Meet Clay Johnston, MD, PhD

Gregg Masters  00:07

You're listening to PopHealth Week on HealthCareNow Radio. I'm Greg Masters Managing Director of Health Innovation Media the publisher of ACOwatch.com and your PopHealth week co host with my partner, co-founder Fred Goldstein, President of Accountable Health, LLC, a Jacksonville, Florida based consulting firm. Our guest today is the visionary Clay Johnston, MD, PhD. Since March 2014, Dr. Clay Johnson has served as the inaugural Dean of the Dell Medical School, and as Vice President for M edical Affairs at the University of Texas at Austin. Johnston's vision is to create a new model for academic medicine that accelerates innovation to improve health and reduce inefficiencies in health care. In 2016, Johnson was named Austinite of the Year by the greater Austin Chamber of Commerce for his leadership in Transforming Health and Health Care in Austin. Previously, Johnston was Associate Vice Chancellor for Research at the University of California, San Francisco. He also directed the Clinical and Translational Science Institute and founded the UCSF Center for Healthcare Value, to engage faculty and trainees in improving the quality of care while also lowering costs. So Fred, over to you. Let's get to know Dr. Clay Johnston, and what he's up to at the Dell Medical School.

Fred Goldstein  01:39

Thanks so much, Greg, and clay, welcome to pop Health Week.

Clay Johnston  01:42

Thank you.

Fred Goldstein  01:42

It's really a pleasure to have you on perhaps you could give our audience a little sense of Dell Medical School, and where you're at with it now I understand this is going to be the first year you have a class graduating.

Clay Johnston  01:52

Yeah, that's right. So we're Yeah, we're brand new school, we, you know, we now have our fourth class just arrived in Austin didn't have a medical school before UT Austin did not have a medical school. So the largest city without one of the few tier one research universities in the US that didn't have one, and huge opportunity, you know, to, to think differently. And so that's really what we're about. So we're looking at what's wrong with our health system? And then how do we create a better future where innovations are really designed to improve outcomes for patients and reduce waste and we bring to bear  modern tools for doing that. And age old tools like, you know, research methods applied to rapid cycle innovation, so that that's the kind of work we're doing and curriculum kind of matches up with that bigger goal.

Fred Goldstein  02:41

Yeah. And speaking of curriculum, you had the opportunity to sort of create a program from scratch. It's, I look through some it's very innovative. Can you talk about some of the differences of how the Dell Medical School program approaches, medical education for the undergraduate level versus the typical medical school we see today?

Clay Johnston  03:00

Yeah, sure. So we were really focused on on training leaders. So now looking at the health system, today, physicians have become the victims of the health system as opposed to really, you know, leading the changes that we all see are necessary within it. So how do we identify and then train the people who can can focus not just on the patient in front of them, but on on the systems of care on the activities that happen outside of the clinic and produce a better health system for leadership qualities, we interview differently, we look for creativity, as well as de-value things like grades and board scores, I mean, you get a decent board scores and grades to to get all the content. But that doesn't shouldn't be the primary factor, it doesn't predict having a greater impact on the world in any way. In, in then we, our curriculum is structured differently, to give us more time to focus on on these other concepts. So we actually take what is you know, traditionally two years of basic science and we squeeze that down to 12 months, other schools are starting to do the same thing or have been few have gotten down to 12 months, I think we may, I don't know if we're the only one but anyway, they not many in then they go into the clinic immediately after that. And then they have this additional third year. It's our innovation and leadership block, and that they focus on, again, the leadership skills, communications, health systems, value based health care, Human Centered Design, they work on projects that have the potential to improve health. And also we we really think that problems in the healthcare system are so difficult that we need to approach it from different perspectives, bringing in other disciplines and not just the traditional interprofessional health disciplines, but also business, Fine Arts, public health, all of those so many of our students also get a second degree during that extra year with the MBA and now our new masters of healthcare transformation, being the most popular and MPH being next most popular. So again, designed the a lot of focus on this sort of systems issues, community health prevention as well, change management, and then that really fills what we make available by cutting the amount of time to focus on, you know, the old rote memorization and those things that we all suffered through when we went to med school.

05:21

Can you talk a little bit about your earlier career, how you got there, and how that influenced the way you thought about this new medical school starting up?

