Stephen Sacca, SF ’90
Director, MIT Sloan Fellows Program
The Boston Globe reported recently that medical professionals in increasing numbers are heading to MIT Sloan for their MBAs. In the MIT Sloan Fellows class of 2014, a full four percent of fellows have a healthcare background—equivalent to the number who hail from banking. Some M.D.s just want to be able to wrap their heads around the complexities of the Affordable Care Act. Others are attracted to the School’s new crop of healthcare-related offerings—the Healthcare Certificate Program, for example. All of them are coming to MIT Sloan because they want to innovate some part of the healthcare universe.
In this issue, we explore the reengineering of healthcare delivery from the point of view of MIT Sloan faculty members Dimitris Bertsimas, Anjali Sastry, and Retsef Levi, who are tackling healthcare systems in the U.S. and in developing countries. You’ll also meet alumni who are introducing landmark changes at some of the most influential hospitals in the country—David Rosenman, SF ’12, Assistant Professor of Medicine at the Mayo Clinic College of Medicine, Melinda Morin, SF ’10, a pediatrician in the Complex Care Service at Boston Children’s Hospital, and Craig Bunnell, SF ’08, Chief Medical Officer at Dana-Farber Cancer Institute in Boston.
After reading this issue, I think you will come away with the feeling that few challenges we face as a people are as stubborn as healthcare—or inspire so many avenues of invention.
What is it about healthcare? We have designed complex satellites that hover thousands of miles above Earth connecting the furthest reaches of the globe, but providing basic healthcare has us stymied. At MIT Sloan, the 20+ members of the faculty whose research encompasses healthcare believe that any rethinking must begin with the basic understanding that healthcare is as much about good management as it is about good medicine.
Retsef Levi, for example, would be the first to tell you that healthcare is about system dynamics, accounting, and marketing. Management of technology, human resources, and leadership. Good healthcare is about devising systems that effectively and efficiently serve those who need care. In a recent MIT Sloan Alumni Magazine article, Levi, the J. Spencer Standish (1945) Professor of Management, noted that two basic approaches to healthcare reform have emerged over the years: viewing healthcare delivery failures as a process re-engineering problem or as an incentive problem driven by the current payment schemes.
What is missing, Levi says, is the recognition that fixing healthcare delivery is a complex management challenge. “Not enough attention has been spent considering the capabilities these institutions need to develop to deliver more cost-efficient, higher-quality care.” This perspective is driving MIT Sloan’s approach to solving the multi-pronged problem of healthcare delivery. It is also driving Levi’s development of a new think tank at MIT Sloan—the Center for Management of Engineering and Healthcare Systems. “We will focus on the organizations and systems that deliver care,” Levi says. “We want to develop a multidisciplinary approach to study them, then propose different ways and develop new analytical tools to structure them and operate them. This includes finances, HR policies, analytical tools, operations and system design, and so forth.”
Levi’s extensive work with academic medical centers in the Boston area has given him a strong grounding in how to partner productively in the medical realm. Such partnerships have already resulted in large-scale implementations with tangible results. Surgery units at Massachusetts General Hospital (MGH) have implemented a new scheduling system devised in collaboration with MIT Sloan that cuts in half the number of patients facing long waits to enter surgery. Read more about Levi’s collaboration with Massachusetts General Hospital.
Dimitris Bertsimas, the Boeing Leaders for Global Operations Professor of Management and the co-director of the MIT Sloan Operations Research Center, has been collaborating with providers to improve healthcare systems for more than a decade. Having lost his mother to diabetes and his father to cancer, his personal motivation has only fueled his professional mission to advance healthcare.
An optimization and decision analytics expert, Bertsimas’ power to reinvent systems lies in his prodigious skill with mathematical models and data analytics. His paper An Analytics Approach to Designing Clinical Trials for Cancer (written with his students Allison O’Hair, PhD '13, Stephen Relyea, SM '13, and doctoral student John Silberholz) won the prestigious 2013 Pierskalla Best Paper Award from INFORMS. The premise is that researchers can statistically predict the outcome of some clinical trials.
