David B. Nash, MD, MBA: Hello, I am Dr David Nash, the dean of the Jefferson School of Population Health, which is part of Thomas Jefferson University in Philadelphia, Pennsylvania. I would like to welcome you to this CME-certified program titled "Population Health: What Health Care Providers Need to Know."

Thomas Jefferson University is a health sciences university in downtown Philadelphia. My office is walking distance from Independence Place and Constitution Hall. This is a picture of the floor of our gymnasium where our undefeated basketball team plays. It is undefeated because we do not have a basketball team. We are a health sciences university. What does that mean? It means that we are 6 schools arrayed around a major university hospital: Jefferson Medical College (now called Sidney Kimmel Medical College); the School of Nursing; the School of Pharmacy; the School of Allied Health (Professions); the graduate science school; and the youngest school on our campus, which I have the privilege of heading, the Jefferson School of Population Health.

Today's course on population health will be divided into 4 chapters. First, an overview of the current situation -- basically the jam that we find ourselves in right now. The second part of the program will cover definitions, both academic and pragmatic, of what exactly is meant by "population health." The third chapter concerns new delivery models focused largely on the Affordable Care Act (ACA) that will connect health reform to population health. The fourth and final component of our program is a look at the future direction for healthcare.

Our first program goal is to describe the challenges in moving from fee-for-service to a value-based population health-oriented system of care. Our second goal is to define "population health" and provide examples of the social determinants of health. Third, we are going to explain how new care delivery models, such as the patient-centered medical home (PCMH) and the accountable care organizations (ACOs), can facilitate the practice of population-based care. Finally, we will discuss the drivers of physician cultural change that will help promote public accountability for what we do. Those are the 4 overarching goals of our program.

Some time ago, back in the summer of 2009, the cover story of the British news magazine, The Economist, warned that reforming health care "is going to hurt."^[1] We have not felt too much of the pain on the providers' side yet, but clearly this is going to be a challenge. We will have to look at changing the very culture of clinical practice and the very fabric of clinical training, and try to integrate the key tenets of the ACA into where we believe population health is going.

In 1918, nearly a century ago, the inaugural meeting of the American College of Surgeons (ACS) was held at the Waldorf Astoria Hotel in New York City. In a verbatim citation from that meeting,^[2] the ACS stated, "all hospitals (what today would be 'all integrated clinical delivery systems') are accountable to the public for their degree of success. If this initiative is not taken by you and me, it will be taken by the lay public."

Here is my view of this fascinating historical tidbit. A century ago, clinicians, our forefathers -- no girls in that group -- were thinking about the same issues we are thinking about today: transparency and public accountability for patient outcomes. Of course, in 1918, health care represented approximately 1% to 2% of the gross domestic product (GDP); today, it is 18% or 19% of the GDP.^[3] The major lesson I take from this is that if we are not in control of the situation, then we ought to be satisfied with what others tell us to do. Of course, I am not satisfied, and I know you are not either.

Lots of other people understand this challenge, but regrettably the United States has the most expensive, least effective healthcare system in the world. According to the best available data from the Institute of Medicine (IOM), The Commonwealth Fund,^[4] and other sources, not only do we spend more on health care than any other country on the planet, but with regard to our society's well-being, resilience, ability to thrive, and quality of life our current ranking is number 17, right below Slovenia. Now, I have nothing bad to say about Slovenia and Americans are not rushing to Slovenia to get their medical care, but what is clear is that due to a host of complex social, economic, and political factors the United States is 17th in the world in terms of what we invest and what we get out of our healthcare system. We could do a better job. I do not know about you, but I would like to be ranked at least in the top 10, given what we spend on healthcare services.

How might we derive better care at a lower cost? What can we learn from the important study released by the Institute of Medicine^[5] (IOM) in September of 2012? There are lots of opportunities for cost savings. Let us start with unnecessary services, inappropriate testing, currently valued at more than 210 billion dollars a year. How about inefficiently delivered services? Every doctor sees that every day. What about missed prevention opportunities, valued at more than 55 billion? Wouldn't it be great if we could save by reducing the number of unnecessary services, by being more efficient? What if we could take those savings and put them back into our healthcare system? What if we could indeed create a continuously learning healthcare system in America? Then, we could achieve the laudable IOM goal of creating the best care at a lower cost.

