After working at the Mayo Clinic in Rochester, Minnesota for nine years, Dr. Marc Patterson decided to change his life. In 2001, he moved to New York City to take a job as chief of pediatric neurology at New York-Presbyterian Hospital (NYPH).
This year, Patterson returned to the Big House on the Prairie. “Sometimes I miss New York,” he acknowledges, “but working in a system that actually functions is worth it.”
Let me be clear: Patterson has many good things to say about NYPH and Columbia University Medical Center, the uptown campus where the worked. “I had a great experience, and fabulous colleagues,” Patterson told me. “Moreover, one of the reasons I moved back to Minnesota is because my family is there.”
Nevertheless, Patterson says: “There is a fundamental systemic difference between Columbia and the Mayo Clinic: Columbia is a traditional academic medical center; [research] that came through the med school provided the money to pay us. The hospital is a separate entity. By contrast, at Mayo, the hospital and the medical school are one. It’s an integrated organization.”
What difference does that make?
Patients Trump Research
“At Mayo the focus is on the patient. The needs of the patient come first. I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine. But research is not the primary focus.
“At most academic medical centers,” he continues, “medical research comes first; education of the students comes second. Clinical practice [caring for patients in the hospital and clinics] is not the priority.”
This isn’t to say that doctors at Columbia don’t strive to give patients the very best care possible. I am a long-time New Yorker, and if I were going to be hospitalized in Manhattan, I might well choose Columbia.
But, at Columbia, “while being an excellent clinician is great, it’s just not as highly regarded as being a brilliant researcher,” Patterson explains. “Here at Mayo, being a superb clinician is the sine qua none—if you’re not able to practice at the highest level, you won’t succeed here.”
I have heard the same story from other doctors at some of the nation’s
top academic medical centers. If you want the money and the glory, you
focus on research. You won’t become a star by being the best clinician,
or even by being a top professor.
At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from
the beginning, a group practice,” says Patterson. “You really have to
be a team player. People in administrative positions understand that
everyone is an important member of the team.”
An Egalitarian Culture
You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary? During those first years, physicians receive “step raises” each year. After that, they top out ,and “he or she is paid just the same as someone who is internationally known and has been there for thirty years,” says Patterson. (“Most could earn substantially more in private fee-for-service practice.” he adds.)
“It doesn’t matter how much revenue you bring in,” Patterson explains,
“or how many procedures you do. We’re all salaried staff—paid equally.
This is very good for collegiality, and people working together,” he
adds. “The culture here at Mayo doesn’t encourage egos. There is not
the same cult of personality that you find at other places.”
At Columbia, by contrast, the pecking order is quite clear: even the
furniture on the floor where a physician works tells him where he
stands. “The floor we were on was perfectly fine,” Patterson recalls.
“But if you walked up a few flights to ENT (ear nose and throat)
surgery, it was a different world—dark wood paneling, different
furniture… These surgeons bring in a much higher return for their
time,” he points out, “and they do some things that require remarkable
skill and training. At the same time, if a psychiatrist spends two
hours with a patient, he may get $200, while all a dermatologist needs
to do is get out the liquid nitrogen…”
The dermatologist can make $200 in a matter of minutes, just by zapping
the harmless crusty brown patches on the back of a middle-aged patient
commonly known as “barnacles of age.”
That celebrity turns on how much money a doctor brings in hardly unique
to Columbia. “Traditional medical centers are much more hierarchical,”
Mayo is the outlier. Its culture is unusual because it is based on “the
very egalitarian ethic of the people who established the place,” says
Patterson, “and the fact that we’re in Minnesota”—a state with a
longtime egalitarian tradition. As a result, “people have the
opportunity to develop skills in whatever they want to do. Our nurses
are superb at doing spinal taps, and they teach our residents.”
“We are starting to make better use of nurse and nurse practitioners
are being integrated into the teams,” he adds. “We also have a lot of
physician assistants here—and they are extraordinary people.
“Turnover is very low. It’s unusual for people to leave here, and when
they do, many like me, wind up coming back. You would be surprised—we
celebrate many 35 and 40 year anniversaries. That fact that people stay
so long is important to the success of the organization.”
