Dr. David Nash, Founding Dean of the Jefferson College of Population Health on Primary Care, Leadership and Quality Improvement

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Marianne O'Hare : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation , health policy , care delivery , and the great minds
who are shaping the health care of th e future.

This week , Mark and Margaret speak with Dr. David Nash, Founding
Dean of the Jefferson College of Population Health at Thomas
Jefferson University in Philadelphia. He's a renowned expert in the
growing discipline of population health, which seeks to empower
primary care through better pay incentives for clinicians and
leadership training that focuses on team based care delivery, all to do
a better job of preventing illness across populations .

Lori Robertson also checks in , the Managing Editor of F actCheck.org ,
look s at misstatements spoken about health policy in the public
domain , separating the fake from the facts . We end with a bright idea
that’s improving health and well - being in everyday lives. If you have
comments , please e - mail us at [email protected] or find us on
Facebook or Twitter or wherever you listen to Podcast and you can
also hear us by asking Alexa to play the program Conversations on
Health Care . Now , stay tuned for our interview with Dr. Dav id Nash on
Conversations on Health Care .

Mark Masselli: We’re speaking today with Dr. David Nash, internist and Founding
Dean of the Jefferson College of population health. Dr. Nash serves as
Principal Faculty member for quality of care programming at the
American Association of Physician Leadership and serves on the
national quality task force on improving population health. He's a
distinguished fellow of the American College of Physician Executives
and frequently named to modern healthcare's list of the m ost
powerful persons in healthcare here. He earned his MD at the
University of Rochester, his MBA from Wharton School of U Penn and
completed his fellowship at the Robert Wood Johnson Foundation
Clinical Scholars at the University of Pennsylvania. Dr. Nash, welcome
to Conversations on Health Care .

Dr. Nash: Thank you. Great to be here.

Mark Masselli: Well, I think some people say you're the dean of population health ,
I'm wondering if you could just share with our listeners your definition
of population healt h , and why is it so essential to improving health
outcomes across the country?

Dr. Nash: Sure. So Thomas Jefferson University now has 10 colleges , we’re the
youngest of the 10 colleges that make up Thomas Jefferson
University. When I came to Jefferson 30 y ears ago as assistant
professor of medicine, I spent 18 years on the campus of the medical
school . In 2003 , as the Chairman of a Medical School Department, we
modeled that department of health policy after Mark Chast a in's first

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such department at Mount Sin ai Medical School , a nd of course Mark
is now the President of the Joint Commission. In 2008 , the Board of
Trustees of the university , voted to create the College of Population
Health and we opened the doors on September 0 9, 2009 . So
population health, I th ink we like to give credit to Dr. David Kindig, our
colleague in his 2003 paper , 16 years ago, David called for an
understanding beyond public health and labeled it population health
that basically said, hey, public health is wonderful but it's too narrow
and population health takes into account , are we delivering the care
in a cost effective and safe manner?

Population health is the roof of the house and the house is supported
by various pillars ; t he central pillar , being public health , and then
health ec onomics, quality and safety and health policy. So we're the
first such college of its kind. There are now more than a dozen
colleges of population health in the country.

Mark Masselli: Well, that's great. One of the things that I note about the Affordable
Care Act is that it's done so many great things.

Dr. Nash: Indeed .

Mark Masselli: About 20 million Americans are covered by it, but there have been
other benefits in addition to access. Walk us through the intersection
of how the Affordable Care Act has he lped building this community of
people who are focused in on population health ?

Dr. Nash: So as Speaker Pelosi so aptly put it, we'll figure Obamacare out after
we pass it. No, so we're, we're still working on it, but the essential
message i s of course, ro ughly 20 million American citizens now have
access to health insurance, therefore access to primary care and
beyond. As best as we could tell research from very good people , t he
bill has saved lives and I think we could all agree to that. But to your
quest ion, the bill has also created the patient centered outcomes
research institute, it created Accountable Care Organizations , i t
created an effect bundled payment. Most citizens who look at the
evidence would agree that Obamacare is a major step in the right
direction . From a population health perspective , certainly when we
got board approval in 2008, we never could have dreamt that less
than two years later the nation would adopt Obamacare, which was
sort of a rocket ship to blast off the better understandin g of
population health. I think Obamacare recognizes that if we reduce
waste, that's good for everybody , l et's try to expand coverage. I
mean, it's doing all these things at the same time and I think it's
central to our mission to promote universal coverag e and universal
access.