The way I see it, we are faced with some key choices. It is probably unlikely that the historical fee-for-service, private practice, small-number-of-doctors-in-their-offices-doing-their-thing model is going to persist. What is more likely is that we will all be forced, one way or another, willingly or unwillingly, into a value-based payment and population health management kind of delivery system. One of the goals of today's program is to help elucidate what exactly a value-based payment system and population health management are. I think it is fair to say we are going to abandon the historical fee-for-service model and enter into a new way of practicing medicine.

The conceptual framework of population health has been around for at least 15 years. In our school of population health, we generally attribute the definition to our longstanding, prominent colleagues like Dr David Kindig, who works in the University of Wisconsin in Madison,^[6]and Dr Ed Wagner^[7] and others on the West Coast, but we believe that the conceptual framework has 3 components.

The first component is health outcomes and how they are distributed within a population. Most of us are familiar with these outcomes, like morbidity, mortality, and quality of life. Then there are determinants that influence the distribution of those outcomes, such as medical care. We will refer to that as the laying on of hands, the work we do at the bedside, whether it is in the hospital or the office. Socioeconomic status is a huge predictor of the well-being of a population as is, of course, genetics -- what your parents endowed you with.

The third piece of the conceptual framework is made up of policies and interventions, like the Affordable Care Act, which influence the determinants, which influence the outcome. These policies and interventions can be social issues or the environment itself. For example, if you live in a "food desert," there may be so much crime in your neighborhood that your children cannot get any exercise outside. And, of course, not only social environment issues but also individual behavior influences the health of a population.

I would like you to keep several things in mind, but at the moment, let's focus on the question of what percentage of a society's well-being is directly attributable to medical care itself. That is an important question.

Another way of looking at the definition of population health is a bit broader.^[8] One aspect is that "health" is comprised of the genetic endowment, socioeconomic factors, the physical environment a person lives in, and his or her individual risk factors. Then there is the role of healthcare, which encompasses the medical care system itself. Both of these are in a sort of soup together, the health role and the healthcare role, leading to well-being, ability to thrive, and resilience. One more time: What percentage of that well-being, ability to thrive, and resilience is directly attributable to medical care?

The answer might surprise you. About 15% to 20% of these 3 critical criteria for a society are directly attributable to places like Jefferson School of Population Health (and the institutions you come from), where we actually care for patients. Thanks to outstanding data from multiple sources, we know that what makes us healthy as a society is largely our own behavior. That is 50% of the story. The environment is approximately 20%, and our genetic make-up is another 20%. And lo and behold, access to care is somewhere between 10% and 15% of what makes us healthy. In the 21st century, our money is largely and overwhelmingly spent on the delivery of those medical services.

How do we reconcile this? We spend a lot of money on medical care and yet it only contributes approximately 15% to 20% to our ultimate ability to thrive, our well-being, and our resilience.

This is a conundrum our entire country is facing. The question is: Can medical care contribute more and can we manipulate these social determinants in a positive way to help us do a better job?

Currently, I practice old-fashioned medicine in my primary care practice, despite the fact that I am at a great leading medical center. Patients come to see me on a scheduled basis. We hope we do a good job and then we bill them. In the population health model, of course, we are going to have to connect all the dots. We are going to have to innovate. What we do will be measured. We are going to have to connect with our patients and coordinate their care. The population health model is completely different from the episodic fee-for-service model.

There are a lot of sources of information, some of them available at our school, and we will provide you with many others for you to investigate -- textbooks on population health,^[9] the journal, Population Health Management,^[10] and there are lots of opportunities to learn more about the definition of population health and what percentage of a society's well-being is derived from the actual laying on of hands. In fact, the most important thing I need to know to be able to tell anyone how they are doing health-wise is their zip code, because in our great country, your zip code pretty much determines how healthy you are.

The IOM has done a great job providing us with additional information in reports like Toward Quality Measures for Population Health and the Leading Health Indicators^[11] that help connect population health to the really outstanding work of the public health community, which is largely responsible for bringing us those national health indicators.

Sadly, in our country, according to recent research and really excellent work published in journals like Health Affairs^[12] and elsewhere, we still have many people who live at the poverty level. In Philadelphia, one-quarter of the population lives in poverty, and half of those people live in what Uncle Sam calls deep poverty. That one-quarter of the citizens in our great town who live in poverty are so poor that they cannot afford to buy any additional food at the end of the month when their subsidies run out. And they could end up in the hospital because of that. Recent research by Hilary Seligman and colleagues^[12] showed that there are actually people admitted to the hospital nationwide for severe hypoglycemia because they are so poor they cannot afford to buy food. I know it may sound unbelievable, and I was incredulous at first as well. Nevertheless, despite all the plenty in America and a national obesity issue, we also have patients admitted to hospitals like Jefferson who simply cannot afford to buy enough food.

