The Value-Based Healthcare Podcast: David Nash

Episode 14 of The Value-Based Healthcare Podcast series is here and our guest is Dr. David Nash. Dr. Nash discusses his career journey from his time as Chairman at the Department of Health Policy at Jefferson Medical College to his current title of Founding Dean Emeritus of Jefferson College of Population Health. He goes into detail about population health, the digital revolution in healthcare and how it relates to social determinants of health.

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Podcast transcription: 

Jay Ackerman:
Hello, I'm Jay Ackerman, CEO of Reveleer, a software company committed to providing health plans with innovative technologies to maximize their return from quality, risk adjustment and compliance initiatives. We're back again with yet another installment of The Value-Based Healthcare Podcast where we engage with thought-leaders and visionaries working across the healthcare ecosystem. Through our podcast, we aim to widen the visibility and voice of people working to change how healthcare is provided and the impact that has on all those who participate in the care delivery chain. Let's get started. Okay. Dr. Nash, are you ready to roll?

Dr. Nash:
I am ready to rock and roll.

Jay Ackerman:
Awesome. Let's begin with a few questions regarding your career journey. Can you tell me a little bit about yourself, and your journey through healthcare?

Dr. Nash:
Sure. Happy to. I'm a walking, talking dinosaur, at least what my millennial children tell me. Listen, I'm a primary care general internist, but I've been in academic medicine my entire career. I did college med school residency, and then immediately after residency I was lucky enough to be a Robert Wood Johnson Foundation Clinical Scholar at Penn Med School. Along with that came an academic complete scholarship to Wharton Business School where I majored in health administration. As soon as I was done with Wharton, I joined the University of Pennsylvania Medical School faculty where I stayed for almost four more years. Then, I got recruited to Jefferson University, also in Philadelphia, Penn's arch rival, about 20 blocks East of the Penn campus, and I've been on the Jefferson campus since 1990, so 30 years on the Jefferson faculty.

Very quickly in that time period, I've had three jobs. That's it. Three jobs in 30 years. I came here recruited to build a staff office called the Office of Health Policy. I was the only doctor in 1990 on the entire medical staff who also had a business degree. Then, in 2003, 13 years later, we created a medical school-based department of health policy, which doesn't sound like a big deal to our listeners, but if you're inside a medical school, it was a huge deal. Then, finally in 2008 the university voted to build a brand-new school, and I got named as the founding dean, and it evolved into the nation's first college of population health. I was the founding dean for 11 years and just stepped down in July of this past summer. My official title now, which is kind of corny, is Founding Dean Emeritus, which means I'm back on the faculty doing my own thing without the day to day leadership challenges. That's my quick story. It's really pretty remarkable to be in one place for 30 years. That's why I said I'm a walking talking dinosaur.

Jay Ackerman:
Yeah. Well, let me pose a few additional questions to the walking talking dinosaur. The move from Penn over to Jefferson, that had to be a big decision for you. What was it that prompted you to make that kind of transition?

Dr. Nash:
Well, that is a really great question. Very insightful. I could feel my butterflies in my stomach as though it were 30 years ago. I think two things, the leadership at Jefferson back in 1990 included a very famous medical school dean, Joseph Gunilla, who is still alive in his mid 80s, who was the longest serving dean of any medical school in America at that point in time. To be asked by a guy who had been around a long time, to be recruited personally by him, and to be told that I'd have a chance to build something from scratch, namely this office of health policy, that was pretty alluring. I was young enough and dumb enough to not realize all the risks. It was kind of a heady thing to be asked to leave Penn and take on this brand-new responsibility.

That was certainly part of it, was the leadership. The other part was, frankly, Penn was an amazing place, still is, lots of really smart people, and I figured maybe I could be a little bit of a bigger fish in a little smaller pond. That was part of my thinking too, quite frankly. Two good reasons.

Jay Ackerman:
Yeah, that's great. That challenge to build the office of health policy, what was the one thing that surprised you the most in setting off to build it?

