Episode 72

A Guide to Fixing American Health Care

with David B. Nash, M.D., MBA

July 14, 2022

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David B. Nash, M.D., MBA
Founding Dean Emeritus, Jefferson College of Population Health

David Nash, M.D. is the Founding Dean Emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy, at the Jefferson College of Population Health. He also serves as a Special Assistant to the Chief Physician Executive of Jefferson Health. He is a prolific author, with a forthcoming book, “How Covid Crashed the System: A Guide to Fixing American Health Care.” Dr. Nash received a Bachelor’s in Economics from Vassar College, a medical degree from the University of Rochester, and an MBA in Health Administration from the University of Pennsylvania

So I wanted like lots of other observers. Let's say "humanism" instead of "heroism", cause heroism implies that it's all about the operator, in this case the doctor. But the system is what failed. The system failed us. Individual doctors did their darnest.



[00:02:02] Gary Bisbee, Ph.D.: Well, good afternoon, David and welcome.

[00:02:05] David Nash, M.D.: Thanks. Great to be together.

[00:02:07] Dr. Gary Bisbee: Well, we’re pleased to have you at this microphone. This show is about leadership as we’ve discussed, and you’ve been a preeminent leader throughout your career. We’ll dig into that as well as your new book here shortly, but first, why don’t we get to know you a bit better? What’s your life like growing up, David?

[00:02:25] Dr. David Nash: Oh boy. So I grew up like leave it to beaver on the south shore of Long Island, NY in a town called Merrick, not too far from a famous beach called Jones Beach. I had one kid brother, and we lived in what I would describe in retrospect as a kind of a gilded ghetto, if you would. It was largely a Jewish community. I went to a huge public high school. My mom and dad both worked full time, which was a little out of the ordinary back in 1960. But I walked to elementary school, it was of course not all Norman Rockwell, but pretty damn close.

[00:03:06] Dr. Gary Bisbee: Well, what did the young David think about leadership?

[00:03:09] Dr. David Nash: I was really lucky to have a dad who told me in junior high about Peter Drucker. And my father was in the very first graduating class at the Sloan School of Management at MIT. My father had a picture of himself with the Alfred P. Sloan. I

mean, how How many 14 year olds know about that? So it was a odd thing to learn about leadership and management even in junior high. But what really motivated me was I had some sense that it’d be great to be a doctor businessman or a doctor leader. And this is of course ancient history. And I didn’t really understand how you could do that. But it’s almost legend in our family. I was in high school. And Samuel P. Martin III, who’s a famous physician leader at that time at University of Pennsylvania. He had a piece in the New York Times about the future of the doctor leader. And I read this thing and I said, “God, this guy. He’s got it figured out.” And. So I was 17, and my father said, “Well, why don’t you write Dr. Martin a letter?” And I’m like all 17 year olds, “Oh gosh, that sounds pretty stupid, but I’ll do it anyway,” just to, keep dad happy. So outcomes the Smith Corona typewriter and I sent Sam a letter. And that son of a bitch called me at my house. Of course, no cell phone, no internet, but I had included my family phone number. And at that point he was already in his sixties, six foot four, Missourian. Anyway. So he called me. He said, “Young man,” essentially, “get on a train. I wanna meet you.” And I thought, “Oh, okay.” I’d never been to Philadelphia. Hadn’t been that far on a train by myself. So, off I went to meet Sam Martin in 1973. And it was I know it sounds corny, but it was transformational between my dad and Sam, but Sam jumping in and saying, “Listen I’ll be your mentor.” “Okay. What’s that?” And he really hung in there with me throughout college, medical school, residency. We actually didn’t reunite until I was a Robert Wood Johnson clinical scholar nearly 10 years later.

[00:05:43] Dr. Gary Bisbee: Yep. Well, in a small world category Sam Martin was my advisor when I was at Wharton.

[00:05:50] Dr. David Nash: Oh my God. That’s so great.

[00:05:52] Dr. Gary Bisbee: it’s really, really.

[00:05:54] Dr. David Nash: You you know, Gary, he was so ahead of his time, and he sort of personally wrangled the Robert Wood Johnson Foundation to give the money, he and David Rogers, they were like co-conspirators, to put together the clinical scholars program. So it was just fortuitous and then to meet Sam and between Sam and my dad, I think those were the two most influential folks especially in young adulthood.

