Nash on Health Policy
Drs. Russ Harris, Dighton Packard, David Nash, and Eric Beck
Can emergency room physicians become the population health workforce of the future? That is the key question I attempted to answer when I delivered the plenary address at the 27thAnnual Leadership Meeting of EmCare at the beautiful Wynn Hotel in downtown Las Vegas. With nearly 900 leaders from across the country, EmCare is a formidable delivery system with contracts connected to more than 500 provider organizations. The bulk of the EmCare leaders are physician medical directors of emergency departments at hospitals of all types. However, EmCare is part of a larger organization called Envision.
Envision also owns American Medical Response, which is a large national ambulance company with an army of paramedics, and Evolution Health, which is a home health care organization that includes podiatrists, nurse practitioners, and mobile diagnostics. You’re beginning to see the picture! EmCare is in the “cat bird seat” as emergency room physicians help Accountable Care Organizations and integrated delivery systems to better coordinate care for patients who might otherwise end up being admitted to the hospital. In the new world order of moving from volume to value, and being more economically accountable for every clinical decision, EmCare emergency room leaders could help ACOs reduce readmission -- and reduce unnecessary admission in the first place.
I found the EmCare senior national group, led by Dr. Dighton Pickard, to be a very engaging and forward thinking group. Dr. Packard is also Chairman of the Board of the Baylor Quality Alliance in Dallas, TX, which is the ACO formed by the merger of Baylor, Dallas, and the Scott and White Clinic. He’s definitely a critically important national spokesperson for the successful implementation of health reform. Between his leadership in Dallas at both EmCare and at the Baylor Quality Alliance, I’m very confident that EmCare will become a critical key player in the implementation of Accountable Care.
I admire Envision Healthcare and I believe they have a great opportunity to become the population workforce of the future. Watch out, community hospital emergency departments—Emcare is coming to a town near you!
Posted: May 5, 2014, 2:38 pm
My “March Madness” really started on Friday, February 28th with my visits throughout several states, including South Carolina, Illinois, Wisconsin and then back home to Philadelphia. I had the pleasure of visiting the South Carolina Hospital Association in Columbia, SC and continued with the Hospital Sisters Health System in Springfield, IL the following Friday, capped off by a trip to the Wisconsin Hospital Association in Kohler, WI – all in the span of two weeks! The highlight of the month, however, was our 14th Annual Population Health Colloquium, March 17-19.
The South Carolina and Wisconsin Hospital Associations really stand out in my mind as state organizations that promote the concept of physician leadership. They have supported physician leadership training for some time and it’s fantastic to see hospital leaders willing to invest resources into this important educational opportunity for doctors. At least in South Carolina and Wisconsin, hospital executives recognize that they cannot succeed under Health Reform without a core group of committed physician leaders.
In between these outstanding programs – and prior to the Colloquium -- I delivered the plenary address at the Spring meeting of the Governance Institute in Tucson, AZ, to 250 attendees, representing 30 integrated delivery systems from 20 states. My speech focused on implementing population health. As part of a special preconference session, accompanied by Denise Murphy and Jim Pelegano, we delivered a workshop on improving “Governance for Quality and Safety” for board members only. This is the third time we have offered this important content to a key leadership audience.
Our 14thAnnual Population Health Colloquium was the most successful one ever! With nearly 600 persons from around the country and over 70 nationally prominent expert presenters, we “hit a home run” in terms of the level of interest and commitment in all aspects of population health. From the President and CEO of Humana, Mr. Bruce Broussard, to the MacArthur Genius awardee from the Camden Coalition, Dr. Jeffrey Brenner, and everything in between, our colloquium tackled all the relevant issues, including pay for performance, bundled payment, Accountable Care Organizations, the social determinants of health and the future of private health exchanges. Our team from the Jefferson School of Population Health all hunkered down in the headquarters hotel for three consecutive nights to ensure that our program exceeded expectations.
I’m relieved and happy that my own “March Madness” is over and, like you, I’m very much looking forward to spring!
Posted: March 26, 2014, 5:35 pm
In 24 years of travelling throughout our great nation, I never had an opportunity to visit Idaho until now. Recently, I had the privilege of being the plenary speaker at St. Luke’s Health System’s two-day, system-wide summit on Achieving the Triple Aim through Population Health. St. Luke’s, headquartered in Boise, the state capital, is the largest employer in all of Idaho, with more than 8,000 associates. Their service area covers a staggering 22,000 square miles. Even more impressive – St. Luke’s is a system that makes operationalizing the Triple Aim their core goal! Their public strategy narrative states:
“Our St. Luke’s strategy is to make your care higher in quality and more affordable and help you become the healthy person you want to be. We believe doing that’s our job, because our mission is to improve the health of the people in our region”.
They hope to achieve better health, better care and lower costs by transforming their clinical care model, the business model and the consumer experience. In fact, their “one side of one page” strategic vision is probably the best such document I have ever seen.
Embracing the Triple Aim enables St. Luke’s to quickly scope out the core components, such as connecting to their communities, eliminating waste, creating a clinically integrated network, becoming a national quality leader, and expanding what they mean by patient-centeredness. They’ve taken recent action to reorganize their governance structure and to streamline governance decision making. They’ve formed a partnership with Select Health to create the Select Medical Network. Select Health, of course, is a wholly owned subsidiary of Intermountain Healthcare in Salt Lake City, Utah. Select Health will act as St. Luke’s insurance partner as they gain experience through their Medicare - Shared Savings Plan, (ACO), and other planned new entities.
Since Idaho has a population of just about 1.2 million , it’s conceivable to me that St. Luke’s has the opportunity to influence the healthcare of all of the citizens of Idaho. Nestled in the Boise mountain foothills, the city of Boise was surprisingly cosmopolitan and the convention center, the site of the retreat, was ultra-modern. What really fascinated me, in addition to dynamic physician leadership at all senior levels throughout the organization, was the commitment of their many board members. Board members in Boise included persons active on the American Hospital Association board, persons who recently helped engineer the merger between Healthwise and the Informed Medical Decisions Foundation and the CEO of the largest privately held potato growing company in the world. By 2015, I have no doubt that St. Luke’s Health System will be a recognized national quality and consumer satisfaction leader, based on national benchmarks, and they will be fully prepared to accept financial risk across the entire continuum of care. Can your system make a similar claim?
