Monday, March 17, 2008

Mayo Clinic -A Slightly Longer Take on Mayo Clinic’s Six Principles

At a recent meeting in Washington, D.C, the Mayo Clinic announced six principles on national health reform. Mayo arrived at these principles after a systematic year long process. It started with a national forum at Mayo, and a series of regional meeting sounding out the physician community and ended in the nation’s capitol.

The principles are,

• America spends enough on health care.

• Everybody should be required to buy insurance.

• Employers should contribute.

• Government should step in for those who can’t afford to pay.

• Electronic records will be required to better coordinate care.

• Medicare should reform its payment system by paying more for good outcomes and less for bad outcomes.


Mayo’s fundamental principles Mayo deserve further comment. I go back about 25 years with Mayo. I respect Mayo immensely. Over the years, I have interviewed their physician chief executive officers. Last year I wrote a chapter in Innovation-Driven Health Care (Jones and Bartlett, 2007) entitled “The Mayo Clinic Innovates the Mayo Way: Leaving Nothing to Chance.”

Mayo approaches what they do methodically, purposefully, and as a unit. Consensus is the order of the day.Their principles command attention. Hundred years ago Mayo pioneered patient-centered, team-oriented, group practice; over the last 30 years or so have consistently delivered care at 20% to 22% below the health care market at large over the last several decades, and over the last two decades U.S. News and World Report surveys of physicians, regularly ranks Mayo either #1 or #2, with Hopkins, as the top medical institution in multiple specialty categories. Mayo’s opinion are not to be ignored.

Now let’s examine the principles one by one.

1. America already spends enough on health care.

This may be. We spend 40% more than either other nation, about 17% of our GDP, while no other country expends more than 12%. I’m deeply suspicious of national ratings, both on money and health outcome ratings. I don’t know how the statistics are gathered, and those entities that collect them, for example the World Health Organization, has a political ax to grind. National cultures and life style differ profoundly. And, being the biggest immigrant nation, our government has less control over social mores. But we certainly have waste and duplication, which be the price of choice and freedom, our expendable incomes, our individualism, and our capitalistic system. Still, Mayo, through its discipline and execution of its group practice model, its emphasis on ambulatory care, its narrowing of income differences between specialists and generaliss, and its innovative systems, has much to teach us.

2. Everybody should be required to buy insurance.

As Massachusetts with its universal coverage model is quickly learning, this is easier said than done. Here Mayo focuses on individual responsibility rather than individual mandates. But for many of the 47 million uninsured Americans, who can afford care but choose not to cough up premium dollars because they prefer to spend money on other things, this may be a tough sell. It is also costly to enforce an individual mandate, particularly among the young, who may regard obligatory payment of premiums, as stacking the deck against the young and healthy to pay for the old and sick. Tracking down non-payers or even getting eligible Medicaid recipients to enroll can be a logistical nightmare. Also, come November, roughly 90% of Americans will be insured, and they may not regard paying federal taxes to support the uninsured as being in their best interests. I do not wish to rain on Mayo’s parade, or to say requiring everyone to buy insurance is not noble or not the right thing to do. It is, but it will cost $110 billion the first year, and that’s just for starters.

3. Employers should contribute.

This is realistic in that it retains our current 60 year old employer-based system, which may prove difficult to dismantle since many employers regard their health plans as potent recruiting tools. The other side, of course, is that health costs make U.S. employers globally non-competitive. It is worth noting that many Republicans favor jettisoning the employer-based system and replacing it with universal tax credits and health care cost deductibility.

4. Government should step in for those who can’t afford to pay.

This is an unarguable point, which everybody agrees upon. With Medicare and Medicaid covering 100 million Americans, government already expends nearly half of all health costs.

5. Electronic records will be required to coordinate care.

No argument here either. But it will be slow sledding. Only 10% to 20% of hospitals and doctors have electronic systems now, and most electronic record systems don’t speak to each other. The personal health rccord is in its infancy, with less than 5% of patients having PHRs. It may be more patients with PHRs will demand doctors have EHRs, and consumer pressures will force doctors to enter the electronic revolution. I am dubious about the pace and practicality of universal coordination via electronic communication. The electronic Holy Grail looks frail at this point. In my opinion, a national health care central nervous system linking all people and all health care entities will require a massive federal subsidization program akin to the 1946 Hill-Burton Act for building hospitals.

6. Medicare should reform its payment system by giving more money for good outcomes and less money for bad outcomes.

This, of course, is the premise under girding the multiple pay-for-performance experiments and programs going on around the country, being pushed by Medicare, Medicaid, and private health plans. I am not all sure P4P will save money or evenly modestly improve care for these reasons;

a) P4P programs to date have shown only modest return on investment in terms of dollars saved or outcomes improved;

b) the administrative burdens and data infrastructure required is expensive and generally exceeds the bonuses given to hospitals and doctors;

c) outcomes depend mostly on lifestyle factors, which are largely outside the reach of doctors, hospitals, and government.

When I think of outcomes, that famous pie-chart showing the percentage impact of various factors influencing health springs to mind: 10% medical care, 20% environment, 20% genetics and DNA, and 50% life-style.

In all of these comments, I may a little too pessimistic about Mayo’s proposals, all of which are noble, and no doubt might work if we had a series of regional Mayo clinics, or their equivalents, dotting the landscape. Another problem, and a big one, is our fee-for-service, which rewards hospitals and doctors for tasks-done rather than for consultations, collaboration, costs-saved, complications-avoided, coordination, or, consensus on what needed to be done. Perhaps consumer-driven care, with consumers gravitating to high-performing physicians, hospitals, or integrated institutions, will solve some of the cost problems.

But as things stand now, Medicare is a big part of the problem, with its 140,000 pages of regulations, its ponderous bureaucracy, its reliance on a fee-for-service systems, its lack of blended payment system rewarding coordination, consultation, and good old fashioned advce, and the very fact that it is the Sheriff of the System, whose marching orders the private system passively follows. Medicare does not reward efficiency or performance, which is one reason Mayo seeks reform. Medicare’s payment system puts downward pressure on Mayo’s $6 billion budget

Concluding Remarks

I conclude this discursive little essay by recalling the words of Oliver Cromwell (1599-1658) to his executioners before he was beheaded,” I beseech you, in the bowels of Christ, think it is possible you may be mistaken.” Mayo is probably mostly right in its ideas about reform, and I are probably mostly wrong. As a widely respected physician-led organization, Mayo has been right too many times in the past. If by some chance, some future historian reads this remarks, it will be said of Mayo, “Right on!” And of my Late Self, “Wrong gone!”

1 comment:

Dr. Val said...

Then I guess I'll be wrong with you. I like your take, and I used to work at Mayo and respect them immensely.

Thought I might see you at the Castle Connolly Physician of the Year awards... alas, it was not to be. :)