“We look at the totality of data that has been developed by the human race,” Bertsimas explains, “and analyze that to identify the most promising treatments.” The innovation is not designed as a replacement for clinical trials but to give researchers the ability to predict which clinical trials might be the most promising, so research dollars are invested in treatments with the best chance of success. Bertsimas is now in discussions with Massachusetts General Hospital about implementing the system.
In collaboration with Vivek Farias, the Robert N. Noyce Career Development Professor, and Nikolaos Trichakis, PhD '11, Bertsimas also has channeled his facility with analytics to develop an innovative method for determining who will receive the 20,000 kidneys available for transplant each year in the U.S. (80,000 people are now waiting). If implemented, their system could increase the years of life gained by recipients by eight to ten percent.
The prevailing method for deciding who receives a kidney has been determined by a scoring rule that prioritizes patients based on their time on dialysis. Bertsimas’ new system focuses on achieving a fair and equitable distribution of kidneys based on age, race, blood type, illness, and other factors that maximize the number of extra years lived by recipients. That eight percent increase in life expectancy distributed among recipients translates to about 2,000 extra years of life.
Collaborating with Allison O’Hair, PhD ’13, and an MIT dietician, Bertsimas has developed a system called LIA (Lifestyle Analytics) that takes into account individual dietary preferences and metabolic responses to foods and diet regimes in an effort to manage weight and sugar levels. Using optimization, LIA gives customized advice about what to eat and when to eat and exercise. Serving as a guinea pig for the plan, Bertsimas lost 30 pounds.
He also worked with a recent MIT Executive MBA program graduate on a startup called Benefits Science, which designs healthcare benefits plans that provide the highest quality healthcare options at the lowest possible cost. “Companies spend billions of dollars on healthcare plans for their employees. Approaching the problem from an optimization perspective, we can figure out by studying employee claims data how to cut those costs while increasing the quality of care to employees.”
Anjali Sastry, MIT Sloan Senior Lecturer in System Dynamics, is transforming the healthcare landscape by bringing together students—among them MIT Sloan Fellows—with clinics, hospitals, community organizations, and startups in emerging economies. The goal: work with these organizations to provide better healthcare. Through efforts like GlobalHealth Lab, Sastry and her students are helping to introduce life-saving interventions to the people who need them by focusing on the practical, operational, and managerial aspects of care delivery.
By next year, Sastry’s GlobalHealth Lab students will have completed 70 projects in 15 countries in sub-Saharan Africa and South Asia. The results so far have been extraordinary. A clinic in a rural pocket of Western Kenya that lacked clean water three years ago now has potable water and an expanded line of medical services—it’s also financially sustainable. A community-based health center in central Uganda added a second healthcare facility, acquired its first ambulance, and qualified for free HIV medications. A diagnostics startup that four years ago was just an idea is now readying for market entry in East Africa and beyond.
Every project takes on a specific problem defined by the partner organization. Members of the MIT Sloan faculty, including Sastry, guide students through the process. “Developing, carrying out, and following up on each project has enabled us to do much more than we ever imagined,” Sastry says. “We've built a platform for ongoing engagement with partners on the front lines of healthcare delivery, and that platform has enabled students to learn about a crucial but under-studied set of real-world problems.”
Sastry notes that it’s one thing to open a clinic or invent a new medical technology, but how do you introduce those innovations into the marketplace to ensure that they reach as many people as possible? “We look at organizations to see how they fit into the healthcare system as it currently exists, asking how each delivers value and how that can be improved.”
Students enrolled in GlobalHealth Lab conduct research with their partner organizations and work collaboratively on site, gathering data on patient problems, shadowing nurses and doctors, interviewing community members, and running field tests on their early ideas.
David Taurus, the founder of the Empowering Lives International clinic in rural Kipkaren, Kenya, hosted a team of MIT Sloan students in 2009. “I was so grateful that the [team] sat with us in the village to talk and to understand [the rhythms of our lives and capture those] in their research,” he says. “Through their research, we now have clean water, we have dental services in our clinic, we have maternal-child health, and we have an eye clinic.”
