Friday, March 20, 2009

Outstanding Health Care Reads at Maggie Mahar's blog

A guest post by a recently retired physician and his response to one commenter in the comments thread is worth the time it takes to read both. The essay lists nine specific areas in which significant steps should be taken to cut costs and improve outcomes at the same time. Very impressive to have a pro speaking clearly and reasonably. Be aware that you are reading something written by a doctor, not a journalist. He's not trying to be clever or poetic. The style is, well, prosaic... but loaded with good information. (Be advised, this is a long assignment. In my usual manner I copied the content to a two-column Word document for easier reading. I like to take it to a comfortable chair and make marks for later reference. I didn't count but this printed out to about fifteen or twenty pages. And comments are still coming in.)

The point that jumps out repeatedly to those of us studying health care is that costs and outcomes are all over the place, but a respectable number of clinics and practices are absolutely getting better results with lower costs. The challenge is to figure out how they do so and get the same dynamic at work throughout the American health care delivery network.

The larger point is simple: doctors make the important medical decisions and government has the power to help them make the right ones by furnishing them with proper feedback. And since government in one form or another is paying half of all medical bills in America, taxpayers and policy makers have every right to expect government to be responsible in its fiduciary duty.

Here is the link to the article.

And here is the doctor's response in the comments thread to an inquiry about the Mayo Clinic's various locations.

I have first hand experience of how Mayo works, but none on Cleveland Clinic.

Despite your comment on Mayo that "they sure seem to run a lot of or's and cath labs and have a lot of the fanciest technology", it turns out that Mayo actually does fewer caths and fewer procedures per patient than most private hospitals. Remember that when you look at Mayo they are seeing many more patients per day/week/month/year than private hospitals. In fact, in Minnesota Mayo does significantly fewer procedures than much smaller busy places in most large cities, including Minneapolis.

Mayo has an institutional emphasis on getting patients in and out quickly. A lot of the reason "they seem to be overstaffed with support staff compared to hospitals i have worked with" is because of that emphasis. Historically, Mayo takes great pride in how fast they can return a typed result of an xray exam or lab -- typically less than four hours after they are ordered. This speed of service translates into decreased costs elsewhere, since sitting and waiting is a costly passtime in many medical institutions. It is not at all uncommon to hear patients comment that they can fly to Mayo from their home, get a thorough workup, diagnosis, and have treatment initiated, and fly back home several days faster than it takes them to have the same thing done at home.

In the end, however, the biggest saving at Mayo is what they don't do. Mayo actually charges more for each individual service than many other centers, but does many fewer of them per patient. The Dartmouth Atlas comments in its last edition that Mayo charges more per service than Mass General, but that cost per patient is significantly less -- around 1/3 less.

The reason that Mayo accomplishes this is that they have carefully thought out protocols covering many patient problems -- and the experience to have been able to evaluate these protocols for effectiveness, including in many conditions that are rarities in most institutions. Mayo also has a strong culture of conformity to its standards, with most providers following the same approaches rather than having variation from provider to provider.

The degree to which the Mayo branches conform to these standards and this culture determines the degree to which they match the performance of the mothership. For example, Mayo Scottsdale -- which has become an "elephants' graveyard" with many experienced senior Rochester staff occupying leadership positions while choosing to spend the last decade or two of their careers there -- matches and sometimes even exceeds the efficiency of the main center, despite being located in what is otherwise a very high cost region.

Other branches have varying efficiency, but still perform more efficiently than other institutions in their areas. The rapid growth of the branches has taxed the ability of Mayo to keep its culture intact at the new clinics, since staff often has no history of connection with Mayo, but Mayo is striving to colonize the "Mayo way" at the new centers.

In the end, low cost centers, whether Mayo, Geisinger, Marshfield, Kaiser Bay Area and Kaiser Portland, Intermountain, or others, have one characteristic: they do more with less. They have a culture which is ammenable to the habit of following proven standards of practice and resisting less efficient approaches. The standards are sometimes written and explicit, and sometimes unwritten but ingrained, but they all result in better care that costs less.

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