Patterson does not sound as if he’s boasting. He didn’t found Mayo. He
didn’t create the culture. He merely works there—and he is telling me
why he likes it.
At the same time, in fairness I should report that the HealthBeat
reader who introduced me to Patterson was an extremely successful
physician at Mayo for many years, and ultimately decided to leave. The
Mayo Clinic is not Nirvana for all fine physicians.
Yet I believe that there is much that health care reformers can learn
by studying how Mayo operates. This is not to suggest that we should
aim to replicate the model coast to coast, putting golden arches over
every new clinic. There is, after all, a difference between healthcare
and hamburgers. Healthcare is not a commodity,
A “Firewall” between the Money and the Doctors
Still, there are differences in the way Mayo is organized that are
worth pondering. For instance, there are no “rainmakers” at Mayo,
Patterson explains, because “there is a firewall between the physicians
and the money. I don’t even know how much Mayo is paid for different
things that I do. I know the billing code, but that’s all. The business
office takes care of all of that.
“I also don’t know which patients are uninsured—and whether Mayo will have to absorb much of the cost of their care.”
Yet—and this is key—although Mayo’s doctors are not worrying about
the dollar value of what they do, they are not more extravagant than
other doctors in dispensing care. Quite the opposite: Extensive
analysis of Medicare records done by researchers at Dartmouth
University reveals that treatment at the Mayo Clinic in Rochester,
Minnesota costs Medicare far less than when very similar patients are
treated at other prestigious medical centers.
The chart below, from the “Executive Summary” of the 2008 Dartmouth Atlas
is an eye-opener. It shows that when researchers compared how much
Medicare spent per patient, on very similar chronically ill patients
during the final two years of life at five top medical centers (UCLA,
Johns Hopkins, Massachusetts General, the Cleveland Clinic and Mayo’s
St. Mary’s hospital), the tab taxpayers paid varied widely,
While Medicare spent more than $93,000 per patient on those who were
treated at UCLA Medical Center, patients at Mayo cost the government
only half as much. As the bottom two-thirds of the chart shows, this is
because, when compared to patients at other medical centers, those at
Mayo spent fewer days in the hospital, saw fewer physicians and were
less likely to wind up in the ICU.
Yet no one would suggest that Mayo scrimps when treating patients.
The Clinic received stellar marks on established measures of the
quality of care, and both patient satisfaction and doctor satisfaction
were higher than at UCLA.
As HealthBeat has pointed out in the past, when it comes to healthcare,
lower costs and higher quality often go hand in hand. Mayo’s patients
are not hospitalized as long as patients at other medical centers—and
don’t see as many specialists—because resources are used efficiently,
and diagnoses are made quickly.
A Fully Integrated System
“Here at Mayo, we can do things in a week that take several weeks to
organize in New York,” says Patterson. This is because Mayo is an
integrated medical center.
For example, “In New York, each division has its own staff to make
appointments. If I wanted several specialists to see a patient, I had
to go through each of those divisions. At Mayo, we have a pediatric
appointment office that makes all of the appointments for pediatric
Patterson still remembers “the frustrations of the system in New
York…It took a lot of time to get things done. If you wanted something
accelerated, we essentially had a trade and barter system—you would
call in favors. We were always reinventing the wheel, rather than
having a system in place.”
It didn’t help that the uptown campus and the downtown campus of New
York/Presbyterian Hospital have different electronic medical record
systems, “and neither of them is user-friendly,” Patterson recalls,
sounding, just for a moment, a little glum.
How could one hospital have two EMR systems that don’t talk to each
other? “When New York Hospital and Presbyterian Hospital merged in 1997
to form NYPH they had different systems,” he explains. Like many large
medical centers, NYPH is now making major investments in pilot programs
to move information out of “silos” and to “enable easier access to
critical clinical information.” But as this 2008 NYPH presentation observes the project will take not only money, but “time” and “culture change.”
Meanwhile, at Mayo, “We have a unitary medical record and a very
effective IT department,” says Patterson. “We developed our own
software, and we can we dictate notes—we don’t have to type.” (This is
a boon because, believe it or not, many doctors don’t know how to
“In the hospital, what we dictate can be transcribed within about an
hour.” Patterson adds. “In the clinic, it’s done by the next half-day.
