Jefferson has one more reason to call itself a population health powerhouse

Navvis and Thomas Jefferson University's College of Population Health have partnered for the nation's first private sector-supported academic chair in population health.

Philadephia-based Thomas Jefferson University pioneered a new way of thinking about healthcare when it established the Jefferson College of Population Health in 2008. A decade later, the institution is again making headlines for crossing the boundaries of academia, medicine and private sector business.

Supported by a $2 million endowment from St. Louis-based Navvis, The Navvis Professorship of Population Health at Jefferson will focus nationwide academic research that identifies methods to create systemic, effective and scalable improvements in health. Unveiled June 25, the Professorship represents an important shift in thinking regarding ways to improve health and reduce healthcare costs.

Becker’s Hospital Review caught up with three leaders closely involved with the unusual partnership fueling the first-of-its-kind professorship. Here, Steven Klasko, MD, president and CEO of Thomas Jefferson University and Jefferson Health; David Nash, MD, dean of Jefferson College of Population Health; and Stuart Baker, MD, executive officer and president emeritus of Navvis, discuss what health system executives really think of population health today, the obstacles healthcare organizations face in addressing social determinants of health, and how the gradual departure from fee-for-service medicine changes what we need from leaders in hospitals and health systems.Dr. Steven Klasko

The following interview has been lightly edited for style, clarity and length.

Question: Say you're hosting a private dinner party with 25 health system executives. Your guests are in the midst of a dozen different conversations when you tap your spoon against your glass and say you want to hear their thoughts on population health. What do you think you'd hear?

Dr. Klasko: What you'd hear behind closed doors is neither insurers nor providers at this point are ready to do the hard and disruptive things that have to happen to live in a population health world. What you hear is we are in this twilight zone for philosophically moving from volume to value and individuals to populations, but the simple fact is the way we are still primarily paid in most places is not supporting that. 

The second thing you'd hear is, from provider perspective, we haven't really faced the question of what happens if we succeed in population health. We have way too many hospital beds in places like Philadelphia, and a lot of population health initiatives are run by hospitals. If we are really successful, the model may be out of business.

Finally, I would say the technology needs to catch up for population health — it's really not at the level we need to make proper decisions.

Dr. Baker: The first point Dr. Klasko made is akin to what happened after the Institute of Medicine report in 1998 about medical errors. I remember talking to CEOs at the time who said, 'I don't get paid to prevent medical errors, I get paid to make them.' These weren't unethical people — they most certainly understood and cared about safety — they were talking about the pure economics of it. I think most people today would say, 'I don't get paid to deliver population health.'

If you think of medical errors, it is not that one person can just work harder or be more careful. It's a system problem. We have to build systems that are less fallible. It's the same idea with population health — we need systems that physicians and clinicians can rely on, that are connected and can do things that need to be done to manage the health of populations better.

Q: Dr. Nash, your piece in NEJM Catalyst — "A Requiem for Population Health?"provides evidence for your perspective that value-based care models are propelling the healthcare system to a place where care teams are reimbursed for health outcomes, reining in rising healthcare costs and placing patients firmly at the center of care. You likened the fact that so many pundits are ready to declare value-based care "dead" to fake news. Can you talk more about this?

Dr. Nash: What we tried to do in that piece was call attention to the fact that, hey we recognize the pernicious payment system is still driving behavior in the old model, but if you look at all economic exigencies, we have to get our focus back on moving from volume to value. No outcome, no income — we coined this four-word term to describe where we think the end game has to end up.

That piece was really our attempt to reach a critical leadership audience to say, 'Don't believe everything you read.' The Medicare trust fund is still at risk, we are still spending 18 percent of our GDP on healthcare, and we don't rank among the top 10 in the world for any outcome measure. Despite Steve's excellent review — we are still largely paid in a fee-for-service model — the underlying issues are pointing clearly in the direction of population-based payments.

Dr. Klasko: Until very recently, a lot of the things David came up with in the College of Population Health were viewed as almost philosophical. What's happening now is people are going back to his book and work that's been done and saying, 'Now we really have to do this. This is not a mock exercise, and it's not philosophy.'

Q: Leavitt Partners released a survey early in May that found while the majority of physicians believe social determinants of health matter, most physicians do not believe it is their responsibility address them. Where should a health system leader or physician leader begin their work, knowing that opinion?

Dr. Nash: This is really tough. We do face this every day. I think if I look at my primary care faculty colleagues, they would probably agree with this statement.

