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Replicating Cleveland Clinic's Success Poses Major Challenges


(Note:  this article is interesting because it underscores tow conclusions one can draw from a number of articles in this website.  First that there is a general lack of good management practice in healthcare.  Paying for performance is the standard in any well run business.  Second that the government has no clue as to what this means or what good management entails.)

President Barack Obama plans to visit the Cleveland Clinic Thursday, an institution he has held up as a model for delivering high-quality and cost-effective health care. But trying to replicate the clinic's approach across the U.S. would pose difficult challenges.

The Cleveland Clinic is one of the country's pre-eminent medical institutions, with a top-ranked heart program that attracts patients from around the world. In addition to the quality of its care, though, what has caught the attention of the Obama administration is how the clinic stacks up cost-wise against similar hospitals.

According to a study of U.S. medical-cost patterns known as the Dartmouth Atlas of Health Care, chronically ill patients in the last two years of life cost Medicare $55,000 on average when they are treated at the Cleveland Clinic, tens of thousands of dollars less than at many highly-ranked academic medical centers.

"We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm," the president wrote in a letter to Sens. Edward Kennedy and Max Baucus last month. "We need to learn from their successes."

The key to the Cleveland Clinic's success, many policy makers say, is its integrated approach. Like other so-called multispecialty clinics, the Cleveland Clinic employs its own physicians, creating teams of specialists that collaborate in treating each patient. By contrast, at most traditional community hospitals, doctors remain independent, private practitioners.

The clinic model makes it easier to coordinate care, implement evidence-based treatments and reduce the red tape of referrals, proponents say. The clinics say their doctors also have less incentive to order unnecessary tests or procedures because they are paid fixed salaries, not on a fee-for-service basis like the majority of U.S. doctors.

Despite the favorable attention from the White House, however, the multispecialty clinic model isn't easy to replicate widely. One issue is cultural: Most doctors tend to be fiercely independent. Working at multispecialty clinics requires that professionals buy into the teamwork ethos and tight hierarchy that have dominated these institutions since their inception decades ago.

"It's a lot more difficult for a community hospital to tell 100 private practitioners it wants them all to start using computers for electronic record-keeping," said John Kastor, professor of medicine at the University of Maryland's medical school. "Physicians don't like others to tell them what to do."

The other problem is economics: the predominant fee-for-service payment system, driven largely by Medicare's payment policies, reimburses hospitals and doctors largely by how much they do to patients, not necessarily for making them healthier.

If anything, American doctors seem to be migrating away from multispecialty clinics.

Multispecialty clinics such as Mayo have complained that the health-overhaul bill unveiled by the House last week doesn't use Medicare enough as a lever to change how medicine is practiced. The House bill does include a provision to reward doctors who join "accountable care organizations" when they provide quality care at lower cost, but only as a pilot. It also includes an experiment in bundling payments to providers, with a fixed fee for caring for a given patient.

The Cleveland Clinic's chief executive, Delos Cosgrove, so far has refrained from commenting on the specifics of efforts in Washington.

The Cleveland Clinic stays profitable by offsetting its losses on Medicare patients with payments from private insurers and thousands of foreign patients who often pay its full list prices. Those prices can be two to three times higher than what U.S. insurance plans negotiate with the clinic. The clinic also pulls in significant revenue from philanthropy; it collected $183 million in 2008.

Even if the clinic's organization and culture can't be easily replicated, its practices can, it argues. Its electronic medical records, for instance, let patients upload their health information, such as weight-loss or blood-sugar data, directly from scales or devices at home. That, in turn, gets patients more involved in their health and keeps them in better touch with their doctors, the clinic says.