The other challenge we face has to do with personal behavior. I hope you enjoy this version of Michelangelo's "David," the famous Renaissance statue in Florence, Italy. This is the 21st century version of that wonderful statue, which shows David in his modern obese form. So what is going on?

A lot of this is related to personal behavior. Here is an interesting question. What percentage of adult Americans currently does all 5 of the following: (1) exercises appropriately at least 3 times a week; (2) does not smoke cigarettes or cigars; (3) eats fruits and vegetables the way their mothers taught them to; (4) regularly wears a seatbelt; and (5) has close to an appropriate body mass index? What percentage of our population does all 5 of these things?

You might be surprised to learn that only 3% -- that's right -- only 3% of American adults can claim that they practice all 5 of these really important healthy behaviors.^[13] And that leads to a really important challenge.

We know that in the 21st century the key determinants of poor health include smoking, an unhealthy diet, physical inactivity, and alcohol consumption. If we made rounds at your hospital this afternoon, I am sure we would note, as the research supports,^[14] that taken together, smoking, an unhealthy diet, physical inactivity, and alcohol consumption account for 40% of all deaths in the United States in the 21st century. It is pretty straightforward. We have to find a better way to tackle these personal behaviors and their impact on health.

Going back to the definition of population health and the social policies that influence well-being, are we reforming health care, or are we reforming health with the Affordable Care Act? What I mean is, the United States spends about 2% of our total healthcare budget on improving the health of our population. Yet chronic disease, which easily comprises 80% of the total disease burden and total spending on health care, has no dedicated federal research funding stream.^[15] From a policy perspective, we are in a jam. We clearly need to spend more on population health and less on individual procedures, inappropriate testing, and the repetitive and ineffective things that we are currently doing.

Way back in 1972, President Nixon famously declared the "war on cancer." The nation has spent tens of billions of dollars fighting this war on cancer, but you and I know that the number 1 reduction in mortality from cancer, the principal reason for the decrease in cancer deaths, is the decline in tobacco use that came about by making smoking socially unacceptable. While billions were spent on the war on cancer over decades, the most important gain, the reduction in cancer mortality, has come largely from a social change.

Let's turn to the third part of this program and ask ourselves: Have we really reached what Malcolm Gladwell called The Tipping Point?^[16] Are doctors, nurses, pharmacists, and others really ready to work together to practice a different kind of medicine? Maybe we will call it "population-based care."

Let's dive more deeply into the Affordable Care Act and see if we can connect the dots between the Affordable Care Act and practicing population-based care.

You might be surprised to learn that health reform builds on current quality infrastructure. We talk about the 5 pillars that support the quality infrastructure that in turns supports health reform. Let me describe each of these 5 pillars.

The first is the National Quality Improvement Strategy. You might be surprised to learn that only a 25-page document^[17] describes how all the federal agencies interdigitate to support the quality agenda of groups like The National Committee for Quality Assurance (NCQA), Centers for Medicare & Medicaid Services (CMS), and others. How are they working together to improve the quality of care?

The second pillar is the new quality measures that are under development; you may be familiar with the score of new measures that are coming our way.

The third pillar is the value-based payment system in which we already find ourselves with Medicare, spending billions of dollars trying to drive value into the system, changing Medicare from a bill-paying organization to a value-driven organization.

The fourth pillar is prevention and wellness, and the Affordable Care Act calls for hundreds of millions of dollars of new investment in prevention and wellness.

Finally, the fifth pillar concerns new entities like the Patient-Centered Outcomes Research Institute (PCORI).

The main message is that the underpinning of health reform is these 5 quality pillars.

Now, let's talk about actual cost containment through payment reform. There are at least 4 underlying cost containment concepts – let's look at each of them.

Our first obligation is to learn to tie payment for healthcare services to both evidence and outcomes rather than to unit of service, moving away from classic private practice fee-for-service to a focus on "Did we do the right test in the first place?" and "Did we achieve the appropriate outcome?"-- a pretty tough undertaking.

The second concept is reimbursement for the coordination of care, which means that we have to find a way to do this better. When our patients leave the hospital and go to a nursing home, rehab center, or a skilled nursing facility, can we do a better job coordinating their care? The research suggests that we have a lot of room for improvement.

