Nash, David B.

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Thomas Jefferson UniversityJefferson Digital CommonsCollege of Population Health Faculty Papers Jefferson College of Population Health2-1-2015Population Health: Where's the Beef ?David B. NashSchool of Population Health, Thomas Jefferson University, David.Nash@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: http://jdc.jefferson.edu/healthpolicyfacultyPart of the Other Medical Specialties CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inCollege of Population Health Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationNash, David B., "Population Health: Where's the Beef?" (2015). College of Population Health FacultyPapers. Paper 68.http://jdc.jefferson.edu/healthpolicyfaculty/68CommentariesPopulation Health:Where’s the Beef?David B. Nash, MD, MBAIn December 2014, I had the opportunity to give a clos-ing plenary presentation—entitled ‘‘Population Health:Where’s the Beef?’’—at the Population Health Forum, theannual event sponsored by the Population Health Alliance inWashington, DC. I’d like to share aspects of that presentationwith you.To close the Population Health Forum, I decided to pose 7questions and then attempt to answer them in turn. The firstquestion was, ‘‘What exactly is population health?’’Because ours is the only School of Population Health, we,of course, know the correct answer! I challenged the audi-ence to think about population health in both an academicand pragmatic framework. I asked them whether populationhealth is a Clayton Christensen disruptive innovation1 or aMichael Porter ‘‘bridge to value.’’2 Or is it really a defen-sive posture, a` la Ram Charan,3 to prevent us from be-coming obsolete? Perhaps it is none of the above.I noted that the academic definition ties back to colleaguessuch as David Kindig,4 now working at the Institute for Po-pulation Health at the University of Wisconsin in Madison.David is sometimes regarded as the ‘‘father’’ of our move-ment. He emphasized the social determinants of health in thedefinition of population health and insisted that medical careis only responsible for 15%–20% of society’s well-being.On the pragmatic side, I noted that current thinking fromorganizations such as Humana and others is that populationhealth is focused on improving many metrics within a givenpopulation. For example, Humana’s enterprise goal states thatthey will improve the health of the populations they serve by20% by the year 2020.5 The pragmatic definition also is focusedon appropriate management of economic risks for clinical de-cision making. I closed the first question by describing anequation from Mark McClellan6: If each primary care doctorcares for 2000 patients, and each patient consumes close to$5000 per year of resources, and each doctor is driving nearly$10 million of spending, that would mean that a primary caregroup composed of 100 physicians would be driving nearly $1billon of health care spending. That makes each medical groupan important economic engine in the context of asking thequestion, ‘‘What is population health?’’.My second question was, ‘‘What are the ingredients ofsuccess in the accountable world?’’I noted that, in my opinion, leadership is always the keyattribute that drives the success of complex organizations. Ifone looks at recent data from the Centers for Medicare &Medicaid Services, 22 of the 29 Accountable Care Organiza-tions that made money in 2014 were led by physicians.7 Phy-sician leadership per se does not guarantee a positive margin,but there is a tight correlation. I spoke of certain managed careorganizations in the late 1990s during the ascendency ofmanaged care in California. Those successful organizationsthat are still with us in 2015 have a major commitment toleadership and the creation of a real culture of practice.Other attributes that augur success included a robust in-formation technology infrastructure, beyond electronicmedical records promoted by companies like Epic Systems.What I noted was the need for a registry function, enablingprimary care doctors, especially, to self-evaluate and im-prove. I spoke of companies like Anvita, Anceta, Phytel,Net.Orange, CrossCurrent, and others.Other attributes that augur success included a willingnessto ‘‘stick to the knitting.’’ For example, companies such asHealthgrades can tell us today how to manage the preop-erative and postoperative care of patients undergoing hipand knee replacement surgery. The organizational andleadership question remains: Are we mature enough to usethis information effectively to drive improvement in clinicaloutcomes, even if it means a change in the local culture ofpractice? Finally, I noted that despite the call for leadership,recent work by colleagues such as Ezekiel Emanuel8 andothers gives us pause as they discovered that most physi-cians are not currently engaged in the hard work of reform,and in fact they don’t, generally speaking, consider the costof medical care in their day-to-day work.The third question I posed was, ‘‘What should we besaying to our employer colleagues?’’I laid out a 5-point plan that called for the delivery systemto engage with employees, other providers, payers, and othercorporations, and with their communities. I noted that