Clay Johnston  05:29

Sure, yeah. I'm a neurologist, stroke neurologist, and I, I began with primary focus on on clinical care, got frustrated, a lot of the things that we did, we didn't really know whether they were right or not. So then got more and more into research, and then got a degree in epidemiology. And then basically came to the realization that the research system that was it was too slow and awkward, we weren't, we weren't really taking advantage of the opportunities to learn. And so I got more into research administration tried to fix the research system, and I became Associate Vice Chancellor for research at the University of California, San Francisco, and ran their clinical and translational science award, the, you know, the big NIH institutes, and came to the realization that actually, it wasn't about dysfunctional research, it was actually about dysfunction in care, that we, the care itself was basically difficult to change that even research findings that were compelling, were slow to be disseminated in care, and that the opportunities to move care forward, were being ignored. And also the research agenda really wasn't disciplined around the things that would likely make the greatest difference to help people. And so then I started a new Institute at UCSF called the Center for Healthcare Value, and, you know, got launched some projects there that were great, but then came to the realization that it's heavy lifting and an institution that that knows how to do everything right already, or at least believes it does. And, you know, UCSF is a fabulous organization, but it does, it's a gigantic organization that does things a certain way it likes to and so then when this became available, you know, the question was, could we, in starting from scratch, really, engineer things optimally take advantage of what can happen in academic medicine, and to stay better aligned with society's interest in so that was really the promise that they brought me out here and and what we've been working on ever since.

Fred Goldstein  07:30

So you made this comment, you know, something that makes the greatest difference in the health of people. And you talked about the care system, etc. So from what I've seen, does that mean you're sort of focused broader, you're looking at it broader, I noticed the third year students are out in the community and doing projects and things like that, is that part of that?

Clay Johnston  07:44

It is part of that. So you know, if you almost over quoted given the quality of the data, but most of health happens outside of clinics and hospitals, whether that's 80%, or 90%, or whatever, no one really knows, but it is most, and yet, our system really isn't about that. It's about you know, patching people up once they're sick and can't can't take it anymore. And and so, rather than spending all those dollars downstream, and all our attention on waiting for people's conditions to deteriorate, can we upstream things, can we start to keep people healthy? No one wants healthcare, actually, they want to avoid healthcare. So how do we acknowledge that, and the difficulty there, of course, is not in what people want, although, you know, people don't necessarily value prevention the way they should. But it's also the business models for supporting that are more difficult. So, you know, thinking through how to move the business in that direction has been a critical part of the work that we're doing to,

Fred Goldstein  08:42

and you talk you mentioned, it's all those dollars downstream, which are sort of the end result of not focusing on these social determinants, issues, etc. But that's sort of the meat and potatoes of the medical school isn't it with those high risk, high cost patients coming in with major, major clinical issues. And you discuss this in your article in JAMA, how do you think about reconciling that from a medical school perspective, and the point you made in your article,

Clay Johnston  09:08

that is the way academic medicine is evolved, it's, you know, tertiary or quaternary care for communities does often disproportionately contribute to care for the underserved and then obviously a place for research and a place for training the next generation but this on the care side tends to be you know, hyper specialized in and that's been encouraged because there's more money there. You know, Primary Cares  harder to make money in, in tertiary care. It's it's more attractive from a business perspective. But the other reason it kind of fits with academia is you, you know, you have the the doctors that teach the doctors, you know that you have the experts that can focus on the rarer things and so you can aggregate those things. putting that in a place that's focused on innovation does make sense But that would just suggest that, you know, only innovation is possible in tertiary care. And that's clearly wrong. I mean, I think if academic medicine, you know, if we're concentrating innovations in academia, which, you know, that's the reason we put so much research there as well, which is one form of innovation and important one. And that innovation ought to cover a whole range of issues that are that are important in that domain. And so I think this focus on the dollar has taken our eyes away from the importance of innovating in these other areas, whether it's in primary care or even before primary care. Now, the before primary care has been even harder, because we've left that for public health. But then public health has been perpetually underfunded, and ignored, and not considered an appropriate topic for for us practitioners. Whereas that's a place where we can, we can gain tremendous value, and other countries have shown us that. And so having leadership coming from those who really care about health to say, you know, we need to take responsibility for health, which means, including intervening at the population health level, allows us to, you know, to have a greater impact on the communities in terms of producing the best outcomes possible.