Margaret Flinter: Dr. Nash, we've spent a lot of times since the passage of the
Affordable Care Act looking at our health care system. When we look

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at the rest of the world, how we do our health outcomes may be still
leaving quite a bit to be desired. If you look at those comparisons,
almost always you find out that there's a bigger investment upfront in
primary care in population health. Maybe sh are some examples if you
can , w hat countries are really executing on this idea of gettin g the
highest value care and through a focus on primary care.

Dr. Nash: Well In most of the Western world, all of whom have better outcomes
at a lower cost than us , t here are typically three primary care doctors
for every specialist. And of course in the U nited States, three
specialists for every primary care doctor, countries that have primary
care at the very center of the system have better outcomes, less
waste, and are much safer. We're not in the top 10 of any measure of
health outcome despite spending , you know, one and half times our
nearest rival, roughly $10,000 per person. So I ask everyone, do you
believe your family got $10,000 of value out of the health care system
for every singl e member of your family in 2018? I've yet to have
someone say, o h yes, it's been a great bargain. So the entire civilized
Western world, as we know it achieves far more with fewer dollars
than we do. One of the key attributes that they all share is the
emphasis on primary care. How many more papers do we need that
says p rimary care is the answer ?

Margaret Flinter: Well, we think a lot about that here in our organization about the
shortage of primary care clinicians. There are solutions. Certainly we
have a 50 year history of nurse practitioners e ducated and prepared
to be primary care providers but too often still not recognized as
primary care providers. Certainly Telehealth , in cluding Telemedicine ,
is going to make a big difference for patients and maybe solve some
of the geographic and the rural mal - distribution issues that we have.
And of course there's the holy grail of making our Electronic Health
Records more interoperable , more friendly. Take any of those
emerging trends and how are they -- ?

Dr. Nash: Yes. Good. How will it all help? Yeah . So let, let's start with m edical
school education. I've been inside the belly of the beast for 30 years.
I've mentored, I mean literally a thousand medical students because
Jefferson Medical College is so large. So you know , Paul Batalden said
it right, Margaret, “ Every system is p erfectly designed to achieve the
results it gets ” , right? So if medical students see that the ologist has
all the prestige, they will want to become an ologist when they see
the implicit culture that rewards the specialist in the training
environment.

So step one, change the training environment. So t w o , financially
reward primary care in part let's do loan repayment, less of an
inequality between super sub - specialist income and primary care
income. I won't give away the store here, but in the faculty prac tice

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plan, average annual, total salary x and 15 x, s o you know who's the x
i s and you know who the 15 x i s. Well to me that's unconscionable and
we need to do way more to promote folks who are at the primary
care x level.

Next step is to let folks work to t he top of their license. You know,
regrettably in my travels to this day, it is not unusual for me to have a
physician come up to me face to face to say , there's no such thing as
physician leadership. We could do a lot more to teach physicians to be
the te am quarterback and primary care could all be about a big team
sport. All of that as a major cultural shift, but we have to start some
place to really implement this kind of dramatic change in making
primary care and care coordination the center of who we a re and
what we do.

Finally, of course, change the payment model. We know that
especially primary care doctors will make traumatic changes in their
clinical behavior for modest increases in marginal income. I'm all in
favor of a bundled payment for congest ive heart failure a s a really
great example putting care coordination, primary care doctors , and
our cardiology colleagues in the center and paying us to go upstream,
shut that faucet instead of mopping up that floors.

Mark Masselli: We couldn’t agree with you more.

Dr. Nash: Well thank you.

Mark Masselli: We're speaking today with Dr. David Nash, internist and Founding
Dean of the Jefferson College of Population Health . Dr. Nash is not
only an expert in population health, but is also active in leadership
d evelopment in health care . We just had on a little while ago your
CEO at Jefferson Health, Dr. Steve Klasko and talking about his vision
for health industry leadership for the 21st century and he says it's a
model built to support team - based care . You did note it was a team so
that everyone in that team can practice up to the top of their license. I
know that every member wants to have an equal voice in there , w hat
are some of the other strategies that you're developing? It takes a n
entire team to work with the patient , y ou know in particular with
population health, we're so much of the intervention is outside of our
four walls. What are you doing to cultivate this opportunity?

Dr. Nash: Let me give you two specific examples , and perhaps Dr. Klasko talked
ab out one of them. So Steve Created the Jefferson on Board
Leadership Training or JOLT , and everything here has to start with the
J , so i n the previous 25 years that I was here there was no leadership
training program was sort of absurd. So JOLT takes the em erging
leaders from across our enterprise , now 16 hospitals, 10 colleges ,
brings them together every month for a year to give them leadership
training, skill building, communication skills, quality improvement

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skills, and all the rest. A program that we cr eated , we ’ve got the board
of trustees in 2014 to mandate that every clinical department in the
medical school must train at least one faculty member to be an expert
in quality and safety. We've now subsequently dubbed this QIPS and
our college is now runn ing and implementing QIPS for the enterprise,
working with a handpicked group who will have a certificate in quality
and safety as another example of training emerging leaders.

