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October 21, 2008

What Makes the Mayo Clinic Different?

Maggie Mahar

After working at the Mayo Clinic in Rochester, Minnesota for nine years, Dr. Marc Patterson decided to change his life. In 2001, he moved to New York City to take a job as chief of pediatric neurology at New York-Presbyterian Hospital (NYPH).

This year, Patterson returned to the Big House on the Prairie. "Sometimes I miss New York,” he acknowledges, “but working in a system that actually functions is worth it."

Let me be clear: Patterson has many good things to say about NYPH and Columbia University Medical Center, the uptown campus where the worked.  “I had a great experience, and fabulous colleagues,” Patterson told me. “Moreover, one of the reasons I moved back to Minnesota is because my family is there.”

Nevertheless, Patterson says: “There is a fundamental systemic difference between Columbia and the Mayo Clinic: Columbia is a traditional academic medical center;  [research] that came through the med school provided the money to pay us.  The hospital is a separate entity.  By contrast, at Mayo, the hospital and the medical school are one. It’s an integrated organization.”

What difference does that make?


Patients Trump Research

“At Mayo the focus is on the patient. The needs of the patient come first.  I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine.  But research is not the primary focus.

“At most academic medical centers,” he continues, “medical research comes first; education of the students comes second. Clinical practice [caring for patients in the hospital and clinics] is not the priority.”

This isn’t to say that doctors at Columbia don’t strive to give patients the very best care possible. I am a long-time New Yorker, and if I were going to be hospitalized in Manhattan, I might well choose Columbia.

But, at Columbia, “while being an excellent clinician is great, it’s just not as highly regarded as being a brilliant researcher,” Patterson explains. “Here at Mayo, being a superb clinician is the sine qua none—if you’re not able to practice at the highest level, you won’t succeed here.

I have heard the same story from other doctors at some of the nation’s top academic medical centers.  If you want the money and the glory, you focus on research. You won’t become a star by being the best clinician, or even by being a top professor.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary?  During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years,"  says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.)

“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally. This is very good for collegiality, and people working together,” he adds. “The culture here at Mayo doesn’t encourage egos. There is not the same cult of personality that you find at other places.”

At Columbia, by contrast, the pecking order is quite clear: even the furniture on the floor where a physician works tells him where he stands.  “The floor we were on was perfectly fine,” Patterson recalls. “But if you walked up a few flights to ENT (ear nose and throat) surgery, it was a different world—dark wood paneling, different furniture… These surgeons bring in a much higher return for their time,” he points out, “and they do some things that require remarkable skill and training. At the same time, if a psychiatrist spends two hours with a patient, he may get $200, while all a dermatologist needs to do is get out the liquid nitrogen…”

The dermatologist can make $200 in a matter of minutes, just by zapping the harmless crusty brown patches on the back of  a middle-aged patient commonly known as “barnacles of age.”

That celebrity turns on how much money a doctor brings in hardly unique to Columbia. “Traditional medical centers are much more hierarchical,” Patterson notes.

Mayo is the outlier. Its culture is unusual because it is based on “the very egalitarian ethic of the people who established the place,” says Patterson, “and the fact that we’re in Minnesota”—a state with a longtime egalitarian tradition. As a result, “people have the opportunity to develop skills in whatever they want to do. Our nurses are superb at doing spinal taps, and they teach our residents.”

“We are starting to make better use of nurse and nurse practitioners are being integrated into the teams,” he adds. “We also have a lot of physician assistants here—and they are extraordinary people. 

“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back.  You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it. 

At the same time, in fairness I should report that the HealthBeat reader who introduced me to Patterson was an extremely successful physician at Mayo for many years, and ultimately decided to leave. The Mayo Clinic is not Nirvana for all fine physicians.

Yet I believe that there is much that health care reformers can learn by studying how Mayo operates. This is not to suggest that we should aim to replicate the model coast to coast, putting golden arches over every new clinic. There is, after all, a difference between healthcare and hamburgers.  Healthcare is not a commodity,

A “Firewall” between the Money and the Doctors

Still, there are differences in the way Mayo is organized that are worth pondering. For instance, there are no “rainmakers” at Mayo, Patterson explains, because “there is a firewall between the physicians and the money.  I don’t even know how much Mayo is paid for different things that I do. I know the billing code, but that’s all. The business office takes care of all of that.

“I also don’t know which patients are uninsured—and whether Mayo will have to absorb much of the cost of their care.”

Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors  in dispensing care.  Quite the opposite:  Extensive analysis of Medicare records done by researchers at Dartmouth University reveals that treatment at the Mayo Clinic in Rochester, Minnesota costs Medicare far less than when very similar patients are treated at other prestigious medical centers.

The chart below, from the “Executive Summary” of the 2008 Dartmouth Atlas is an eye-opener. It shows that when researchers compared how much Medicare spent  per patient, on very similar chronically ill patients during the final two years of life at five top medical centers (UCLA, Johns Hopkins, Massachusetts General, the Cleveland Clinic and Mayo’s St. Mary’s hospital),  the tab taxpayers paid varied widely,

While Medicare spent more than $93,000 per patient on those who were treated at UCLA Medical Center, patients at Mayo cost the government only half as much. As the bottom two-thirds of the chart shows, this is because, when compared to patients at other medical centers, those at Mayo spent fewer days in the hospital, saw fewer physicians and were less likely to wind up in the ICU.

Mayospending

Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA.

As HealthBeat has pointed out in the past, when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to organize in New York,” says Patterson.  This is because Mayo is an integrated medical center.

For example, “In New York, each division has its own staff to make appointments.  If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”

Patterson still remembers “the frustrations of the system in New York…It took a lot of time to get things done. If you wanted something accelerated, we essentially had a trade and barter system—you would call in favors. We were always reinventing the wheel, rather than having a system in place.”

It didn’t help that the uptown campus and the downtown campus of New York/Presbyterian Hospital have different electronic medical record systems, “and neither of them is user-friendly,” Patterson recalls, sounding, just for a moment, a little glum. 

How could one hospital have two EMR systems that don’t talk to each other? “When New York Hospital and Presbyterian Hospital merged in 1997 to form NYPH they had different systems,” he explains. Like many large medical centers, NYPH is now making major investments in pilot programs to move information out of “silos” and to “enable easier access to critical clinical information.” But as this 2008 NYPH presentation observes the project will take not only money, but “time” and “culture change.”

Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson.  “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.) 

“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”

Patients, Like Doctor, are Equal –and Many Need Charity Care

Some say that Mayo operates in a bubble that separates it from the real world. Their may be some truth to this. Certainly, Mayo has created a very special culture.

But the assertion that Mayo is “different” because the vast majority of its patients are very wealthy and thus easier to treat than the patients at most academic medical centers just isn’t true.   

The Mayo Clinic in Minnesota sees many local patients.  “And like New York, we have minorities—just different minorities,” Patterson explains. “At Columbia, I saw many Dominican patients who lived close to the hospital in Washington Heights” (a low-income neighborhood that is beginning to attract middle-class New Yorkers).

“At Mayo, we have Spanish speaking migrant workers” Patterson explains. (In the 1990s the number of foreign-born Latinos in Minnesota shot up from 9,200 to more than 62,000).

Surprisingly, Minnesota also is home to many refugees from Africa. Somalis began flowing into the state from refugee camps in the 1990s, in part because several well-organized faith-based Minnesota groups made them welcome, and in part because the economy was strong and jobs for immigrants who didn’t speak English were available.  Today an estimated 30,000 Somalis reside in the state. “And they are not well off,” says Patterson, comparing them to the poor patients he saw in New York.

Minnesota has a history of active volunteerism regarding immigration and refugee resettlement, which helps explain why its foreign-born population more than doubled during the 1990s—from 110,000 to 240,000. 

The immigrants include some 60,000 Hmong, an ethnic group that fled mountainous regions in Southeast Asia. Most of those who settled in Minnesota come from Laos. Some readers may recognize the Hmong from Anne Fadiman’s brilliant book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. From his years at the Mayo Clinic, Patterson is familiar with the cultural divide which make the Hmong difficult patients for many Western doctors. “They believe in supernatural forces,” he explains. Nevertheless Mayo treats them—and regularly advertises for Hmong interpreters.

Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”

That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.

Although its $1.6 billion endowment gives Mayo a stable base, it is not awash in money. In 2007 it operated on a relatively slim margin of 2.9 percent; that year revenues grew by 9.6 while expenses rose by 8.5 percent, “due in part to Mayo investments in patient care and research activities, as well as information technology infrastructure,” the annual report explains.

When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”

At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson.  “At Columbia, we had private offices and a Medicaid clinic, I tried to give people 90 minutes, but in the clinic, it was hard to do that.”