The students also helped the clinic improve its pricing strategy, enabling it to offer a broader variety of services. Now, Sastry and her colleagues are looking to better quantify each project’s impact, which she hopes will reveal the potential for management to improve global health delivery.
Sastry has further expanded MIT Sloan’s opportunities for impact with Business Model Innovation: Global Health in Frontier Markets. The course examines ambitious startups and pioneering organizations across the globe that are scaling up primary care, increasing access to life-changing surgery, treating heart disease, and addressing countless other critical medical issues in resource-starved markets.
Global Health in Frontier Markets looks at how NGOs and private organizations are supplementing the work of governments and filling in critical gaps. Sastry points out that while struggling governments may not have the necessary resources for process innovation, philanthropic partners like the Kaiser Family Foundation, Merck for Mothers, and the Bill and Melinda Gates Foundation can fund bold new programs that pilot innovative methods to prevent the spread of HIV or reduce maternal deaths.
"A central theme in this class is how to fit healthcare innovations into existing systems. For example, innovations in cervical cancer screening can prevent the deaths of so many women in rural Africa—but not if those women can’t get to the hospital for surgery after diagnosis. It’s a matter of system dynamics. No innovation should be implemented in a vacuum. We have to understand how every improvement fits into the system.”
The course Business Model Innovation: Global Health in Frontier Markets has been popular with MIT Sloan Fellows—in the healthcare field and in other industries. In addition to meeting some of the most influential change-agents in the developing world—billionaire philanthropist Ratan Tata was a recent class guest—they learn the latest strategies for driving improvements in healthcare delivery where they are needed most.
Here’s what current fellows had to say about the experience:
“Given my desire to establish a healthcare diagnostic center in Nigeria post-Sloan, this course brought home with resounding clarity some of the challenges facing global healthcare delivery—scalability and sustainability—but also the possibilities. Efficiency is possible in developing markets, despite perceptions (and my own personal experiences) that suggest otherwise.”
Adebayo Adeyemi, SF ’14, Nigeria
“I had the chance to experience the vivid dynamism of entrepreneurial efforts in many countries and learned how to incubate and develop sustainable healthcare business models without the support of traditional resources or infrastructure.”
Takao Miki, SF ’14, Japan
“Providing sustainable, affordable healthcare to people in frontier markets is a daunting challenge. This program showed me a way to develop various disruptive business models that address this problem. It also inspired me to start my own primary healthcare facility to serve the rural community of India.”
Hasitkumar Dangi, SF ’14, India
“This class made me reexamine global health. Professor Sastry showed me that worldwide health problems are not just about diseases or logistics. To have a sustainable impact, any global health initiative must also know how to forge interconnections among patient populations, health ministries, and NGOs.”
Christian Michael Lim, SF ’14, United States
“I have worked for corporations in the healthcare industry in Africa. This class provided great insights and a chance to get different perspectives on global health challenges. I saw that to get basic healthcare to poor and middle-class populations in emerging markets, we need to create solutions that integrate creativity, technology, and passion.”
Karim Ghazaoui, SF ’14, Morocco/France
“I was impressed that a system as basic as SMS could be used to prevent the shortage of medicine. And I realized that I could actually make a difference in this area with my Internet business background.”
Jae Yong Lee, SF ’14, Korea
“Meeting the protagonists in the case studies and hearing their stories made me realize the scale and seriousness of the healthcare problems in developing regions. But it also revealed a silver lining—how organizations are combining their skills and experience to create powerful solutions.”
Masaru Yokota, SF ’14, Japan
“This course made me realize that while there are many well-funded startups with innovative ideas willing to tackle healthcare issues in frontier markets, the main obstacle lies with a country’s lack of infrastructure and quality control. The absence of a safe supply chain prohibits many citizens from getting access to quality healthcare.”
