Doesn't this imply there is a need for an activist agenda tied to legislation and policy reforms as well as the focus on
changing individual behaviors?
Nash: Yes. We are a society of laws and governance. The social determinants of health can be influenced – for better or worse –
by legislative and regulatory actions. The Obama Administration's Affordable Care Act [ACA] is already having a demonstrable
impact on the practice of population health, as do rules handed down by the FDA, the Centers for Disease Control [CDC], the
HHS Center for Medicare and Medicaid Services [CMS], and many other regulatory bodies, including those at the state level.
Our work here at the School and with others seeks to shape the policy environment so that it supports the broad, multi-disciplinary
objectives I cited earlier: inclusion, transparency, evidence and value.
What about quality standards? There are huge, largely unaddressed costs linked to the high rate of medical errors in treating
Nash: Quality and safety are central to population health, if only because endemic failures in this area diminish the value of
that institutional 15 per cent contribution to well-being. Medical errors now constitute the fourth leading cause of death
in the US, claiming on average more than 200,000 lives each year. This occurs despite the substantial evidence we now have
on best practices that, if applied consistently, would shrink this lamentable statistic. Many experts assume that solving
medical errors is a simple task – much like requiring bicyclists to wear helmets or to drive within the speed limit. The truth
is far more complex. One of the biggest contributors to the problem is that quality does not follow the patient when he leaves
the hospital. The vital outpatient experience is not addressed, patients will fail to follow instructions or not understand
them. Either way, the end result is an unacceptably high rate of hospital readmission, often leaving the patient in a worse
condition than before.
Quality and safety problems are hardly new. The seminal work on this topic remains the National Institutes of Medicine [IOM]
study "To Err is Human," which was published 14 years ago. Does this suggest to you that population health is not hitting
the mark, in terms of fostering improvements in the standard of care?
Nash: It's a fair question to ask why there has been so little progress. Data shows the US is actually trending worse; figures
updated by the IOM to July 2013 put medical error in fourth place on the mortality charts, whereas the original study had
it at sixth. And the IOM cities the US at 17th –just behind Slovenia –among countries in outcomes for the money we spend on
Why the lag? It's because progress has not been uniform; the implementation of standards is piecemeal and haphazard. We have
an inverted pyramid of incentives, where massive resources are being poured into resolving highly complex interventions for
the very sickest patients while we neglect longer-term, community-based investments around the social determinants of health.
In the former case, we see an explosion of quality and safety measures that hospitals must meet under the ACA; if they don't,
they face penalties involving the forfeiture of federal reimbursement payments when patients are readmitted within 30 days
of discharge, or where there are too many hospital-acquired infections. There is now an economic incentive to deliver more
value, especially when patients are being treated in the more costly acute care setting.
This change is important. It represents progress. Hospital costs represent the largest category of health spending. Hospitals
now have an economic incentive to deliver value. The ACA has several important provisions that also require these institutions
to demonstrate their activities deliver a broader benefit to the community, which is a key tenet of the population health
approach. Instead of just certifying to HHS that a facility provided x dollars for uncompensated care, the law stipulates
the provision of evidence that such spending had an empowering impact on the community.
How are these external trends influencing the priorities and work plan of the School?
Nash: Jefferson's program is but five years old – it also happens to be one of the most exciting and consequential periods in health
system reform. Our curriculum has a strong emphasis on learning to navigate within the health sector, with four Master's degree
programs: including public health policy [online], healthcare quality and safety [online], and finally a new online Master's
in health economics and outcomes research. No one else in academia has put this constellation of inter-disciplinary products
in one place, under a single roof. In terms of research, our faculty is working on a variety of projects. One example is a
study of Italian pensioners looking at strategies to ensure pharmaceuticals deliver the highest value for reimbursement. Another
is a review of the economic challenges to treating cancer here in the US, where we are examining the most cost-effective pathways
to new drug therapies based on genomics. And we have a large body of research focused on making the governance structure of
US hospitals more efficient – what structure is best suited to improving health outcomes?
Our faculty also makes a point to participate in the policy arena. I work as an adviser to the Pennsylvania Health Care Cost
Containment Council, which advises the Governor and legislature on the efficient delivery of state health services; and where
I also chair the Council's Technical Advisory Group. The Council and our group compile and publish outcomes data from every
hospital in the state. It should be no surprise that we uncover some really amazing variations in outcomes across the state.
Spreading best practices to limit these variations is a key goal, one where we have made some progress. At the federal level,
I am a member of a National Quality Forum expert panel charged with the task of creating new standards to measure how well
hospitals do on community engagement. Finally, the School is working with the city of Philadelphia on smoking cessation and
obesity programs for young people that emphasize direct community involvement outside the health sector, including parents,
teachers, pharmacists and employers.