Gregg Masters 00:06
This is PopHealth Week on HealthcareNOW Radio. I’m Gregg masters Managing Director of Health Innovation Media and the producer co-host of the show. Joining me in the virtual studio is partner co-founder and principal co-host Fred Goldstein, president of Accountable Health, LLC. PopHealth Week engages industry leadership and stakeholder voices spanning payer provider patient, vendor and regulatory communities in population health best practices and strategies to create private label thought leadership content connect with us at www.popupstudios.productions or follow in direct message me on Twitter via @GreggMastersMPH and that is Gregg with two G’s. On today’s episode, our guest is David B. Nash MD MBA the founding dean emeritus and full time faculty as the Dr. Raymond C. And Doris and grandon, Professor of Health Policy at the Jefferson College of Population Health, his national activities, including curator and master of ceremonies for the annual and quite popular Population Health Colloquium now in its 21st year. And with that introduction, Fred, over to you.
Fred Goldstein 01:23
Thanks so much, Greg. And, David, welcome to PopHealth Week
David Nash 01:25
thanks. Great to be back.
Fred Goldstein 01:28
Yeah, it’sid been a number of times on the show. So it’s always great to discuss something and you’ve got this new book out, which makes it even better. So really appreciate you coming back on. So let’s talk about how COVID Crashed the system by you and Charles Wohlforth. So tell us a little bit why did you decide to write this?
David Nash 01:44
Sure. So Charles Wohlforth, I met Charles, in the fall of 2019 pre pandemic, at a great meeting in midtown Manhattan, seemed like a super nice guy told me he was science and medical writer, take his card and we had a meal together. I didn’t think too much of it other than a nice guy. Of course, that was the let’s call it November of 19. And then 2020, and March. And so spring of 20, Charles reaches back out to me, Fred and says, Hey, remember me? And of course I did. He said, Listen to you’ve got a great voice. And I’m a great writer, we’ve got to get together and tell this story. Nobody’s telling the story. And my first reaction was, oh, gosh, I got a lot to do. Do I really need to do this too? And honestly, Fred, Charles was very persuasive and super articulate guy. And he said, Look, you know, don’t decide today. But I really think that you could fight COVID with a book. And I thought, wow, okay, I hadn’t really thought of it quite that way. And at that point, Dr. Esther Nash and I were more worried about our daughter on the front line than I was about writing a book. But Charles said, this is that’ll be your contribution in part to the battle. Okay, so a couple of weeks later, I said, Okay, what do we do now. And I’ve written a lot of books, more than two dozen, but they’re textbooks and not the kind of book you go to the bookstore to buy. Anyway, so we had to find an agent, write a sample chapter and a detailed outline, fill out the whole author questionnaire. And our agent was wonderful. She shopped it around, we got to Rowman and Littlefield, a very well established house in Maryland. Got the acquisitions editor. And then basically, it was then a race to the deadline, which was December 31, 2021. So we spent, we spent nine months every other week on a 90 minute zoom call. And I did all the outline with Charles and then every call was focused on a chapter. And I have a great medical student who helped me Zach Goldberg, we had over 400 references, you know, so it was a crazy process. But the why the why was, I’m going to use my big mouth to write another book to tackle COVID Instead of trying to fight at the bedside, which clearly I’m way too old and out of shape to do so that that’s the punch line.
Fred Goldstein 04:44
Well, I love the folk the fact that you said you’re using this to tackle COVID Because you’re actually taking on the entire healthcare system.
David Nash 04:52
Now, as you know, and it’s so great to be back on this wonderful program. It’s all about systems thinking. Right? And And given what was going on in the background with the 737 Max, and then that New York Times best seller about the total duplicity on the part of Boeing, and my work with guys like John Nance and others, and I thought, you know, basically, this is just a giant plane crash, and all these people are dying every damn day. Imagine, just imagine, if a triple seven went down every day at Philly International, I mean, we would close it all down, and we ground every airplane until they found, you know, whatever three pieces were broken. So that’s how we came up with the crash scenario and the NTSB investigation. And and as you know, from the book, I mean, there isn’t really a black box, but it became evident what the black box would have contained, right. And for guys, like you and me, no real surprises here. Obviously, this plane was doomed on takeoff. Right? And then we spent half the book about what a disaster, but I was really motivated with Charles’s, obviously, expert help to make the whole second half of the book. Okay, so what can we do now, and end with a list of recommendations like an NTSB report, so the analogy, we thought was pretty apt and we stuck to it. And Charles was on board. John Nance is one of the people we interviewed clearly in the book to sort of help us make it work. And it comes together, you know, it that kind of reads like a novel, in a way, it’s a story, right? It’s not a textbook, it’s not a scholarly, you know, manifesto, it ain’t that. It’s a story. And it’s an incredibly important story to tell. And I’m grateful for Charles’s help. And I hope it’ll be a best seller.