[00:06:23] Dr. Gary Bisbee: Right. So did, after that meeting with Sam, did that pretty much lock in your feeling about medicine and the fact you could cohabit both medicine and business?

[00:06:32] Dr. David Nash: Yeah well, at least it showed me that there was somebody who knew how to do it, and I ended up majoring in economics as an undergrad. And then did all the pre-med requirements as sort of a second major. And I was able to manage that. Some of it was Sam’s help and good advising. And I went to Vassar. So I was in the second co-educational class at Vassar, of course for my children, Vassar always been co-ed. But you know, obviously it had a century and a half, and then they finally took boys in 1972. I entered in 73. And they made it flexible to be able to major in Econ. I wrote a senior thesis on health maintenance organizations, which had just been named by Paul Elwood. It was crazy. So luckily again, good advising, flexible undergraduate school. And then, off I went to Med school directly from Vassar having majored in Economy. Gary, I didn’t know how to turn a microscope on, let alone look through it. So I didn’t do too well in Year 1 and Year 2 at Rochester. It was pretty bleak.

[00:07:49] Dr. Gary Bisbee: Well you know, another small world category is Vassar and Yale were talking for a while about I would call

[00:07:57] Dr. David Nash: That’s exactly right. And it was a failed merger. We would call it today.

[00:08:01] Dr. Gary Bisbee: Yeah, while I was actually on the advisory committee at Yale, I was working with the people at Yale about doing that.

[00:08:08] Dr. David Nash: Wow.

[00:08:09] Dr. Gary Bisbee: And so again, small world. So at what point David, you actually did then decide to go to Wharton and get your degree? What prompted that thought?

[00:08:19] Dr. David Nash: So, in 10 years of correspondence with Sam and usually I would see him once a summer. He basically said, “Look, you gotta apply to this Robert Wood Johnson Clinical Scholars Program, and that’s the route to go to Wharton. So if you get into the Clinical Scholars, you got a free ride. All tuition books, everything into Wharton Graduate School in Health Administration. So it was fantastic to get applied, get accepted to the Clinical Scholars. Sam was the leader, of course. And with that came entrance into, I had to take the business boards and all of that, but I finished a traditional 3-year-Medicine residency at what was then Graduate Hospital at the University of Pennsylvania. I finished that on a Friday and Monday, I was in summer school at Wharton. I mean, that was a mind bender. I hadn’t been in the classroom in over 3, 4 years of Med School and residency. And we all started a cohort. There were five of us, a pretty incredible group of colleagues. And I was sitting in a marketing class, I’ll never forget it, in Wharton at the end of residency. So this must have been June of 1984 and I’m like, “What am I doing here?” It all sounded good on paper, Gary, and then you had to show up and do the work. And I was good like in Marketing and few other, but Finance, my God, Finance is the Organic Chemistry of a business school. That’s how I would describe

[00:09:57] Dr. Gary Bisbee: Yes, that’s true. Well, let’s move on to Jefferson now, Jefferson University. Where you’ve been for more than 30 years and named professor and founding Dean of the Jefferson College of Population Health. So, major kind of involvement and leadership there, but could you describe Jefferson university for us? There’s been some changes over the last couple of years.