Read St. Luke's President and CEO, Dr. Pate's blog at http://drpate.stlukesblogs.org/.
Posted: February 26, 2014, 5:17 pm
As a former health reporter for the Miami Herald, writing a story about obesity in adolescents – particularly focusing on Hispanic females – impacted me tremendously.
I was heartbroken to hear about the troubles these girls faced: being treated as outcasts and made fun of at school, crying themselves to sleep at night, having low self-esteem, and not understanding what led them to this point.
When I decided to pursue a degree in public health and leave newspaper reporting behind, I knew there was one thing I never wanted to forget: Data alone can’t impact someone the way a story can.
When Dr. Shiriki Kumanyika came to speak to students at Thomas Jefferson University recently about policy and environmental change for obesity prevention, I was struck by her presentation.
Dr. Kumanyika, a public health leader and president-elect of the American Public Health Association, spoke about the importance of being socially aware when combating a challenging issue such as obesity and the steps necessary to achieving change.
She is everything I aspire to one day be: A public health leader with drive, passion, determination, vision, and the ability to implement plans that lead to effective solutions.
Although every race and ethnicity is affected by obesity, disparities are vastly present. Obesity is more prevalent among minority populations, particularly African-Americans and Hispanics. This is seen in both adults and children.
Progress has been made, and there have been improvements. We’ve seen policy implementation, research and reports, media involvement and the First Lady’s campaign – just to name a few – but obesity persists.
Obesity prevention is challenging but it can be achieved through changing environments, community engagement, population oriented approaches, and policies.
“If you keep hammering away, change can happen,” she said. “We want to look back ten years from now and see the social movement. What should the world look like when we fix this?”
That is a question that has continuously ran through my mind, even almost two weeks after Dr. Kumanyika’s presentation: What would the world look like without obesity?
The data Dr. Kumanyika presented reinforced why achieving policy and environmental change for obesity prevention is so important but her passion and message is what stuck with me, and many other students, not the numbers or the charts.
When disparities are present, crafting a message becomes even more important. Data and research drives public health, but stories and impact drive the population.
Elizabeth DeArmas is a student in the Master of Public Health Program, Jefferson School of Population Health.
Posted: February 25, 2014, 3:41 pm
top-ranked orthopedic hospital in the entire country every year and to recently celebrate your 150th birthday, but the Hospital for Special Surgery has gone one step further by hosting the seventh consecutive Cohenca Safety Day, a special day set aside to celebrate quality and safety. Real leaders understand just how important it is to continuously build this sort of a culture!
The day started with Journal Club, featuring some of the smartest house officers in orthopedic surgery. We reviewed three articles, including one focused on wrong-site surgeries. House officers were well acquainted with this literature and demonstrated that they understood the importance of a checklist in establishing a “just culture”. Following Journal Club, I had the opportunity to address the medical staff leaders, where I spoke about the national movement to provide a broader and deeper curriculum in quality and safety as exemplified by the Jefferson School of Population Health and the recent AAMC strategy called Teaching for Quality. I’ve written an editorial about this that you can find in an upcoming issue of Population Health Matters, JSPH’s quarterly newsletter.
Then it came time for the major staff presentation of the day, “Leadership for Quality and Safety”. Here, in brief, I encouraged staff at this top hospital in the country to embrace their leadership role. By doing so, they ought to set the tone for the rest of the country and promote transparency and accountability in everything they do. Then, they should train a future set of leaders in orthopedic surgery who will centrally go forth and proselytize the mission to improve all surgical outcomes.
The busy morning concluded with a roundtable discussion, which was distinctly inter-professional, including the Chief Nursing Officer, the chief residents, members of the quality improvement team, risk managers and clinical service line leaders. We had a free-wheeling one hour conversation that touched on sensitive topics, such as, behaviors in the operating room that need to be improved and related cultural challenges. The Hospital for Special Surgery is indeed a special place! It was a great privilege for me to be their seventh consecutive honoree and follow such luminaries as Jim Bagian, Bob Wachter and Peter Pronovost. Does your institution take a day to celebrate the progress you’re making in promoting an organization-wide agenda for quality and safety?
Posted: February 6, 2014, 5:26 pm
Having spent my entire childhood in Merrick, Long Island, it was a real pleasure for me to return very recently to neighboring Plainview to address the South Nassau Communities Hospital Strategic Planning Board Retreat. Not only did I have the opportunity to enjoy a real New York bagel, but I also met some wonderful, hardworking leaders at an important community hospital.
Like many freestanding community hospitals in the nation, South Nassau is trying to assess the next steps it should take in our rapidly changing healthcare system. I spoke about “Population Health: The Secret Sauce” and I encouraged the leaders to start thinking about new ways to connect with their community.
I specifically addressed the recent National Quality Forum report regarding the creation of measures for hospital-based community engagement. Given that most of its medical staff members are still in private practice, an institution like South Nassau has an additional challenge: there is a modest physician organizational hierarchy. Most physicians, while well meaning, attend to areas of their own interest and expertise, with little regard for coordination across the entire continuum of care. Part of the retreat was an opportunity to expose its board of directors to these very challenging issues and to generate a series of potential strategies to address them.
I was joined at the retreat by my longtime colleague, Nathan Kaufman, of Kaufman Strategic Advisors in San Diego. Nate did a great job, entitling his presentation, “A Crucial Conversation about Healthcare-Acquired Inflections.” Following my talk, Nate was able to build on the platform of population health and he further advised the attendees to consider some options, including joining another larger system on Long Island and working more closely with medical staff members in the emergency department and with hospitalist physicians.
Later that afternoon, Richard Murphy, President and CEO of South Nassau, led a panel discussion with many of his own senior leaders. We concluded the day with four breakout sessions, tackling such topics as network development, medical staff alignment, financial necessities, and enhancing the patient experience.