Those who suggest that Mayo operates in a separate world often assume that it can afford to be so magnanimous when caring for indigent patients because so many of its beds are filled with Saudi Sheiks. Patterson acknowledges that “at Mayo, we do see a number of quite wealthy people—but that was true in New York too.” Indeed, high-income patients typically flock to prestigious medical centers like Johns Hopkins, UCLA, Mass General and New York-Presbyterian. 

So when officials at a medical center like UCLA try to argue that Medicare’s bill are higher when patients are treated in L.A. because the hospital is treating a different “population” of patients suffering from and “more complex” and “more severe illnesses,”  this doesn’t quite ring true. Certainly, it is hard to believe that the difference is large enough to explain bills that are 80 percent higher.

As Dartmouth’s Dr. Elliott S. Fisher, a co-author of the study comparing Medicare spending at five academic medical centers, points out:  “We are comparing patients with identical outcomes — all were dead in two years. So it’s unlikely that differences in the severity of illness account for the variations we saw.”

It also is  important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.

“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.”  So Medicare spends more at UCLA—and some patients are over-treated. 

But Not All Mayo Clinics Are Created Equal

Mayo offers lessons for reformers. Still, it’s not easy to replicate the success Mayo enjoys in Minnesota.  Not even Mayo can do it.

Over the years, the Mayo Foundation system has grown beyond its original Rochester, Minnesota site, establishing group practices in Phoenix, Arizona; Jacksonville, Florida; Eau Claire and La Crosse, Wisconsin as well as in several other communities in Minnesota and Iowa.  But when Dartmouth’s researchers examined how these spin-offs use their resources, they found “surprising” variations.

“Indeed,” the report observes, “the spectrum of approaches to caring for patients with severe chronic illness ranges from a low resource input, low-intensity end-of- life pattern favoring primary care to high resource input, high-intensity end-of-life care relying on medical specialists. In short, we find no evidence that providers in these systems use a distinctly Mayo Clinic strategy for allocating resources and managing chronic illness.”

It is worth noting, however, that at the four Mayo practices that Dartmouth’s researchers studied, the quality of care turned out to be either “very high” (LaCrosse and Phoenix) or “above the national average” (Jacksonville and Eau Claire.)

The variation suggests that it may not be the Mayo “system” that lifts Mayo’s flagship Minnesota hospital above the tide. Rather, some observers suggest, it may be the highly egalitarians and collaborative “culture,” which puts patients ahead of everything and everyone else, that makes the Mayo Clinic in Rochester, Minnesota  so special.

These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the first examples of group practice in the United States. As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other:  “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.

More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.

Nevertheless, the 2008 Dartmouth Atlas does provide sufficient data to support the thesis that integrated delivery systems are likely to provide the most efficient high-quality care. And the report makes it clear that Mayo is not the only integrated system that stands as a benchmark for excellent collaborative care. Both Intermountain Healthcare (IHC) in Utah and the Sutter system hospitals in Sacramento are singled out for praise. 

So the structure of the system is important. But so is the soul. On that point, I would argue that we should pay attention to the “firewall” between the doctors and the money at Mayo. Ideally, in any medical center, the money and the businesspeople should be on one side of that wall; the doctors and the patients on the other side.  Clearly, someone has to make sure that the hospital can stay afloat financially.  But too often, money gets in the way of medicine. 

In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?

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Comments

Christopher M Hughes, MD

Terrific piece. I've linked to it at my blog:
http://cmhmd.blogspot.com

Withheld for obvious reasons

Unless you happen to be an employee and aren't bringing in any 'new' money to the Mayo.

pedriatric ENT

Glad to hear that both patients and physicians are happy.

-Kaylee

Mike Smith

In May of '09, my wife (age 62/second grade teacher) was discovered to have a Glioblastoma Multiforme malignant brain tumor.

Dr. Ian Parney removed 90+ percent of the tumor when other hospitals wouldn't consider surgery, and today Dec 24, '09, we're celebrating Christmas at our home with our family.

While she's certainly not out of the woods with this horrible cancer, at least she's still hear.

Without Dr. Parney and Mayo, I'd be going to one of my kid's homes for Christmas, alone.

When they say Mayo is "special", it's that way because of the staff....from the highest of the high to the least paid. Not one duplicate test, not one harsh word, not one late appt.

And now, Obama and his cronies are going to ruin places like this. With Obama care, my wife would most likely now be dead because she would not have been allowed to see a neuro for at least three months.

Thanks Mayo, for all you do.

And for the "employee" above bitching about the money...go elsewhere. I'm sure Mayo would love to have your ass out the door, you whiny little *****.

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