Then there is something called bundled payment for hospital and physician services. We can do this either by episode, ie, based on an admission, or based on the patient's overarching condition. Next year your provider organization would receive a lump sum, a bundled payment, for any patient with a particular diagnosis, like congestive heart failure, for instance.

The final concept concerns systems that offer accountability for the results. It sounds like 1918 all over again -- accountability and transparency. We have to organize patient management across different care settings.

A range of [health care delivery] models already exists or are under development. As we move from left to right on this slide, you will note an increasing amount of economic risk assumed by providers and an increasing need for coordination and integration of services. I would argue that most of us already have some experience with rudimentary pay for performance program. We also know that Medicare is no longer paying for "never events" (wrong-site surgery) or certain sentinel events. We are all working hard to reduce our hospital-acquired infection rate. We are all working hard to reduce mortality from sepsis. We know that if a patient has a never event, we should not get paid. That is pretty straightforward, but there is a variety of other models coming our way, including

bundled payments for an acute episode.^[18] Imagine that your delivery system gets 1 lump sum when the patient is admitted to the hospital, for example. That lump sum would need to be divided between the doctors, nurses, the pharmacy budget, heat, light, electricity, the mortgage -- you get the idea. We will have to figure out how to appropriately and effectively divide that bundled payment (the lump sum) while maintaining the goal of delivering high value care. I would suggest that the bundled payment is going to be a total sea change, a complete cultural change in how we practice medicine. Each of us is going to have to figure out what we contribute to overall patient outcomes.

As we keep moving to the right on this slide there is more risk, more complexity...and that brings us to the patient-centered medical home (PCMH).

The patient-centered medical home is fundamentally different from how I currently practice primary care medicine. My practice is still all about personally providing care to individuals who come in the door, and I assume I am doing a pretty good job. The medical home of the future is all about teamwork and providing care for a population. The actual performance of all the practitioners is measured on a regular basis and the results are shared with them so they can improve their performance and do a better job. This calls for care navigators and a backbone of health information technology. Delivery of care in a medical home is quite different from how I was trained to provide and currently practice medical care.

We know then that the health care of the future is going to be a team sport. Who is going to lead that team? I hope it is primarily physicians, but maybe there will be other individuals leading the team, too. If the teams are going to be led by doctors, we will need additional training and to learn additional skills that will help us be good team leaders.

The final model is the accountable care organization, and I am sure you have heard that there are different types: a Medicare shared-savings plan, Pioneer Health plans, and a commercial ACO. It doesn't matter what you call it -- we are headed toward the era of public accountability for patient outcomes.

We are going to need tools to help us practice population-based care. Some of these tools might be things like a registry that shows how our patients are doing. This slide is a screenshot of the type of registry tool that you and I may one day be using. This population benchmark report is exactly the kind of thing I am talking about. Wouldn't it be amazing if I could get feedback on all my patients who have diabetes, heart failure, or severe hypertension? That information would tell me how I am doing as well as how I am doing compared with a local benchmark or regional best performer. Then I could explore ways to improve my performance at the local level, with the goal of reaching a regional or national benchmark. I am pretty confident that one day we will be paid based, in no small part, on how we actually perform using these registry tools and information technology backbones.

In fact, I am pretty confident that we are headed toward a world in which we will drive population health through these accountable care organizations, and all of us will need to meet established quality metrics. We are going to adopt new care processes and assume greater and greater levels of economic risk, and we need to find better ways to engage with the population so that patients are motivated to participate in their own health care and stay well.

I have created a population health to-do list. It has 7 items on it, but I am sure there are many others that can be included.

The first thing we have to do when we talk about population health is ask ourselves, especially if we are in a large organization providing care:^[19] What are we doing to care for our own people? Health risk assessments, wellness and prevention programs? How are we doing with the care of our own employees?

The second question is: Are we doing a good job of keeping persons who are healthy, healthy? Are we providing them access to the gym, healthy food, time away from work? We know from research^[20] that we have to keep individuals who are well, well.

Patient-centered medical homes sound like a great idea. There is a long research history backing them up, but who will lead them in the future? What kind of training will those leaders get? The registry function sounds good to me, and I am looking forward to having a registry to help me do a better job in the future, but most of the currently available electronic medical records are just that -- an electronic chart. They do not yet have that important registry function.

