“No Outcome, No Income”: Dr. David Nash on Redesigning the US Health Care System for a Healthier Future

Even with the most advanced medical technology in the world, the United States continues to rank low in patient safety, high in cost, and worse in outcomes. According to Dr. David Nash, that reality is not just a flaw—it’s a design feature.

“Every system is perfectly designed to achieve exactly the results it gets,” said Dr.Nash, Professor of Health Policy at the Jefferson College of Population Health. “So we shouldn’t be surprised that we’re in the jam we’re in.”

In a recent episode of Khan Klinics, hosted by Dr. Amir Khan in collaboration with American Muslim Today (AMT), Dr.Nash offered an unflinching look at why the current model of American medicine fails—and how we can rebuild it from the inside out.

Population Health: A New Foundation

At the heart of Dr.Nash’s career is his pioneering work in population health—a field that redefines care not around individual illnesses but community-wide well-being. It blends public health, policy, economics, quality, and safety under one roof.

“Public health is the foundation,” he explained. “Then we surround it with health policy, economics, and clinical quality pillars. Put it all together—and that’s population health.”

Dr.Nash was handpicked to lead Jefferson’s new college in 2008—before the Affordable Care Act. “I was sitting in the right place at the right time,” he said. “They just said, ‘Let Nash do it.’”

The Missing Ingredient: Patient Engagement

In Dr.Nash’s view, transparency and partnership are the bedrock of better care. “Nothing about me without me,” he said, echoing Harvard’s Dr. Tom Delbanco.

As a policy advisor in Pennsylvania, Dr.Nash pushed for public reporting of hospital outcomes. “We’ve built one of the oldest and most robust databases in the country,” he said. “Even down to the physician level.”

True patient engagement, Dr.Nash stressed, means giving people access to data, tools, and knowledge. “Being a patient is a big job,” he said. “We have to treat patients as partners, not subordinates.”

Yet, many physicians resist. “We’re trained to see ourselves as the center of the solar system,” he said. “But in an era of ChatGPT, digital health, and democratized information, patients must be active participants.”

The Cultural Wall: Why Doctors Resist Reform

Dr.Nash identifies two huge barriers to reform: medical culture and outdated measurement.“Doctors don’t like admitting they can do better,” he said. “It makes them feel vulnerable.”

That mindset, Dr.Nash said, is a legacy of training that puts doctors on pedestals. “We need to move from autonomous experts to accountable experts,” he said. “But our culture is still stuck in the past.”

Outdated metrics don’t help. “Are we measuring the right things?” Dr.Nash asked. “We used mortality for heart surgery in 1991. That’s not enough in 2025. We need smarter, clinically relevant metrics that account for race, poverty, access, and other social determinants of health.”

Why Physicians Must Lead—But Aren’t Trained To

“Most doctors never receive leadership training,” Dr.Nash said bluntly. “Yet we expect them to teach, lead, and manage a $4 trillion industry.” He called for a radical redesign of medical education. 

“We need to sink the barge,” Dr.Nash said. “Start fresh. Bring in students from liberal arts backgrounds. Teach systems thinking, behavioral economics, safety science, and how to lead teams.”

While more schools now offer population health and healthcare quality degrees, the majority of medical colleges still ignore these areas. “It threatens the status quo,” Dr.Nash said. “And the people who become deans often come from traditional, grant-focused pathways.”

Prevention vs. Profit: The Broken Incentives

So how did American health care become so reactive? “Blame the combination of Medicare, the Hill-Burton Act, and fee-for-service medicine,” Dr. Nash said. “It created a toxic brew that rewarded procedures, not prevention.”

Unlike countries like Australia, where Nash recently spoke on tour, the U.S. emphasizes doing more—not doing better. “Their entire GDP is smaller than what we spend on health care,” he said. “Yet their outcomes are better across the board.”

“Prevention doesn’t fit our temple of technology,” Dr.Nash added. “It doesn’t make money.”

In 2008, Dr. Nash coined a phrase that would become his rallying cry: No outcome, no income. “It was my pithy way to introduce value-based care,” he said. “If you want to get paid, do it right.”

That means following science, cutting waste, improving safety, and delivering the right care at the right time. “We’re in a nonlinear system,” Nash explained. “You can’t know if something works unless you measure it—and most doctors aren’t trained to do that.”

COVID-19: Culture, Failure—and a Second Chance

In his book How COVID Crashed the System, Dr.Nash and co-author Charles Wulforth dissect the pandemic through a cultural lens.

“Our biggest failures were rooted in exceptionalism, federalism, and individualism,” he said. “We refused to learn from other countries. States competed instead of cooperating. And we cared about ourselves—not each other.”

But there were bright spots. “Hospitals adopted incident command culture,” Dr.Nash said. “Every day, they asked, ‘What’s working? What’s not?’ That self-assessment mindset needs to stick.”

And yet, Americans seem ready to forget. “When the dying stops, the forgetting begins,” Nash said. “That’s where we are now. But if we don’t learn, we’ll fail again.”

The Power and Peril of Artificial Intelligence

When ChatGPT passed the medical board exam with 85 percent, Dr.Nash had an epiphany. “I studied for a year and got a 79,” he said. “That was a wake-up call.” However,  he sees AI not as a threat—but a tool. “It won’t replace us. It will enhance us,” Dr.Nash said.

From diagnostics to risk stratification, AI can flag sepsis, tailor treatments, and factor in social determinants—faster and more accurately than ever.

Still, Dr. Nash warned, “We don’t know what we don’t know. That’s why physician leadership is essential in building ethical, patient-centered AI tools.”

Despite his critiques, he remains hopeful. “I have a positive view of the future,” he said. “Otherwise, I wouldn’t be doing this work.”

For Dr.Nash, true reform must be moral, not just technical. “We owe it to our patients, our communities, and ourselves,” he said. “Because if we don’t fix this broken system—someone else will. And they might not get it right.”