Dr. Nash:
Well, again, great question. I think I was pretty naïve, given it was 30 years ago, so I was 34 years old, and I figured "How hard could this be? I'll just come and show them how compelling and how smart I am." For the first year nobody paid any damn attention. That was pretty surprising. I guess I didn't realize how set in their ways many medical school faculty members were, and here's this young whippersnapper. I had some different thoughts and ideas about what we might be involved in and how we might approach it. For example, back in those days, any doctor could order any drug they want for any patient. Nobody cared what it cost or whether it was even the right drug. I mean it was kind of, if you would, in retrospect, a little bit like the Wild West and I guess I didn't anticipate just how autonomous most of the faculty really were. It took some getting used to.

Jay Ackerman:
As a leader building Reveleer, I rely heavily on a mentor and a coach outside the company to kind of help me with some things that seem obvious and that I struggle with, or trying to gain alignment on topics internally. Did you have anybody that served in that role as a mentor or coach helping you kind of manage those dynamics and think a bit differently about that?

Dr. Nash:
I sure did. I'm so lucky in retrospect. Quick story, and you couldn't make this up if you tried. Let's go back to 1973, Jay, and I'm a senior in high school, in a big public high school on the South shore of Long Island, New York. I'm applying to college and I'm interested in both business and medicine. That was about all I, you know, that was my level of detail. There was this New York Times story about a pretty amazing doctor educational entrepreneur at Penn Med School. His name was Samuel P. Martin III. I read this piece and he was talking about in 1973 training physician leaders for the future. I thought, "Wow, this is exactly like what I'm interested in." My late father, God bless him, he said, "Well, why don't you write Dr. Martin a letter?" I said, "Ah, come on, that's dumb."

Of course, I took out my Smith Corona typewriter, because you know, dinosaurs, 1973, no internet obviously. I wrote him a letter and I said, "Hey, I'm this young person and you're doing some interesting stuff. I'd really like some advice." That son of a gun called me at my home on Long Island and said "Any 18 year old who writes me a letter like that, I got to meet you, get on a train and get to Philadelphia." Holy mackerel. From 1973 until he died in 1994, Sam Martin was that mentor. In the end of his life, which overlapped with my coming to Jefferson, he was crucially important in helping me to overcome the unanticipated surprises and to navigate the treacherous early in my career of faculty waters. That's the somewhat long-winded answer to, did I have a mentor? The answer is definitely yes. I was really lucky to have Sam for almost 20 years.

Jay Ackerman:
Wow. Well I really appreciate you sharing that story. Maybe last question on kind of the current role, so making the transition out of being head of the school to now being full time back in the faculty role, what prompted that and what are you hoping to accomplish?

Dr. Nash:
Great. I've always been a strong believer that leaders need to train the leaders of tomorrow. That's been really what I've been about at Jefferson almost for the three decades I've been here. Then, I realized two years ago that the day to day wasn't that much fun anymore. I've found that I was not patient with people, that I really wasn't focused on the strategic goals. Essentially, the day to day people issues that all leaders face, and especially ones who are building something from scratch, it started just to become kind of a burden instead of something that I found energizing. That was one issue. Second issue was I felt that turning 64, I should really probably step out of the way and let younger people get into it. In our culture, in academic medicine, 64 is not old. As our listeners probably know, mandatory retirement for a Deloitte partner at 62, no questions asked.

I thought time to step aside and practice what I preach, which is let young people, after you support them, let them have the opportunity. I think it was a question of some modest burnout, wanting to give young people a chance, then finally I wanted to return to my own work. I think I have probably one more book left in me and I'm very interested in governance as it relates to the private sector and healthcare, and helping to educate folks at the governance level about population health. I thought now it'd be a good time for me to take advantage of this part of my career. My wife calls it David Nash 2.0, it just took me 30 years to get to 2.0.

Jay Ackerman:
Alright, well let's go talk to David Nash 2.0. Dr. Nash, let's talk about what industry trends you are watching most closely in healthcare.