Fred Goldstein 06:57
It really is great. It’s a good read. First of all, it’s really good to read it. It’s got great stuff, because you go from personal stories of your daughter, to what’s going on at Northwell to, you know, looking at Payviders and the system itself. And then, of course, you mentioned, as Gregg said, before the show public health, what’s going on with public health. So what would you say are the key takeaways from the book?
David Nash 07:26
Okay, so look, I think our audience for PopHealth Week, these are super smart people, and they’ve been on the journey, like we have for a long time. So none of this is really a surprise. But when you start really thinking about it, okay, so take homes, Are we really gonna sit back after a million deaths and do nothing different? mean that to me, that’s the main message. And I see that all kinds of places big and small, like, let’s just get back to business and more admissions and fill those beds and do more casts and more cancer and more ortho and, you know, guys, yes. Why don’t we ask ourselves the question, what’s the real business that we’re in? Right? I mean, it sounds familiar, Fred. So the take homes are we got this platform that’s an inferno, not just smoldering, but totally consumed with fire? Are we going to just stand there, watch it burn and do nothing different? That’s the take home message, I think. And so are we going to take this once in a industry opportunity to attempt to fix what’s broken? Look, I’m running out of time I’ve been at Jefferson for 32 years, I’m 67 years old. They’re not I, you know, I can keep talking. Not too many people are gonna keep listening. So we’re running out of time to make these changes. That’s the take home message.
Fred Goldstein 08:57
Right. And I think, you know, if you think about the David, you’ve been talking about population health for some time, and you’re still banging that hammer, saying, Hey, we got to move this direction. And a lot of this are actually Population Health type approaches.
David Nash 09:10
Totally,
Fred Goldstein 09:11
within your answers of what we need to do. So do you really think the message, you know, and not based on your discussions or the book itself? But, um, I’m seeing, like you said, everybody’s sort of going back a bit. Are we going to make the move or enough of the system, people gonna to make the move to make this happen?
David Nash 09:34
Boy, you know, I’m an optimist. And I’m definitely a glass is half full kind of guy. I don’t know, Fred. I’m awfully worried. I’m awfully worried I what I do hope is that one of the best outcomes of the book would be to stimulate exactly this kind of conversation amongst the people who have the wherewithal, the influence, the moral authority to go get something done. Let’s give me let’s, let’s give some examples, right? So, look, there’s a lot of great people in medical education. But we’re hamstrung by ACGME, LCME, the residency requirements, but okay, somebody’s got to put his or her foot down and say, I’m not going to put up with this anymore. We’ve got to train people to become the Doctor of tomorrow. Okay, so there’s the Bernie Tyson medical school, there’s Geisinger , maybe Walmart will have a medical school. So we got to give those folks a platform, that’s one example of the kind of thing I hope will happen. Second thing, that Payvider that’s a clunky term, we were talking about provider three years before the pandemic, right. And all of a sudden, now you see integrated delivery systems, purchasing or merging or doing a joint venture, with a big bad managed care organization, whether it’s Medicare, Medicaid, whatever it is, growth in ACOs. Okay, so maybe that’s another route, what we do know is you got to go upstream and shut that faucet rather than mopping up the floor. I’ve been talking about that literally for 13 years non-stop. So that’s another good example. But if the book stimulates the conversation amongst the people who could really make a difference, which I believe is everybody, then we will be successful. And you know, you gotta go back to I’m old enough to remember, you know, my junior high looseleaf binder, height of the Vietnam War. If you’re not a part of the solution, you’re automatically a part of the problem. And I just can’t be a part of the problem. I got to be out there saying, Listen, I don’t have every answer, certainly not. But if I could get the right people together to talk about what we got to do, then that’s the road to redemption for sure.
