Q&A: 'If Mayo was a high-cost provider, we would be cut out of many of these networks'

Mayo Clinic, which has a 150-year history as a medical practice, now operates 22 hospitals and draws patients with complex needs from all over the world to its 1,243-bed flagship facility in Rochester, Minn. The organization has also garnered praise for insulating clinical decisions from financial incentives by paying physicians under a salary model with no productivity bonuses.

But even though Mayo is built to let doctors be doctors and has been ahead of the curve in studying how to measure and reward value in healthcare delivery, it isn't immune to challenges such as physician burnout and the mounting pressure to reduce costs and adopt value-based payment models.

Bob Herman, Modern Healthcare's Midwest bureau chief, interviewed Mayo President and CEO Dr. John Noseworthy while he was in Chicago as co-chair of a consortium of 12 health system CEOs convened with the American Medical Association to address physician burnout. The following is an edited excerpt.

Modern Healthcare: What are some of the main causes of physician burnout and how are you rectifying them?

Dr. John Noseworthy: Physicians who work by themselves and don't have a team to support them are struggling in this environment where there is so much paperwork, clerical burden, the electronic health record, all the regulations, computer-facilitated order entry—all of those basically drain the joy from the physician's work. A recent study showed that for every hour physicians spend with patients, they are spending two hours on the computer, and that's just not what they feel medicine should be about.

MH: And one of the things you've done is as simple as reimbursing for meals to bring people together to talk?

Noseworthy: It's an interesting bit of research, and it was studied in two large clinical trials. If a doctor says, “Give me an hour a week to do with what I wish” or “assign me to go to lunch with eight of my friends to have some time together”—the same amount of time—they both came out of that with more joy in work. But the only one that really stuck and had persistent benefit was the camaraderie that was built up through the lunches. So, we now have 1,100 physicians who go out in small groups on a monthly basis, and Mayo pays for their lunch.

MH: Mayo Clinic is making a big investment in electronic health records. It is spending roughly a billion dollars on a new Epic EHR system. How is that affecting physician burnout?

Noseworthy: Everyone who studied electronic health records, regardless of the vendor, is finding the same thing: It is very difficult for the physicians to learn, to sustain, and it does add to the time on a computer as opposed to being with patients. The promise of EHRs is that it will improve the quality of care and the safety of care. If you go from a written record to an EHR it's hard; if you go from one EHR to another it is hard. So we are putting everything we can in place to educate our physicians to reduce that difficult transition period, but we need to find a way, working with the EHR vendors around the country, to say, “How can we make this more intuitive and less burdensome?”

MH: What is Mayo doing in terms of value-based contracting?

Noseworthy: We have been innovating and collaborating with payers—both government and the private payers—to understand the most highly complex (patients), the sickest of the sick, who come to Mayo. What are the outcomes that you expect, and what contributes to the cost of their care because they are so ill and they have so many comorbidities? How do we best recognize and measure that? We have bundled payments for transplants. We have had those for 14 years. We have now moved to a bundled contract with a large employer for all of their complex cancers, breast, lung and colon, specifically. We have done less of the capitation model to this point, but all these things are being studied, and we are basically building a machine at Mayo to understand the data and then make sure that the measurements are accurate for the complexity and the outcomes that we produce so that we can be successful and we can drive innovation in the care of patients with serious and complex illness, which is where we excel.

MH: The bundled payments in this instance are when an employer will pay for the employee's travel and the procedure at Mayo Clinic. Do you foresee more employers being interested in that?

Noseworthy: We would like to see this grow more broadly with all the payers, employers, private payers and the government, because we do think that it drives value—so much value that one of the employers pays not only for the patient but also for their spouse to travel to Mayo, have all the diagnostic studies and the procedures that they need for this complex condition at no cost to the patient. We believe if we learn how to study and measure this appropriately going forward that this will be a good thing and drive a higher-value—and hopefully a financially sustainable—healthcare system for the country. That's what the country needs.

MH: Insurers are moving to narrow networks to cut out what they deem are high-cost providers. How do you view this trend?

Noseworthy: If it was the truth that Mayo was a high-cost provider we would be cut out of many of these networks and that would hurt the organization tremendously. As I already mentioned, when you really study this, for most of these complex conditions, we are actually not a high-cost provider. We are actually a high-value provider with lower total cost of care. But the onus is on Mayo Clinic to prove that to those creating the networks. Folks say, “Why are you spending so much time studying the science of measurement? You are the No. 1 hospital in the nation again. You've got five stars from CMS. They obviously think you are doing well.” But we had to be sure that the work that we do with the sickest of the sick and the outstanding outcomes that we produce are properly recognized and reimbursed and not simply someone saying, “Well, a hip is a hip is a hip,” because it isn't.