JOLT and QIPS , two steps in the right direction , we still have a long
way to g o. If it were up to me, I would have every medical student
read Peter D rucker and John Kotter and all the rest because that's
what makes or ganizations great and enduring.

Margaret Flinter: We're very focused on training the next generation , and the ability to
lead a team is something we expect of everybody who is an emerg ing
leader in the organization.

Dr. David Nash: Wow, well , to your credit .

Margaret Flinter: One of our approaches is that it really has to be interprofessional
training. Everybody has the potential to be a leader of the team or the
practice , t ell me what your experience i s and what you're learning
about training leaders in a n interdisciplinary interprofessional way to
be able to pass that leadership role kind of back and forth among
people to have different people taking those roles , I know the folks
out in Minnesota have been doing a lot with this, but we'd love to
hear what your experience i s at Jefferson .

Dr. David Nash: Great. We share space on this floor with probably one of the nation' s
top five centers for interprofessional education called Jefferson
Center for Interprofessional Education. It has a physician and
pharmacist, co - executive director. I'm a fan, but I also am a healthy
skeptic and here's why , t he trainees ; medical students, nursing
students, pharmacy students are very rarely in the same room
together , and that is a huge challenge. It's because of accreditation
and other issues , s o yes, I'm well aware of the progress in Minnesota
and elsewhere. On the other hand, are we colle ctively in the
classroom really working in an early stage together? Very, very
modestly.

More importantly, I think is at the bedside , h ow does the team
function? Is there equity in the views? Are there pharmacists
embedded with the house officers ? Are the nurse practitioners called
upon ? I think there are baby - steps everybody could take that would
go a long way to improving this, but this is an uphill battle. Again, it's
all about the culture. When you come and you make grounds in a
place like ours, it's p retty clear who's who and who's in charge. If we
could improve upon the leadership training so everybody feels like
they're participating and it's pretty clear that we're better together

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than we are individually. That'll be a b ig step for physicians anyway ,
e verybody wants to be a quarterback. Can you imagine a football
team of all quarterbacks? Well, that would be a problem. That doesn't
win a football game.

Mark Masselli: Well, Dr. Nash speaking of uphill battles , I want to sort of connect two
points that you've made. The difficulty of shifting culture and the
other for our country to promote more value based care. We had the
opportunity, Margaret, the other day to have Leah Binder from
Leapfrog r eally just talking about the -- I think the good news that
t here had been a slight reduction of the number of preventable
deaths in hospitals , but it was still up at 160,000 , it was still 500
people a day. So talk about how we're going to make this shift --

Dr. David Nash: I wonder if our listeners know right in th e same building where I'm
sitting is the D ean in charge of the Physic ian Assistant Training
Programs. Training in quality and safety is mandatory for physician ’s
assistance . If the public knew that no such mandatory rule exists in
medical education, what d o you think their reaction would be?

Margaret Flinter: I’m not sure I’ll do that.

Dr. David Nash: Right , and imagine if you were the Chancellor of the University of
North Carolina and you woke up last week and you saw that front
page, New York Times story where doctors feeling so compelled that
they surreptitiously recorded the meeting of the quality committee
because they were so concerned of what was happening to those
children in that open heart surgery program. It ’ s 2019 , let's get on
with it. I have be en for 30 years unwavering in total transparency as it
relates to outcomes and error reporting. We wrote about this in JAMA
in September of 1991 so, you know, I'm very disappointed we haven't
moved this ball as far down the field as I would like. Then to s ee a
headline like that, imagine being at UNC -- o h, and how about
Jacksonville Children's Hospital just two months ago , and h ow about a
major hospital in Texas? We could go down the list. What do you
want to take out of the curriculum? That's what most me dical
educators ask me. Should we throw out the heart and then we could
put in quality, this is what I get asked all the time.

Margaret Flinter: That conversation goes on in all sorts of disciplines, yeah.

Dr. David Nash: In all in every place.

Margaret F linter: I think the --

Dr. David Nash: Systems training, that's what we need.

Margaret Flinter: Yup. Hearkening back to Mark's comments about Leah Binder , I think
that show sent a lot of people back to looking at their states. But
when you know that your o wn state is rated for safety, you compare

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hospitals, people started asking a different set of questions and
people I think want their hospital to be successful. They want
everybody to have an A rating.

