The Mayo Clinic Vision: Radiology’s Role in Care Delivery
Integrated health care delivery systems such as that pioneered by the Mayo Clinic, Rochester, Minnesota, have been heralded for their low-cost, high-quality care and greater efficiency. With all eyes on potential new models for health care delivery—particularly in the imaging field, where skyrocketing costs and questions about appropriate utilization have created a climate ripe for additional cuts to reimbursement—ImagingBiz.com speaks with Glenn Forbes, MD, a radiologist at Mayo and former CEO of the Rochester clinic, on radiology’s role in the health system of the future. 
Glenn Forbes, MD ImagingBiz: Why has integrated delivery caught on in some markets, but not in others? What are the obstacles to this health care delivery model? Forbes: Integrated delivery systems have caught the attention of a large segment of those discussing health care reform for a number of reasons. Some very demonstrable goals are being achieved in terms of outcome, delivery, and affordability, so people are wondering, what’s different about integrated delivery, and is that a template we should emulate? There are already many integrated delivery systems around the country. Some are large; others are smaller. At Mayo, we have worked on this model for over a century and have a lot of experience with it. Why does it seem to work in some areas and not others? It takes a certain level of commitment to fundamental values and principles. The first is focusing on the needs of the patient. Everybody has to get together and make a fundamental commitment to service. The second principle is working collaboratively as a team toward that end. It’s not about what’s best for myself or my particular area—it’s subjugating all that. This is nothing unique that can’t be achieved, but historically, a lot of our delivery of medicine in the United States is very fragmented. We’ve got hospitals on one side of the street, we’ve got physicians on the other side; there are specialists in one building and primary care physicians in another. That fragmentation has put us where we are, and bringing that all together in one system requires that first fundamental commitment to values and principles. You have to build a culture around that, embedding it in your governance and policy, and frankly, that takes time. There are also a few obstacles: The pieces of health care service are embedded in a conventional model, and that’s hard to overcome. If you’re a hospital and own all your hospital operations, to start suddenly collaborating with a physician practice is very difficult. It takes time and a lot of effort, so part of the impediment is leaving the model we have now and transitioning into another. Another point I’d make is that as we go through this social reengineering process of national health care reform, we have to change how we resource and pay for care. We believe here that payment reform is as critical as delivery reform as we change national health care. We need our incentives for payment aligned in the right way. If those incentives don’t drive a team approach, then that itself is an impediment. Part of it is the model and part is the structure of our payment. Both need to be changed to an interdisciplinary approach. ImagingBiz: What is it about integrated delivery that promotes the efficient delivery of high-quality care? Forbes: This goes back to one of the fundamental issues: focusing on the needs of the patient. If we’re making that the fundamental premise of an integrated delivery system, then how do we define quality? Patients want a good outcome and a safe outcome, and obviously, they want accessibility in terms of service and affordability. That has to supersede some of our individual interests as clinicians. An interdisciplinary model, bringing different specialties together to work collaboratively, allows your institution to operationalize a lot of common processes better, aligning your incentives in a way you might not be able to do if you’re not integrated. An example of that: If a man comes in with leg pain, the first question shouldn’t be who has his or her hands on the ultrasound transducer. The patient has leg pain and wants to be helped. On the delivery side, we’re thinking, “Is this a neurologic problem? Is this a vascular problem? Is this a muscular problem? Who’s the best person to assess that?” Let’s say that you figure out it’s a vascular problem. What do you need to do to increase the blood flow? Radiology plays a strong role in diagnosis, as well as treatment; cardiology plays a role; vascular surgery plays a role. The patient is assuming that we’ll figure out what he needs and what’s best for him. The patient isn’t in a good position to tell us what to do, so we have to bring together everyone who has a skill set in this area to manage the patient’s needs. Maybe we’ve taken care of his leg, but now he needs physical therapy; maybe he needs help paying for it. My point on all this is that the more you can bring all these different issues together to focus on the various needs of the patient, the more you can bring in a common approach and not get discombobulated. Integrated delivery allows you to focus on the needs of the patient, to manage the common processes better, and to standardize the different approaches you have to measure quality and bring its elements together. ImagingBiz: The Mayo model calls for employment of physicians. When and why was that implemented, and what role does this play in Mayo’s high-quality, low-cost health care delivery model? Forbes: Employment is not a word that we really use in our culture. All of us are employed, but we don’t think of it that way. On the other hand, if you asked me whether I feel that the Mayo Clinic is part of me, I would say yes. There’s a strong sense of ownership, but not in a business sense. We moved into this model around the turn of the past century, when our founders, two surgeons working with their dad, were joined by some partners from other areas. They decided to pool their resources, including their work with hospitals and clinics, and everyone would work as one group to serve the needs of the patient. All of the physicians here are very much engaged in a real sense of ownership and