ROI-NJ: I assume the title of commissioner of New Jersey’s Department of Health was never something you dreamed you would add to your resume one day. Reflecting on it, how does it feel?
Shereef Elnahal: My career has gone in a lot of different directions. I’ve been one to sort of take opportunities based on whether I think I can have impact and if I have the right mentors in place. Having applied for the White House fellowship when I was in my last year of residency, I had about 10 months left, I thought I was going to be there a year and then go back to clinical medicine. But I was presented with an amazing opportunity to stay and serve, so I took it. I do not regret a single step I’ve taken. I do miss seeing patients, of course, but I think what we’ve been able to accomplish in the VA, and what I’m able to do here in New Jersey hopefully makes it all worth it.
ROI: You’ve moved from having been in the clinical sphere into more of a political sphere. Any greater ambitions?
SE: I don’t characterize it as politics. I characterize it much more as management and policy. I haven’t run for office, don’t plan on it. But, of course, the job — parts of it are political. What that really means to me is having the right stakeholders behind you in order to get something done. I’ve made it clear to all the stakeholders I’ve met with — whether it be hospitals, other organizations and associations, all of which have an interest in serving people, but also have financial interests — is they can come to me with a proposal, or ideas that will improve the public health. And I will support that. And here are my public health priorities.
But that’s my job. My job is to do that, not take sides in a debate where I don’t see the needle moving in terms of public health.
I’ve got nothing but positive responses to that. I think people understand that I haven’t been in New Jersey for my professional life, thus far, and, so, I don’t really have any ties to any particular industry or constituency. I think that’s part of the rationale of why the governor asked me to do this.
ROI: You’ve already made some administrative changes on a topic the governor is passionate about. How did you end up making the change and what were the obstacles?
SE: It’s for unclassified employees, so it doesn’t apply to everyone, but it’s within my span of control. We’re going to allow people to use vacation days and sick time up front for things like maternity leave. My own situation (was the inspiration). My wife is delivering soon, and I had to fight to get two weeks off. So, when I walked in, I said I need to do for the employees that I can what I am trying to do for myself. I think it’s only fair to do that. We are also making sure to review all the compensation for female versus male employees to make sure there is no disparity there (as per Murphy’s first executive order). Just following the rules, and I agree with the rules. Almost my entire senior management team here are women, and it’s been great. We are going to have good, fair, equitable work environment.
ROI: How do you regulate an increasingly complex and operationally diversified industry?
SE: What you’re describing are really positive changes. You have hospitals and payors working together to provide better value. The entire model and concept around accountable care and alternative payment models is centered on that. So, that regulatory complexity is something I’m willing to accept and, in fact, embrace, if I think patients are benefitting and the state is benefitting. When you are innovative in your thinking in how you deliver care, you’ll get some complexity in how we oversee, and we have to evolve according to that. I’ve met with some hospital associations already, and what I’ve told them is, ‘Challenge our thinking in the way we regulate you. If you think you can operate in a way that benefits people, that doesn’t necessarily align with our rules and regulations, I want to hear about that.’
Because there are reasonable ways to make adjustments if those changes abide by the law and they improve public health. I asked for their help in doing things like having better health information exchanges and interoperability. If there is one legacy I want to leave as far as the health system goes, it is building a massive interoperable network so that patients can own their data when they travel from place to place. We don’t have that yet in New Jersey. We have the beginnings of an infrastructure to be able to do that, but as much as they are going to as me for stuff, I’m going to ask them for stuff, to help us advance these things and build the right infrastructure.
ROI: What is the balance to strike of the state funding and subsidizing health entities?
SE: The state does have a very important role in buttressing the safety net for patients. We have a lot of uninsured patients in New Jersey. That uninsured rate has gone down since the Affordable Care Act and since Medicaid expansion in New Jersey, but there are still a lot of people, like undocumented immigrants, in New Jersey. From an ethical standpoint, we have to make sure they are treated when they enter a hospital. And hospitals are eating those costs and they are not going to be compensated, even by the legislation we have seen nationally with the ACA and locally with Medicaid expansion. So, there has to be something we give them to compensate.
ROI: Any ideas on how to change the way hospitals are reimbursed by state funding?
SE: We’d have to talk to the Legislature, but, in an ideal world, you’d want to tie payment to value. That’s why you have alternative payment models, bundle payments, episode-based payments, etc. Could we explore something like that in charity care? I’d have to consult with the Legislature and the governor.
ROI: The state has a lot of unique resources to be able to respond to things going on at the federal level. We are home to a number of pharmaceutical companies, have individuals chairing on national boards and associations that frequently visit Washington, D.C., and New Jersey’s congressional delegation. Any thoughts on how to leverage this?
SE: My direct statutory purview doesn’t include that. But, what I will say is, I’ve seen interesting partnerships and business models where some pharmaceutical companies and earlier stage companies have done with payors to make things easier for patients and improve health. So, where they can be partners in that, I’m very open to having discussions with them and make sure we can facilitate those interactions. There are a lot of players in this industry and a lot of personalities as well.
I’m willing to meet with anyone who has new and innovative ideas. I’m going to bring my ideas to the table to my team at the Department of Health and push for ideas in the Legislature — there are already a lot of good ones I’ve seen — to accomplish those goals.
ROI: You didn’t offer any insight into your personal preference, or which method of settling disputed bills you supported in the out-of-network debate during your hearing in front of the Senate Judiciary committee. Do you have an opinion on the best method?
SE: As an administration, we haven’t homed in yet on one particular idea, that’s what I wanted to articulate during the hearing, because there are still discussions ongoing. I think there are a lot of things you can do that work. We have seen case studies in other states solving this problem through different mechanisms. However, that looks at the end in terms of a bill, and passes, there’s a lot of vigorous debate for the means to an end I think we all agree with — high, out-of-network billing that ends up reaching patients. Surprise billing is not what we want to see. We want to see premiums go down for people in New Jersey; premiums are extremely high here. And I think there are ways we can do this that maybe not all parties would find is their first choice, but they will find acceptable going forward. But we will see what goes through the Legislature, and we will implement — as a whole team, as state government — whatever comes out.
ROI: On a lighter note, what about New Jersey has surprised you so far?
SE: I heard a lot about the environment here before I came. I was on the transition team, but what surprised me most is, I’ve seen so many different stakeholders ultimately have the right values and have the right set of goals. There’s a lot of cynicism in politics, there’s a lot of cynicism in government. I’m seeing much less of that than I was told I would see. And, for the most part, I’ve dealt with honest brokers who really — they, of course, have goals that benefit themselves — want to benefit the state. I have not been disappointed, yet, by the folks I’ve met in health care.
It really makes me optimistic. I think we really can partner across different constituencies, industries and agencies in government and get amazing things done. Part of it really is the tone that our new governor is setting. This is going to be a turnaround operation. We are going to make New Jersey one of the best states to live in. Health care is a big part story and I’m really honored I’m going to get to lead it.