In the meantime, if someone needs to access your notes, they can dial
in and listen to the dictation.”
Patients, Like Doctor, are Equal –and Many Need Charity Care
Some say that Mayo operates in a bubble that separates it from the real
world. Their may be some truth to this. Certainly, Mayo has created a
very special culture.
But the assertion that Mayo is “different” because the vast majority of
its patients are very wealthy and thus easier to treat than the
patients at most academic medical centers just isn’t true.
The Mayo Clinic in Minnesota sees many local patients. “And like New
York, we have minorities—just different minorities,” Patterson
explains. “At Columbia, I saw many Dominican patients who lived close
to the hospital in Washington Heights” (a low-income neighborhood that
is beginning to attract middle-class New Yorkers).
“At Mayo, we have Spanish speaking migrant workers” Patterson explains.
(In the 1990s the number of foreign-born Latinos in Minnesota shot up
from 9,200 to more than 62,000).
Surprisingly, Minnesota also is home to many refugees from Africa.
Somalis began flowing into the state from refugee camps in the 1990s,
in part because several well-organized faith-based Minnesota groups
made them welcome, and in part because the economy was strong and jobs
for immigrants who didn’t speak English were available. Today an estimated
30,000 Somalis reside in the state. “And they are not well off,” says
Patterson, comparing them to the poor patients he saw in New York.
Minnesota has a history of active volunteerism regarding immigration
and refugee resettlement, which helps explain why its foreign-born
population more than doubled during the 1990s—from 110,000 to 240,000.
The immigrants include some 60,000 Hmong, an ethnic group that fled
mountainous regions in Southeast Asia. Most of those who settled in
Minnesota come from Laos. Some readers may recognize the Hmong from
Anne Fadiman’s brilliant book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.
From his years at the Mayo Clinic, Patterson is familiar with the
cultural divide which make the Hmong difficult patients for many
Western doctors. “They believe in supernatural forces,” he explains.
Nevertheless Mayo treats them—and regularly advertises for Hmong
Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent
$182 million providing charity care and covering the unpaid portion of
Medicaid bills—plus another $352 million on “quantifiable benefits to
the larger community” which included “non-billed services, in-kind
donations and education.”
That year, 100,000 benefactors gave the Clinic a record $373
million—enough to pay for the benefits the Clinic provided for the
community, but far from the amount that would be needed cover the
charity care Mayo provided.
Although its $1.6 billion endowment gives Mayo a stable base, it is not
awash in money. In 2007 it operated on a relatively slim margin of 2.9
percent; that year revenues grew by 9.6 while expenses rose by 8.5
percent, “due in part to Mayo investments in patient care and research
activities, as well as information technology infrastructure,” the
annual report explains.
When it comes to serving Medicaid patients, Mayo is generous with its
time and talent. “Here, there is no distinction between Medicaid
patients and other patients,” says Patterson. “I wouldn’t know whether
they are on Medicaid, or have insurance from their employer. The
business office knows that.”
At many academic medical centers, Medicaid patients are seen mainly by
residents in a separate clinic. “At Mayo no one is seen only by
residents. And we routinely spend 90 minutes with a new patent —going
through X-rays, and a complete examination,” says Patterson. “At
Columbia, we had private offices and a Medicaid clinic, I tried to give
people 90 minutes, but in the clinic, it was hard to do that.”
Those who suggest that Mayo operates in a separate world often assume
that it can afford to be so magnanimous when caring for indigent
patients because so many of its beds are filled with Saudi Sheiks.
Patterson acknowledges that “at Mayo, we do see a number of quite
wealthy people—but that was true in New York too.” Indeed, high-income
patients typically flock to prestigious medical centers like Johns
Hopkins, UCLA, Mass General and New York-Presbyterian.
So when officials at a medical center like UCLA try to argue that
Medicare’s bill are higher when patients are treated in L.A. because
the hospital is treating a different “population” of patients
suffering from and “more complex” and “more severe illnesses,” this
doesn’t quite ring true. Certainly, it is hard to believe that the
difference is large enough to explain bills that are 80 percent higher.