Dr. Nash:
Great, so there's a couple of things I think that we're paying rapt attention to. Let's start with the biggest, which is population health. What the heck is that? We believe that tenants, the tools of population health going upstream to shut the faucet rather than constantly mopping up the floor, that the tools of understanding the social determinants, focusing on the chronically ill, focusing on care coordination, getting good data to feed back to doctors, nurses, and pharmacists about their own performance, making sense out of all the quality measures that are out there, this is the blocking and tackling that we believe is going to help us on the road from volume to value. In fact, we have a four-word saying that we copyrighted about a year and a half ago that I am responsible for. We call it "No outcome, no income." That's pretty pithy, don't you think? No outcome though, income, and so that's a huge trend that we're following, probably the biggest.

Second trend is the digital revolution, and especially as it relates to connectivity with patients. Let me give you some concrete examples. Jefferson Health System just finished our 100,000th video visit with patients. Number 100,000 in three years. Pretty incredible. We're studying that. I have colleagues who are amazing leaders in the hotel and medicine spheres. Second trend after pop health is really consumer connectivity.

Third big trend that I know many of our listeners care a lot about is artificial intelligence, but we use the term population health intelligence, which is our umbrella term for AI, augmented intelligence, predictive analytics, and I'm very interested as to where we're going with pop health intelligence and tools that we might use to also improve performance. Those are some of the key trends we're definitely tracking pop health, pop health intelligence, and consumer engagement.

Jay Ackerman:
Staying with social determinants of health, do you think the health plans predominantly see it as a philanthropic effort, or a financial driver behind it?

Dr. Nash:
Well, boy, that's the $64,000 question at the moment. It's a tough call. I think certainly the for-profit managed care industries, the big boys, United, Anthem, Cigna, Humana, these organizations are very savvy, and they know that tackling some of the social determinants will have a great return on investment down the road. It's the tough current balance between demands of Wall Street, shareholder returns, but they also know that by going upstream and shutting off that faucet, by tackling nutrition, exercise, obesity, opioid abuse, poverty, housing, that longer term there will be a great return on those investments. In the not-for-profit payer world, mostly the Blues plans, I think they're poking their nose under the tent here. They're poking their toes under the tent of social determinants. A good example would be the Blues investing in some social determinant companies. Delaris is the one that comes to mind. I think we're starting to see that Wall Street understands the role of social determinants and by investing in these new companies and in the social determinants directly, we are going to achieve a pretty good return on investment. 

Jay Ackerman:
What do you see as the, if we look out a couple of years, the biggest driver to turning it into something that is a must have and it's driven by strong financial incentives?

Dr. Nash:
Great. I think the biggest driver, that's an excellent question. The biggest driver in my opinion would be bundled payments. You could call it capitation, global fee. Look at the great state of Maryland, I mean Maryland is unheralded, but it's delivering high quality, good outcomes at a competitive price. I mean, I would call that value, and they're doing it uniquely under a statewide budget, a ceiling. At the local level, more nationally speaking, I think on the legislative level, nationally speaking, I think bundled payment is the way to go, because that makes primary care doctors and specialists look in the mirror, it makes them work together. We know that if you align the economic incentives, you will change doctor behavior. We know this and there's solid research to support it. I think if I had to pick one tool that really promotes looking at the social determinants and working together and doing it right, I would say it's capitation would be the old term, and bundled payment would be the newer term.

Jay Ackerman:
That's great. What do you see as the greatest barriers or challenges that affect patient improvement today?

Dr. Nash:
Wow. Yeah, that's gigantic. I think there's two major things that, again, I've spent literally 30 years struggling with. One is, I could describe it in three words for you, ‘unexplained clinical variation.’ One more time, ‘unexplained clinical variation.’ What the heck is that? That is basically doctors do what we train them to do. I went to Rochester for medical school. I know I have the right answer. I mean, without being facetious of course, but believe me, that is the extant attitude. I'm pretty good at what I do. In the absence of closure of the feedback loop, I'm going to keep doing it my way. Guess what? My way is different from your way, which is different from your way. We got 150 medical schools and we almost have 150 ways of doing the same damn thing.