Later that afternoon, Richard Murphy, President and CEO of South Nassau, led a panel discussion with many of his own senior leaders. We concluded the day with four breakout sessions, tackling such topics as network development, medical staff alignment, financial necessities, and enhancing the patient experience.
Is the freestanding community hospital a thing of the past? Will institutions like South Nassau Communities still include the word “communities” in their title? Can a freestanding institution marshal the necessary resources to create the tools critical for practicing population health, like a patient registry, population health analytics, and broad engagement with community resources? In my closing comments, I counseled its board of trustees to invest in the most important attribute of all – developing a physician leadership class for the future.
In my view, the rate limiting step that all freestanding community hospitals face is exactly that—our lack of attention to the creation of specially trained doctors who can make community engagement at a freestanding hospital a tactical reality. I think they heard me loud and clear.
Posted: January 24, 2014, 8:23 pm
The NSHS Medical Group is a powerful force in the metropolitan New York City area, with more than 2,500 practitioners spread across most of Long Island and a good part of the Manhattan marketplace as well. As a delivery system, NSHS is a juggernaut led by the charismatic Michael Dowling. They appear to be everywhere and have just formed their own insurance entity whereby they are now taking economic risk for some aspects of their clinical decision making. NSHS is already working as though it were 2017!
In my after dinner comments, I covered four key topics. First, I gave a brief overview of the impending value-based payment environment. By 2017 nearly 10 cents of every Medicare dollar will be tied to some type of performance measure.
Then I tackled some of the cultural challenges that clinicians face. I reminded the group that doctors have two jobs everyday. Job #1 is the job of doctoring. Job #2 is learning the skill-set to improve job #1.
In the third part of my comments I touched on the quality foundation of the Affordable Care Act. Here I admonished the attendees to recognize that reform can really be summarized in four words—“No Outcome, No Income”! Finally, I drew on my Humana board experience to describe the future of patient engagement and the retailization of the insurance market. A robust question and answer period followed my remarks well into the evening.
I’m confident that NSHS will be very well positioned to tackle the delivery system challenges we all face.
Posted: January 16, 2014, 7:58 pm
Last week, as the opening keynote speaker at the second annual Phytel Executive Summit, I had an opportunity to interact with literally scores of their customers (large, multi-group physician practices and integrated health systems) from around the country. Each told an interesting story about how the Phytel tools enabled them to change the physician practice culture and promote an outcomes agenda based on population health measures.
Peggy O’Kane, the founding President and CEO of the NCQA, followed me on stage. She reinforced many of these same messages, and together we delivered a “one-two punch” that helped to set the stage for the rest of the Phytel meeting.
Phytel’s software can integrate data from multiple sources across systems (think Epic, Cerner and AllScripts) and deliver to doctors on the frontlines outstanding benchmark information about their own performance relative to both regional and national standards. The only way, in my view, that we will make progress under the ACA is with the use of such population-based registries.
Few firms, especially those in healthcare’s Information Technology sector, have population health tightly woven into their corporate DNA. Phytel, headquartered in Dallas, is one of them. From their publications, including Population Health Management, a roadmap for provider-based automation in a new era of healthcare, to their Executive Summit in Dallas, this is an outfit that lives, breathes, and executes on the population health agenda!
Regular readers know that I am all about physician leadership, reducing waste, improving safety, and practicing based on the evidence. The Phytel toolkit enables us to do all of these things and get the job done.
Can your practitioners benchmark their daily performance?
Posted: December 9, 2013, 5:39 pm
The venerable Greenbrier Hotel is often referred to as America’s Hotel. Nestled in the mountains in White Sulphur Springs, West Virginia, it is famous on several levels. First, it is a hotel visited by virtually every U.S. President since Truman. In the early 1990s, the existence of an underground bunker suitable to accommodate both houses both of Congress in the event of a Soviet nuclear attack was made public; now one can tour this unique and, thankfully, abandoned facility.
The Greenbrier is also the setting for the fall meeting of the Governance Institute (TGI). TGI is the premier educational organization for healthcare board members in the country, and I have had the privilege of serving as afaculty member for TGI for more than 20 years. On Sunday, October 20th, I had a very busy day doing what I love... leading an all-day “boot camp” for board members along with Dr. Jim Pelegano, the Program Director for our Master’s Degree in Quality and Safety.
This boot camp is a full-day immersion in the basics of quality and safety from a governance perspective. We reviewed such critical topics as the history of the quality and safety movement, the composition of the board committee on quality and safety, and challenges that boards will face under health reform. The nearly 40 attendees at this boot camp engaged in an all-day discussion with Dr. Pelegano and me on some of the critical issues they face.
At 4:30 pm, I delivered the opening plenary address, entitled, “Population Health—The Key to Quality” for all 200 attendees at the larger TGI meeting. I always enjoy the TGI events as it gives me an opportunity to compare my own board service (with Main Line Health in suburban Philadelphia), to other boards from literally around the nation.
The Greenbrier event reconfirmed for me the importance of the board’s ongoing commitment to the quality and safety agenda as we build Patient-Centered Medical Homes, Accountable Care Organizations, and other assets to deal with health reform. Most board members at community hospitals around the nation have no clinical training and, as a result, programs like TGI give them critical skills necessary to fulfill their ultimate fiduciary responsibility – to deliver the safest and highest quality care possible. What sort of training does your board receive? Is their skill set adequate given the challenges we all face? TGI could be the answer to both of these very important questions.
Posted: November 13, 2013, 5:48 pm
Remember that great movie classic starring the amazing Tom Hanks and Meg Ryan? Who could forget that romantic rendezvous on the observation deck of the Empire State Building?
My trip to Seattle wasn’t romantic, but it was “sleepless.” I had the privilege of addressing the Second Annual Everett Clinic Leadership dinner. Everett is one of probably two dozen remaining physician-led, multispecialty, fully integrated group practices in America. In March 2013, I spent two days with some of their emerging leaders reviewing the core tenets of quality and safety. Their entire organization has embraced an ambulatory quality and safety agenda, from its board of directors down to each and every primary caregiver throughout their system.
