Saturday, August 1, 2009

The Mayo Clinic: A Model for Appropriate Care But Can It Survive As Such?

I believe that a recent Time Magazine article (June 29, 2009) written by Michael Grunwald about health care conveys some truths about our health care system. Mr. Grunwald cites the Mayo Clinic as an example of how very high quality medicine can be delivered at a fraction of the costs compared to other referral centers. I agree with his assessment. Quoting from the article, “Last year, Mayo lost $840 million on $1.7 billion in Medicare work. It compensated by charging private insurers a premium for the Mayo name, but they’re starting to balk. ‘The system pays more money for worse care,’ says Mayo CEO Denis Cortese’. ‘If it doesn’t start paying for value instead of volume, it will destroy the culture of the organizations with the best care. We might have to start doing more procedures just to stay in business’”.

There are some real insights conveyed in these few sentences. One, medicine is primarily the art of using available knowledge and science applied individually to each patient. Every patient is unique with individual characteristics and needs. A thoughtful physician must take into consideration many factors in suggesting the proper therapy for each patient. This kind of medicine is presently practiced at the Mayo Clinic without the additional billions of dollars touted as the cure-all by our political leaders and various pundits. If a physician cannot think conceptually about patients taking into consideration the entire clinical picture all the billions spent on comparative research will not be of value and will not help. Obviously at this time The Mayo Clinic does not need this additional research.

The second point, just imagine losing $840 million on $1.7 billion in Medicare activity and feeling the need to become another procedure mill to stay afloat. Why is it that the Medicare payment system, a government program, financially punishes the good players and rewards the bad? And would not the number one business of government in the Medicare program be to develop a system of care delivery that emphasizes patient by patient decision making (see appropriate care committees) to replicate the present Mayo model? The answer I believe is that our leaders in Washington look at problems globally and not as the accumulation of millions of individual events. Governments need to count widgets to justify payment and do not know how to account for the intangibles like thinking, individuality and human trust. The result is an overabundance of quantifiable widgets at great excess costs and a diminution of value in thinking, communication and personnel satisfaction.

Although during the present discussion about health care reform one hears about paying for outcomes, we hear more about Medicare cuts in reimbursement to hospitals and physicians. But, these proposed cuts are global and not based on the individual needs of each patient. This is especially unfortunate because if we could inject the wisdom displayed by the Mayo Clinic into all of our health care there would be more than enough resources to provide universal coverage. And this would be accomplished at a decreased percentage of gross domestic product devoted to health care rather than the increases intrinsic to the present proposals.


Michael Kirsch, M.D. said...

Medical excess is rampant in the medical community, particularly in the emergency room, as detailed in current posting at
As a physician, I am sure that I am contributing to this culture of excess. This will be very hard to break as there are so many forces that converge to fuel the cycle of unnecessary medical care. There are financial conflicts, patient demands, defensive medicine and reflexive medicine without much thought. Comparative effectiveness research would target this, but I'm not sure this effort will get airborne.

Kenneth A. Fisher, M.D. said...

Dr. Kirsch,
Thank you for your comment.I am more skeptical about comparative effectiveness research than you. As physicians we will still have to apply the literature within the conceptual framework of each of our patients, every one being unique. Besides we as a profession should insist on newer therapies having to prove themselves better than existing ones before they become generally available. Then retrospective comparative effective research would not be necessary. I would be interested in your thoughts about my appropriate care committee system to address the multiple factors you have mentioned that do impinge on physician behavior.

Michael Kirsch, M.D. said...

The oversight committee system you propose is problematic, in my view. You are correct that physicians, already having been stripped of much of their control over their own profession, will reject ceding oversight to an overseeing board. In addition, a board doesn't change physicians' instincts, it only issues and enforces regulations. It does not target the fundamental flaw of why we physicians pursue medical excess. Rather than further shackle the profession, I would opt to reeducate us, realizing this is no easy task. Medical training programs would have to adopt this mission. Reimbursement strategies might be adopted that could help to drive this system forward. Finally, the public needs to have some 'skin in the game' so they can question physicians more closely as to whether the proposed test or treatment is truly essential.