participation, in leadership—in what I would call real decision making. The profession is very engaged in the decision making and strategizing of the organization, so we have a sense of ownership in the execution. All of our physicians are salaried, which removes financial incentives from the commitment of the physician toward the service of the organization. People ask me what a radiologist makes at the Mayo Clinic, and I’ll tell you what the answer is: The right answer is that the physician makes the right amount of money so that he or she responds, “Gee, I’m not sure. I don’t really think about it.” We don’t want money to be a driver. When I’m thinking about what excites me as a radiologist, I’m thinking about how can I serve the patient, my love of the science, and my commitment to our mission. That’s how we think about these kinds of things. ImagingBiz: With the availability of federal stimulus funds for improved health IT connectivity, how should health systems leverage these funds to further their goals? Forbes: This is a key element. Health IT is a fundamental building block in fostering an interdisciplinary approach. One of our early founders formed, for us, the first integrated medical record, over 100 years ago. At the turn of the century, people would take their reports home and stuff them into desk drawers. He suggested that the medical record be owned by Mayo; if there was a laboratory interest or an observation, they started putting it in one common record. Everyone in the country yawns now, but that was a new idea back then. The technology has now moved us into the digital information age, so electronic medical records that standardize all the input are available to anyone who touches that patient, and they are supported by robust infrastructure. ImagingBiz: Many payors are attempting to rein in the cost of high-tech imaging by implementing preauthorization programs that add significant costs to the hospital’s administration of these services. How should the field handle the issue of preauthorization? Forbes: I am troubled about the current state of preauthorization. I think it negates everything I was just saying. The best way to approach the appropriate utilization of imaging is for the experts in imaging really to be involved in the care of the patient—but not for themselves; for the needs of the patient. The important thing is to ask is, “What is the right exam to do here, what is the right way to do it, and how can I do it as appropriately as possible?” To do that, radiologists need to be consultants working as part of an interdisciplinary team. That’s a difficult step, but it’s incumbent on us, as radiologists, to step forward to be stewards for imaging. Speaking as a radiologist, I think the integration of imaging is a fundamental step toward the new models and paradigms in health care. I am very energized to encourage my radiology colleagues to play a leading role in this. Imaging is a heavy resource user. Everyone knows what an MRI costs, and it’s incumbent upon us, as radiologists, to determine the best way to use this technology for the patient. It’s absolutely critical. Working as consultants, we don’t want just to give an answer on an exam; we also need to participate in and guide the use of that technology for the better service of the patient. Radiology can and should play a large role in how our health systems deliver care.Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.
Glenn Forbes, MD ImagingBiz: Why has integrated delivery caught on in some markets, but not in others? What are the obstacles to this health care delivery model? Forbes: Integrated delivery systems have caught the attention of a large segment of those discussing health care reform for a number of reasons. Some very demonstrable goals are being achieved in terms of outcome, delivery, and affordability, so people are wondering, what’s different about integrated delivery, and is that a template we should emulate? There are already many integrated delivery systems around the country. Some are large; others are smaller. At Mayo, we have worked on this model for over a century and have a lot of experience with it. Why does it seem to work in some areas and not others? It takes a certain level of commitment to fundamental values and principles. The first is focusing on the needs of the patient. Everybody has to get together and make a fundamental commitment to service. The second principle is working collaboratively as a team toward that end. It’s not about what’s best for myself or my particular area—it’s subjugating all that. This is nothing unique that can’t be achieved, but historically, a lot of our delivery of medicine in the United States is very fragmented. We’ve got hospitals on one side of the street, we’ve got physicians on the other side; there are specialists in one building and primary care physicians in another. That fragmentation has put us where we are, and bringing that all together in one system requires that first fundamental commitment to values and principles. You have to build a culture around that, embedding it in your governance and policy, and frankly, that takes time. There are also a few obstacles: The pieces of health care service are embedded in a conventional model, and that’s hard to overcome. If you’re a hospital and own all your hospital operations, to start suddenly collaborating with a physician practice is very difficult. It takes time and a lot of effort, so part of the impediment is leaving the model we have now and transitioning into another. Another point I’d make is that as we go through this social reengineering process of national health care reform, we have to change how we resource and pay for care. We believe here that payment reform is as critical as delivery reform as we change national health care. We need our incentives for payment aligned in the right way. If those incentives don’t drive a team approach, then that itself is an impediment. Part of it is the model and part is the structure of our payment. Both need to be changed to an interdisciplinary approach. ImagingBiz: What is it about integrated delivery that promotes the efficient delivery of high-quality care? Forbes: This goes back to one of the fundamental issues: focusing on