We know social determinants are important, but how are we as individual doctors going to tackle this? You can't — it's a system issue. Part of the fix is to get this into the curriculum for medical, nursing and pharmacy schools on day one. Younger doctors will recognize it takes a system fix, but education at the individual doctor level right now does fly in the face of the population health perspective. There is tension there, no question.

Dr. Baker: Many of us physicians were trained as individual performers, who were supposed to be 'in charge.' When I walked across the stage at Johns Hopkins 45 years ago and got my medical degree, the dean said, 'You are now the captain of the ship.' To the contrary, population health is a team partnership idea with everyone contributing where they need to.

Dr. Nash: Jefferson's medical school is trying very hard with new curriculum to tackle some of these issues, and we are very much a part of that change in the curriculum. We've got to start training people in a completely different model.

Dr. David Nash

Dr. Baker: In Hawaii, we worked with HMSA, the state's Blue Cross Blue Shield plan. We helped them go from a primary care, fee-for-service system to a value-based model, and in doing so we interviewed hundreds of primary care doctors. I would say every single physician said, 'We'd love to do something about social determinants, but we don't know how. We're not trained. It's hard. We don't have time, energy, knowledge or capability to solve problems like depression, homelessness or food disparities.'

I think the answer is this: Let's build an ecosystem that connects community services and all the departments cities and states have. Let's connect them to our record-keeping for patients, so there is a way where I as a doctor can refer patients in a supported system to the right community and social services. That enfranchises everyone. If these services are not organized, it is really difficult to access them.

Dr. Klasko: Some of this also falls on the boards and trustees of institutions, as well as the way leaders are compensated. We have six academic medical centers in Philadelphia, yet we have among the greatest discrepancies in life expectancy [in the country]. I would argue that one option is for the boards of nonprofit entities and insurers to say [to top executives]: 'Twenty-five percent of your incentives are going to be based on what is happening in Philadelphia — not whether your hospital has a bigger MRI than your competitor.'

This is the case for me; 25 percent of my personal incentives are based on working to address the impact of social determinants. This year Jefferson launched the Philadelphia Collaborative for Health Equity to establish partnerships with social agencies across the city. The CEOs of the health systems don't really talk to each other about those things. My guess is if their incentives are tied to this work, they'd start to talk to each other.

Dr. Nash: The chief population health officer has some of his or her compensation tied to how they address social determinants of health. What Steve is advocating is that the same happens at his level. It's analogous to where we were with the chief quality officer and tying outcomes to his or her compensation, when of course this whole thing is so complicated it has to be at the system, CEO and board level.

Q: The Navvis Chair of Population Health at Jefferson University is the first private sector-sponsored endowed chair for population health. Can you tell me more about what this role entails, and what you believe it signals to the healthcare and medical communities at large?

Dr. Baker: We are really excited about this. We want to show we are absolutely committed to the idea of population health, and the big piece we're interested in is the need to apply academic rigor to prove which interventions and approaches really work. Then there is real need to convey that educationally to the field.

The things we're interested in supporting Jefferson to explore are social determinants of health, physician engagement, person-centric care, provider networks and payment transformation strategies. We have a lot of optimism. These efforts will contribute toward a long-term impact. Population health is so much about the harmonization of science and medicine, the art of healing and the business of health. This chair is a way to support that and figure out how to do it better.

Dr. Nash: There are probably three or four other endowed chairs in population health, but typically from individuals or foundation donors, and none are national in scope. This is the first chair we are aware of with a private, for-profit sponsor like Navvis, so it is breaking the mold for sure. This will also be the third endowed chair in our college, which is more than anywhere else connected to health policy and population health.

This person has not yet been recruited, but what we hope to do is leverage this amazing opportunity by bringing first-rate scholars, researchers and teachers to campus to help continue sculpting this field. We are going to be out and about looking all over the U.S. to bring the best people to our college. We are always going to be nation's first college of population health, but we are tracking up to 10 additional schools nationwide that are following our lead — reading our textbook, doing deep dives in the curriculum, attending our annual colloquium and one-week population health academy.

Q: Do you think population health demands a hospital or health system leader with different job qualifications than what have been sought out in years past?

Dr. Baker: Yes, and one critical way is they have to be consumer-focused. They have to care deeply about what the experience is and what the outcomes are. They have to live and breathe that, which is still fairly new inside of healthcare. You have to understand and experience, somehow, the day to day. It is this incredible focus on the customer. Frankly, the customer is never fully satisfied. Jeff Bezos, CEO of Amazon, says that is the opportunity.

