Mayo Clinic’s goal: A health care system that fits a town

Last winter, as the country bickered over death panels, Tea Parties and socialized medicine, a woman quietly observed life in Austin, Minn. She visited community centers, hung out with pastors and interviewed workers at Hormel, Austin’s main employer and maker of SPAM.

What that cultural anthropologist at Mayo Clinic’s Center for Innovation found is the basis for perhaps the most ambitious attempt to design a new health care model not just for Minnesota, but the rest of the country. Mayo, based nearby in Rochester, Minn., is currently conducting a bold three-year experiment to determine whether an integrated community-based health care system can produce healthier citizens.

Mayo’s effort embodies the “medical home,” a popular reform concept that emphasizes the social environment that impacts public health, not just the medical care itself. In other words, how can schools, churches, employers, hospitals and other local groups work together to better care for sick citizens and prevent chronic diseases like diabetes and heart failure?

A handful of health outlets have embarked on medical home projects–driven by the idea that better preventive care will cut skyrocketing long-term care costs. Until now, though, most efforts to reform the health care system have been modest and piecemeal: a smattering of technology (software, electronic patient records), financial incentives (employee health and wellness programs), and physical infrastructure (redesigned medical facilities). Mayo says its project will try to do it all: designing a system for an entire town.

“There have been only slight modifications to the current system,” said Dr. Douglas Wood, a Mayo cardiologist leading the project. “That’s not real transformation. We’re trying to do something very different than the rest of the country. We’re trying to transform the way we deliver care to the community, how we interact with people in their everyday environment.”

In some ways, Austin is the ideal guinea pig for Mayo. The town boasts a manageable 22,000 people, with a sizable elderly (12.6 percent) and Hispanic (15.1 percent) population, according U.S. Census data.

Austin has only one hospital, the Mayo-owned Austin Medical Center, and two main employers (Hormel and Quality Pork Processors Inc.), both of which are deeply interested “in improving the standard of living and spending less on health care,” Wood said.

Those factors “makes [the town] easier to manipulate” for the study, he said. In other words, Mayo and its partners  have considerable control over remaking Austin’s health care system and can quickly make changes if needed.

The first step in the project, according to Mayo officials, was to study Austin and how citizens viewed and used health care.

“We wanted to really understand our customers” by using the same strategies companies like Apple Inc. employ to gauge shoppers, said Adam Rees, chief administrative officer at Austin Medical Center. “There are very few medical centers that try to understand how the community defines health care.”

After spending four months in Austin, the Mayo cultural anthropologist developed a treasure trove of data, which Mayo is only starting to analyze. Among her findings:

• Motivation. The No. 1 reason people want to stay healthy is because someone else depends on them. Mayo officials say they can use that insight to craft messages to motivate consumers and change their behavior. For instance, a doctor might tell patients to quit smoking not because they are the sole breadwinner in the family. The patients need to stay healthy to continue to support the children.
• Church. One pastor spent a considerable time visiting homes of Hispanic residents discussing health issues. Churches might prove to be a valuable social outreach resource  for health care, hospital officials say.
• Resources. Austin boasts an impressive array of social service agencies, but the groups don’t communicate well with each other or the public.

“There are an insane amount of activities but people aren’t accessing them,” said Lorna Ross, design manager for Mayo’s Center for Innovation. “The agencies were giving conflicting advice. They weren’t behaving like a community. No one had connected the dots.

“We didn’t need more services,” Ross said. “We didn’t need more money. We need some kind of a health choreographer.”

As a result of the study, the hospital is exploring several options, said Joan Broers, vice president of primary care at Austin Medical Center. For example, the hospital will soon host a “Community Health and Wellness” event to showcase all of the town’s social services.

Austin Medical Center might establish “care coordinators” for patients between visits. Such coordinators could work with the local Hyvee supermarket to develop an appropriate menu for an obese patient. The hospital could also restructure teams of nurses to help doctors properly prepare for a patient visit ahead of time, Broers said.

Mayo could also work with employers like Hormel and Quality Pork to better spot mental health problems like depression among workers and offer appropriate counseling or pharmaceuticals before the condition worsens and reduces productivity.

Dr. Carol Holtz, a primary care physician at Austin Medical Center, said she wants to take a more active role in her patients’ lives outside of the office. She recalls a depressed diabetic patient who, despite her doctor’s advice, was not getting proper exercise. Holtz envisions working with the YMCA to enroll the patient in community swimming classes.

Mayo’s project, like most medical home endeavors, faces one major obstacle: payment. Medicare currently pays for volume, not quality of care. Without fixing the payment system, experts say efforts like Mayo will fall short.

“We’re stuck in the fee-for-service model,” Minnesota Health Commissioner Dr. Sanne Magnan recently told a forum held at the University of Minnesota’s School for Public Health. “We don’t pay providers for a nurse to call a patient at home and try to coordinate care.”

Holtz said health care reform “creates new responsibilities for doctors. But the payment system is not aligned with what the doctor wants to do. We can’t get reimbursed for care coordination or counseling, only for face-to-face visits.”

However, some organizations think federal reform will help foster the medical home concept. Dr. Frederick E. Turton, chair of the American College of Physicians’ Board of Regents, told American Medical News that the law also takes the first steps toward breaking the link between pay and volume of services. The legislation also provides new funding for health IT efforts to support medical home projects.

Wood also notes the federal Department of Health and Human Services is encouraging pilot projects to develop new payment models by exempting towns like Austin from Medicare rules. He said employers like Hormel, which pay for the bulk of workers’ health care costs, are eager to participate in the Austin project.

Wood has other reasons to be optimistic. He supports the concept of “accountable care organizations” that financially reward doctors and hospitals for quality care and superior medical outcomes. Under Minnesota’s health reform law, passed in 2008, the state this year will establish a  peer-grouping system that measures and compares the cost and quality of care provided by physicians.

The project’s real challenge is to prove that it works, Wood said. The hospital needs to design a study that scientifically proves the medical home concept produces better medical outcomes than traditional care. In addition, Mayo also needs to identify the right benchmarks to measure progress or the lack of it.

For example, Wood says counting the number of days workers spent in hospitals is far more valuable than measuring a person’s Body Mass Index.

“You have to measure what people can find useful,” he said.

This is the first in an ongoing series looking at Mayo’s project in Austin, Minn.