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The Dirty Dozen Redux

Published online ahead of print, December 2020
Web Exclusives - Editorial
David B. Nash, MD, MBA
Editor-in-Chief, American Health & Drug Benefits
Founding Dean Emeritus, Jefferson College of Population Health, Philadelphia, PA
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This year is a year like no other. For the first time, our annual Population Health Colloquium, which is typically held at a beautiful hotel in the city of Philadelphia, PA, was converted to a virtual event. Instead of celebrating our twentieth anniversary with 650 colleagues in person, we conducted the meeting online over 3 jam-packed days this October.

Typically, at the outset of our colloquium, I review the top 12 trends in population health from my own perspective. I have previously referred to these trends as the “Dirty Dozen,”1 after one of my favorite movies that carries the same name, about a rescue mission in World War II—the 1967 flick featuring a dozen tough guys, including Lee Marvin, Telly Savalas, Jim Brown, and Donald Sutherland. Perhaps you’ve seen it?

Based on our 20th Anniversary Colloquium, allow me once again to review the dirty dozen trends that have defined 2020.

1. We dedicated the colloquium to the memory of Dr Li Wenliang, the brave 33-year-old ophthalmologist who warned the world of the novel coronavirus and then died from it in Wuhan Central Hospital, China, on February 7, 2020.2 The world now owes him a great debt of gratitude, because the pandemic has changed our lives forever.

2. We passed another important milestone, the tenth anniversary of the passage of the Affordable Care Act (ACA). At the time of this writing, concerted political forces continue to discredit the accomplishments of the ACA and indeed seek to overturn it. Millions of our citizens could forfeit their sole source of health insurance coverage if this were to occur.

3. Another sad reality is that even the people who are lucky enough to have employer-sponsored health insurance find it increasingly unaffordable.3 For the first time now, the average health insurance premium paid by the employer and the employee for a family plan is $20,000 annually.3 The average annual income of the typical American family is $60,000.4

4. The summer of racial unrest and the rise of the Black Lives Matter movement have catapulted the Chief Diversity and Inclusion Officer into the “C” suite of healthcare delivery systems nationwide. It is simply too early to tell if this organizational role can erode decades of institutional racism and inequality.

5. Marketplace consolidation on the provider side has accelerated, with little evidence that “bigger is indeed better.”5 Sadly, one cannot yet claim that these regional multihospital systems and their attendant corporate leadership hierarchy deliver safer, better, and less expensive care that is more in tune with the needs of the populations they serve. Let’s hope that we can improve this reality soon.

6. The digital transformation of healthcare has finally begun in earnest, and has been powered by telemedicine, especially during the first few months of the initial surge in COVID-19 infections in the United States in April, May, and June of 2020.6 This transformation is likely to continue, with advances in remote patient monitoring and related technologies. Some people have already sounded the death knell of the routine office visit forever.7

7. The inexorable rise in the influence of robots in healthcare will continue unabated.8 Robots will be cleverly disguised as pets to help reduce the epidemic of loneliness among our elderly. Flying robots and their related drones will become ubiquitous, delivering prescription medications and home health supplies.9

8. Most large for-profit health insurance companies have had a record-setting year, as a result of a near shutdown of all payments for elective services for nearly 4 months. This excess cash on their books, coupled with crippling economic losses on the provider side (for the same reasons!), will stimulate the creation of joint ventures,10 and, in turn, will blur the line between payers and providers, giving rise to the “payvider,” a clunky, but important, new phrase in our healthcare lexicon.

9. Despite being understandably overwhelmed by the development of vaccines against COVID-19, progress on the personalized medicine front will continue. There will be further integration of these discoveries into practice,11 especially as the Centers for Medicare & Medicaid Services payment for CAR T-cell therapy expands.12

10. The convergence of artificial intelligence, machine learning, and predictive analytics will contribute to the expansion of “health assurance,” a term that is best characterized in the new book UnHealthcare, which I recently reviewed in these pages.13 Care delivery will be “always on,”13 and patients and providers will be connected continuously, which will drive down costs and improve outcomes.

11. “The decade of the yold, or ‘young old’”—which includes people aged 65 to 75 years—will be further characterized by “drastic changes in health spending,”14 namely, further disruption of financial markets, social and class expectations, and public policy for healthcare. These yold persons (now including yours truly) will be a “new boon to themselves, to economies, and to societies.”14

12. The final trend is my heartfelt hope and prayer for the evolution of our republic, and for the development and successful dissemination of effective vaccines against COVID-19, which are just around the corner. I know that most Americans share my angst in this regard.

I hope that our 2021 Population Health Colloquium will see us happily returning to downtown Philadelphia for an in-person reaffirmation of the importance of our work together.

What are your own dirty dozen trends? As always, I am interested in your views. You can reach me at This email address is being protected from spambots. You need JavaScript enabled to view it..


  1. Nash DB. “The Dirty Dozen.” Am Health Drug Benefits. 2018;11(6):271-272.
  2. Baker G. China’s crisis exposes a badly flawed model. Wall Street Journal. February 15-16, 2020:C2.
  3. Abelson R. Employer health insurance is increasingly unaffordable, study finds. New York Times. Updated September 30, 2019. Accessed November 24, 2020.
  4. Semega J, Kollar M, Shrider EA, Creamer JF. Income and Poverty in the United States: 2019. September 2020. Accessed November 24, 2020.
  5. Eickholt L. Why many integrated delivery systems have not enhanced consumer value, and what’s next. NEJM Catal Innov Care Deliv. January-February 2020;1.
  6. Nash D. Population health “BC and AC”: Before COVID & After COVID. Presented at the National Committee for Quality Assurance Quality Talks; April 28, 2020. Accessed November 24, 2020.
  7. Eby D, McGookin E, Duncan J; for the IHI Leadership Alliance. COVID has made the office visit a dinosaur. Medium. June 17, 2020. Accessed November 24, 2020.
  8. Purtill C. Stop me if you’ve heard this one: a robot and a team of Irish scientists walk into a senior living home. Time. October 4, 2019.
  9. Nash DB. “Alexa, refill my omeprazole.” Am Health Drug Benefits. 2017;10 (9):439-440.
  10. Bannow T. Hackensack Meridian, Horizon Blue Cross and Blue Shield launch NJ Medicare Advantage plan. Mod Healthc. September 14, 2020.­and-blueshield-launch-nj-medicare-advantage-pl.
  11. Pritchard DE, Moeckel F, Villa MS, et al. Strategies for integrating personalized medicine into healthcare practice. Per Med. 2017;14:141-152.
  12. Jacobson C, Emmert A, Rosenthal MB. CAR T-cell therapy: a microcosm for the challenges ahead in Medicare. JAMA. 2019;322:923-924.
  13. Nash DB. UnHealthcare. Am Health Drug Benefits. October 2020.
  14. Parker J. The decade of the “young old” begins. Economist. The World in 2020. December 25, 2019. Accessed November 24, 2020.
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Last modified: August 30, 2021