David Nash, M.D., is one of the best-known pioneers in the world of population health management and related areas, in U.S. healthcare. For two decades, he has been leading change, and urging his fellow physicians and other healthcare leaders forward, to transform the U.S. healthcare industry from a volume-based payment and delivery system, to a value-based one.
Dr. Nash, the author of numerous books and countless articles, was named Founding Dean of the Jefferson College of Population Health (JCPH; itself a part of Thomas Jefferson University in Philadelphia) in 2008. He is also the Dr. Raymond C. and Doris N. Professor of Health Policy. He is a board-certified internist who is internationally recognized for his work in public accountability for outcomes, physician leadership development and quality-of-care improvement.
Dr. Nash will be chairing the Eighteenth Population Health Colloquium, to be held at the Loews Philadelphia Hotel in Philadelphia, next week, March 19-21. He and his colleagues at JCPH will be bringing together a host of national leaders in the population health/care management/value-based payment and delivery area, to discuss a broad range of important policy, payment, strategic, and operational topics in that broad area. He spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding the current moment in—and future prospects of—the population health management phenomenon. Below are excerpts from that interview.
David B. Nash, M.D.
Starting at a “40,000-feet-up” level, what would your elevator speech be these days, to explain the strategic and operational landscape around population health?
My elevator speech is that we have to move from volume to value, to prevent the U.S. healthcare system from collapsing under its own weight; and whether the private sector does it first, or Uncle Sam does it first, someone has to do it. And [the path towards a value-based payment and delivery system] is moving inexorably forward.
One of the interesting things about the speeches that were made last week at the HIMSS Conference and elsewhere, by federal healthcare officials, was their stated commitment to compelling providers forward towards value, even as they also support the idea of free-market-driven healthcare change.
And we weren’t at HIMSS, but we were thrilled that Secretary Azar [Alex Azar, Secretary of Health and Human Services] and Administrator Verma [Seema Verma, Administrator of the Centers for Medicare and Medicaid Services] have explicitly embraced value-based payment.
So, I’ve been saying for some time that building the foundation for population health initiatives in the U.S. healthcare system has been a bit like what happened when they built the Transcontinental Railroad in the 1860s, where at one point, people were literally taking pickaxes and breaking ground in the Rocky Mountains in order to lay the first tracks there. Where would you say we are right now in terms of laying the broad foundation or population health management across the U.S. healthcare system?
I would say that we’ve got most of the track laid, and the train is running slowly, and we’re testing the track right now. That’s about where we are with this.
Is there enough of a critical mass of literature now to help guide those who wish to pursue a population health management path?
That’s a great question. We think there’s just enough critical mass now, yes, a lot of it communicated in our Population Health Journal. But the evidence to support the journey, has reached a critical mass, yes. The evidence we’re lacking is the critical timing. But the road to redemption is paved with V-B payment. How fast we can lay that down, now that is a problem.
Do most physicians in practice understand what’s going on now, on a broad level? And where are they in terms of their buying into the reality, and accepting where everything’s headed?
To be honest, I believe it [physicians’ buying into the reality of payment and delivery system change] is breaking down along age-related lines. Physicians 60 and over, and forget about it. Those 45 to 60? They’re grudgingly aware of what’s going on; they’re not really going to dramatically change what they do, but they’ll cooperate just enough to maintain their status. Those 30 to 45? They’re saying, count me in. Of course, there are exceptions in all the age categories; but in terms of broad generalizations, this one holds up.
Inevitably, then, with regard to most of the over-60 physicians in practice, you just have to work around them?
Totally! We totally have to work around them here. You have to kind of make a command decision, and move forward, and accept reality, and do what you can do.
So, looking at that key 45-to-60 group of physicians in practice, what are the critical success factors in engaging them to get cooperation to participate in transformational change?
Honestly, the key is pain. If you’re a primary care physician, you’re experiencing pain right now [with payment shifts], and things are going to change, and that will motivate you. If you’re a subspecialist, the economics aren’t there yet, so you won’t change dramatically. But as the pain level increases, you change. That’s what’s pushing physicians forward.
One of the things we’ve heard consistently from everyone is that you have to give physicians meaningful and actionable data. What is the key to working with that data, with physicians?
There are several keys involved. The feedback using that data, has to be timely, delivered by respected peers, and severity-adjusted, and you’ve got to teach the doctors “how to fish.” In other words, if you just say, “Here are your outcomes, they’re terrible, and you’d better improve,” you won’t get far at all. But if you show them how to improve, the doctors will stampede to improve. We never had the data before without the EMR, so that’s given us a huge opportunity.
What about the impact of the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] law? Has it sent some physicians into a panic to become salaried?
Sure, absolutely, it’s related. Those 45-to-60 guys are getting bought by delivery systems or by insurance companies. UnitedHealthcare is now the largest doctor employer in America; I don’t think most people know that.
Are the analytics capabilities where they need to be? We hear from every single provider leader we speak with, that the analytics solutions are not yet what they need to be to be fully usable.
No, we’re not even close. The electronic charts are fine; anybody could do those. What’s missing is the population health tools. And we’re in orbit here with probably 10 companies claiming they’re doing population health analytics; and the vendors are generating a lot more heat than light right now.
How quickly will the tools become truly adequate for everyone’s purposes? Are we talking about, say, two years or so, here?
I would say it’ll happen in about two years. And let’s not forget that by 2020, 60 percent of Medicare payment will be at risk. So there’s strong economic incentive there to get these systems up to speed.
In other words, the burning platform is going to be there?
Yes, absolutely, for sure it will.
You and I have been talking about these subjects for over 20 years now. Looking back on the past two decades, and forward to what might come next, how optimistic, or pessimistic, are you, about the near-term future of this work?
Oh, I’m tremendously optimistic! In fact, I’m grateful that I’ve lived to see us reach the tipping point, totally. In a tiny way, that’s vindication. You’ve known me since the beginning, so you know.
And, looking back to 20 years ago, a lot of the knee-jerk resistance that we saw among most physicians in practice back then, is falling away now, correct?
Yes, it absolutely is. You’d have to be an uninformed citizen, to ignore the macro trends.
What would your core message be for our core readership audience, CIOs and CMIOs, and other senior healthcare IT leaders?
Here’s the message: your core audience has the technology to help reduce unexplained clinical variation, by showing the real data. And if they can move that agenda forward, that will help immeasurably. We’ll definitely need that help going forward.