Systems Thinking and the Minnesota Medical Model: Or, It Takes 10,000 Practicing Physicians to Tango

Key Words – system thinking, multispecialty groups, hospital systems, electronic records, protocols, evidence-based care, outcome based-care

Summary of interview with Kent Bottles, MD, President of Institute of Clinical Improvement, St, Paul, Minnesota

Preface: I practiced in Minnesota for 25 years and served as editor-chief of Minnesota Medicine fo 15 years. During these years, the penchant of Minnesota physicians to congregate in multispecialty groups and in large hospital based systems always impressed me. The average sized medical group, at least those salaried or functioning under the umbrella of a parent organization, is over 150 physicians. These organizations, and their physicians, tend to pride themselves on their discipline, and their ability to learn, to act together and to improve care.
Here are excerpts of an interview with Kent Bottles, MD, President of Institute of Clinical Improvement (ICSI). Kent has been president of the Institute of Clinical Improvement, in St. Paul, Minnesota for two years. The complete interview will appear in www.modernmedice. com.
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"Q: What does the Institute of Clinical Improvement do, and how long has it existed?"

"A: Health Partners, the Mayo Clinic, and Park Nicolette founded ICSI in 1993. It started out as an evidence-based medicine shop to provide physicians with scientifically-valid guidelines. That didn’t totally transform medicine, so ICSI got more involved. So then it began helping doctors and hospitals redesign in how they do work, using Six Sigma, Planned Do Study Act, and Lean. Most recently, we’ve become engaged in payment reform and health care reform. Basically we’re a collaborative of hospitals and physicians, for-profit health plans, and employers in the upper Midwest. We seek to decrease per capita costs and increase quality."

"Q: Has ICSI transformed the culture in some way in its 17 years of existence?"

"A: What ICSI has done is that you created a safe place to bring in different constituents – government, health plan physicians, patients, employers, primary care physicians, and specialists. Most health system problems are difficult because there are no simple answers, but somehow if you can aggregate the wisdom of the crowds of all those people, you can do exciting things."

"We’ve got a Diamond program for treating depression in primary care that uses case managers and liaison psychiatrists in which all health plans pay for this new way of delivering care. We’ve achieved tremendous clinical outcomes."

"We also have a high-tech diagnostic imaging program with has replaced pre-authorization for CT and MRI scans with embedded decision support in the EMR that allows the doctor and patient to discuss the imaging procedure that’s about to be performed. This has eliminated the need for prior authorization because people agree about what’s to be done."

"By convening all the parties and having everybody understand each person’s point of view, we’ve solved tough problems you couldn’t solve on your own."

"Q: The use of imaging has increased in recent years about 15% to 17% annually for the Medicare population. Has the ICSI approach cut the growth rate?"

"A: Absolutely. It has decreased costs about $60 million a year and reduced unnecessary radiation. Because of our positive results, we’ve been called back to Washington to brief the Medicare folks and Senators about our success."

"Q: How has ICSI changed the conditions for independent doctors on the ground? Minnesota is now in an advanced state of consolidation, with most doctors either belonged to large groups or working as salaried employees of hospitals."

"A: There still are independent doctors in Minnesota, but the trend has been toward consolidation and integration. One of the things ICSI has done has been to allow smaller groups to have a voice into how we implement baskets of care or medical homes. We have on our board the administrator of a 7 person family practice."

"Q; I now live in Connecticut, where the average sized group is 4 while in Minnesota the typical group is now 100 or more. That difference changes the dynamics in how doctors practice."

"A: Absolutely. The pressure towards large groups are incentives to get electronic medical records, to participate in pay-for-performance, and to deal with all this money coming out of the Office of the National Coordinator. These pressures are why more doctors are joining multispecialty groups or becoming employed by hospitals."