The number one challenge is unexplained clinical variation. Second big challenge is we have a lot of measures out there, as I'm sure you would agree, Jay, lots of measures. About a third of them make no sense clinically. Why are we collecting data on certain things that just make no sense and aren't changeable, and not only aren't changeable, aren't going to improve outcomes. That's all part of the measurement mania that we have to get our arms around. To summarize, I think unexplained clinical variation and poor measurement mania, really contributing a lot to the challenges that we're facing.

Jay Ackerman:
That's great, well, how about taking one of those, either the unexplained clinical variation, or the measures, and what do you think we should do to address these barriers and challenges?

Dr. Nash:
Let's take unexplained variation because this is a Reveleer sweet spot. I think if you give doctors, nurses, pharmacists, good information in a non-punitive way, in a timely way, delivered by a peer about their own performance, number one, good closure of the feedback loop about their own performance, and number two, you give them the tools to learn how to improve performance, if you do those two things, you better get out of the way because these clinicians will stampede to improve. No doctor I know wants to be a B-plus student, not a one. They all want to be at least A-minus, preferably A-plus. Reducing unexplained clinical variation means I need a registry function. I need to know how I'm doing relative to my peer group, and then I need to not only understand those so-called gaps in care, then I have to be taught how I close those gaps and I need resources as well to help me close those gaps.

Jay Ackerman:
That's a great perspective on that. Can we talk about the public and what recommendations would you have for the public regarding their empowerment and ownership of their own health and wellbeing?

Dr. Nash:
Outstanding. Well, here's the sad reality. Let's put some numbers on your great question. We know from multiple research sites, it's pretty depressing, but if I asked our listeners, what percentage of adults, taking all comers, in the country do the following five things, don't smoke, wear a seatbelt, eat their fruits and vegetables, are at a close to an appropriate body mass index. What percentage of adults do all these things and exercise regularly? The answer is 3% I mean, that's staggering. 3% of adults nationwide do all five of the recommended things. Don't smoke, wear a seatbelt, exercise, watch their fruits and vegetables, and are close to an appropriate body mass index. That is staggering. I'm all about, well how do we engage with the other 97%? And the answer to that is, with whatever it takes. For millennials it's going to be Instagram and text messaging. For baby boomers, it's going to be telemedicine. For the elderly, we're going to have to go to where they live and bring them to a senior center.

I mean it's all about patient connectivity. If we could enhance it with technology, great, Fitbit and all the rest. If we can't enhance it with technology, then we still have an economic incentive to get the elderly to the senior centers so they won't be lonely, they won't be depressed, they won't get dementia, and they won't cost the system a fortune. To answer your great question, to me, it's all about finding ways to engage with patients of all sizes and shapes across the age spectrum and preferably with folks who are still healthy. Because the real savings, as we know, is by keeping the well well, and by tackling the 5%, that's all it is, who drive 80-plus percent of the total cost. 

Jay Ackerman:
Yeah, no, that's great. Meet them where they are, right?

Dr. Nash:
You bet, as necessary. Absolutely.

Jay Ackerman:
Alright, so we talked a little bit about individual members in our wellbeing. Let's talk about healthcare executives. What advice might you have for healthcare execs? Maybe we can take it as kind of two parts. Health plan execs and then maybe kind of health system executives.

Dr. Nash:
Great. Payers first, providers second. You good with that?

Jay Ackerman:
Yeah. Perfect.

Dr. Nash:
Great. Wow for payers, I'd actually probably tell them both the same things, this is a little corny answer, but it's really heartfelt. Hey guys and gals, let's find a way to work together. About 10 months ago, I first heard the corny term a 'payvider'. I don't know if our listeners are up on this, the payvider, which is obviously payer and provider partnership. I am all about moving forward 2020 and beyond, payer-provider partnerships, because look, payers don't actually necessarily take care of anybody, and providers don't really understand, generally speaking, the measures and the cost imperative. I think you're going to see in the marketplace heretofore never experienced payer-provider partnerships. I would say to each group, find a way to get a partner and partner up, and then learn from the partnership experience. I think we both have a lot to learn from each other. Speaking as I do from two worlds, 30 years inside the belly of the beast on the provider's side and 10 years as a board member of the Humana corporation.