What about the retail clinics at the corner drugstore, like Walgreen's and CVS? Should we partner with them? We have done some interesting work here at Jefferson and we know that an insulin-dependent patient with diabetes might visit an endocrinologist at Jefferson 2 or 3 times a year. However, that same patient is in Walgreen's more than 3 dozen times a year, so maybe a retail clinic is also a good site for providing not just primary care but also ongoing patient education.

I am personally in favor of looking for managed care partners. These managed care organizations are experts in managing risk, and perhaps we can learn something from them.

Finally, and probably of greatest importance, how are we training the leaders of the future? What are the competencies and skill sets they are going to need?

Regrettably, most medical leaders really do look like deer in the headlights at the moment. They just have not had the training or opportunity to learn the new skills we predict will be necessary to practice population-based medicine.

The major themes are still transparency on all the outcomes and accountability for what we are doing, both from a clinical and an economic perspective. A good chunk of this can be summarized by something we have been talking about at Jefferson for the last 4 years. We call it "No Outcome, No Income," meaning that if you do not achieve a good outcome, you may not get paid, or you are going to be paid less. This concept is closely associated with population health and healthcare reform.

How can we get from here to there? As I have already noted, a big part of that depends on changing the culture of care. There are at least 5 things we have to do to change the culture. Number 1, we have to practice medicine based on the best available evidence and we have to get that good evidence to practitioners at the point of care. We have to reduce unexplained clinical variation. It simply cannot be true that there are 15 different ways to treat heart failure in your hospital or mine -- maybe 3 ways, but not 15. We have to reduce slavish adherence to professional autonomy, which is really a fancy way of saying, "Hey, we know we are good." What we are saying is, "In God we trust; all others, bring their outcomes data." We have to measure and close that feedback loop. We have to give doctors good information about their performance and practice in a timely and nonpunitive way. Then, we have to give them the skills to improve, and then we have to get out of their way as they stampede trying to do a better job. Finally, we have to engage with patients across the continuum of care.

I am sure you have read in the New York Times^[21] and elsewhere that health plans currently are using predictive health analytics to contain cost and improve healthcare outcomes. These organizations are trying to learn as much as they can about patients, some of which admittedly sounds scary. They might learn, for example, that a patient does not own a car, so it might be hard for him or her to get to various appointments or to coordinate care. Certain aspects of a patient's medical history, when more widely shared, may actually help the organization do a better job of caring for that patient. Even how that individual shops might have an impact on patient health, especially when it comes to buying items such as groceries.

I have the privilege of serving as a member of a number of national organizations and committees, like the National Quality Forum (NQF).^[22] Their taskforce is looking at multi-stakeholder input on the national priority of improving population health by working with communities.

The NQF taskforce started with more than 700 measures of community engagement; we initially reduced those to 72 frameworks, and now we are working on just 40. These frameworks are going to be important, because we are trying to figure out what is the best way to hold a delivery system like a hospital accountable for the health of the population. For example, should we be growing crops to feed poor patients, like some hospitals are doing in the Midwest? That would be difficult in downtown Philadelphia. Should we be engaging with the local school system, nursing homes, and colleges and universities? What is the best way to engage with the community to improve the health of the community?

One way to engage, at least according to Wall Street,^[23] is to build all kinds of new companies. You and I both know that health care is big business.

Although fragmented, the health and wellness landscape provides a fantastic new opportunity for organizations to practice patient engagement, from disease management companies to wellness and on-site clinics, to the digital centers and quantifiable "selfers," people who like to track every aspect of their own bodies -- exercise, sleep, etc. Wall Street is excited, and when they get excited, they invest money. They are trying to engage patients in a completely new way so that we can all move forward in this new world order of population health.

Finally, I am excited about our School of Population Health. Here on the campus of Thomas Jefferson University in Philadelphia, we currently have 4 key master's degrees. Quickly, let me review them with you: our master's degree in public health, a fully accredited traditional and well-regarded program; our innovative, totally online asynchronous programs in health policy; health care quality and safety; and applied health economics and outcomes research. If you are interested in public health, health policy, quality and safety, or health economics and outcomes research, I hope you will join us, either in person or online. It is really, really exciting. It is a privilege for our school to be participating in the process of connecting the dots between health reform and population health.

I would like to thank you for joining us and for participating in this 4-part program on population health. To earn CME credit for participating in this program, please click on the Earn CME Credit link. Please also take a moment to complete the program evaluation that follows so we can practice what we preach and improve our programming.

Thanks again for joining us.