All 500 clinicians who attended the dinner were celebrating their culture of cooperation, teamwork, and putting the patient at the center of everything they do. The theme of my after-dinner talk was that every Everett doctor is a leader. It was my distinct privilege, at least for one night, to participate in a doctor culture that emphasized collegiality, appropriate test ordering, and working together to do the best that they can in an era of decreasing resources.
While most organizations decry the impact of the Affordable Care Act, my sense was that Everett has got it right! Frankly, I was envious of their culture and I would challenge most Faculty Group Practices to achieve even half of what the Everett team has been able to do without a medical school, without a research agenda, and without trainees in their midst. Maybe they know something we don’t.
Among the many privileges of traveling across our great country is the opportunity to embrace different cultures of practice. The culture of practice at Everett, in my view, is very well situated, not only for survival under the ACA, but to thrive moving forward. Is your clinical practice able to say the same thing?
Posted: November 5, 2013, 4:35 pm
|In Houston, Dr. Nash had a captive audience -- that's a statue outside the Houstonian Hotel -- when he addressed Texas Children's Hospital's Advanced Quality Initiative.|
Texas Children’s, a massive organization in downtown Houston, has a longstanding system-wide quality and safety training program called the Advanced Quality Initiative (AQI). Typically, I am the kick-off speaker for each AQI cohort. Cohorts comprise a heterogeneous group of emerging leaders ranging from frontline nurses and administrators to seasoned physicians across different sub-specialties. It’s one of the few training programs where doctors, nurses, pharmacists and administrators train side by side, for months at a time, from a cadre of nationally recognized experts, including John Nance, Larry Staker and Jim Reinertsen.
My kick-off presentation typically focuses on a brief history of the quality and safety movement; an explanation of how we got into our current “jam” and how we might emerge from it with new measures and a renewed devotion to achieving value for the money we spend. This ninth AQI cohort was an enthusiastic group and the conversation was engaging, free-flowing and heartfelt.
From the “land of oil,” I flew to the city of “bourbon and jazz,” where I also participated in one of the most longstanding, well-established, and well-respected leadership training programs at the Ochsner Clinic.
Ochsner is a major provider in the Gulf Coast, with a large multi-specialty group practice, a core tertiary care facility and scores of ambulatory centers throughout the region. It is a real force under health reform, with an active Accountable Care Organization structure and multiple risk-bearing contracts. In the “Big Easy,” Ochsner is the market leader.
The leadership training program is also inter-professional, with administrators and physicians sitting side by side for 1½ days a month over a nine-month period. Again, my role at Ochsner was to cover the waterfront about the quality and safety movement, with a special emphasis on how we might reduce variation, reduce error, and improve value.
Like at Texas Children’s, the Ochsner team was highly engaged in the four-hour conversation. Texas Children’s, Ochsner Clinic, Iowa Health, Sutter, and just a handful of others represent the leading organizations that recognize that one of the key attributes of good leadership is to prepare the leaders of tomorrow. What is your organization doing to prepare tomorrow’s leaders?
Posted: October 18, 2013, 6:09 pm
We’re especially excited at the School of Population Health to be working with our colleagues at HealthLeaders Media. If you’re a working healthcare professional, you’re familiar with HealthLeaders Media, a multi-platform media company dedicated to meeting the business information needs of healthcare executives and professionals.
The current issue of HealthLeaders magazine, winner of the 2010 American Society of Healthcare Publication Editors Magazine of the Year Award, includes initial results of the Population Health Survey, part of a series of monthly Thought Leadership Studies. These Intelligence Reports offer timely data, expert analysis, and actionable recommendations on key issues every month. JSPH was a major contributor to this report.
With 61% of respondents to the survey saying they have selected a patient population and are working to improve the health of that population, it is clear that healthcare leaders recognize the importance of population health management. That’s the good news. As we know, improving the health of a defined population requires a complex set of activities, many of which are new to healthcare providers.
A detailed report and analysis can be found here. Take some time to process the findings of this report and be sure to let me know what you think in the comments section of this blog.
I’ve been receiving a lot of feedback from Philip Betbeze’s piece, “Don’t Expect Physicians to Lead Change,” which you can read here. During a recent trip to Nashville I sat down with Phil, whose column, Leadership Corner, appears every Friday on the HealthLeaders Media website. His piece sheds light on the need for better leadership training for physicians. Under healthcare reform, physicians will play a big part in whether or not healthcare costs will moderate and quality will improve. But, as Phil writes, in most cases physicians are unprepared to play a leading part because the large majority have no leadership training.
Be sure to take a few moments to read Phil’s piece. I would love to hear what you think the comments section of this blog.
Finally, JSPH will be participating in an upcoming HealthLeaders webcast about physician leadership in population health. Population health is of great interest to the HealthLeaders audience, but its concepts and processes clearly can’t be implemented without agreement, involvement, and leadership from physicians. HealthLeaders has been conducting webcasts for many years, and they continue to be a great way to drill into important topics through the first-person perspectives of experts. I’m proud that our School can play a role in this important initiative.
Posted: October 14, 2013, 12:53 pm
|Dr. Nash with Regina Holliday, an artist and plenary speaker at the Planetree meeting, with her painting depicting Dr. Nash as a caped crusader.|
Parlez-vous Français? My high school French proved to be quite inadequate for my plenary presentation at the annual meeting of Planetree in Montreal. Planetree, with more than 200 hospitals nationwide and scores more overseas, held their annual 1,000-person event at the Montreal Convention Center. Groups like Planetree do tremendous work worldwide in promoting the notion that only an engaged patient can truly achieve value for the resources that they expend. It’s a message that is true in the developed world and in the developing world too.
My presentation focused on patient engagement. I described, in some detail, that improving connectivity with patients is among the key strategies for implementing health reform in the United States. Companies, such as Humana and U.S. Preventive Medicine, are at the forefront of patient engagement efforts in the United States. At Humana Corporation, significant resources have been devoted to exploring innovative ways to engage with plan members. New technologies, such as online gaming, reimbursement online for healthy food shopping and related activities are all part of the Humana portfolio. U.S. Preventive Medicine’s web-enabled, personal health portal called Macaw – named after a long-lived parrot.