Fred Goldstein  11:21

So at the same time, in this viewpoint, academic medical centers too large for their own health, you also made the comments that academic medical centers must reduce the reliance on fee for service medicine, the associated pressures to retain market share, raise prices, and increased consumption of healthcare. Instead, they should leverage expert leaders to develop and coordinate new models of care, focusing on solutions that enhance value, is that going away from healthcare into other services? Or as you mentioned, is it focusing on primary care? Do you have some examples where that could occur? Or you're seeing it happened with academic medical centers?

Clay Johnston  11:53

Sure, yeah. But actually, it kind of can occur across the board. And that's really the intent here, it can occur in tertiary care as well. There are opportunities for us to be really obvious opportunities for us to make improvements across the board. So yeah, I think for us specifically, we are, we are focused on all aspects. So I mean, I'll give you in their examples. There are many other institutions that are doing work in the space, it's not just us, but it's just obviously easier for me to talk about our own work, you know, one is in subspecialty care. So you know, joint pain is a major expenditure, it's increased dramatically, there's a, there's a lot of waste in that system, a lot of joints get replaced, and the patient outcomes are not necessarily great. I mean, there's some fabulous places, but, you know, we're we're not measuring outcomes as well as we should, we're not looking at at cost, like we need to. So that was an area that we redesigned early on, did it from scratch, looking at team based care, including some technologies based on reported outcomes, constantly improving that care over time, and that was a place where we could show early on that, yes, we could dramatically improve outcomes, we could improve the experience, and we could reduce cost. In this instance, I'm not talking about just joint replacement surgery, I'm talking about joint pain, so upstream from the decision to do the surgery. So that's an example of, you know, kind of tertiary care thing that just can be rebuilt in a way that just makes more sense. Now, our system does not maximize fee for service revenue. In fact, kind of the opposite, we do a bunch of things that are not reimbursed and fee for service. So that's a risk for us. Lots of other places aren't going to do that. But you know, we're doing that first, because it's the right thing to do. And then obviously, the risk that we're taking is that the payment models haven't caught up to what it is we're doing on the other end of the spectrum. Or I'll say in the middle, maybe primary care just makes sense, right? If you're taking to an insurance dollar, and then you're managing that insurance saw, you're going to have the greatest impact by managing at the primary care level. And it doesn't mean the gatekeeper kind of approaches that were taken early on, you know, back in the HMO hysteria days but it means in carefully managing and considering your patients and meeting their needs, and hopefully avoiding more expensive downstream costs. So I think the place that a lot of places have ACOs they're starting to do this work. Sometimes ACO isn't large enough. And so they haven't converted the way they think about care. But it's a it's a space that we're working in and and we're growing in and trying to figure out how to navigate but then the new new area, it really is this upstream area, how do you take a fixed population and work outside of clinics and hospital and make them healthier and keep them healthier? And their, you know, the sustainability issues are the problem who's going to pay? Why are they going to pay in? So yeah, we're we're working in that space as well trying to figure out it's easy. Well, I shouldn't say easy, but we have been very successful in getting grants to test various things in that area. But there have been plenty of tests in that area. The key is, who pays for him when the grant is done. And so, you know, our emphasis has been on bringing payers to the table and saying, Well, what evidence do you need? In order for you to commit to pay for this going forward? Should it be successful, whether it's a program to control hypertension, or to convert pre diabetics to non pre diabetics, or to use food to programs to improve diabetes control and patients and reduce insulin use? You know, those are the kinds of things that we're that we're looking at. And that's why so good cancer screenings, another one that that fits in that category as well.

Fred Goldstein  15:40

You mentioned payment models not not coming in as quickly as you're transitioning your care delivery system. And you then discuss just recently just now, you talked about talking to the health plans about, hey, what sort of data do you need to justify paying for this service? Are you still thinking of structuring those additional services as a fee for service payment? Where the health plan is going to see the offset and the risk? Or are you looking to try to structure contracts where you take the risk? And then you're, you're in essence, earning the savings off of the fact that you did something not typically done in a care system at reducing care needs?