As Dartmouth’s Dr. Elliott S. Fisher, a co-author of the study comparing Medicare spending at five academic medical centers, points
out: “We are comparing patients with identical outcomes — all were
dead in two years. So it’s unlikely that differences in the severity of
illness account for the variations we saw.”
It also is important to keep in mind that, “contrary to popular
assumptions, it’s the volume of services, not the price per service,
that accounts for most of the variation in Medicare spending” observes
Dr. Jack Wennberg, the founder of what is now known simply as “the
Dartmouth research.” And as more than two decades of Dartmouth research
have shown, it is the supply of hospital beds and doctors that drives
volume—not patient demand. When more resources are available, as they
are at UCLA, patients spend more time in the hospital and undergo more
procedures. Yet outcomes are no better; often they are worse.
“UCLA knows it has a problem,” Wennberg confided in an interview last
year. “But what are they going to do—close down beds and fire doctors?
They need that stream of revenue that comes from the beds and doctors
to service their debt.” So Medicare spends more at UCLA—and some
patients are over-treated.
But Not All Mayo Clinics Are Created Equal
Mayo offers lessons for reformers. Still, it’s not easy to replicate
the success Mayo enjoys in Minnesota. Not even Mayo can do it.
Over the years, the Mayo Foundation system has grown beyond its
original Rochester, Minnesota site, establishing group practices in
Phoenix, Arizona; Jacksonville, Florida; Eau Claire and La Crosse,
Wisconsin as well as in several other communities in Minnesota and
Iowa. But when Dartmouth’s researchers examined how these spin-offs
use their resources, they found “surprising” variations.
“Indeed,” the report observes, “the spectrum of approaches to caring
for patients with severe chronic illness ranges from a low resource
input, low-intensity end-of- life pattern favoring primary care to high
resource input, high-intensity end-of-life care relying on medical
specialists. In short, we find no evidence that providers in these
systems use a distinctly Mayo Clinic strategy for allocating resources
and managing chronic illness.”
It is worth noting, however, that at the four Mayo practices that
Dartmouth’s researchers studied, the quality of care turned out to be
either “very high” (LaCrosse and Phoenix) or “above the national
average” (Jacksonville and Eau Claire.)
The variation suggests that it may not be the Mayo “system” that lifts
Mayo’s flagship Minnesota hospital above the tide. Rather, some
observers suggest, it may be the highly egalitarians and collaborative
“culture,” which puts patients ahead of everything and everyone else,
that makes the Mayo Clinic in Rochester, Minnesota so special.
These are values that can be traced directly back to William Mayo and
Charles Mayo, who, together with their father, William Worrall Mayo,
founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the
first examples of group practice in the United States. As Doctor
William Mayo explained
in 1905: “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 has become
necessary to develop medicine as a cooperative science.”
The Mayos also made it clear that patients’ interests were not well
served if doctors competed with each other. Late in life William
emphasized that in addition to making a commitment to the patient,
doctors must make a commitment to each other: “Continuing interest by
every member of the staff in the professional progress of every other
member,” would be essential to sustaining the organization’s future.
More than one hundred years later, building a health care system that
adheres to such a collective vision of its mission may be difficult.
Perhaps it can only be done in Minnesota.
Nevertheless, the 2008 Dartmouth Atlas does provide sufficient data to
support the thesis that integrated delivery systems are likely to
provide the most efficient high-quality care. And the report makes it clear
that Mayo is not the only integrated system that stands as a benchmark
for excellent collaborative care. Both Intermountain Healthcare (IHC)
in Utah and the Sutter system hospitals in Sacramento are singled out
So the structure of the system is important. But so is the soul. On
that point, I would argue that we should pay attention to the
“firewall” between the doctors and the money at Mayo. Ideally, in any
medical center, the money and the businesspeople should be on one side
of that wall; the doctors and the patients on the other side. Clearly,
someone has to make sure that the hospital can stay afloat
financially. But too often, money gets in the way of medicine.
In the end, Mayo offers proof that when a like-minded group of doctors
practice medicine to the very best of their ability—without worrying
about the revenues they are bringing in for the hospital, the fees they
are accumulating for themselves, or even whether the patient can
pay—patients satisfaction is higher, physicians are happier, and the
medical bills are lower. Isn’t this what we want?