[00:10:22] Dr. David Nash: Oh boy. Yeah. I I’ve had a ringside seat to the changes too. So the short story is I was at Penn Medical School. When you finished the clinical scholars, you kind of automatically became like a assistant professor of Medicine. So I spent five years on the Penn faculty. And again, just luck and circumstance, Joseph Gonnella, who’s still alive at 85, was the Dean at what was then called Jefferson Medical College. And he reached out to me. Of course, they are only about 30 blocks apart from Penn to Jefferson. Joe reached out to me. To his credit, I’m some young punk. And he wrote to me, and he said, “Look, I don’t have any faculty members who have been to business school. I would just like to meet you.” So, back then I went and met Joe and he liked to have a glass of wine with every lunch, just an amazing character. And he paved the way for me to leave Penn and got recruited to Jefferson in a new job that nobody had ever had before called Directing the Office of Health Policy. And basically Gary, I was a staff officer to the Dean of the Med School and the CEO of Jefferson University Hospital which was a pretty big deal. They had never had a doctor reporting to the hospital president, and I had a staff job. did all kinds of doctor education and grant writing. It was really a fantastic opportunity to get to know the leaders and learn the organization. And 13 years into that staff job, I finally said, “Look, we have all these resources. Health Policy is kind of important. The costs are going up. We got to get our arms around this.” And I essentially petitioned the new Dean of the Medical School at that time, Tom Nasca, to say, “Let’s create a department of health policy. And I reached out to Mark Chason, who, I’m sure a lot of folks remember, Mark at that time was a Chief of Health Policy at Mount Sinai. He had been of course, Commissioner of Health. He was a huge deal. And Mark gave me great advice about how to create a new Med School department. Anyway, short story, we became a department of Health Policy right around 2013 or so. And I had, I mean, a 2005. And I had that job until we had yet a new university president who said did a strategic plan. And Robert Barchi, who went on to become president of Rutgers, but when he was at Jefferson, he said, “Nash, you are going to help me build a new school, and we’re gonna come up with a new name.” And so the truth of the matter is. Robert Barchi was the one who had the guts to say, “We’re gonna do this. And you are it.” And it was lucky cause I was already on campus. So the recruiting to be the Dean of the first college Population Health was one face to face conversation with a pretty powerful university president who didn’t broker any questions. And basically said, if you don’t do this I’ll find somebody else. So we went from office to department to college and that whole thing took more than 20 years obviously, but pretty amazing. And then I was Dean for 11 years. And 11 years in a leadership role, as all the great leadership books will tell you, that’s probably one year too long. 10 years is really just about the right time, I think, to be in an executive position. So I voluntarily stepped down, rejoined the faculty, and it’s been a great, great home for me. But at the same time, I think you have to recognize, no one’s gonna be in one place for 32 years anytime soon. Again, in Academic Medicine, I mean, my grown children think I’m a walking-talking dinosaur. They’re probably right.

[00:14:31] Dr. Gary Bisbee: Well, population health is an interesting area, and certainly it’s evolved tremendously over the time that we’ve been there. But how would you describe population health now, David, cause this kind of lead into the book, How COVID Crashed the System, but how would you describe population health now?

[00:14:54] Dr. David Nash: Yeah, well, Gary, great question. Let’s go back to 2008 when I kind of got the assignment, and then we opened the doors to the school in 2009. That’s still a whole year before Obamacare. What we said in 2009 was population health was like public health on steroids, that it included things that historically the public health community did not talk about. Two main things, measuring the quality and safety of care, and looking at the cost of care. So what we said more than a decade ago was population health was all of public health plus quality and safety plus health economics. Essentially, that’s how we described it. Of course. Lots of smart people like David Kindig and others were writing about population health as early as 2003, 2004. So, in the modern definition, I think it’s still public health is at the center, healthcare quality, health economics, health policy, and now health data and data analytics, all of that is population health. In the operational terms, pop health management, I think, is our new way of describing how are we gonna achieve value for the money that we’re spending. I think that’s what in the modern lexicon, population health management is all about value based care, achieving value. We accept all of those things, but in the early going, I think we always had to recognize public health was at the center, and we added three key areas, if you would, economics policy and of course, quality and safety. But Gary, I gotta tell you one quick story. When Bob Barchi was considering calling it population health, I got on a train and went to the Council on Education in Public Health, CEPH, in Washington, DC. And I said, “We’re gonna call our school population health.” They said, “Well, we don’t care what you call it, but you better make sure that if you offer the masters in public health, that you meet all of our requirements.” So we sort of struck a deal that, “Yeah, we’ll get the MPH piece. We’ll get that accredited. But around all that, we’re gonna build these other programs.” And they went for it. We had a handshake and they, to their credit, they stuck to it. As long as we did all the MPH things they wanted us to do, they were cool with that. But again, fortuitous, great timing, a year after Obamacare. I mean, we were rocking and rolling in population health. And of course I don’t have to explain that to too many people today. One thing about the pandemic for sure is I don’t have to explain epidemiology or population health, like I used to every single day.

[00:17:53] Dr. Gary Bisbee: Right. It’s still hard for people to spell epidemiology, David,

[00:17:56] Dr. David Nash: Yes. That’s a tough one. Pop health is a lot easier for sure.

[00:18:00] Dr. Gary Bisbee: But let’s move on, 10 years after you founded the school or so we ran into COVID, and obviously major effect from COVID, but so your new book, How COVID Crashed the System, really is I think an exceptional book. You’ve developed a framework to understand not only what happened with COVID, but how we can fix the system as well, your recommendations for that. So why don’t we get into that? But the first thing I’d like to ask really is this term “Crashed System.” What do you mean by “crashed”, David?