Engaged patients are more likely to follow their recommended care plan – taking their prescriptions, keeping recommended appointments with their care provider, and sticking to diet and exercise regimens. Patients who are fully engaged in their health, therefore, should achieve a greater value for the money they spend and should reduce unnecessary utilization of tests and procedures. The largely Canadian audience seemed to resonate with this message. I enjoyed meeting and talking with a number of them in person during a 90-minute book signing event after my talk, and look forward to continuing the conversation with people I meet on the road.
Posted: October 14, 2013, 12:44 pm
I am always enamored of systems that take one day a year to celebrate the gains they have made in improving the quality and safety of the medical care they deliver. Saint Joseph Regional Medical Center celebrated its 2nd Annual Quality Summit on October 3rd in Mishawaka, Indiana, a stone’s throw from South Bend.
Saint Joseph is one of the “stars” in the CHE-Trinity constellation. (This merger of CHE and Trinity has produced, what most agree to be, the second-largest religious affiliated not-for-profit healthcare system in the nation). Led by their dynamic President and CEO, Mr. Albert L. Gutierrez, Saint Joseph has won numerous awards for their work in the quality and safety arena. As the keynote visiting speaker, I had an opportunity to link their progress in quality and safety to the work that we all face under health reform; that is, by practicing population-based medicine, we will reduce waste, practice using appropriate evidentiary guidelines, reduce error, and deliver a higher value for the money we are spending.
Following my opening plenary, Dr. Paul Harkaway, the Vice President for Clinical Integration and Accountable Care, from their corporate headquarters in Livonia, Michigan, gave an impassioned talk about the need for physician participation in the clinical integration agenda. I applauded Paul’s presentation as it explicitly laid out the need for physician training in leadership skills, quality and safety, and population health. It reinforced for me the importance of our ongoing work at JSPH in developing well-equipped leaders who will thrive in our rapidly evolving healthcare environment.
When leaders spend a day together to do a deep dive on quality, safety, and population health, that alone is reason for celebration. I’m confident that CHE-Trinity, led by constituent members like Saint Joseph, will be able to successfully tackle the challenges we are all facing. One step at a time they will build the physician leadership team of the future, today.
Posted: October 10, 2013, 6:54 pm
I am fresh from a beautiful fall weekend at the venerable Sagamore Hotel on Lake George in upstate New York. This was, however, not a typical getaway to enjoy the fall foliage. For this first official weekend of fall, I had the privilege of opening the annual leadership meeting of the Hospital Association of NY State, where I explained the importance of population health to 200 hospital trustee leaders.
My talk focused on trustee-level involvement in the agenda of improving the health and well-being of populations. I urged the trustees to fulfill their principal fiduciary responsibility by first measuring and improving the quality and safety of the care delivered in their hospitals. Then I urged them to allocate resources to train a cadre of physician leaders who could help, not only to improve the quality and safety of care, but to lead their institutions on the road to managing population health. Trustees bear the ultimate responsibility for the implementation of the population health agenda.
I focused on the move from volume to value and re-emphasized the importance of the community in the well-being of individual persons. I drew comparisons to my work with Humana and how Humana has every economic incentive currently aligned to keep these patients well, and out of the hospital. The trustees were very receptive to my message and many hospitals at the community level are already joining together in collaborations that allow them to take on economic risk for larger populations.
New York is such a diverse and important state; “so goes New York, so goes the hospital industry!” Having grown up in suburban Long Island, NY, and then attending Vassar College in Poughkeepsie and the University of Rochester Medical School, it was a bit of a homecoming for me. I also had the privilege of meeting the current leaders of the University of Rochester Medical Center, my alma mater.
Posted: October 1, 2013, 1:41 pm
Our JSPH team has just returned from the nation’s capital, where we hosted the 12th Annual National Quality Colloquium.
Having moved this meeting from the Harvard campus to the heart of Washington, DC, we were able to attract many key national leaders to kick off this important event. Drs. Mark McClellan, Rick Gilfillan and Carolyn Clancy were our top three headliners. They all delivered a similar message. Mark McClellan, as the Senior Fellow and Director of Healthcare Innovation and the Value Initiative at the Brookings Institute, basically noted that most of the improvements in quality and safety are very much related to how providers are paid. He re-emphasized the power of economic incentives to drive improvement in outcomes.
Dr. Gilfillan, most recently the founding Director of the Center for Medicare and Medicaid Innovation (CMMI) in the Centers for Medicare and Medicaid Services (CMS), reinforced Mark’s message. He noted that reform has accomplished a great deal and that tools, like value-based purchasing, reducing readmissions, PQRS, the value modifier and the Partnership for Patients, have all had a positive impact in improving the outcomes of care, reducing costs, and generally speaking, delivering greater value for the money Medicare spends. He gave an uplifting and fact-filled presentation.
Finally, Carolyn Clancy, after a decade of service at the Agency for Healthcare Research and Quality (AHRQ), is now within the leadership of the Veteran’s Administration – the largest integrated delivery system in the country. Carolyn reflected on lessons learned from AHRQ that she is importing to the Veteran’s Administration. I’m glad that she is at the helm, as our veterans deserve high quality care too!
The Quality Colloquium generated uniformly positive feedback and we appreciate the work of our colleagues from many organizations that helped to make the program such a success. We owe a debt of gratitude, too, to MedStar Health in suburban Washington, to Kaiser Permanente for hosting our reception at their amazing Center for Wellness in downtown D.C., and finally to many of our sponsors and exhibitors who made the program possible.
Sometimes, I believe, we mistakenly think that we’ve overcome the challenges regarding quality and safety as we move head over heels into patient-centered medical homes and Accountable Care Organizations. The 12th Annual Quality Colloquium only reinforced for me just how much work remains to be done in implementing safe care, effective care, patient-centered care, and care that will make a difference.
Posted: September 24, 2013, 7:43 pm
The futuristic Cerner Tower is composed of stainless steel reaching high into the sky. A closer examination reveals that it is the famous DNA, double-helix at the core, and wrapped around the core are a series of bits and bytes—1’s and 0’s that hold the whole tower together. It is majestic in its simplicity and innovative in its design.