byinvesting in companies that promote prevention and well-ness, we will not only improve our own bottom line, but wewill send a strong cultural statement that we put our moneywhere our mouth is. Here, I referred to the work of ourcolleagues, Ronald Goetzel9 and Ray Fabius.10 I ad-monished the audience to divest funds from companies thatdon’t practice prevention and to actively seek organizationsthat publicly address this issue. In so doing, they may alsoimprove their own return from an equity investment.Jefferson School of Population Health, Philadelphia, PA 19107POPULATION HEALTH MANAGEMENTVolume 18, Number 1, 2015ª Mary Ann Liebert, Inc.DOI: 10.1089/pop.2015.18111My fourth question was, ‘‘What changes will we needto make in health sciences education to produce leaders forthe future?’’Here, I focused largely on the work of our own school andour 4 master’s degrees, our various certificate programs, andour work across the board to disseminate the tenets ofpopulation health.I made mention of our commitment to medical education;in particular, our work with colleagues at the Association ofAmerican Medical Colleges in Washington, DC and theAmerican College of Medical Quality (ACMQ) in Bethesda,MD. For example, our school recently hosted the ACMQannual education conference for medical students and othertrainees, a program that garnered an audience of more than50 medical students from a dozen medical schools. This wasa clear demonstration of young persons’ interest in the sci-ence of systems thinking, process improvement, care coor-dination, and error reduction.I explained to the audience that while we move thepopulation health agenda forward, we must not lose sight ofthe fact that medical error remains a very important chal-lenge and that, by all accounts, errors are responsible forhundreds of thousands of deaths in our country.11My fifth question was, ‘‘What will population healthleaders of the future look like?’’Based on aspects of my ongoing work with my colleague,Rita Numerof,12 I noted the evolution of a new senior officerin the delivery system. Specifically, I see the transformation ofthe hospital-based medical director to the vice president formedical affairs, to the chief medical officer, and today, to thechief population health officer (CPHO). I noted leaders aroundthe country with population health in their title, such asTimothy Ferris at Partners in Boston, Marc Gourevitch at NewYork University, and Ken Kizer at University of California,Davis. I asked, what are the attributes and competencies of aCPHO? Of course, a CPHO must have not only leadershipexperience but core competencies in fields that resonate withour school, such as behavioral economics, epidemiology,process improvement, and care coordination, among others.Finally, I admonished the audience to note that the boardsof trustees of most currently structured delivery systemsmay not be adequately prepared for the challenge of popu-lation health.13 Specifically, governance of delivery systemsmust change to keep pace with the transmogrification of thedelivery system itself. When an integrated delivery systemowns physician practices, nursing homes, rehabilitationcenters, and the like, the board of trustees bears all the fi-duciary responsibilities for the outcomes across these dis-parate settings. What kind of competency does your boardexhibit in any aspect of this evolving system?My sixth question was, ‘‘What will real patient engage-ment look like by 2020?’’Patient engagement in the next 5 years will be charac-terized by an explosion in new technology that will enablepatients to stay connected in real time with all of theircaregivers. Beyond e-mail, texting, and Skyping, I see high-fidelity telemedicine helping to shape patient engagement. Iam excited about the work of Tom Delbanco14 and hiscolleagues at Harvard Medical School, who demonstratedthat sharing the medical record with patients not only helpedproviders to improve clinical outcomes but also gave themgreater enthusiasm for their work.I noted that the ‘‘retailization’’ of health insurance woulddemand total transparency and accountability of the healthcare system. I predicted that by 2020 we would see allphysician-specific outcome measures that are more com-prehensive than the Physician Quality Reporting Systemavailable online 24/7. I made note of the work of our col-league Tom Lee15 at Press Ganey and some of the progressthey have made toward physician-specific accountability forimproved patient communication at the University of Utahand elsewhere. With complete transparency and account-ability, we will create a true marketplace enabling the retailmodel to function.I warned the audience that this was a provocative pre-diction, but I am confident that research from colleagues likeJoe Kvedar16 and others will help us see the pathway towardtrue transparency.My final question was, ‘‘What do we need to do togetherto advance this field?’’First, I suggested that the audience do some backgroundreading. Work from Sarah Varney in her lead article in theNovember 2014 Politico Magazine17 and the dreadful in-equalities of medical care in states like Mississippi; theentire November 2014 issue of the Harvard Business Re-view, focused on the internet of things; and finally the