When Nirav R. Shah, MD, MPH, was confirmed as New York State's Commissioner of Health in January 2011, he faced a daunting challenge. The state was in the midst of a huge budget crisis. Shah's boss, Governor Andrew Cuomo, told him that as part of a plan to balance the state's budget, he needed the commissioner to reduce Medicaid's growth from its current 13 percent annual rate to 4 percent. At the same time, he expected Shah to increase access to—and improve the quality of—health care throughout New York.
At age 38, Shah was the youngest New York state health commissioner ever. He had no time for on-the-job training. He immediately began working with the Medicaid Redesign Team, a statewide group of stakeholders and experts established by the governor to trim New York's $53.5 billion Medicaid program. From the very start, Shah drew on lessons he learned from his participation in the Robert Wood Johnson Foundation Physician Faculty Scholars program to address this massive challenge and accomplish the goals set forth by the governor.
Engaging the Public to Help Make Difficult Decisions
RWJF Physician Faculty Scholars, which ran from 2006 through October 2012, sought to strengthen the leadership and academic productivity of junior medical school faculty. Scholars received funds for a three-year research project, along with mentoring, networking, and other supports. Shah, then an assistant professor at New York University School of Medicine, received his award in 2007.
One lesson that Shah learned during his fellowship was the importance of listening and communicating clearly, which he absorbed from members of the program's national advisory committee—in particular his mentor, committee chair Harold C. (Hal) Sox, MD, then the editor of the Annals of Internal Medicine and professor of medicine at Dartmouth Medical School.
"These people [the advisory committee members] are incredible communicators at a personal and professional level," Shah says. "When I have Hal Sox as my mentor, I learn from his example. Whenever he was in New York giving a speech, I watched him and learned from the master himself."
"That is the nature of this job," he says of his state position. "In a highly political environment, there is a lot of emphasis on communication."
As the newly-appointed health commissioner, Shah worked closely with the Medicaid Redesign Team to solicit ideas from the public and advocacy groups about how to save money in the Medicaid program while ensuring quality.
He recalls the poignant example offered by a woman who came to the microphone at a public meeting in Buffalo.
"You send me home from the hospital 10 times a year in an ambulance. Instead of paying $400 for each ambulance ride, pay $40 for a cab voucher."
These public engagements—through community forums, the state's website, and other avenues—generated some 4,000 ideas, many of which made it into the health department's proposals for savings. By April 2011, just three months after Shah became health commissioner, the state legislature had passed 78 proposals submitted by his office. These proposals collectively saved $4 billion in the first year while increasing access to an additional 154,000 people. New York is on track to save $34 billion over five years, according to Shah.
Helping Patients Become Engaged With Their Health
Shah's Physician Faculty Scholars award was hardly the first support he'd received from RWJF. He was an RWJF Clinical Scholar from 2001 to 2003 and a Health-e Technologies grantee in 2004. In his work, he became a leading researcher in the use of electronic records to improve the effectiveness and efficiency of care.
An internist, Shah knew that many "best practice" guidelines exist to help patients make behavior changes and improve their health. But these guidelines are often complex, hard to remember, and lack a simple, interactive way for patients and clinicians to jointly decide on concrete steps to take. Shah believed that patients and their clinicians would be more likely to benefit from these guidelines if they had an easier way to use them.
His research project for RWJF Physician Faculty Scholars sought to address this problem. In 2007, he launched the Outpatient Cardiovascular Guidelines Applied in Practice study at Geisinger Health System in Pennsylvania, where he was an associate investigator. He developed a system to use information technology to prompt patients to reduce their risk of heart attacks.
The system uses electronic health records to identify clinic patients at high risk of a heart attack or stroke who had risk factors that could be addressed through prevention. These patients are invited to come early to already scheduled appointments. There, a research assistant guides them through a touch-screen interactive program where patients can learn about their risk of heart disease, choose changes to make such as exercise or medication, and then see how their risk would diminish over time as a result. That information is also sent to the doctor, who can discuss options with the patient during the appointment.
With widespread adoption of electronic health records in the coming years, Shah's study may provide one model for the delivery of preventive care, according to Iris F. Litt, MD, who was national director of the Physician Faculty Scholars program.
Gaining a Broad Perspective
As he carried out his research, Shah said he benefited from the wide-ranging perspective that Sox, his mentor, brought. "He was most critical of my project, which made me know that he was on my side," Shah said. "He gave me the most challenging of critiques. He asked the hardest questions and he framed them in a national policy perspective.
"He would bring multiple stakeholder perspectives to the table: 'Okay, if I were Medicare and had to pay for it, how would I pay?' 'If I were a specialty society, why would we care?' Or 'If you had to make to the business case to companies, how would you do that?' "
Tackling complex health issues from a variety of perspectives continues to help Shah as he strives to strike a balance between containing costs and providing quality health care.
Creating Time for Family, Outside Interests
RWJF Physician Faculty Scholars helped Shah in one other crucial way—and it is one that is frequently ignored in career development programs.
The people he met at the Scholars program's national meetings are workaholics, Shah says, "Yet they are able to have amazing lives outside their professional work. They led by example. I sat down with national advisory committee members and they talked about what they did on vacation. One went RVing with his family for a month across the country. It showed they were able to do all they have done at the national and international level, and they are still able to be involved in the arts and culture, and with their family."
Shah has two young children and said that he has taken that message to heart. He tries to be home for dinner most nights with his family, and he bikes and plays tennis regularly. He also takes his family on business trips as often as he can.
In the Scholars program, "We talked a lot about discipline and how you need to focus on what is urgent and important and not just urgent," Shah said. "You are a better scientist if you have outside interests and have a life so that you don't burn out."
Because many scholars are still early in their careers, it may be too soon to judge the real impact of the RWJF Physician Faculty Scholars program. However, several scholars are already taking leadership positions in academic medical centers, in local, state, and federal government, and are conducting innovative research projects with the potential to affect health and health care.
"The Physician Faculty Scholars program developed a cadre of physicians—65 in total—who will or who have become productive, creative, and influential physician researchers and leaders," said Senior Program Officer David M. Krol, MD, MPH, former director of the RWJF Human Capital Portfolio. "It also filled a niche for some physicians who wanted to pursue research that would likely not have been funded by other sources."