Fred Goldstein 11:57
So that brings up an interesting idea, David, could you convene, or put some effort into convene that kind of, because I’m thinking from a political, political perspective, we need to get rid of 85% medical loss ratio rule, the only thing that does is keep costs going up? There’s no reason for Payvider either to make people healthy, because they’ll make less money. And so could you pull that and you about to answer that question, let me let you get to it.
David Nash 12:21
Well, what we hope what we hope is in part, and it’s a tall order, admittedly, but look, we haven’t been together for the PopHealth Colloquium in three long years. I’m praying, literally praying, November 7, eight, nine will be safe, it’ll be great to be back together in person, we’re going to have a night set aside Tuesday night, November 8, where myself and several other authors and very timely books about the health care, we’re gonna have a book, seance, you know, to talk about these issues, and try to get a groundswell of support. And by the way, it’s going to be election Eve, as well. So Holy mackerel, it’ll be a high wire act, we’ll have televisions, we’ll be watching the returns, we’ll be talking about health care. You know, Fred, our listeners know, we are the biggest business in our great country. And whatever happens to healthcare is going to affect the entire country and vice versa. So we got a $4 trillion monster that most people who look at the data would agree, 1 trillion of that spending makes no damn sense. Can you name another industry, anywhere in our country where that’s the case, you know? So that’s why venture capital and private equity, why they’re pouring money and energy into our field because they think, Wow, if I make a 1% margin on a trillion dollars, that’s a lot of money. So we can cut that waste. But back to your question, the only people who can reduce waste are the people inside the system itself. That’s why I called it the Trojan horse strategy, you know, get inside the system to try to make the change. I really do believe that that’s part of what the book is about. And, you know, trying to explain health insurance to Joe and Jane, you know, on Broad Street in Philadelphia, it’s hard to do. It’s awfully hard. That’s why Charles and I wrote, you know, hang in there with us. It’s complicated. No, this is may not be bedtime reading, or you got to read it four times before you understand what the heck we’re talking about. But even so it’s it’s incredibly complicated. But if we start the conversation and get it in the right direction, and engage with the right people, I’m optimistic.
Fred Goldstein 14:48
Well, that’s great. It’s nice to have an optimist in the group. And I’m looking forward to the Colloquium. Obviously, that’s going to be one heck of a session. And, you know, I’m thinking about this. You just mentioned the concept of an individual You know, asking them to kind of manage this thing, which they can’t. It’s so difficult complex. But one of the groups you talked about in the book is employers, and you implore them to take control. But again, that’s going to require a fair amount of education, won’t it?
David Nash 15:16
It sure will. So let’s talk about that. I mean, not the first time you and I have even tackled this issue, right. And in our city, we’ve got my great friend Neil Goldfarb, the Philadelphia Business Coalition on health part of the national movement, doing all the right things, transparency and accountability showing the LeapFrog scores are holding employers responsible while giving them great education. This week’s Journal, the American Medical Association, a really great piece on chief medical officers for employers who then are reaching out to guys like you and me. Okay, so maybe we’re making some progress. But I would say I’m a pretty easy grader, I would give most employers at best a b minus as to how they managed health care costs, it’s still all about the brokers, get me the best price, you know, keep it under control, give me the biggest network. That’s ridiculous in the 21st century, give me a network that has good outcomes. And give me a network that you could prove that people are following the evidence, they’re not being wasteful, they’re communicating, they’re coordinating, they’re not doing stuff they ought not to be doing. I mean, on and on. So do employers do that? I don’t really think so. I really don’t. I think there are a lot of employers, especially medium ones, who think, you know, all hospitals are about the same and all doctors are about the same and, and in Philadelphia, if you don’t have all five major medical centers in your network, well, no one’s gonna use it. That’s nonsense. And we got to get past that. Well, hopefully hard to do off the hook.
Gregg Masters 17:06
And if you’re just tuning in, you’re listening to PopHealth Week. Our guest is David B. Nash, MD MBA, the founding dean emeritus and full time faculty as the Dr. Raymond C. And Doris and grand and Professor of Health Policy at the Jefferson College of Population Health.
