Schooling for a new way to do health care
HANOVER, N.H. - Jim Yong Kim has for years been part of the small army of smart people trying to lead Americans to better health at lower cost. As Dartmouth College president, Kim has started training platoons of health-care-oriented professionals in delivering better care.
Kim put together elements of Dartmouth's medical and business schools under an independent institute to start a master's degree program where the emphasis is on such things as cockpit-style checklists for operating rooms and up-to-date electronic medical records accessible at the patient's side.
It means communication, patient follow-up, and washing hands.
The first class began its 18-month run this summer.
"Health-care reform needs champions," Kim said during a lecture on campus, in explaining the impetus for the program and producing new kinds of leaders.
Combining health-care and business studies is not unusual. The University of Pennsylvania's world-famous Wharton School graduated its first health-care M.B.A. class in 1971. It requires two years of study on campus.
But the Dartmouth program is unusual - unique in Dartmouth minds - because of the combination of focus on delivery at the patient level, along with its use of distance learning via the Internet and the need for buy-in from students' bosses, who often pay the $83,600 tuition. Students continue in their regular jobs during the program and often work on projects in their workplaces.
The program is backed by a $35 million anonymous donation to Dartmouth.
The first class of 47 people, from 17 states and two foreign countries, includes doctors, nurses, chief financial officers, consultants, foundation employees, military members, insurers, government planners, and health-systems leaders. Many applied as groups. Oklahoma State Sen. Tom Adelson is paying his own way but working with people from a Tulsa hospital that gets many low-income patients with chronic problems such as diabetes, heart disease, and asthma - problems seen in many U.S. cities including Philadelphia. The youngest student is 37, and most have spent at least 20 years in health care.
"We were trying to attract a student body that was in the real world," said Al Mulley, director of the Dartmouth Institute for Health Care Delivery Science, who has spent 30-plus years as a doctor and teacher in Boston hospitals and at Harvard. "We weren't sure we wanted people who could afford to take two years off or whose organizations could afford to send them away for two years. Our argument to CEOs was that this really will be unique."
Class member Mike Lachenmayer, a Lower Merion resident and director of business process optimization for Amerihealth Administrators, which manages health-benefit plans for Philadelphia-area companies large enough to be self-insured, said he could not leave his job or family solely to work toward another degree. The mix of students and professors from many points on the health-care compass helps him think of immediate improvements and look over the horizon.
"It's the old story about making a better buggy whip when the cars are coming out," Lachenmayer said, referring to the changing national goal of better health outcomes for less money, versus more services in the fee-for-service model that has dominated American health care for decades. He downloads lectures, then listens during his 40-minute commute to his office in Horsham.
The course requires 15 to 20 hours of work per week, including online videoconferencing for group projects and four campus visits.
Kim earned medical and anthropology degrees from Brown and Harvard, ran the AIDS/HIV unit of the World Health Organization, and cofounded the health-care nonprofit Partners in Health. He has seen and helped create health-care systems in places with no electricity or running water, and where diseases long eradicated in the United States are rampant, so he dismisses suggestions by those in U.S. health care that their patients are somehow sicker than elsewhere.
"We're trying to get at a fundamental frame shift in the way we think about the importance of delivery," Kim said. Systems engineers, internal corporate communications experts, and other such specialists need to mingle with the usual medical personnel. "Those are the fields that will shine a light on what we do in hospitals and help us get to better outcomes at lower cost."
The Patient Protection and Affordable Care Act became federal law in 2010 with the promise of bringing better health care to more Americans for less overall cost over time.
"Dr. Kim and the Dartmouth people, and they are not alone, intuited that it was important to train a new cadre of professionals to deliver better care to achieve better outcomes, and have that line up to advance research in areas like operating-room procedures and ward rooms," said Don Berwick, chief administrator for Medicare and Medicaid Services. A Harvard-trained pediatrician, Berwick was appointed by President Obama in 2010. "This administration is very committed to innovation and deeply committed to quality. A lot of that is reflected in the Affordable Care Act."
The requirement to buy health insurance will give millions more people access to care, assuming the Supreme Court doesn't strike down all or part of the law, but Kim wants more from Obama.
"I'd like him to stand up and say, 'Access to care was the first step and we took a big step in that direction. But now we have to begin tackling the problems of cost and quality really seriously,' " Kim said. Beyond presidential advice, Kim is not afraid to tell back surgeons, for example, they cannot do operations just because they get reimbursed more for a procedure without producing better results. "I have little sympathy for the people who say, 'Damn it, I'm going to do more back surgeries and you're not going to tell me what to do.' Is that a sacrifice? Gosh, I think that is just a movement toward evidence-based medicine."
Penn's David Asch, a medical doctor, Wharton M.B.A. and executive director of the Leonard Davis Institute of Health Economics, complimented the Dartmouth leaders, but is proud of Penn's approach. He said more business-medical training is good, in part because doctors often hit a "gauze ceiling" as they climb organizational ladders.
Paul Danos, dean of Dartmouth's Tuck School of Business, said there was little resistance in his department to collaborating in the health-care initiative because "everybody knows that medicine is in a heap of trouble and everybody knows that it is not going to be solved by one discipline looking at it from a myopic point of view."
The United States spends about $2.5 trillion per year on health care, almost 18 percent of gross domestic product. Nobel Prizes were awarded last week for slicing and dicing genes, but a study published in the April edition of Health Affairs said one in three people falls victim to an "adverse event" - such as a medication error, infection or fall - after admission to a U.S. hospital.
"I keep saying," Kim said, "the real rocket science is in the delivery."
Learn more about Dartmouth's program that places an emphasis on delivery of health care. And find more coverage of the Philadelphia region's pharmaceuticals business.