Clay Johnston  16:15

 Yeah. So I would say all of the above, I mean, the other way is we're trying to basically create products that fit under an insurance under an ACO or other insurance product. So all of those are, are being tested in we're seeing what what works and in the market where young organization as I, as I mentioned early on, and so we we don't have full coverage, we can't be, you know, all things. We can't meet all requirements and ACO. And actually we don't we think that the important function of redesigning intensely, that if we were just say, okay, we're doing everything now we've got it all figured out, that would be a lie, you know, yes, we could do it. But we wouldn't have redesigned everything. So we're kind of bucketing out the things conditioned by condition to look at each one. And that's the way we're thinking of economics and thinking of the way that we are marketing, what it is we're doing. Now we get to this point, where it's easier not to have all those sales discussions. And so we're kind of working on that now,

Fred Goldstein  17:21

are the students also involved in some of that thinking, and as you work through some of those programmatic, etc?

Clay Johnston  17:27

Yeah, so definitely the students are, you know, when they're getting their exposure to the clinics, they're seeing what an integrated practice unit really looks like. So they're definitely a part of that. And then the students are all working on some projects that has the opportunity to improve health. And so that could be, you know, they are they're not, you know, standing up integrated practice units, they don't have the expertise to do that. But they could be involved in it, or they could be doing the, you know, the focus group work that goes into planning, or, you know, an example is the, the students in their Peds rotation set up a whole new system for for parent education around medication use. That was sort of their idea. And they launched it and tested it, and now it's standard in the hospital. So sometimes it's just a component of what it is we're doing.

Fred Goldstein  18:16

 That's fascinating. It's great to see them getting involved like that, as you look at the Medical School over the next couple of years. Are you structured in the typical way? medical school is departments and department chairs and things like that? Are there some differences that you've put in place, given how you're looking at the healthcare system?

Clay Johnston  18:36

Yeah, so it's where it's kind of a hybrid. The strong department structures that exist in most medical schools, we, we think are getting in the way for doing the right thing for patients. Because the reality is that in these integrated practice units, you have experts from a variety of different domains, and you want them all working together and not worried about, you know, the finances and how dollars flow, you want them to be coordinated, and making the overall right decisions for patients. So we do have departments because it's easier to recruit chairs than it is to recruit vague titles of leadership. Everybody knows what a chair is, and they're, you know, comfortable with applying for those jobs. And also, it fits with our training model, although we're, you know, within thinking about different training models for residency, for example, in clerkships, but then the funds flow is different in that basically the departments are the home for faculty, their academic home, but then they're loaned out into integrated practice units. And so those could include people from multiple different departments. And then the finances of an integrated practice unit are looked at distinctly and there's a leader of integrated practice unit. So joint pain integrated practice unit it includes an you know, an orthopedic surgeon, it includes a psychiatrist it includes social worker, a trainer, a physical therapist. dietitian, others in that team works together in the finances of that group are understood within that unit leasing time for departments. So that makes sense. It's kind of a weird hybrid system, but it seems to be working. Yeah,

Fred Goldstein  20:15

it's definitely a little different from the standard one. But obviously, as you create these cross functional teams, or add individuals to teams, you need to look at things a little bit differently. And what's your impression? Obviously, I've seen some literature and on the website talks about population health, imagine these populations, you know, there's sort of still this ongoing battle, is population health, the right approach? What about precision medicine, etc? Where do you think that falls?

Clay Johnston  20:39

Yeah so I think, I think population health is where we need to go, you know, in terms of what those interventions look like, we have to be able to justify that the intervention made a difference. I think that's where we've stumbled before made a difference in a to a to someone who's feeling the financial pain, and we handle our benefits of you intervening. And so that's, that's really where we're focused. So precision medicine, I think, is a wonderful idea. Obviously, medicine has become more and more precise all the time. I mean, we we didn't even diagnose Alzheimer's disease not that long ago. And, you know, I mean, we we've become, we will continue to become progressively more precise. And I think precision medicine certainly has demonstrated great utility and in the cancer space, you know, identifying specific subsets of cancer that will respond to therapies. But I think when you have a, you know, a population where you have a third of patients with hypertension adequately treated, then I think you were to focus on, well, what genes are causing, you know, some rare disease seems misplaced. It seems like we know, hypertension has a huge impact on health, we have 10s of drugs, maybe over 100 drugs that work for hypertension, many of them very well tolerated all and many of them very cheap. We know how to diagnose it, and yet we leave it untreated. So it seems to me that until we get until we get our act together, until we recognize what it is, we're here to do, which is improve outcomes for patients, that we we don't have any business looking at details, because they're shiny new bottles, as opposed to things that you know, we ought to have done decades ago,