Dr. Klasko: I agree — the simple answer is yes, and here are even more ways:

The first thing is we need leaders willing to be bold. When you look at other industries that have gone through great transformations, the leaders who have succeeded were those who were willing to make decisions that held in long-term but may have brought short-term hits. We will go 180 degrees from where we are. If you believe that, you have to work harder and really be a leader who is willing to add other leaders to your faculty and medical staff who can build culture change and take short-term hits, because there are going to be a lot of nonbelievers.

We started in 2013 a telehealth program that moved care away from Jefferson, an academic medical center. When we decided to expand and have four mergers, those mergers were based on a hub-and-hub model, not a hub-and-spoke model. We wanted to get care to where people are. We set up a program to set people up for unscheduled care outside of our ED. We make a lot of money by having people come to an academic medical center's ED. Care outside of it is the right thing to do — it keeps people close to home with better outcomes, even though it's not how we are getting paid today. All those brought short-term hits to the traditional strategy of getting patients into an academic medical center. What it will demand is leaders that (a) expect change, (b) are willing to be in it for the long haul and (c) are willing to take an entrepreneurial approach.

Jason Kidd has a great quote: 'We are going to turn this team around 360 degrees.' Are we really? If I am successful, I am going to need 20 to 25 percent fewer beds. Leaders have to be bold enough to say, 'Let's talk about that.'

Finally, where you put people who report to the CEO in an organization really sends a signal to where the organization is headed. We are a $5 billion organization. The people who report to me as we move forward will be a very different group of people — the enterprisewide CNO, the chief quality officer, the chief innovation officer, chief population health officer. These are the people really moving us into the future. A more traditional reporting structure to the CEO may be the folks running each hospital and people responsible for finances.

Q: Organizations may call themselves leaders in population health, but this can be a difficult title to back up — seems as though the goal post for population health can move easily. What, in your opinions, illustrates leadership in this dimension?

Dr. Nash: I would like to see actual measures of population health-based improvements in health. There are publicly available measures (accessible for free) from the CDC, Robert Wood Johnson Foundation, HHS. I urge leaders to pick one or two and get to it. See if you can actually move the needle.

Q: What classes are medical school curriculum lacking today that are necessary for us to really move the needle in population health?

Dr. Klasko: [We cannot afford to think] incrementally when we need transformation. We have not more than incrementally changed how we select and educate medical students even though we've gone through transformations with technology. Then we are amazed when they are not more empathetic. You have to fundamentally change medical school curriculum, which is dominated by biochemistry then includes three days of quality curriculum and four days of public health curriculum in the last year. How do you make those disciplines — population health, social determinants of health, quality — longitudinal across the curriculum for all four years?

Dr. Nash: I don't think it is only a medical school challenge — it's also pharmacy and nursing. We would love to see the tenets of population health diffused into all three professional training schools. Our textbook got a head start and is in 80 graduate programs around the country, including nursing, public health, pharmacy and medical institutions. It will take more than one textbook and more than 80 schools to really make a big difference. I would challenge every medical school, for starters, to ask, 'What are we doing today to train the leader we all agree we are going to need for the future?'

Dr. Stuart Baker

Dr. Baker: As a physician, you are inside the system. When you are outside the system and just a regular guy or gal, it is very difficult. I don't think physicians are familiar with how hard and inconvenient it can be for patients and consumers. Every executive and clinician must be really concerned about these issues, and the key to moving forward is aligning clinical teams to the goals of population health and the cumulative experiences and outcomes of individual consumers.

Dr. Baker: For the last 30 years, if you think about two circles — health plans on the left and providers on the right — you have this whole zone in between where the patient and community are. Between the health plans and providers is the frictional interface where a lot of opportunities exist to improve quality and experience, and lower costs. 

Q: What are your thoughts on the barriers or opportunities that exist at the intersection between health plans and providers when if comes to population health initiatives?  

Health plans and providers are each responsible for certain things that are much better when done together and in an aligned fashion. The rules and regulations put in place for how health plans pay providers have become somewhat nonsensical and counter to what we are trying to do in population health.

Each party is indelibly wed to their current system. The health plans have to show the employers, most of whom are now self-insured, what their dollars are going for. Providers are trying to support the industrial health complex they've built. So it's hard for them to be concerned less with facilities and more with facilitation of care.

Now you are seeing health plans partner with or actually become providers — and vice versa. When that happens, you can get a much more logically aligned payment structure. That's how you align outcomes with incomes and build the kind of environment, partnerships and performance criteria that reward the experience, costs and outcomes that consumers and patients want.


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