I just returned from Cerner World Headquarters in Kansas City, where I had the privilege of addressing 150 leaders from across all of their business units. Cerner invests heavily in education for their team members, emerging leaders and for customers; something that any Dean could really embrace!
I spent 2-1/2 hours outlining my vision of where population health has come from and where it ought to go, especially given the changes brought by health reform. They embraced my message and we had an interchange that lasted nearly the entire day. Cerner has an entire unit devoted to population health and a deep bench strength of consultants fanning out to clients and would-be clients, educating them about population health.
The Cerner Innovation Center itself, is a view into the future—a future characterized by linking technology at the level of the patient, to technology inside the hospital, the office, the ambulatory clinic, the pharmacy, and of course, the home. Cerner seems well situated to embrace all that accountable care can deliver for our country. They are going to move from an electronic medical record company to a true healthcare information delivery platform that will demonstrate value.
Matthew Swindells, the newly appointed Senior Vice President for Population Health and Global Strategy, has recently emigrated from the UK to lead aspects of the Cerner strategy. He’s joined by other able leaders like Dick Flanigan, Robert Campbell, Chad Greeno, Lisa McDermott, Michael Allison, and Donna O’Connor.
I was impressed by the Cerner team and their transformation reminds me of another famous corporate transformation. Remember when IBM built mainframe computers? IBM transformed itself into a global information powerhouse. I bet Cerner is going to transform itself into a global information powerhouse too!
Posted: August 30, 2013, 1:58 pm
The Gaylord Opryland Resort and Convention Center is one of the largest indoor facilities – with restaurants, gardens, and ballrooms – in the United States. It was the appropriate setting for the annual HealthTrust University Conference and Vendor Fair, sponsored by the HealthTrust Purchasing Group in suburban Nashville, TN.
I had the privilege of delivering the plenary talk immediately after the charismatic CEO of the company, Mr. Ed Jones, welcomed everyone. The 3,700 assembled supply chain leaders, financial directors, pharmacy managers and others from around the country, were an enthusiastic audience. I strongly believe that hospital and delivery system based supply chain leaders are going to play an increasingly important role in health reform. After all, they do the bulk of the purchasing and they are on the “firing line” having to demonstrate value for the money being spent.
By becoming more efficient, by demonstrating value, by cutting waste, supply chain leaders are going to play a key role in making the HCA work. I implored the audience to invest in leadership training for clinicians of all types, especially physicians, nurses and pharmacists, as these clinical leaders make most of the decisions about supply chain purchases. The executive leadership team of HealthTrust – Mike Berryhill, John Paul, Gary Pack and Doug Swanson – seemed like a group that “gets it!”
Following my formal remarks, Ed Jones and I engaged in a question and answer session in front of all of the attendees. We reinforced the need to reduce waste and to prepare for moving from a world of volume to value. Were the leaders of your supply chain lucky enough to be in the Opryland Resort and Convention Center? You should save the dates for next year, July 28-30, 2014, also at the Gaylord Opryland Resort and Convention Center. Finally, special thanks to the outstanding sponsors who helped to make the conference a possibility, including Astellas, Elekta, and a score of others.
“Nash in Nashville” – it does have a certain ring doesn’t it?
Posted: August 26, 2013, 6:44 pm
I just returned from Boardman OH having spoken to the Board of Trustees of Catholic Health Partners (CHP). They are one of the best managed, most forward thinking, multi hospital systems in the country. I was privileged to have been a board member of CHP for more than ten years with my tenure ending in 2009. The Board is aggresively focusing on a population health agenda---they are participating as a Medicare ACO, they are creating alliances with managed care organizations like Kaiser Permanente and, they are seeking out new partners such as Summa and others. Their leadership academy has produced a core group of system leaders who are now committed to producing value and reducing variation. In a word, CHP appears to get it!! I told the board that I was "bringing coals to Newcastle"...that they could be teaching me about population health. I just helped them to refine their focus and to recognize once again, that physician leadership will also be vital to their success. I also reinforced the fact that we will all need more primary care doctors but waiting for medical schools to "produce" them will take far too long. Therefore, we need to practice team based care and engage all practioners in this effort. I am confident that CHP, and their leaders such as Mike Connelly and Jane Crowely,are firmly headed in the right direction. It will be a struggle,but if I were a betting man, my money is on this team. Is your Board engaged in the population health conversation?? DAVID NASH
Posted: August 16, 2013, 1:42 am
I just returned from my first trip to Wyoming where I gave the plenary presentation in Casper at the first ever joint meeting of the Wyoming Business Coalition on Health, the Wyoming Hospital Association and a local community hospital, the Wyoming Medical Center. About 200 people attended this multiple stakeholder event to discuss the future of the payment landscape for medical care in their rural state. Considering that the population of Wyoming is just over 575,000, an audience of 200 people was quite a turnout!
My presentation focused on how to practice population-based care in order to deliver the best outcome at the most cost-effective price; a panel of local experts reacted to my presentation and to questions from the audience. The panel included the President of the Wyoming Medical Society, the CEO of Wyoming Medical Center, the CEO of two other critical access hospitals, the local Assistant City Manager for the City of Casper and the Medical Director of the unique Wyoming Integrated Care Network. The Wyoming Integrated Care Network is a loose alliance of 28 Patient-Centered Medical Homes from across the state. These 28 PCMH’s represent over half of all of the primary care doctors practicing in Wyoming!
I was struck by several take home messages from this trip to Casper. First, imagine bringing together comparable stakeholders in your regional environment? I have little confidence that we could have achieved this kind of all-encompassing meeting even in Philadelphia! Another theme emerged, in that these groups seemed genuinely willing to work together, to share data on patient-level outcomes, and to find a way to broaden the population health agenda. Surely there are many obstacles, but the mere fact that they were all sitting together in one room is very impressive to me.