Fred Goldstein 17:23
It’s going to be I mean, you think about, I can’t tell you how many people I’ve just talked to personally who say, Well, my doctor needs to be in that network. But excuse me, unfortunately, your doctors in the bottom half, you don’t want you know, and trying to get that message across is very difficult.
David Nash 17:40
Very hard. Look, you know, we all have heroes in healthcare. I have a whole bunch of heroes, among them, you know, just Atul Gawande, right? Not everybody’s equally doing a good job. We know that. And it’s a bell curve, distribution of performance and outcome. So I’d rather have people at the right end of that bell curve in my network. And I think we have the tools, the technology, what we don’t have is the political will to say you’re in and you’re not. And for the guys and gals, who aren’t, we’re gonna give you an opportunity to improve. We’ll even teach you how, and we’ll give you a shot at getting into the network.
Fred Goldstein 18:18
Absolutely.
David Nash 18:19
Some of this Fred is vocabulary when you hear narrow network, right, that’s like war cry, right? That that’s the wrong word, High Performance Network. That’s the network I want to be
Fred Goldstein 18:31
that narrow network came from the 90s, when in fact, it did narrow the network based on price and not based on quality
David Nash 18:36
based on price. So it’s like, and then we got to as you and I have chatted about, you know, what I used to call somewhat disparagingly, you know, any breathing provider. Well, that’s a crazy wants to be in that network, not me, right. So employers have a lot of work to do.
Fred Goldstein 18:56
For my class, I just did a talked about Palm Beach ACO down in Palm Beach, the number one ACO in the country from savings, you know what they do every year, they dropped the bottom 10% of their providers.
David Nash 19:07
Sure.
Fred Goldstein 19:08
And those kinds of things. They’re tough. But and then what you have to do is obviously give the resources to help those providers move back up into the, into the realm of continuing to do the right stuff.
David Nash 19:18
It’s counterintuitive that Palm Beach could achieve savings, that’s for sure. But but you know, if done, right? It certainly it certainly can work.
Fred Goldstein 19:27
It may help a little bit with a high base.
David Nash 19:29
Well right. Right. But like we talked about in the book, you know, the waste, anybody could cut costs. That’s easy. Close a program, close the hospital, reducing waste. Oh, that’s gut bustingly difficult, hard work. And that’s where doctors, nurses, pharmacists working together with good leadership, with the tools, with the data. And today, there’s no excuse. There’s great companies that can help you get the data and organize it and every test I’ve ever ordered, it’s all online. Now you could see how does Nash do versus everybody else in the practice. Let’s get into it. And it doesn’t have to be punitive, certainly not. But if you give us the tools, and you give us good data, get out of the way we’re going to stampede to improve. That’s always been true.
Fred Goldstein 20:20
Absolutely. And one of the areas you touched on also is the whole issue of, you know, the disparities COVID and racism and what we saw in these various communities, just tragic,
David Nash 20:32
tragic. Well, I have to say, personally, this was really eye opening. For me. It’s one thing to have the College of Population Health and our great journal and the textbook and the Colloquium. But to see it in our own city. On a day to day basis, people dying, guys and gals who drove the buses kept the trains going delivered, the groceries fought the fires, it was a disaster. And when you delve deeper, and you see that a lot of these folks never have a paid holiday or barely making minimum wage, they had to show up because they had to eat. And then when they got sick, they went home, the places aren’t big enough to you know, isolate in the guest bedroom. And then all of a sudden, we wonder why communities of color got crushed, not to mention underlying terrible health measures of obesity and hypertension and diabetes and all the rest. It’s a toxic witch’s brew of poverty, ill health, poor jobs, structural challenges, you put that all together? Well, no wonder that people of color were dying it three, four or five times the rate of age match non on black non colors. It’s just unbelievable what happened. And not just in Philadelphia, of course, and this is not a new story. Let’s go back to David Ansel’s great book 2017, the death gap in Chicago. I mean, this was well described, which is why we say in the book, no surprise, terrible, but no surprise, but speaking personally, to see it in our own town, it really was a eye opener for me, I didn’t really get it. Honestly, as much as, as maybe I should have. But seeing it for that first year that that just was a heartbreaker.
Fred Goldstein 22:33
And you talked about I mean, that was obviously a huge Inferno going on within this broader COVID issue.
David Nash 22:38
Totally.
