, despite the 4 trillion dollar spending, here’s the punchline: about a quarter of that is of no value and dangerous, and duplicative, and wasteful.
So population health explicitly says, look, let’s take that trillion dollars of waste and figure out a way to transfer those resources and put them to better use. A good part of my own personal work and especially in the leadership training with doctors is my long-held belief that the only people who can fix this are folks like you and me. Do you want Uncle Sam telling you how to fix healthcare? Or your state representatives? You get it, right? So we’re all about finding a way to work together to be more efficient, practice based on the evidence, and reduce the waste so we can take those resources and apply them to prevention, to nutrition, to exercise.
Ultimately, there are two ways to summarize all this. We’re going to believe in two key things. We’re going to go upstream and shut the faucet instead of mopping up the floor. Meaning, let’s not build another bariatric surgery center for obese, poor children in Philadelphia. Instead, let’s go upstream and figure out the fact that they have poor nutrition because there’s no food in the food deserts where they live. That’s a great example. And the second example, which is something we copyrighted 10 years ago, is that we got to change the payment system. The easiest way to explain that is our four-word saying: no outcome, no income. Now, not that you’re not going to get paid, but let’s pay people in our industry for doing a better job. And that better job includes being safer and reducing waste. You know, any knucklehead can reduce cost. That’s easy. Cut a program, fire these people, shut that hospital. I mean, you don’t have to have any medical training to cut costs. The only people who can reduce waste are the folks who write the orders. So, you know, reducing waste is a professional obligation for doctors, nurses, pharmacists, and everybody else in our industry. That’s how we view it. So, go upstream and shut the faucet, first key. No outcome, no income, second key.
Michael Kopko: Love that. Great vision. We’re totally aligned. Let’s talk through what are some of the breakthroughs that you either see coming or could be coming to help clinicians achieve that outcome?
Dr. David Nash: I can think of maybe two or three things and maybe breakthroughs are a little dramatic, but I get it. Despite all of the challenges with electronic medical records and folks going home at night to finish all theirs, look, what the EMR has done to provide an instantaneous profile of physician practice behavior. Look at the work of people like Atul Gawande, Peter Pronovost, Bob Wachter, you know, the whole amazing crew that I’m grateful to be a part of. What these leaders have helped us to understand is that there’s a normal distribution of doctor behavior and it’s a bell curve. 10 percent of primary care doctors are knocking it out of the park. They get great patient satisfaction scores. They’re great diagnosticians. They’re efficient. They don’t waste resources. That’s 10 percent. 80 percent, like yours truly, are doing the best we can. And then 10 percent need remedial help.
So what can we do with that 80 percent? So one breakthrough is, well, let me see how I’m doing relative to a peer group. So get me the data, whether it’s through an EMR or clinical decision support tools or other tools that are out there like Innovaccer and other great companies that are trying to give people good information, actionable information as to how they can improve. Let’s make a list. Is it a generic drug prescribing? Is it appropriate therapy for congestive heart failure? You don’t seem to know what you’re doing when it relates to type one diabetes. So breakthrough one is better information delivered in a timely, non-punitive way. That’s huge. None of that existed when I trained, but for my physician wife and me, our doctor daughter, she grew up with all of this. She gets it: report cards, closing the feedback loop, giving her good information is part of her DNA. So that’s one. I think the second breakthrough is a conceptual one, and that is the idea that, and I’m smirking because, you know, I never trained this way, but poverty means you don’t have good health. Hello? Right?
Let me give you a concrete example. Sad as it is. So look, I was in primary care practice for 30 years. I could tell you and our listeners, I never once asked a patient: you have any food in your refrigerator? I mean, it’s sad to think about. Was it very expensive for you to drive here and park at our beautiful downtown facility? I never once asked that question. Why? Well, I was trained that patients are lucky to get to see me. Why? Because I’m great. And since there’s no prevailing evidence to the contrary, and no benchmarking, and no data about my performance, I believed everything they told me, because training was all about autonomous decision making. So breakthrough two is, hello, those social determinants, your zip code is more important than your genetic code. And your credit score is going to tell me a whole lot more about your behavior than anything I learned in medical school. That’s breakthrough two. And breakthrough three, which, you know, Mike, I’m hoping I’ll be around to see. Breakthrough three is going to be the application of neural networks and artificial intelligence beyond machine learning. You know, machine learning is ultra cool — radiology, mammography, all of that — but we’re at the precipice of going way beyond that. I think the best example I could give is again, a personal story. So you know, CHAT GPT 2.0 took the medical boards and got an 85, that’s seven points better than me. So I think that’s going to be breakthrough number three.