[00:18:38] Dr. David Nash: So the idea we had, and I owe a lot to my co-author, award winning writer, Charles Wohlforth, who I had met pre-COVID, and we’re about seven, eight months into the pandemic. And literally Charles called me and said, “Listen, I heard you speak. And you must be thinking about all these issues, and we gotta write a book together.” And I thought, “Oh, good Lord. Okay. Let’s do it.” So I came up with this idea having been influenced by people like John Nance and others and Peter Pronovost and Bob Wachter, a whole host of fantastic national leaders in quality and safety. And I thought, “How could we frame a book that people will actually read while we’re in the middle of the pandemic?” And I thought, “Well, we would never tolerate a jumbo jet crashing in Philly International, killing all 350 people aboard every damn day.” I mean, that would be unheard of. So that’s what COVID was doing. And I thought, “Let’s make it like an NTSB airline crash investigation. We’re gonna go find that black box.” So Charles and I, we find the black box and no surprise to hardened investigators, it’s a multifactorial, Swiss cheese, James Reason, all the things we had been talking about in quality and safety for two decades came true, which was, in a sense, every system is perfectly designed to achieve exactly the results it gets, right? Paul Batal then Don Burwick and all the others. I mean, we weren’t surprised that it crashed the system. And so the metaphor that we used was, “The healthcare system was an airplane that was bound to crash during the pandemic.” And then the second half of the book is, “Okay, what we learned from the black box, if you would, and what are our recommendations to get this 737-Max back into the air?” And of course we couldn’t shut down the healthcare system, obviously, like we could the 737. So we spend the whole half, the second half of the book describing, I think, some pretty pragmatic, relatively straightforward things that we didn’t discover, but we tried to package and synthesize and describe in a way that a mass market book that appeals to every reader so everybody could understand it. And, one good example of course, is drawing on my 32 years in medical education, well, let’s have a different kind of doctor to start, right? And let’s build a different kind of doctor for the future as just one example of how do we get this phoenix to rise again, if you would. But the metaphor that we stuck with was, it crashed the airplane, and the airplane was the healthcare system. And then, how do we get this plane back in the air? That was the metaphor.

[00:21:42] Dr. Gary Bisbee: So that’s good. That’s helpful perspective. You got right into leadership, David, in the second chapter. So I like that, but talked about failures of leadership. Can you work your way through that for us, please?

[00:21:55] Dr. David Nash: Sure. Well, where should we start? Look, you and I know, and our listeners, we appreciate the heroism at the bedside, but the failure of leadership from the very top of the country, CDC, NIH, FDA, the White House, and then down to individual healthcare systems, largely unprepared insufficient PPE, nobody really was worried about a pandemic. I certainly didn’t have it on my mind at all. So, failure of leadership of course is woven throughout the whole book, from the very top of the country and all the major organizations that were supposed to protect us, but whatever your politics, let’s not forget, we had withdrawn from the World Health Organization. FDA wasn’t ready. CDC came up with a test that didn’t work. I mean, you gotta go back and remember what was going on in the late 2020. It scared the pants off of me, for sure. It was particularly scary, Gary, because, my physician wife and I were blessed with three children, one of them is an attending physician who was on the very front lines from day one. I mean, we were petrified. So, I needed a way to get this out there. It was like a exorcism almost to write about it and say, “Look, what are we doing here?? So, having been inside the belly of the beast for three decades, I think I had a pretty good idea of what was working and what wasn’t. On the other hand, we had examples of exemplary leadership. We were blessed at Jefferson to have amazing physician executives, who we called, they called our pals in Italy, Christmas 2019. And those Italian doctors and nurses told us, “You better get ready. It’s worse than you can ever imagine.” And they did. And Dr. Bruce Meyer, great example, our top, top doctor, he had been in Texas with the first Ebola case. So we had leaders who, they knew what they were doing on a day-to-day basis, but the real failures weren’t at that level. The failures were at the national level.

[00:24:18] Dr. Gary Bisbee: Yeah, David, if you look at it you can say lack of funding. You can say infectious disease. It doesn’t have the same ring as surgery. We don’t allocate resources to that. Insurance companies don’t exactly even know how to pay for it, you get into this later in a book, of course. But, how do you kind of sort through all of that and say, “Here’s the two or three reasons why we weren’t prepared so that we can figure out how to prepare going forward”?