the needs of the patient. If we’re making that the fundamental premise of an integrated delivery system, then how do we define quality? Patients want a good outcome and a safe outcome, and obviously, they want accessibility in terms of service and affordability. That has to supersede some of our individual interests as clinicians. An interdisciplinary model, bringing different specialties together to work collaboratively, allows your institution to operationalize a lot of common processes better, aligning your incentives in a way you might not be able to do if you’re not integrated. An example of that: If a man comes in with leg pain, the first question shouldn’t be who has his or her hands on the ultrasound transducer. The patient has leg pain and wants to be helped. On the delivery side, we’re thinking, “Is this a neurologic problem? Is this a vascular problem? Is this a muscular problem? Who’s the best person to assess that?” Let’s say that you figure out it’s a vascular problem. What do you need to do to increase the blood flow? Radiology plays a strong role in diagnosis, as well as treatment; cardiology plays a role; vascular surgery plays a role. The patient is assuming that we’ll figure out what he needs and what’s best for him. The patient isn’t in a good position to tell us what to do, so we have to bring together everyone who has a skill set in this area to manage the patient’s needs. Maybe we’ve taken care of his leg, but now he needs physical therapy; maybe he needs help paying for it. My point on all this is that the more you can bring all these different issues together to focus on the various needs of the patient, the more you can bring in a common approach and not get discombobulated. Integrated delivery allows you to focus on the needs of the patient, to manage the common processes better, and to standardize the different approaches you have to measure quality and bring its elements together. ImagingBiz: The Mayo model calls for employment of physicians. When and why was that implemented, and what role does this play in Mayo’s high-quality, low-cost health care delivery model? Forbes: Employment is not a word that we really use in our culture. All of us are employed, but we don’t think of it that way. On the other hand, if you asked me whether I feel that the Mayo Clinic is part of me, I would say yes. There’s a strong sense of ownership, but not in a business sense. We moved into this model around the turn of the past century, when our founders, two surgeons working with their dad, were joined by some partners from other areas. They decided to pool their resources, including their work with hospitals and clinics, and everyone would work as one group to serve the needs of the patient. All of the physicians here are very much engaged in a real sense of ownership and participation, in leadership—in what I would call real decision making. The profession is very engaged in the decision making and strategizing of the organization, so we have a sense of ownership in the execution. All of our physicians are salaried, which removes financial incentives from the commitment of the physician toward the service of the organization. People ask me what a radiologist makes at the Mayo Clinic, and I’ll tell you what the answer is: The right answer is that the physician makes the right amount of money so that he or she responds, “Gee, I’m not sure. I don’t really think about it.” We don’t want money to be a driver. When I’m thinking about what excites me as a radiologist, I’m thinking about how can I serve the patient, my love of the science, and my commitment to our mission. That’s how we think about these kinds of things. ImagingBiz: With the availability of federal stimulus funds for improved health IT connectivity, how should health systems leverage these funds to further their goals? Forbes: This is a key element. Health IT is a fundamental building block in fostering an interdisciplinary approach. One of our early founders formed, for us, the first integrated medical record, over 100 years ago. At the turn of the century, people would take their reports home and stuff them into desk drawers. He suggested that the medical record be owned by Mayo; if there was a laboratory interest or an observation, they started putting it in one common record. Everyone in the country yawns now, but that was a new idea back then. The technology has now moved us into the digital information age, so electronic medical records that standardize all the input are available to anyone who touches that patient, and they are supported by robust infrastructure. ImagingBiz: Many payors are attempting to rein in the cost of high-tech imaging by implementing preauthorization programs that add significant costs to the hospital’s administration of these services. How should the field handle the issue of preauthorization? Forbes: I am troubled about the current state of preauthorization. I think it negates everything I was just saying. The best way to approach the appropriate utilization of imaging is for the experts in imaging really to be involved in the care of the patient—but not for themselves; for the needs of the patient. The important thing is to ask is, “What is the right exam to do here, what is the right way to do it, and how can I do it as appropriately as possible?” To do that, radiologists need to be consultants working as part of an interdisciplinary team. That’s a difficult step, but it’s incumbent on us, as radiologists, to step forward to be stewards for imaging. Speaking as a radiologist, I think the integration of imaging is a fundamental step toward the new models and paradigms in health care. I am very energized to encourage my radiology colleagues to play a leading role in this. Imaging is a heavy resource user. Everyone knows what an MRI costs, and it’s incumbent upon us, as radiologists, to determine the best way to use this technology for the patient. It’s absolutely critical. Working as consultants, we don’t want just to give an answer on an exam; we also need to participate in and guide the use of that technology for the better service of the patient. Radiology can and should play a large role in how our health systems deliver care.Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.