Let’s summarize. Recognizing that we’ve got data now to really drill down deep into doctor performance, that’s one. Two, we have the understanding of the role of the social determinants of health, a big part of what Pearl is all about. And three, we’ve got on the near horizon, not just clinical decision support, but enhanced capabilities with now publicly available, not very expensive, Chat GPT 2.0, 3.0, soon, 4.0. Very powerful stuff. I’m reading Tom Lowry’s book, Bobby Pearl’s book. These are great thinkers who are really in our industry and who really understand and cut out the jargon and are giving us, I think, a roadmap for where and how we’re going to use AI in medicine.
Michael Kopko: It’s a very compelling vision, I believe it’s on its way.
Dr. David Nash: Yeah, let’s just hope I’m around to see it. That’s my biggest concern right now.
Michael Kopko: So you mentioned primary care a couple times. You’re a primary care provider as well.
Dr. David Nash: Yes, I am indeed a primary care general internist, a dying breed.
Michael Kopko: Yeah, so I’ve seen you’ve written about burnout. You’ve written about some of the issues. It’s a tough time to be in primary care. What do we need to do to keep folks in the game? And what do we need to change to make sure that the game’s attracting talent because one of the problems — as you well know — is specialty and other roles really get compensated properly. And so you have this challenge of where does the talent want to go in the first place?
Dr. David Nash: All right well, buckle your seat belt, ok? So, we got to look at it over the spectrum of training and I’ll give you the milestones, but it’s a great question and I have some pretty strong beliefs here, supported by a lot of research evidence. So, people come to medicine for all kinds of reasons, good, bad, indifferent, but mostly good. The envy of the world is still American medical education. No question about it. But when you come to a traditional medical school, so let’s say roughly 150 allopathic med schools in America, probably 120 of them are pretty traditional. So the whole idea of, you know, memorization and you better be good at chemistry and biology and, by the way, we’re taking mostly undergraduate science majors, and there’s no special test for empathy, and yes, your grade in organic chemistry, even in 2024, is still important. This is ridiculous. Because we have solid educational research showing that none of that stuff matters. You look at the Mount Sinai experiment over decades. The punchline is: when kids get a traditional UME undergraduate medical education and they finally get into the clinical component, what do they see?
They see a reward system where the folks who are super specialists, many of my good friends, reap all the rewards, and these medical students are smart critters. They look around the socialization process, and any normal person would say: well who gets the rewards and who’s the lowest person on the totem pole? So then I’ll ask you the rhetorical question. You want to be the lowest guy or gal on the totem pole? Certainly not. Especially after you busted your butt to get to med school, which is super expensive and stressful. That hasn’t changed, by the way. So, part one of the primary care challenge goes all the way back to day one of medical school. Because, what’s the mission, right? Some med schools are built to create the Nobel Prize winners of the future. Some are built to create community practitioners and look like the communities that they serve and everything in between. So American UME is a very heterogeneous thing. But the thread that connects it all is still autonomous training, individual decision making, and the lack of systems thinking. So it’s all about the idea that doctors are in charge. If it fails, it’s you. If it’s successful, you’re a genius. That’s absurd in a complex system in America’s biggest business. All right. That’s UME. Great. Then we moved to GME graduate medical education and their super competition for dermatology, orthopedics.
And let me give you my personal reflection, having been on the faculty here for three decades. Sydney Kimmel Medical College, a great medical school, 200 years old, is one of the largest private medical schools in America with the largest alumni, living alumni, practicing alumni group anywhere. So I have personally mentored hundreds of medical students, in part because of my interest in being at a big place like this. So I have three decades of experience that say, to your point, sadly, and your question, specialization is more important to these learners than ever before. The system pounds out of them the notion that there’s anything more to primary care beyond just coordination and being the quarterback, or worse, the gatekeeper. And the reward system is tangible. You could almost taste it. It’s so powerful. GME perpetuates that. Okay, so we’ve got UME, GME, and then the final piece, practice. Most specialists are not participants in any kind of value-based care arrangement. As Pearl and our listeners know, capitation, global payment, bundled payment, aligning economic incentives — none of this typically affects specialists. Now, of course, there are exceptions, right? So, the Oncology Institute and a handful of other things in cardiology, oncology, maybe some orthopedic bundle payment stuff that still exists. The kidney folks, nephrologists tried this and it didn’t work. So, the final piece — UME, GME, and practice — the practice piece is still all about: I’m a super specialist expert with a narrower focus and I expect rewards to come from my expertise. And again, look, these are some of my best friends. I’ve been the beneficiary personally from great, high technology care. I’ll give you a personal example: last fall I had my second spinal fusion surgery. Not something you’d ever want to do if you didn’t have to. I’m grateful for people like Jim Harrop and his team. But I also had access to inside information about where to go, who ought to do it, how to get the best care. Despite all that, you still could be subject to medical error, a post op infection, all kinds of things if you’re not as well informed.