Meredith Randolph Quick, SF ’14, United States
“We learned about very unique, innovative approaches but, just as important, about models that expertly combined elements of traditional approaches to dramatically improve healthcare delivery. The in-class discussion was enriched by visits from high-profile leaders in the healthcare industry. The course is a must for any student interested in healthcare.”
Ulrike Fiona Domany-Funtan, SF ’14, Austria
The Affordable Care Act has generated many defenders of the existing free market healthcare system in the United States, but the statistics underline the need for a major overhaul. The United States spends more on healthcare than most industrialized nations with per capita spending at 17.7% of its GDP, compared with Sweden (9.5%), Denmark (10.9%), Canada (11.2%), and Germany (11.3%)—all countries with reputations for top-notch healthcare.
Despite that spending, Americans don’t visit the doctor regularly—only 4.1% as opposed to 13.1% in Japan or 9.7% in Germany. Hospital stays are also shorter in the U.S. but cost more than twice what they do in France or Germany. These statistics come as no surprise to three MIT Sloan Fellows who are at the forefront of healthcare delivery innovation in the United States. With firm footing in both the worlds of medicine and management, they each are working to improve that statistical profile-and the U.S. healthcare experience.
Craig Bunnell, SF ’08
Chief Medical Officer
Dana-Farber Cancer Institute
Bunnell acknowledges that new health insurance realities have posed prodigious difficulties, but he’s not interested in rolling back time. “Change is difficult,” Bunnell says, “but necessary. We have an ethical and economic imperative to repair this nation’s healthcare system. Yes, we felt the disruption of the Massachusetts healthcare law, but we also saw the impact. After the legislation was introduced, that percentage of uninsured in Massachusetts dropped to one to two percent—the percentage of uninsured across the rest of the country is somewhere around 16%.”
For Dana-Farber, “disruption” meant a potential barrier for some patients. Although the hospital is one of the most prestigious cancer centers in the world, new low-cost health plans created by the legislation prohibited some patients from turning to Dana-Farber for care. That barrier to access threatened the Institute on myriad levels. “The revenue we derive from patient care also subsidizes a wide range of patient support services and helps to fund our research into new and better therapies.”
Bunnell points out that while Dana-Farber collaborates with pharmaceutical companies to conduct research on new treatments, pharma-sponsored research tends to be inclined toward discoveries and drug development that also will fuel company profits. Dana-Farber’s research program, on the other hand, is not focused on the bottom line, concentrating instead on promising treatments that may not necessarily result in a high financial return on investment. If Dana-Farber has to cut back its research program, critical cancer research will be curtailed—research that might not be pursued by any other entity.
Bunnell says that the new health legislation forced Dana-Farber to revisit its mission. Should the hospital cut services that don’t pay for themselves, such as palliative and survivorship care? Should it eliminate expensive “extras” like social workers, psychologists, nutritionists, resource specialists and patient navigators—services that Dana-Farber considers critical to those with cancer and therefore the organization’s mission?
“Our ah-ha moment was that no, we did not want to cut that over-and-above level of service,” Bunnell reports. “In fact, we decided we would increase our level of service. We would attract patients because of the sheer quality of our care.” Bunnell says that every new patient who calls Dana-Farber can choose when they want to be seen—even the very next day. The focus, he says, is always on the patient, not the providers.
Bunnell notes that although the hospital administration has resolved to maintain that high quality of care, it also is working to keep prices low enough to serve the broadest possible population. Its cost-cutting measures, however, actually further increase the level of service. “Because we treat so many patients with so many different kinds of cancer, we are establishing a broad range of evidence-based clinical pathways to ensure the safest, highest quality, consistent, and effective care. We don’t have to reinvent the wheel every time a patient comes through the door. We know how to proceed without costly unnecessary steps.”
Dana-Farber, Bunnell points out, is the only cancer hospital to offer genomic testing, free of charge, on the tumors of every new patient as part of a major research study funded by the Institute. As we move to start linking what we learn from genomic testing with our vast clinical experience, we are poised to make advances at an ever-accelerating rate—advances that were previously unimaginable.”