Jay Ackerman:
That's fantastic. Let's go up one notch and let's talk about CMS. If you could push for one change from CMS over the next couple of years, what would that be?

Dr. Nash:
Wow. Roll out more bundled payment experiments across both inpatient and ambulatory diagnoses, and hurry up. We don't need five years of research on each of these. Cut it in half. More and faster.

Jay Ackerman:
More and faster. A tough call for them, right?

Dr. Nash:
That's right.

Jay Ackerman:
Yeah. But we can certainly push them, right?

Dr. Nash:
You bet. Absolutely. I would bet, to my previous answer, some big payer-provider partners could really push this and make it happen.

Jay Ackerman:
Well, Dr. Nash, I knew we'd have a lot to talk about with such an interesting career that you've had, and you certainly haven't disappointed. Let's start to bring this to a close, and we'll bring it to a wrap with our rapid-fire round. Kind of five quick questions. No right or wrong. Just top of mind for you. I know you're a runner, so what was your favorite run or race that you've completed?

Dr. Nash:
Oh boy. Yeah, with a lot of pain, years ago, in California, the so-called Bay to Breakers run, that was one. In Portland, Oregon, a half marathon that practically crippled me when I was done.

Jay Ackerman:
Alright. It's a timely one with the New York Marathon just having wrapped up.

Dr. Nash:
Yeah, I don't think I could go the full 26 miles. Half a marathon was pretty damn good.

Jay Ackerman:
Yeah. What was the last great book that you've read?

Dr. Nash:
Well, boy, among my favorite books are Atlas Shrugged by Ayn Rand. In fact, I like a lot of her stuff. Those are some of my favorite books ever. More recently, I really like the book Bear Town, and it's been a best seller, has a Scandinavian author. It's about this sort of isolated rural town, fiction town where opposing ice hockey teams, and what that does to the culture and competition. Really great fiction, but my all-time favorite is Atlas Shrugged.

Jay Ackerman:
Alright. Well as a former hockey player, I'm going to have to pick that one up.

Dr. Nash:
You got to read Bear Town. Definitely a great, great book.

Jay Ackerman:
Alright, a little deeper here, if you could redo one decision in your life, what would it be and why?

Dr. Nash:
Wow. One decision. I think if I had more athletic prowess, it would have been great to be on some teams in high school and college, I was too busy studying.

Jay Ackerman:
Then, we're getting a little lighter. How about favorite app on your mobile device?

Dr. Nash:
Oh, well that's easy. Now, it's called Tiny Beans and it's so I could have a private chat and private photos of my 15-week old grandson, so Tiny Beans. That's what the millennials are using when they don't want to have their infants out on social media.

Jay Ackerman:
Wow. Alright. I hadn't heard of that one.

Dr. Nash:
It's great.

Jay Ackerman:
Okay. This should be an easy one for you as an avid reader and someone from the world of academia. How about your favorite quote?

Dr. Nash:
Wow. My favorite quote, "If you want to make a silk purse out of a sow's ear, you've got to start with a silk cow." Which basically means surround yourself with great talent. That's the only way to succeed and I've been incredibly lucky to be able to do that.

Jay Ackerman:
Well, that's a perfect place to wrap on. At Reveleer, we're working to build this company. We're working very hard to bring in great talent and when you bring in one great new hire that brings in your next great hire, right? Talent wants to work with other great talent.

Dr. Nash:
Always.

Jay Ackerman:
Well, Dr. Nash, thanks again for your time and your openness. You've been a great guest and had a lot to share.

Dr. Nash:
Thanks very much. Really enjoyed the opportunity.

Jay Ackerman:
Same here.  Thank you for joining us today. Listen to more episodes at reveleer.com or find us through your favorite podcast platform. For episode updates, follow Reveleer on LinkedIn.