[00:24:50] Dr. David Nash: That’s a great question. So in the black box, what do we find? Well, it’s pretty straightforward. $10,000 a year in 2019 to pay for healthcare services per person, including children, in the United States, 20% of the GDP, 4 trillion dollars. While at the same time, we were spending 400 bucks per person on the public health infrastructure. So what do you think was gonna happen, right? When there’s a total disconnect, lack of communication, no infrastructure, who’s in charge of vaccinations. Look, it was a classic-American-scientific-individualism-great story to have the mRNA vaccine ready in record time, by the way, two University of Pennsylvania investigators who had been in the backwater for a decade, no one paid any attention to. So the science was sort of available. They did an awesome job on the science. But from a political-social population health perspective, what a disaster. And in my own great city of Philadelphia, where I’m awfully proud of, coming from four great academic medical centers, we were caught flat footed and we got one out of four people in this town live in poverty. So between the poverty, the pandemic, the structural racism, and decades of ignoring certain populations, that’s all in the black box that we discovered. It didn’t take any kind of expertise to understand that, “Wow, we were headed to a disaster.”

[00:26:30] Dr. Gary Bisbee: You tracked Michael Dowling, the CEO of course in Northwell Health from.

[00:26:35] Dr. David Nash: One of my heroes, right.

[00:26:36] Dr. Gary Bisbee: One of the beginning from the beginning, basically. And you had findings there that I thought were interesting. But one little section of the book was called hazards of heroism. Can you describe that for us please, David?

[00:26:49] Dr. David Nash: Sure. It’s a little controversial. And again, let’s remember, I got a daughter on the front lines. So look. If we call every doctor, a nurse, a hero, what that does is reinforce the mythology that doctors can fix and control and run every system and do it right. Well, we know that that’s not true, not even close to being true. So I wanted like lots of other observers. Let’s say “humanism” instead of “heroism”, cause heroism implies that it’s all about the operator, in this case the doctor. But the system is what failed. The system failed us. Individual doctors did their darnest and we have thousands of healthcare providers died. Let’s not forget. Over 3,600 worldwide, right? Policemen died from COVID more than from gunfire. So the notion of heroism, we thought, actually was counterproductive. And holding the doctor as the hero that she can do everything, I don’t think that’s a good model for the future. It’s the system. 85% of the time, at least, Gary, we know, failed systems lead to failure and to death, not people. 15% of the time, it’s individuals. So let’s get at the system this. That’s the key message that we also discovered in the black box, for sure.

[00:28:24] Dr. Gary Bisbee: Yeah, that makes sense in that context, for sure. And I think what you’re basically saying is, physicians and caregivers were outstanding, heroes in that sense, but it’s really the system that needs to be changed. And we can’t rely on these heroes, individual heroes, because the system isn’t getting it done.

[00:28:47] Dr. David Nash: And you and I know that when we have overreliance on the heroism mythology, what happens? Well, we get burnout. And we get mass nurse resignation, which is what we’re facing today. So I would not want to be a house officer right now having lived through COVID. I don’t know how these young people did it quite honestly. I have huge respect for them, and I’m glad that I was way too old to contribute on the front lines. In fact, back at the beginning of the pandemic, they had multiple tiers, T-I-E-R. And I joke like gallows humor, “if they call me, you better head for the bunker.” I was in the final tier. We got close to it, but I never got called in. And we could poke fun of it now kind of, but wow, that was scary. And that’s all about the system, not about individual heroic behavior.

[00:29:45] Dr. Gary Bisbee: So in this same chapter of the book talking about Northwell Health, you had a section called, “Is Bigger really Better?” Work us through that please, David.

[00:29:56] Dr. David Nash: Again, a pretty provocative part of the book. And my best friends are in big, multi-hospital delivery systems. I think the country would like to understand better. Are these big, multi-hospital, not for profit systems doing a better job? Look, I think certainly the big systems survived COVID intact because they were big, and they had the resources and the people power. That I think is hands down true. The future questions are, “Are these bigger systems more efficient, more cost-effective and safer?” And the research evidence on those three counts is not very positive in terms of bigger is better. So there’s a controversy. There’s dynamism here. We needed bigness to survive now. Is it going to serve us well moving forward? That’s open to discussion. And it’s a complicated area, very complicated, and has to do with, in my view, what’s the true north? What’s the real business that we’re in? Those are big questions that we do try to tackle in the second half of the book. But is bigger better? Well, it got us through the emergency. Now we are going to need to really look in the mirror and answer that tough question.