In summary, it’s still all about aligning those economic incentives and changing the culture so that primary care folks are not just the gatekeeper or the care coordinator. They’re central to improving health. So, sadly, to answer your question finally, I think we’ve lost our true north, to borrow a phrase from a great book. The true north is improving health. Well, darn. When you look at the data, we’ve done everything but that. So, heart disease, cancer, stroke, COVID, medical error. That’s what kills Americans today. And our life expectancy is in the wrong damn direction and worse than in any other country that we would like to compare ourselves to in the western developed world. For the greatest amount of spending. I don’t get it. That is what our work is all about. Trying to sort that out.
Michael Kopko: Yeah, I think, I think a lot of people still don’t get it in the sense of it’s a problem that’s been ongoing. And it’s an issue that’s been with us for a while. You mentioned a little bit about the role of the private sector, the role of government. As an educator, as a practitioner, how do you think about the proper way to engage government policy and, to the extent you’ve thought about ever influencing it, how did you do that?
Dr. David Nash: Yeah. Great. It’s a tough question. So let’s go back to March of 2010, and, whatever your politics, President Obama gets Obamacare passed. And for the first time in modern medical American history, we have universal coverage and universal access. Not single payer, but we have access and coverage. What does the data show since March of 2010? For our college, it was a big deal, it was a rocket booster to population health and the growth of CMMI and ACOs and all the rest, and more broadly, it got us on the road publicly to saying everybody ought to have access to pretty good coverage and a primary care doctor. Have we achieved the full vision? No, but there’s no question that the research evidence shows we’ve reduced mortality, we’ve improved access for people of color and in certain disease categories, we’ve made some pretty amazing advances. A lot of this is at risk today for all kinds of reasons: increasing costs, post COVID, and all the rest.
I don’t think we talk enough about what America’s biggest and most important business is all about. What’s the business of healthcare? The business of healthcare is to improve health. Sounds corny, but that is not how we actually operationalize it. The business of healthcare in America, even in the not for profit sector, is growth, and making a margin, and reinvestment, and research, and education, and all the multi-part missions of a complex place like Jefferson. Are we spending society’s resources in the best possible way? Well again, it’s a really important and complicated question. My own view — based on lots of work by me and many others — is that saying we certainly could do a better job is putting it politely.
What about your question, for profit American medicine? I’ve been on both sides of the fence. I spent 10 years on the board of Humana. So I got to see how it’s done. I know it’s counterintuitive, but Humana, like all the big for profit insurance companies, is all about spending wisely, improving health, tackling the social determinants, and returning shareholder value. Do you know that Hospital Corporation of America is one of the largest pieces of the puzzle in graduate medical education, with thousands of interns and residents, paid for by Medicare, working in a for profit hospital? So before we start pointing fingers, who’s got the true north, right? It’s a tough question. But, collectively, there’s no doubt in my mind that for leadership of the current system, it’s a wake up call for them. And they know exactly what we’re chatting about here today. They know that we gotta realign economic incentives.
Now to get to the government part of your question. We were very supportive of Obamacare. Whatever the politics, keep that out of it, but who wouldn’t want to see greater access and greater coverage and people of color getting a primary care doctor and somebody paying attention to prevention and getting coverage for colonoscopies and mammographies and all the rest. I mean, that’s an amazing accomplishment. Well, about 50 percent of Americans wanted it to go away, right? Let’s not forget. And people voted against it even though they were on the exchange themselves. I mean, crazy, crazy stuff. So, I believe that CMS and CMMI, and all the commercial payers, know that if you change economic incentives, you will change clinical decision making.
This is stuff the public probably still doesn’t really understand. And the proof of this would fill the conference room we’re sitting in, right? So if you change economic incentives, you will change clinical behavior. The evidence is incontrovertible at this point. The question is, how do you change things for the good? You don’t want to change it so nobody gets any services. But what I would argue is, if you pay people to keep patients healthy, we’re gonna rearrange everything to make that happen. Basic stuff. Let me tell the story. So in all my training, and my experience as a primary care doctor, which I did a day a week, pretty much, maximum, and I did inpatient attending. So I did my part, but I didn’t make my living doing primary care. So I know there’s naysayers out there who, that’s the first thing they’re gonna say. But I’ve been a student of this and a researcher of this for 30 years. So, the way I was trained in primary care was very traditional, UME and GME at great places, Rochester, Penn, and elsewhere. And then in my own primary care practice here at Jefferson over 30 years, I would hear: hi David, here’s your patient list for today. We’re really glad you’re here. Get busy. Do your thing. Wow. So, let’s stop there for a moment. From a systems perspective, that assumes a lot of stuff. That assumes I know what I’m doing. It assumes that people on either side of me and the other examining rooms also know what they’re doing. We hardly ever really talk to each other unless we have a difficult case or a difficult patient, and there’s very little closure of the feedback loop about how we did. That was the pervasive model. Here’s the list. Dig in, get busy. No formal training in health economics, behavioral economics, exercise, exercise physiology, nutrition, none of that. And, selfishly, which I already alluded to, we had the notion of thinking “hey, I’m great, it’s really good that you’re here.”