Rural states face particular challenges as they attempt to implement the core tenets of the Affordable Care Act. When your patients may be hundreds of miles away, it’s awfully difficult to think of ways to effectively engage them. It seems quite challenging to imagine how they will implement bundled payment or related innovative schemes, but our colleagues in Casper appeared undeterred. We could all learn something from our colleagues in a rural state as they look inward and find new ways to collaborate, innovate, and thrive in this challenging new environment.
Posted: July 22, 2013, 4:08 pm
There was good news last week for President Obama. The Affordable Care Act – Obamacare – may not be the train wreck that critics have painted it since being signed into law over three years ago.
Last week, The New York Times reported that individuals buying health insurance on their own will pay significantly lower insurance premiums next year in New York and many other states. Supporters of the new health care law credited the drop in rates to the online purchasing exchanges the law created, which they say are spurring competition among insurers that are anticipating an influx of new customers.
This is great news for the President, no doubt. It’s evidence that the ACA can hold previously rising premiums in check
But let’s not take our eye off the ball here. To me, this is further evidence that the ACA addresses insurance reform as much as it does health care reform, perhaps even more so. The law accomplished one really important thing: it recognized that universal access to healthcare is critically important. But it ignores three out of the four essential pillars of meaningful health reform. Those four pillars are: (1) create value in the system, (2) cover everyone, (3) coordinate care, and (4) promote prevention and wellness. The ACA addresses only the second pillar.
What’s missing from meaningful healthcare reform at the national level is a deeper understanding of the true drivers of waste, error and uneven quality. In the coming years, we must focus on building all four pillars of health reform.
That’s the story I’m waiting to see.
Posted: July 22, 2013, 2:28 pm
Accountable Care Organizations have been attracting a lot of attention lately, with the recent article in The New York Times and Don Berwick reportedly advising some Pioneer ACOs in their dispute with CMS about how to measure quality. Here on the TJU campus, Jonathan M. Niloff, MD, spoke at the JSPH Forum on ACOs and ways of achieving organizational alignment and management through healthcare transformation. Dr. Niloff, Chief Medical Officer for MedVentive, is responsible for the strategic development of population health analytics and solutions.
ACOs take up only seven pages of the new health law yet have become one of the most talked about provisions. This latest model for delivering services offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs. An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. In the new law, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.
During his talk at the May 9 JSPH Forum, Dr. Niloff described the often difficult realities of making an ACO work. A successful ACO implies less revenue per patient – a scary proposition for any health system. In an environment of less revenue per patient, it is crucial to keep the patients that were going out of the system, within the system. Growing the network is also vital. “Ultimately, it’s about aligning more physicians, gaining the allegiance of more physicians to your program to drive better coordination of care.” A successful ACO also requires a population health approach to managing healthcare by identifying patients most at risk and putting programs in place that captures those patients and drives specific programs focused on improving quality and coordination of care.
One health provider that seems to have this figured out is Advocate Health Care, based in Oak Brook, Ill. Described in The New York Times piece as an innovator in the accountable care approach, Advocate Health Care has seen hospital admissions decline nearly 9 percent. The average length of stay has declined, and many other measures show them providing less care, too. Under Advocate’s deal with Blue Cross Blue Shield, certain patients are assigned to the accountable care framework – about 380,000 – and their health costs are projected. If Advocate achieves savings below that amount while meeting explicit quality targets, it splits the money with the insurer. If not, its revenue is at risk.
The Affordable Care Act has helped encourage a shift to Advocate’s payment model – an estimated 428 accountable-care organizations now cover four million Medicare enrollees and millions more people with private insurance.
Still, many remain skeptical that we have arrived at the right set of measures to allow us to declare one ACO a success and another a failure. Perhaps what is needed is a set of definitive measures, beyond readmission rates and average length of stay, that can tell us how a specific population is doing.
I’m sure that by now, many of you have had experience with ACOs. What are your thoughts? Are ACOs part of the answer to alleviating Washington’s long-term deficit problems? Feel free to weigh in on this issue in the comment field below.
Posted: May 16, 2013, 3:26 pm
JSPH Director of Communications
The Jefferson community was treated to true insider’s look at comparative effectiveness research last week when Robert W. Dubois, MD, PhD, visited campus to speak at the Jefferson School of Population Health Forum.
Dr. Dubois is the Chief Science Officer at the National Pharmaceutical Council, where he oversees NPC’s research on policy issues related to comparative effectiveness research, as well as how health outcomes are valued.
During his talk at Jefferson, “Applying Comparative Effectiveness Research and Evidence-Based Medicine to Everyday Decisions,” Dr. Dubois provided a simple definition for CER (“CER is what works, for whom, under what circumstances”); described the evidence needed to guide decisions; discussed concerns that evidence is not being used well, and outlined examples of policies impacting individual treatment, evolving payment environment, and use of real-world evidence.
“What I’m hoping is that I’ll open your eyes to some of these choices so that we collectively choose wisely,” Dr. Dubois said. “Once you’ve figured out what to do, you have to do it. None of this is going to work if we don’t make it embedded in how we make choices.”
CER, Dr. Dubois said, if you do it narrowly -- drug A vs. drug B, therapy A vs. therapy B, and looking at the cost of those interventions “you’re going to get it wrong more often than you’re going to get it right.” Policy implications, he noted, are extremely important in the CER world.
Following Dr. Dubois’s talk, members of the School of Population Health’s Grandon Society were invited to remain for a private question and answer session, which led to interesting discussions about bundled payments, rapid-cycle learning in healthcare systems, and the Patient-Centered Outcomes Research Institute(PCORI). Asked about the political reality of bundled payments, Dr. Dubois replied “I think it’s a reality; the American public is running with the concept,” pointing out that 10 percent of American patients are in accountable care organizations (ACOs), which reward doctors and hospitals for working together to improve quality and to control costs.
Asked about his “take” on bundled payment systems, Dr. Dubois offered, “A lot of this is religion, it’s belief. I, in my core, believe this is the right way to go.”
The audio portion of Dr. Dubois JSPH Forum presentation is available on Jefferson Digital Commons by clicking here.
Posted: April 24, 2013, 2:26 pm
We may be a little late to the dance on this, but it needs to be acknowledged that the Affordable Care Act marked its third anniversary in March…despite 39 (unsuccessful) attempts to have it repealed.