[00:31:20] Dr. Gary Bisbee: Yeah. What do you think about the relationship between the large health systems and public health in a sense that the public health infrastructure was not able to administer vaccines, administer tests, and so on, in a large part that defaulted to the health systems. Do you see going forward that health systems will become more involved in public health as we saw during the pandemic, David?

[00:31:47] Dr. David Nash: Well, we can only hope, I think it’s all about the implicit and explicit culture. The explicit culture, we had a bifurcation going back to 1965 when Lyndon Johnson signed Medicare into law, Gary. Look, it’s been all about the temples of technology. There’s no temple built to honor prevention. And so, it’s not cool. It’s not sexy. Forgive me. It’s not where medical students wanna model their behavior to become a preventionalist. They don’t. So, can we have deeper relations between the roughly 150 major academic medical centers and the public health infrastructure? Boy, that’s a tall order. In Philadelphia, I would say we did a pretty good job. The presidents of the hospitals met regularly with the commissioner of health in the city, but the city was distinct from the county, which was distinct from Harrisburg, our capital. The whole thing was crazy. No one really knew who was actually allocating the vaccines as a good example, right? So I hope we’ll have better relations, but we got to change the reward structure and the implicit culture before we can have better relations.

[00:33:07] Dr. Gary Bisbee: Let’s move on to the second part of the book, which was “A Guide to Fixing American Healthcare.” And you went right at it which was a good thing, in my opinion, you went right at incentives, aligned incentives, and also brought up then pay-viders. I think we probably have a sense of aligned incentives, although I’d like to have you get into that in a moment, but on the pay-vider-side, can you describe what you mean by that? David?

[00:33:34] Dr. David Nash: Sure. It’s a bit admittedly, a bit of a clunky term, payer-and-provider. And we were talking about the pay-vider back in 2018, 2019. So the pandemic again shined like a spot light on any kind of joint venture or ownership model where payers and providers are totally economically aligned, so that providers can capture as much of the premium dollar as possible, and it aligns economic incentives to practice prevention, promote wellness, or in a word what we’ve been saying for a decade at our college, “go upstream and if you would shut the faucet instead of mopping up the floor.” So for example, in the world of more is better, let’s build another bariatric surgery operating room to conduct bariatric surgery instead of ‘teaching nutrition’ and ‘exercise physiology’ and ‘have better food’ and ‘do away with food deserts’, you get the idea. So the incentives currently are to do more bariatric surgery. Or, another great example is a ‘do put in more cardiac stents’ instead of practicing cardiac prevention. So the system rewards the bariatric surgery and the stent placement. That is the major ill that we are facing. The more you do, the more you get paid. Well, human nature is, “Let’s do more.” So when you create the pay-vider, you have a fighting chance to align incentives and say, “Hold on a minute. Let’s coordinate care. Let’s tackle that food desert. Let’s tackle poverty, homelessness, gun violence.” Like, go back to Mike Dolan. Great example, an unbelievably important public spokesperson fighting gun violence. Well, every damn hospital president should be following Mike’s example. How about climate change? If you tackle homelessness, food deserts, gun violence, that would go an awful long way to improving health in this great country. But if you don’t get paid to do that, uh-oh, we got a lot of fixed costs in a gigantic system like ours. So these are the leadership challenges for the future.

[00:36:05] Dr. Gary Bisbee: Yeah, that’s for sure. What models of pay-vider do we have, David, that you could refer to that we’ve got some experience with?

[00:36:14] Dr. David Nash: Yeah, they come in a couple of flavors right now. I could think of at least two that, certainly are out there. One is a joint venture. So we’re seeing more and more, and I would bet that will continue even with big national for-profit-payers like Manna and Cigna and Aetna and all the others, say what you will. Their economic incentives are already aligned in the right direction. Put aside whatever view you’ve got of the insurance companies. But there is no doubt that the humanities of the world are organized economically to go upstream and shut the faucet. And they have a lot of good evidence to prove that. So one model is a payer-provider joint venture working together, they set up yet a third organization to carry out that mission. Another model is a purchase, and we’ve seen that, or a merger even of largely, mostly big provider organizations going to buy or merge with a payer organization. Good example, our marketplace, Jefferson Health, 18 hospitals. We now own a Medicaid-managed care plan. That’s the first time ever in the 30-plus years that I’ve been there that we’ve got a payer-provider kind of structure. We call it an integrated-delivery-financial system, but I like pay-vider. So summary, joint venture or some kind of ownership. Those are the extant models, and I’m sure there’ll be more models coming out there. But it’s a clunky term. I get it. But I think it helps to emphasize how important aligning those economic incentives to go upstream, and practice prevention and prevention is just, there’s no temple to support prevention, for sure, not.