Then there’s disruptive primary care and there’s 20 companies doing this, and you’re helping other organizations try to get to this, right? So the day starts in disruptive primary care with the question, after an interprofessional team meeting, that says, okay, from our deep electronic medical record knowledge and our AI and our clinical decision support tools: who isn’t here today who needs to be here? Bingo. That’s the difference. And then part two: let’s go get our van to get Mrs. Smith here because her creatinine in the last three months went from one to two to three. Holy moly, we have a problem. That approach differs from how I was trained, which instead asked: is Mrs. Jones here today? Well, in that case, we better check her creatinine, right? And the reason for that was no countervailing economic need to do anything different. But in the disruptive practices, and look, we all know who they are, right? They’ve all been bought and merged: Oak Street, Iora, Absolute.. And now it’s CVS, no more Walmart, but maybe Walgreens, we’ll see. Can they make this happen? The jury’s still out, but if we could organize payment, training, and health services research along the lines of: we’re here to improve health and to tackle the social determinants, guess what? When you give primary care doctors the wherewithal to tackle these tough challenges, burnout decreases. So to decrease burnout, you need to do two things backed by research evidence, not just Nash. One is, I, as a doctor, want to participate in the system of the care we’re delivering. So I got to be part of the decision making. And two, give me as a physician some leadership training so I can actually lead a team. Instead of just assuming that, you know, I survived medical school and residency and I’m automatically a good leader. Which is what we assume today. So, number one, participate in the system. Number two, explicit delivery of training to help doctors be a better team leader. When you ask doctors, they all want to be a quarterback. Have you ever seen a team of all quarterbacks? They wouldn’t do too well. So, That’s the future for me on where primary care has got to go.
Michael Kopko: Great. Let me ask one more question. You recently wrote a book on the lessons of COVID. What’s the big lesson that we all need to have learned from going through a very traumatic, very intense experience? What’s the lesson we can’t forget?
Dr. David Nash: It’s a great question. I wrote “How COVID Crashed the System: A Guide to Fixing American Health Care” along with Charles Wohlforth, my co author, who is an amazing science writer from Princeton. This was my book report on COVID. I was home, petrified out of my mind that our doctor daughter — who was on the front lines of taking care of the first COVID patients at her hospital, not too far from where we’re sitting — was going to get COVID and die. That was my first priority.
But back to the book, here’s the take-home message. In all of human history, when the dying stops, the forgetting begins. I really hope that one and a half million Americans didn’t die in vain. That’s my take-home message. Are we really — as leaders in this crazy system, America’s biggest business — are we going to just forget that one and a half million Americans died and just get on with the usual? Or are we going to refocus, realign, get the resources where they need to go, look at those social determinants? That’s the take home-message of the book.
Michael Kopko: That’s great. As a final conclusion, I know we’ve had a really rich conversation on your views and philosophy. Can you take us back to you as a child growing up: what was it like, and why did you choose medicine as your path?
Dr. David Nash: Okay, you’re really pushing on this. Great. Some of this is in the book, so it’s a little embarrassing. So look, I grew up in a middle, upper-middle class family in a gilded ghetto, on the South Shore of Long Island, New York, in a Jewish family where education was everything. My father was not a doctor. My mother was a schoolteacher and my father was a businessman, but my kid brother and me are both physicians, we’re both married to doctors, we have other doctors in the family, and it was all about assimilation and education.
And so, I don’t know where it all came from, but the only place that I deviated a little bit was thinking: medicine, I get it, but I’m also interested in business. And so I was very lucky to find mentors, even at age 17, who could help me with this idea that I had. My parents are long gone, but a long time ago, I was very lucky to find a mentor at the University of Pennsylvania — Samual P. Martin III — who at the time was super famous and had helped create the Robert Wood Johnson Clinical Scholars Program. I met Sam when I was 17 years old and he had recently been featured in a crazy New York Times article about doctor leaders of the future. It’s totally corny, but my father said: you know, why don’t you write Dr. Martin a letter? Of course, no email, no cell phones, so I sent Sam a letter. He called me in my home on Long Island and he said: get on a train, I’ve got to meet you. And I said: I’ve never been to Philadelphia. How do you do that? So off I went to meet Sam Martin and that was a critical turning point. So what’s the message of this corny story? Mentorship is important, and so is culture and assimilation.
Michael Kopko: This was wonderful. Great to be together. Dr. Nash, on behalf of Pearl, thank you for everything you’ve done.
Dr. David Nash: Thanks, really great.
Michael Kopko: It’s our pleasure.
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