Fred Goldstein  22:26

you've obviously very successfully started up this medical school, you're now into the fourth year, you can have your first graduating class, looking down the road five years, Dell Medical Schools, an overwhelmingly great success, what does it look like? And what is it accomplished?

Clay Johnston  22:42

Yeah, from from my perspective, we really have to change the financial model. And I don't mean just in for academic medicine, I don't just mean for the money that we get from providing care to patients, locally, I mean, that we have to figure out how, you know, the way we scale innovations related to new drugs, new devices, they those kinds of innovations happen in the systems of care, and whether those are prevention oriented, population health oriented, primary care oriented, or tertiary care oriented. But there's an opportunity for those to scale not through publication, which has failed us, but through other means that are more that are that are more effective. And I think that's going to be business models, doesn't have to be for profit business models, but business models, I think that those ought to come from academic medicine. And if we can figure out how academic medicine can actually reap financial benefits from its innovations, as opposed to from providing more and more care whether or not it's the right thing, or not, from a community perspective, but really focus on innovations, then I think we've really aligned what academic medicine is best suited to do. And society's interests. And those innovations in the systems of care with those are really the things that are missing, you know, internationally, in the health systems, we create systems of care that are just extremely slow in changing and ignoring some of the low hanging fruit.

Fred Goldstein  24:15

If you had one message for obviously, other academic medical centers may have different things going on with them. What would you tell them to focus on now?

Clay Johnston  24:27

Yeah, it was so that when I I don't propose to tell you what to do, because I mean, frankly, there, I think that the country, the world benefits from our various of foci. I mean, I think the, it is fabulous that we have some institutions that that are just powerhouses in basic science, we absolutely need discovery in basic science. It's great that others really understand how to do clinical research extremely well and, you know, study new Drugs, devices, diagnostics, all that it's great that others are really focused on providing, you know, more docs for the community and for rural areas. So, you know, I think there's a whole range of wonderful things that that academic medical centers are doing. I do think that, you know, I'm a little hard on scale, I'm not saying scales a bad thing. In that opinion piece, I'm, what I'm really saying is, we just have to examine what scales doing to us and how it's dictating the decisions that we're making. And I think the places that have scale, and there are a number of them, the one thing I would ask them, is, if they're using their scale, to get more bargaining power, in order to to be reimbursed at higher rates, I understand why because, you know, they have all kinds of other costs associated with their mission, but that in itself, is not necessarily optimally aligning them with the what was their community's needs. And so,

Fred Goldstein  25:59

right,

Clay Johnston  25:59

that temptation for growth, you know, instead, it should be what folks say it is, which is, you know, aggregating gives us an opportunity to create coordinated care and offer more services in high level services in a distributed fashion. That's what they all say. So then I would just say, then prove it, and actually focus on that, and show that your outcomes are better, and show that you actually care about costs. And as you're driving down costs in the in the system that you're providing, I think that's what the large ones need to work on.

Fred Goldstein  26:29

Thank you so much clay, that's gonna have to be it for today's show. I really appreciate you coming on.

Clay Johnston  26:34

My pleasure. Thanks for having me.

Fred Goldstein  26:36

And back to you, Greg.

Gregg Masters  26:37

And thank you, Fred. That will be the last word on today's informative broadcast. I want to thank Dr. Clay Johnston, the inaugural dean of Dell Medical School and Vice President for Medical Affairs at the University of Texas at Austin for sharing his vision for academic medicine and the pioneering work at the Dell Medical School. For more information on Dell Medical School or to follow their work, go to www.Dellmed.utexas.edu and follow both Dr. Johnston and the school on Twitter by  @ClayDellmed, and @DellMedSchool  respectively. For PopHealth Week, my colleague Fred Goldstein, Dr. Clay Johnston, and HealthCareNow Radio this is Greg Masters saying Bye Now.