Although David B. Nash is a doctor, he believes that factors like behavior, genetics, and environment are more important than medicine in determining a person's health.
But he sees a new model for healthcare in New Jersey -- the Medicaid Accountable Care Organization -- as a potential vehicle for addressing some of these social determinants of wellbeing.
As dean of the only school of population health in the country, at Thomas Jefferson University in Philadelphia,Nash is the acknowledged leader in this emerging field.
Population health has three elements: the health of a group of people; the factors that influence this population’s health; and the policies that affect these factors.
Speaking at a conference in Plainsboro, Nash described a basic challenge facing healthcare providers, noting that only 3 percent of Americans have five basic characteristics of good health: exercising 20 minutes three times per week; not smoking; eating fruits and vegetables regularly; wearing seatbelts; and having an appropriate body mass index.
But medical training doesn’t focus on those essential elements of good health.
“I never had one formal day in all 30 years of practice [that trained me] how to really do a good job in getting patients engaged in these activities,” Nash said.
The, which are expected to launch later this year, are intended to focus on coordinating patients’ care as well as the social supports that can help them engage in healthier behavior.
For example, organizations in Trenton and Camden are planning to employ nurses who work closely with social workers to help residents who are homeless.
Nash said this approach holds promise for patients with chronic conditions, by coordinating their medical care along with their nonmedical needs.
“We’re going to have to get them housing, education, counseling, good food, social structure,” Nash said. “You’re going to need an army of care coordinators, social workers, counselors, navigators. I hope the managed care plans will fund this new delivery system, because in the end everyone will save money if we’re able to make this work.”
He noted the case of a woman who had undergone procedures to insert heart stents 10 times. But what she really needed was for a provider to notice that she didn’t have enough money to buy heart medication, which was leading to repeated emergencies.
“Let’s not kid ourselves, this is a very different delivery system -- it has very little to do with getting admitted for heart failure,” Nash said. “You know, the whole goal here is going to be -- that heart failure admission is a failure of our ability to coordinate the care.”
Providers must become aware of how factors other than medical care affect their patients, both in Medicaid ACOs and in the health system more broadly.
“It’s all that other stuff,” Nash said. “It’s the housing, it’s the lack of access to food, it’s the broken families . . . It’s all that messy stuff. It’s a complex story, so it can’t have a medical fix to make it work.”
Nash sees the 2010 Affordable Care Act as taking the first steps toward necessary reforms. While the law focused on making changes to insurance, it included programs like the Medicare Shared Savings ACO program, which shifts some payments to providers from fee-for-service toward managing population health. But he sees more dramatic steps in the future, as healthcare continues on this path.
“Our industry’s going to have to go through a deep self-evaluation -- we’re going to have to ask ourselves, are we doing the right tests, are we doing the right procedures on the right people at the right time? Should we put 95-year-old people on dialysis in the intensive care unit?” Nash asked.
He emphasized that too much spending on health goes toward providers, saying of doctors: “We haven’t had enough pain yet.”
While Nash sees Medicaid ACOs as one of several potential models for improving population health, he is concerned that most providers still lack the information that they need to improve the health of entire populations of their patients. For example, most doctors lack computer systems that will provide information on the health outcomes of all of their patients with diabetes, and allow the doctors to compare the results to other doctors who are using different treatments.
Nash sees a great deal of potential in the Medicaid ACO approach. Population Health Management, a journal edited by Nash,published an article in October 2013 about New Jersey’s Medicaid ACO program.
Nash’s message appeared to resonate with the roughly 100 healthcare experts that gathered at the conference, which was sponsored by the Nicholson Foundation and the New Jersey Health Care Quality Institute’s Affiliated Accountable Care Organization initiative.
Nicholson Foundation Deputy Director Joan Randell noted that the foundation has been focused on helping the potential Medicaid ACOs to build capacity, so that they will be able to apply the lessons that they learn more broadly. She noted that the state recently issued the final state regulations for the project and expressed hope that communities like New Brunswick and Atlantic City will join the established organizations in Camden, Trenton and Newark.