[00:38:12] Dr. Gary Bisbee: Well, I think the term may be clunky, but it gets the job done. What about Pfizer model? A lot of people talk about that. When you talk about

[00:38:20] Dr. David Nash: Sure. Sure. And, we interviewed the leadership at Bernie Tyson School of Medicine out in Oakland, and of course, Kaiser’s a great model. I had a transformational summer at the Kaiser Research Center in Portland, Oregon in 1978. So, I get it. But it’s largely not exportable as Kaiser has seen. Sure. There’s some pockets of Kaiser-like, staff model HMOs out there. But that’s not the model that we think is exportable to the rest of the country. This is a big, complicated, heterogeneous nation. No single model’s gonna work. It can’t. So that’s why we think the pay-vider, which is pretty local, market-specific, is something to seriously consider.

[00:39:09] Dr. Gary Bisbee: Yes, for sure. So the book has five recommendations for where we could focus in and ultimately change our healthcare system. We don’t have time to dig into each of those five, but could you just zip through those five for us, David?

[00:39:28] Dr. David Nash: Sure. So look, I think the most important thing of our recommendations is, to me after 32 years at Jefferson University, we’ve gotta change the training paradigm. It all starts there, because real change gotta come from the bottom up. It can’t be dictated from top down. So to me, the most important recommendation we’ve got is, we’ve got to build a different kind of team, medical team, for the future, starting by changing both undergraduate and graduate medical education. We gotta change how we pay for medical-care services. We have to have better leadership to focus on what’s our true north. And we have to improve connectivity with consumers. When we talk about digital health, that’s got to be more inclusive. I mean, those were the key take home messages, I think. And of course, every system is perfectly designed to achieve the results it gets, so what are we doing for the next pandemic? That’s another part of our recommendations that we better be better-prepared and have better communication and care coordination. These are all very pragmatic suggestions.

[00:40:43] Dr. Gary Bisbee: David, what can a private sector do? I mean, you look at private sector leadership. You look at the government. What can the private sector do to move this ball forward?

[00:40:54] Dr. David Nash: Wow. Well, let’s remember that almost 50 cents of every dollar spent on healthcare in this country comes from the private sector employers. We’re the only country in the western world where you work, those are the organizations who are paying the healthcare bills. Crazy. So, my view would be employers have been on the sidelines for way too long. Sure. There are business coalitions who have made progress, including one in our own city. I get it. But I think employers need to be much more active in understanding that not all care is created equal, there’s massive variation and cost and outcome. Why are they tolerating it? Here’s the analogy I would make, Gary. Look, there’s so much variation in what we do. Imagine if you bought a Ford, and if you bought one from the east coast, the muffler’s on the right side. But if you bought one in California, the mufflers on the left side, cause that’s how they felt like doing it. Well that’s healthcare. No employer ought to tolerate the kind of massive, unexplained, expensive, dangerous variation that we got. All the experts, we didn’t discover this, all the experts agree. A trillion dollars of waste. Oh my God. What if we could reallocate even a small percentage of that waste into prevention and vaccination and digital health and patient education. It’s a crime that there’s so much waste. And waste is harmful too, not just expensive. So let’s figure that out. We know how to do that.

[00:42:39] Dr. Gary Bisbee: This is a great place to land, David. The book is called How COVID Crashed the System. Well done. The book is I believe going be published in early October. Is that right, David?

[00:42:52] Dr. David Nash: That’s right, but you could go to Amazon right now, and just put in Nash. And you know, we’d love to have a pre-publication order. That’s for sure, Gary.

[00:43:01] Dr. Gary Bisbee: Okay. Buy it now. It’s a good one. So David, thanks again for being with us. Really enjoyed our discussion. Good day.

[00:43:08] Dr. David Nash: Thanks again for having me.

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