Fred Goldstein 22:38
You talked about the individuals who ran into that fire and said we’re gonna solve those problems. That one case I think it was with someone going with vaccines or something into
David Nash 22:47
Yes, yes, Dr. Stanford and others. You know, I give the Jefferson leaders a lot of credit, I was super proud of the day to day amazing folks who were in charge, some of them now gone, but who are on the frontlines of organizing our response? It’s awfully hard. I mean, there was no infrastructure, who, no way to keep a record of who got a vaccine and who didn’t. And where should we go? And how do we talk to people who don’t trust us at all? And how do we treat people when there’s no doctor who looks like them? And all of that stuff came to a head? Oh, and then of course, you know, murdering’s and Black Lives Matter movement and riots all at the same time. I mean, it was unbelievable confluence of these events. And then even corny stuff, like, deputy editor, JAMA saying, well, there’s no structural racism because doctors aren’t racist. Well, okay. That was like the final, you know, that gave me insight that, no, we just don’t get it. And, and then you realize that if that’s the status quo, and that’s the leadership, we got a long ways to go to sort this out. And I’m not Pollyanna, I’m really not. But I am realistic enough to say, well, we got to have a different approach. But if you’re going to get paid to do more, that approach will not work to keep people healthy. It’s not going to drive the creation of more primary care centers, it’s not going to get into the toughest poorest zip codes in the city like Philly. It’s going to take outside resources, hence our project with Novartis and closing the gap and other related activities. But these this is a drop in the bucket compared to the greater challenge of the health care system is the final common pathway for all of the social determinants right when you look at it, outside looking in poverty and ill health all come together in you know creating the need for healthcare services, and diabetes out of control, obesity, cardiovascular disease, where the final common pathway for all of that. So it’ll take a societal change and saying, what’s the core business that we’re in if the core business is improving health? Okay, well, let’s organize to improve health. But I would argue we haven’t even had that conversation. What’s the core business? And how are we going to get paid to implement the core business? not trivial. And we try very hard to raise those questions in the book. It’s complicated.
Fred Goldstein 25:39
It’s very complicated. So David, you mentioned the Atul Gawande. And obviously we had the news about Amazon acquiring OneMedical, is that Haven 2.0 Is that a VC play? What is that?
David Nash 25:49
Yeah, good question. I hope it’s not Haven 2.0. With all due respect to our Atul and the team? Well, look, it’s not unexpected. Amazon has been nibbling on the edges, right with pillpack and other opportunities. And Alexa, you know, I wrote a piece Alexa, refill my Omeprazole and have it delivered and bring some recipes on low reflux diet, right. So I think it’s to me a step in the right direction, because it’s going to be disruptive. And that’s great. And it’s going to put the provider community on notice that this is just the first of many salvos across the bow of this boat, that stuff is not going to remain the same. And I’m looking forward to see and I wish them well,
Fred Goldstein 26:36
thank you so much for coming on. The book is great, how COVID Crashed the System. It’s really a good read. And but also, as you said, it has great ideas on what we can do to begin to try to fix the system. So I really appreciate your efforts in writing this and putting the time in. I know that was a lot of work.
David Nash 26:51
Well. Thanks so much. Great to be together. And I hope we’ll see everybody November 7, eight, nine in Philadelphia,
Fred Goldstein 26:57
absolutely head to the Colloquium. It’s the place to be and with that, thanks again, David. And back to you, Gregg.
Gregg Masters 27:03
And that is the last word on today’s broadcast. I want to thank our special guests David B. Nash, MD MBA, the founding dean emeritus of the Jefferson College of Population Health for his time and insights and preview of his new book how COVID Crashed the System do follow his work at Jefferson via at jefferson.edu/population-health and on Twitter via @Nashpophealth and the college via @JeffersonJCPH. And finally if you’re enjoying our work at PopHealth Week, please like the show in the podcast platform of your choice. Share with your colleagues and do consider subscribing to keep up with new episodes as they’re published. We stream live on HealthcareNOW Radio weekdays at 5:30am 1:30pm and 9:30pm. Eastern, and for you left coasters 2:30am 10:30am and 630 Pacific for PopHealth Week my co-host Fred Goldstein. This is Gregg Masters saying please stay safe everyone. Bye now.