Mayo Clinic leaders offer health reform vision, prescriptions

'Learning Organization' is key to patient-centered, affordable health system

ROCHESTER, Minn. -- In an essay published in the April issue of Mayo Clinic Proceedings, Mayo Clinic CEO Denis Cortese, M.D., and Chief Administrative Officer, Robert Smoldt, diagnose problems in American health care and offer prescriptions for reform, suggesting solutions based on the concept of a "Learning Organization."

The main problem with the U.S. health care system, the authors write, is it isn't a system. "Currently, a myriad of professionals and organizations provide health care, but no vision has ever been articulated for these disparate parts to function together and learn from each other," they write. "This paper describes a vision for all health care to function as a dynamic learning organizational system."

The core concept for the Mayo Clinic reform proposal comes from Peter Senge's book, The Fifth Discipline, in which he describes learning organizations as places "where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together."

The Mayo Clinic leaders are bringing forward their proposals because of their conviction that fundamental reform is required to ensure quality care in the future. "Health care as it exists in the United States today is not sustainable," says Dr. Cortese. "Health insurance premiums consistently increase faster than inflation or worker earnings, 46 million Americans lack insurance, and the percentage of employers offering health coverage dropped from 69 percent to 60 percent in the last five years. Nearly half of physician care is not based on best practices, and each year 98,000 Americans die from a medical error. And five years from now, when the first baby boomers qualify for Medicare, we will be on the cusp of a crisis if changes are not made."

Smoldt says if the goal is cost-effective, quality health care, then current financial incentives are seriously misdirected. "Medicare's payment model creates a built-in financial incentive for medical centers to provide more services, even though recent studies involving patients with chronic diseases show no evidence that doing more improves either medical outcomes or patient satisfaction," he explains.

"Reducing payment rates for office visits has led to shorter, more numerous and less effective appointments. And because their financial responsibility for patients ends when Medicare coverage begins, insurance companies do not have financial incentives to best help patients over a lifetime -- especially if the costly complications are unlikely to show up until age 65."

The authors say a new future for American health care begins with a common vision of a patient-centered learning organization that provides the best care at the right price, the first time. Key elements of a learning organization for health care include:

*Professionalism -- "Professionals in a learning organization," they write, " should expand their knowledge through perpetual education, pass on knowledge through teaching or mentoring, and add to the body of knowledge through basic, clinical or health sciences research."

*Systems Engineering -- Physicians need training in engineering principles and partnerships with engineers to improve the processes of care. Mayo Clinic has used systems engineering for 100 years, starting with Dr. Henry Plummer's development of the unified medical record for each patient, replacing the practice of each physician keeping separate notes. As another example, Virginia Mason has used Lean management principles to continuously improve and redesign processes to eliminate waste, requiring fewer staff members and less rework, resulting in better quality.

*Information Technology (IT) -- All helpful information about an individual's health care should be available to both physician and patient -- anywhere in the world -- within one second of pushing a computer key. Examples include medical and family histories; medication lists that automatically check for potentially dangerous drug interactions; test results and radiology images; best practices with links to the latest medical literature and disease management strategies for the patient's condition; the individual's unique genetic profile to individualize treatment; and clinical trials for which the patient may be eligible. Unfortunately, only 15 percent to 20 percent of U.S. physicians' offices and 20 percent to 25 percent of hospitals are using electronic medical records.

The authors suggest the learning organization vision for health care could be best achieved through a "consumer-driven, market-based model that delivers universal coverage to all Americans -- a model similar to the Federal Employee Health Benefits Plan (FEHBP) or the Universal Health Voucher Plan . Relying on market principles can help us achieve our vision for health care. But within this model, providers, patients, insurers and the government also must modify their roles."

"A market-based insurance model similar to the FEHBP, which functions well for government employees, would ensure fair, universal access to private insurance, with the government providing financial assistance to those who need help purchasing insurance," they write. "FEHBP is affordable, offers choice, covers drugs, has no state mandates and allows people the right to purchase more options. Employers would not be required to provide health insurance, but, in the interest of their business or employees, could choose to contribute to the cost.

Employees could use the employer payments to cover all or part of the cost for any insurance plan on the national menu. The federal government could coordinate these insurance offerings through an organization like the Office of Personnel Management, which currently runs the FEHBP at a relatively low administrative cost."

Smoldt says the FEHBP model would enable the government to focus its limited resources on those who need help, would preserve consumer choice by enabling patients to be more fully engaged as the purchaser and the customer, and would allow a dynamic private market more freedom to provide the innovation and increases in productivity that can contain health care costs. "It also would prevent people being excluded from coverage because of a pre-existing condition, because all of the insurance companies would be required to accept all patients during the open enrollment period," he says.

The authors stress that while they believe the principles they have outlined provide a strong foundation for a learning health system, "we also realize that others have creative ideas about how to transform health care in order to meet the needs of patients." Dr. Cortese says it is crucial that the discussion begins in earnest, and to that end Mayo is hosting the Mayo Clinic National Symposium on Health Care Reform, May 21-23, 2006, in Rochester, Minn. Details are available at www.healthpolicysymposium.org.

"In this essay we are presenting a vision and proposing a means to achieve it," Dr. Cortese concludes. "For true reform, and for a health system that is truly a system, we need a common vision that can only be developed through a national discussion. We look forward to being part of that discussion, and hope to facilitate moving from discussion to concrete action."

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A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 75 years and has a circulation of 130,000 nationally and internationally. Articles are available online at www.mayoclinicproceedings.com.

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