Executive Session: Globetrotting for ideas to transform U.S. healthcare Podcast Population Health Sign in to save David N. Gans MSHA, FACMPE, SENIOR FELLOW For many physician practice leaders, one of the first places they might turn to for best practices in operations often is the renowned Mayo Clinic. The unique ways in which Mayo has approached the shifting needs of care delivery for the past century and a half was recently the subject of a new documentary, “The Mayo Clinic: Faith – Hope – Science,” by esteemed documentary filmmaker Ken Burns. The film aptly opens with a quote from William James Mayo that underscores the impetus for the formation of medical groups in the early 20th century and the ongoing need for looking far and wide for ideas that will continue to improve healthcare: The sum total of medical knowledge is so great and wide-spreading that it would be futile for any one man to assume that he has a good working knowledge of any large part of the whole. The very necessities of the case are driving practitioners into cooperation. 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's no surprise that one of the longtime leaders of the Mayo Clinic, as a source of wisdom for others in the healthcare field, has affixed his attention to the world at large for concepts and modalities that could help improve care practices here in the United States. Robert K. Smoldt was chief administrative officer at Mayo Clinic before his retirement and subsequent move to Arizona State University, where he partners with former Mayo Clinic CEO Denis A. Cortese, MD, to direct the university’s Healthcare Delivery and Policy Program. Smoldt’s focus has primarily been with providers and the delivery of medical care, and the ASU program invites close to a dozen medical centers annually to share good work they are doing. With his impressive list of contacts, that group has expanded internationally. “We have worked with medical centers in the U.K., in the Netherlands, Singapore, Japan and a little bit in Switzerland and Australia,” Smoldt said. “We’re trying to learn the good things from wherever they are.” This is a continuation of a tradition established by the Mayo brothers – William and Charles Horace, respectively – in the early 1900s, traveling the globe by boat: “They went all over the world, they’d hear somebody is doing something good … and they brought it back and they did it. “We should learn from others,” Smoldt added. “We’re not perfect. We can always improve.” These global perspectives help us understand where the United States stands in the bigger picture of healthcare across the world. Case in point: The Netherlands has private providers, private insurance and an individual mandate, similar to the United States following the passage of the Affordable Care Act. The difference? The Netherlands has less than 0.2% of its population uninsured since it mandates universal coverage and instituted a large penalty that’s more than the annual cost of insurance to push individuals into coverage. Smoldt offers other key examples of successes seen internationally: The United Kingdom’s National Institute for Health and Care Excellence (NICE), which is operationally independent of the government, does something that would be considered somewhat controversial here in the United States: “They look at new modalities, and they try to see what are the years of quality-adjusted life gained from a new modality and how expensive it is,” Smoldt said. “So you can look at the cost per year of good living achieved, so it helps them figure out what should be covered and what shouldn’t.” Singapore has mandatory savings programs similar to U.S. Health Savings Accounts (HSAs) for health spending – including Singapore's MediSave and MediShield programs – that have been hailed by The World Bank for resulting in “low costs, excellent health outcomes and full consumer choice of providers and quality of care.” Of paramount importance here at home has been the issue of increasing cost while maintaining global leadership on research and development of new procedures and drugs. When asked if the United States is getting its money’s worth, Smoldt said to begin with the most expensive segment of our society’s healthcare spend: “20% of the population [represents] 80% of the cost,” he said. “So let’s go to the medical conditions that are the most expensive and then say, ‘These are the ones we’re going to address to pay for a value and evaluate how this is being done.’” Keeping the provider perspective at the forefront of such a discussion remains a crucial component, he added, recommending physician input on what patient outcomes would be measured and how to risk adjust them. “Let the people who are doing the work come up with the answers,” he said, then spend two years figuring out, by organization, which providers are getting good outcomes, the costs for the care delivered and then paying at the efficient quadrant. For a practice executive to micro-size this concept, it is not especially difficult. Smoldt, drawing from his time at the Mayo Clinic, believes any department can do this by generating reports on condition-specific outcomes and cost per patient. Once practice physicians gather an understanding of costs for days in hospital, medications and other considerations, this opens the door to establishing who your outlier physicians are and beginning the process of improving an individual doctor’s performance. As to the right combination of global best practices that could help improve the U.S. healthcare system, Smoldt pointed to the work of the late Odin Anderson, a renowned medical sociologist, as the proper lens to think about that question. Anderson’s conclusion was that a nation’s health system will reflect the kind of social values held by the people. “He didn’t think that a single-payer system would work here because the people of the United States love their individual freedom and they want choice,” Smoldt said. Anderson thought universal healthcare was the right direction to go, but that it should be achieved through the model of the Federal Employee Health Benefit plan. “It’s private insurance, you look at all these options you have, and you pick one, and the government pays part of it and you pay part,” Smoldt said. “There isn’t any one right answer,” he noted.