So, three years down the road, the question, with a nod to the late Ed Koch, needs to be asked: “How’m I doin’?” Well, despite Republican leaders in Congress who regularly denounce the ACA, vow to block funding to carry it out or even repeal it, the answer is “not bad.”
Although the date for full implementation of most provisions of the law is January 1, 2014, the ACA has already had an impact on the goals of expanded coverage of the uninsured, improved access and better care delivery models, broader access to community-based long-term care, and more integrated care and financing for beneficiaries who are dually eligible for Medicare and Medicaid. While the ACA remains controversial, with many debates about its future as well as provisions already implemented, implementation is moving ahead.
Beginning in 2010, young adults up to age 26 can remain on their parents’ insurance policies even if they are no longer living with a parent, are not listed as a dependent on a parent’s tax return, or are no longer a student. According to Census data, over two million young adults have gained coverage under this provision, contributing to the decline of 1.3 million in the number of uninsured Americans in 2011.
Additional highlights include:
- 17 million Americans now receive some kind of free preventive service, such as flu shots, and 34 million Medicare recipients received free preventive services in 2012
- 17 million children with pre-existing conditions are now protected against being uninsured
- More than 107,000 adults with pre-existing conditions finally have insurance under the federally run insurance program
- 21 million received care from expanded community health centers; 3 million more than previously served
- $1.1 billion in rebates, an average of $151 per family, was paid by insurers that failed to meet the benchmark of 80 to 85 percent of premium revenues on medical claims or quality improvements
- Since 2010, more than 6.3 million older or disabled people have saved more than $6.3 billion on prescription drugs.
Perhaps most importantly, there are signs that the ACA has already started to help slow the growth of health care costs and improve the quality of care through value-based purchasing programs, strengthened primary care and care coordination, and pioneering Medicare payment reforms. For each year from 2009-2011, National Health Expenditure data show the real rate of annual growth in overall health spending was between 3.0 and 3.1 percent, the lowest rates since reporting began in 1960.
Speaking of primary care, providers get increased Medicare and Medicaid payment rates under the ACA, according to a Kaiser Family Foundation report. The law provides for a 10 percent bonus payment on top of the regular Medicare fee schedule amount for many services provided by primary care physicians (and other practitioners) from 2011 through 2015. The law also requires states to raise their Medicaid payment rates in 2013 and 2014 to Medicare payment levels for many primary care physician services. As a result, Medicaid primary care fees will increase by 73 percent, on average, in 2013 although the size of the increase will vary by state.
As a recent editorialin The New York Times noted, one of the most promising aspects of the ACA is its focus on improving quality. According to the editorial, the percentage of Medicare patients requiring readmission to the hospital within 30 days of discharge dropped from an average of 19 percent over the past five years to 17.8 percent in the last half of 2012, an improvement due in large part to penalties imposed by Medicare to providers to encourage better coordination of care after a patient leaves the hospital.
It’s also worth noting that, as we here at JSPH have, the ACA supports population-based prevention activities through a new Prevention and Public Health Fund. This Fund has been used to make over $1 billion in critical investments in programs aimed at reducing the burden of chronic disease an improving overall health of communities. Funding has supported Community Transformation Grants in 36 states to reduce the incidence of heart attacks, strokes, cancer, and other diseases; rebuilding the immunization infrastructure, tobacco cessation programs; and substance abuse and suicide prevention activities.
Happy(belated) Birthday, ACA. This School of Population Health feels you’re on the right track, and we feel we are, too.
Posted: April 15, 2013, 6:10 pm
JSPH Director of Communications
The School of Population Health acknowledged National Public Health Week (NPHW) by hosting a lunchtime symposium, “Meeting Again at the Crossroads: Social Work and Public Health.” Since 1995, the first full week of April has been a time when communities across the United States recognize the contributions of public health and highlight issues that are important to improving our nation.
This year, JSPH took a closer look at the connection between public health and social services. Although the two fields share historical roots, their paths have diverged until recently. But today’s complex health issues require the expertise of both professions and the lunchtime symposium explored the intersection of public health, social services, health care, and health policy.
Moderated by Darlyne Bailey, PhD, LISW, Dean and Professor at the Graduate School of Social Work and Social Research (GSSWSR) of Bryn Mawr College, panelists included Cindy Sousa, PhD, MSW, MPH, an Assistant Professor at GSSWSR; Jennifer Campbell, PhD, MSW, a consultant, and Lecturer at GSSWSR; JoAnne Fischer, MSS, Executive Director of the Maternity Care Coalition and Bryn Mawr alumna; and Christina Miller, MSS, Senior Program Director of the Health Promotion Council, and also a Bryn Mawr Alumna.
Each provided a vital element of the formula that fuses public health and social work, from Christina Miller’s work with the Health Promotion Council, which has programs that include chronic disease risk reduction and professional education and consulting; to Cindy Sousa’s research on investigations of violence, stress and trauma and their relationships to health and well-being; to JoAnne Fischer’s work making the needs of mothers and their families visible through policy advocacy and research as executive director of the Maternity Care Coalition; to Jennifer Campbell’s work strengthening grantmaking for an aging society.
The symposium served as a poignant reminder that many quality improvement techniques – including the promotion of evidence-based treatments and well-coordinated care – can improve health outcomes, but their influence is often limited by factors beyond clinicians’ control, such as patients’ education, employment, and social support. In order to address the social and economic factors that affect health, quality improvement initiatives must reach beyond the traditional boundaries of the health care system. The panelists gathered at JSPH this week was representative of the community-based partnerships that bring a wide range of stakeholders – health care providers, educators, business leaders, social service providers, community organizations, and clergy – together to promote healthy behavior, improve access to primary and preventive care, and reduce health disparities.
The program also further strengthened the partnership between JSPH and GSSWSR. Last fall, the schools began offering a dual degree MSS/MPH program, acknowledging the long-standing synergy between social work and public health, and also recognizing the growing interest among professionals to further their preparation by earning multiple graduate degrees.
Posted: April 5, 2013, 7:49 pm