The MDD Interview
Nash sees healthcare's mission as improving care while cutting costs
1st of 2 Parts
Interview by JIM STOMMEN
MDD Contributing Writer
DAVID B. NASH, MD
Sees Healthcare Changing
David B. Nash, MD, was named the founding dean of the Jefferson School of Population Health (JSPH; Philadelphia) in 2008, following an 18-year tenure on the faculty of Jefferson Medical College. JSPH provides innovative educational programming designed to develop healthcare leaders for the future. Its offerings include masters programs in public health, healthcare quality and safety, health policy and applied health economics. JSPH also offers a doctoral program in population health science.
Nash is a board-certified internist who is widely known for his work in outcomes management, medical staff development and quality-of-care improvement. Regularly named to Modern Healthcare's list of Most Powerful Persons in Healthcare, his national activities cover a wide scope. He has authored more than 100 articles in major journals, has edited 22 books, and currently is editor-in-chief of five major national journals.
MDD: You were named the founding dean of the Jefferson School of Population Health in 2008. Tell me about JSPH's mission and how it has evolved over its first four years of existence.
Nash: I've been on the campus of Thomas Jefferson University for 22 years, the first 18 as a faculty member in Jefferson Medical College, which is now our sister school. I first became an endowed professor of health policy in Jefferson Medical College, and then the chairman of the department of health policy. When we got a new university president a number of years ago, he was very interested in creating a new entity as part of his plan to transform our campus into what's called an academic health sciences center. That's a code word, really, for health sciences schools collectively being called a university without an undergraduate school, business school, law school. Thomas Jefferson University has six schools -- medicine, nursing, pharmacy, allied health, graduate school, and then the School of Population Health.
The mission of our school is to create a new kind of leader for the future; a leader who is committed to implementing new systems and new designs to improve the overall health of the public. We do that through four master's degrees -- a master's in public health, a traditional, fully accredited program in public health, which is still on campus, primarily at night; and then three very innovative online programs in healthcare policy, health economics and outcomes research, and healthcare quality and safety.
At the moment we're a unique entity nationwide, there's no other school of population health, although there are several medical school departments of population health that are spring up around the country. Hofstra Medical School on Long Island and New York University in New York City and other institutions have departments of population health within their medical schools, but the Jefferson School of Population Health is the only independent entity like it within the United States. We did find a school of population health in Auckland, Australia, and (laughing) I'm trying to convince the provost that I should go on a fact-finding mission while the Australian Open tennis tournament is being played in Melbourne.
MDD: I noticed on your website quite a number of posts from students, and from reading them, it's evident that they 'get it' in terms of what their future role is going to be.
Nash: It's exciting. I'm very grateful about a number of things. No. 1, to survive on one campus for 22 years. I've only really had three jobs, so I'm grateful for that. No. 2, my lifetime interest in all of these issues is now front-page news, whereas when I first got here 22 years ago, nobody really cared that much about it. And No. 3, health reform is coming at a perfect time for us. People ask me if I'm not tired of doing this, and I say, 'Heck, it's front-page news; who can say that about their job every day?'
MDD: I wanted to ask about the Grandon Society, which had its official debut yesterday, right?
Nash: This is our effort to create a membership organization of like-minded individuals who will support the school at a modest economic level. We believe the society will be a source of wonderful programming and an opportunity for visitors to dive deeper with us on certain issues. And a portion of the revenue will go toward scholarships for students because when you ask people to give money, they want something positive and tangible to come from it; they just don't want to have you use it for salary support, say -- they want to see who's benefitting from it.
MDD: Improvement of the quality of care is one of your major areas of interest. What's new in that regard?
Nash: So much is new, especially all the measures under the Affordable Care Act [ACA], so Uncle Sam published in March of 2011 the national quality improvement strategy that engages the entire federal government in the quality improvement agenda, groups like the Department Health and Human Services, AHRQ (Agency for Healthcare Research and Quality), PCORI (Patient-Centered Outcomes Research Institute), CMS (Center for Medicare & Medicaid Services), FDA. It's an incredible 20-page document outlining all the directions for these agencies. The bill also brought us scores of new quality measures, both inpatient and outpatient, so I would say ACA is a major boon to the quality and safety industry. Now that's the good news; the not-so-good news is that by every measure we still have a long way to go, first to improve the safety of care and then the quality and the outcomes. Medical error remains the fourth-leading cause of death in the United States 12 years after the publication of To Err Is Human, so we have a long way to go in this arena. All the new measures are great, but we still need to make as lot more progress.
MDD: You've talked about reducing overdone and inappropriate testing. Ordering an array of tests has become a staple of medicine for many physicians, in part as a means of guarding against later malpractice claims. How does that culture get changed?
Nash: That's the $64,000 question. Quite frankly, the only way to change that culture is starting at the medical-school level, so we're attacking this problem on multiple fronts. One is that as early as the first and second years of medical school we're giving lectures and infiltrating the medical-school curriculum with this material. We have a special day in the third year called inter-clerkship day where the entire third-year class comes together for a day to talk about their role in reducing medical errors.
We are engaged with all the residency program directors as they face new accreditation standards as they relate to quality and safety. They're actually all using a textbook we edited that was recently published. And at the attending and more senior doctor levels we're talking about not just choosing tests wisely, which is important, but we're also talking about reducing waste, reducing inappropriate testing.
But we know ultimately that really the only way to attack this problem is by changing the payment system. Probably the best lever to change doctor behavior is a bundled-payment program where hospitals might receive a single lump sum, like a DRG, but would include the doctor fees and other fees -- a longitudinal payment, or payment for the care of a person over time. It's almost like capitation in drag.
The spectrum of activity in this regard is from medical school through attending-level interactions, but this isn't going to change anytime soon; it's going to be a generational shift by the time we're all done with the work involved.
(In Part 2 of this interview next week, David Nash talks about designing medical devices to measure outcomes, the need to gather economic endpoints in clinical trials, the nature of two companies on whose boards he serves, the state of healthcare innovation in the U.S., and his reaction to the Supreme Court decision on ACA.)