Dr. David Nash: I can't help but re member , w e're comin g up the August 14, 1991 issue
of JAMA, our team here in Philadelphia and our colleagues at
Dartmouth, the two lead papers, a little known Harvard p ediatrician
wrote the editorial Don --

Margaret Flinter: We know who .

Dr. David Nash: And Don said to admit that you could do a better job as an expert
makes you vulnerable.

Margaret Flinter: To err is human, absolutely.

Dr. David Nash: We're publishing a special issue to speaking of that, of our journal, the
American Journal of Medical Quality , c ome September o f 2019 , we're
going to have a 20th anniversary issue. We went back and we looked
at the top articles in our journal in the last two decades that most
referenced. It's fascinating to see , so on a good day I feel like we have
made some progress with lots of help of course. And then there are
days I think University of North Carolina what’s it all about .

Margaret Flinter: We've been speaking today with Dr. David Nash, Founding Dean of
the Jefferson College of Population Health. You can learn more about
his wor k by going to jefferson.edu/population - health or follow him on
Twitter at @nashpophealth. Dr. Nash, we want to thank you for your
groundbreaking work in advancing population health and for joining
us today on Conversations on Health Care .

Dr. David Nash: W ell, thanks for having me. I really appreciate it.

[ Music ]

Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journa list and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. politics.
Lori, what have you got for us this week ?

Lori Robertson: The Measles outbreak in the United States and around the world has
sparked misinformation on social media. One false Facebook meme
blamed illegal immigration from South America, but the virus was
eliminated across both North and South America in 2016. The recent
outbreak is due largely to inadequ ate vaccination rates in some
communities . Measles was eliminated in the United States in 2000
and as mentioned from the entire North America and South America
continents six years later . Elimination means cases can still occur, but

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that the disease hasn't been continu ously spread for a year or more.

Recently the virus has been brought into the U.S. by people who have
traveled to places where there is an outbreak or where the disease is
still common, such as parts of Europe, Africa, Asia, and the Pacific.
From those travelers , the disease can then spread in U.S. communities
that have unvaccinated people.

The measles outbreak in New York City, which started in 2018 and
spread in the orthodox Jewish community, was brought on by
travelers who had been in Israe l where a large outbreak is occurring.
The CDC has said , this year marks the largest number of measles cases
since the disease was eliminated in the U.S . It said , misinformation
about vaccines was “ a significant factor contributing to the outbreak. ”

Simil arly the Executive Director of UNICEF and the Director General of
the World Health Organization issued a joint statement that cited
online misinformation about vaccine safety as a contributing factor in
the rising number of measles cases in high and middle income
countries , and that's my fact check for this week. I'm Lori Robertson,
Managing Editor of Factcheck.org

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Pu blic Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com , we'll have
FactCheck.org's Lori Robertson check it out for you here on
Conversations o n Health Care.

[ Music ]

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Asthma is one
of the leading causes of trips to the emergency room for children and
there are of ten a correlation between high density low income
neighborhoods and more trips to the hospital for treatment and
intervention. When officials at Boston Children's Hospital noticed a
spike in asthma outbreaks in certain neighborhood clusters , they
decided t o do something about it. They launched the Community
Asthma Initiative. They realize d that if you could treat the
environments in the patient's home that might reduce the need to
treat the patient in the emergency room.

Dr. Wood: The home visiting efforts work with children and families that have
been identified through their hospitalizations emergency room visits
of having poorly controlled asthma and also it's a teachable moment.

Mark Masselli: Dr. Elizabeth Wood heads the program and says the first step is to
identify the frequent flyers. Then they match with the community
health worker who visits their home several times and assesses the

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home for asthma triggers .

Dr. Wood: And they work on three areas ; u nderstanding asthma itself,
understanding the medic ations and the need for control medications ,
and then working on the environmental issues.

Mark Masselli: Families are given everything from HEPA filter vacuum cleaners to air
purifiers. They are told not to clean with certain toxic products and
the homes are monitored for the presence of pest or rodents.

Dr. Wood: What's remarkable is that there was a 56% reduction in patients with
any emergency department visits and 80% reduction in patients with
any hospitalization .

Mark Masselli: The Community Asthma In itiative , a simple re - shifting of resources
aimed at removing the cause of disease outbreaks in the community ,
leading to healthier patient populations , n ow that's a bright idea.

[ Music ]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: I'm Margaret Flinter.

Mark Masselli: Peace and health.

Conversations on Health Care is recorded at WESU at Wesleyan
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