entireOctober 22/29, 2014 issue of JAMA, devoted to rising healthcare costs. Once one gets a grounding with these references,we can more clearly visualize the road ahead.I believe that this road will be characterized by engagingwith other organizations, most especially the businesscommunity. I see groups like HERO, the National BusinessCoalition on Health, and even Sanofi Aventis (with theirspecial emphasis on diabetes care), as partners in the workof the Population Health Alliance.I asked the audience to join our school by submitting theirwork for consideration of publication in our journal, and Inoted, once again, that solid research helps to ‘‘raise allboats’’ and disseminate progress in our field.I called for the continuation of our legacy of advocacyand wondered why the US government took so long to en-dorse a surgeon general18 —one like Vivek Murthy who iscommitted to reducing violence from firearms. I thoughtsocial activism among physicians, led by persons like Mi-chael Stillman19 at the University of Louisville, is importantas we return to our core professional roots.I asked that additional organizations be brought ‘‘into thetent,’’ such as the Robert Wood Johnson Foundation, whichhas recently realigned all of its philanthropic efforts towardbuilding a culture of health. Similarly, the Institute forHealthcare Improvement and their new effort to improve100 million lives ought to be welcomed under the popula-tion health ‘‘tent.’’Finally, I highlighted a recent press release that was theculmination of nearly a year and a half of work between thePopulation Health Alliance and the Jefferson School ofPopulation Health. We hope to promote the dissemination ofeducational offerings, joint exploration of possible externalfunding from grants, and the desire to expand the mem-bership of the Population Health Alliance.Based on feedback that I received both in person andonline, my 7 questions stimulated the audience to thinkabout our collective future. I hope that our readers will makea renewed commitment to the field of population health and2 COMMENTARYjoin us at the journal to improve the well-being of our cit-izenry.Author Disclosure StatementDr. Nash declared no conflicts of interest with respect tothe research, authorship, and/or publication of this article.Dr. Nash received no financial support for this article.References1. Christensen CM, Grossman JH, Hwang J, eds. The inno-vator’s prescription. A disruptive solution for health care.New York: McGraw Hill, 2009.2. Porter ME, Teisberg EO, eds. Redefining health care.Creating value-based competition on results. Boston: Har-vard Business School Press, 2006.3. Nash DB. N=1. American Health and Drug Benefits. In press.4. Kindig D, Stoddart G. What is population health? Am J PubHealth 2003;93:380–383.5. Humana. https://www.humana.com/about/company-profile/.Accessed December 31, 2014.6. Mostashani F, Sanghavi D, McClellan M. Health reformand physician led accountable care: the paradox of primarycare leadership. JAMA 2014;311:1855–1856.7. Angood P. Keynote Presentation: Future Leaders in Qualityand Safety. 2014. http://jdc.jefferson.edu/flqs/2014/. Ac-cessed December 30, 2014.8. Emanuel EJ, Steinmetz A. Will physicians lead on con-trolling health care costs? JAMA 2013;310:374–375.9. Goetzel RZ, Henke RM, Tabrizi M, et al. Do workplacehealth promotion (wellness) programs work? J Occup En-viron Med 2014; 9:927–934.10. Fabius R, Thayer D, Konicki D, et al. The link betweenhealth and safety and the health of the bottom line: trackingmarket performance of companies that nurture a ‘‘culture ofhealth.’’ J Occup Environ Med 2013;55:993–1000.11. Rice S. Despite progress on patient safety, still a longway across the chasm. http://www.modernhealthcare.com/article/20141206/MAGAZINE/312069987. AccessedDecember 19, 2014.12. Numerof R, Nash DB. Defining the job description forpopulation health. http://www.modernhealthcare.com/article/20140426/MAGAZINE/304269978. Accessed December 30,2014.13. Morrissey J. Success factors and barriers on the journey toclinically integrated networks. Trustee 2014;November/December;8–12.14. Delbanco T, Walker J, Bell SK, et al. Inviting patients toread their doctors’ notes: a quasi-experimental study and alook ahead. Ann Intern Med 2012;157:461–470.15. Lee T. Certifying the good physician. A work in progress.JAMA 2014;22:2340–2342.16. Center for Connected Health. Defining the future of tech-nology enabled care. http://connectedhealth.partners.org/about/default.aspx. Accessed December 31, 2014.17. Varney S. Mississippi, burned. How the poorest, sickest stategot left behind by Obamacare. http://www.politico.com/magazine/story/2014/10/mississippi-burned-obamacare-112181.html. Accessed December 19, 2014.18. Curfman GD, Morrissey S, Drazen JM. Where is the sur-geon general? N Engl J Med 2014;20(371):1928–1929.19. Stillman MD. The affordable care act, one year later. NEngl J Med 2014;21(371):1960–1961.Address correspondence to:David B. Nash, MD, MBAJefferson School of Population Health901 Walnut Street, 10th floorPhiladelphia, PA 19107E-mail: david.nash@jefferson.eduCOMMENTARY 3

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Population Health: Where\u27s the Beef?

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