Bunnell says that Dana-Farber is also launching multiple new research programs that build on the decades of clinical research they’ve performed since achieving the first remissions in cancer with chemotherapy in 1947. One recent venture is a new immunotherapy center—the first of its kind—aimed at developing immune therapies that can be used to treat many different cancers. “What we learn from our research fuels our care which, in turn, fuels our research. If new healthcare legislation makes us rethink what we do and why we do it, it’s all good. We improve both our level of care and our bottom line.”
Melinda Morin, SF ’10
Pediatrician, Boston Children’s Hospital
Complex Care Service/Program for Patient Safety and Quality
During her time as an MIT Sloan Fellow, Melinda Morin took an avid interest in systems engineering. “I became enthralled with complex systems—like nuclear submarines—and with figuring out how to mitigate risk.” When Morin, a pediatrician who has always had a special interest in patient safety, returned to work at Boston Children’s Hospital after graduation, it was only natural she would take a good hard look at her own equally complex system—healthcare.
One of the innovations Morin is a part of is the hospital’s experimental Complex Care Service (CCS), a team of experienced pediatricians, nurses, social workers and administrative assistants. Through the CCS, Morin and her colleagues provide comprehensive, coordinated, and centralized care for children with complex medical and developmental needs. A CCS team now caring for a baby from Dubai with particularly confounding symptoms, for example, includes a geneticist, cardiologist, infectious disease specialist, immunologist, rheumatologist, pulmonologist, anesthesiologist, and a specialist from the Vascular Anomalies Center. Traditionally in healthcare, these specialists would visit the baby separately rather than as part of a collaborative team dedicated to the child’s coordinated care.
Morin says that researchers at Boston Children’s Hospital are looking at the Complex Care Service model to answer the question: What would happen if every individual in the healthcare ecosystem had a team dedicated to his or her health? Assuming the patient would receive better care, could the system be rendered economical? Morin points out that if every patient had a basic primary care team consisting of an internist, a nurse practitioner, and a clinical assistant that distributed responsibility the model could well be economical by increasing efficiency and mitigating morbidity. Each member of the team would know the patient’s medical history and be able to respond when the patient had a need, involving other team members as necessary. If the patient developed a heart problem, for example, a cardiologist would be invited onto the team.
Morin isn’t surprised at the brouhaha surrounding the Affordable Care Act. She points out that over the last several generations, most healthcare innovations have been focused on gadgetry like robotics and devices. “Of course, such inventions have added immeasurably to the quality of life of many people,” she adds, “It’s just that few pioneers have applied that level of ingenuity to the operations side of healthcare. Our medical devices might be 21st century, but our processes are ancient.”
Why the failure to move forward? “Change is hard enough in other aspects of our lives,” Morin says, “but healthcare is an especially sensitive area. We feel vulnerable when it comes to our health.” More than that, though, she says that current healthcare reform requires a seismic shift in perspective, looking at healthcare as a patient-centered rather than a physician or hospital-centered system. “Like any service industry, healthcare should be designed around patient needs, but it hasn’t been. The prevalent model often focuses on the convenience of the provider.” She notes that it can be every bit as difficult for patients to make that shift in perspective as it is for medical professionals because the existing physician/patient dynamic has been in place since any of us can remember.
“With models like the Complex Care Service,” Morin says, “we hope we can show the medical world that new systems can make everyone’s life better.”
David Rosenman, SF ’12
Assistant Professor of Medicine
Mayo Clinic College of Medicine
Founding Director, Preclinical Block
Mayo Medical School
David Rosenman is changing medicine by changing medical education. As Director of the Mayo Clinic’s Innovation Curriculum, he is creating a new breed of doctors who are well-rounded and patient centered—physicians as adept at communication as they are at diagnosis. Included in FierceHealthcare’s “9 People to Watch in Healthcare,” Rosenman oversees a key component of the four-year curriculum at Mayo Medical School. It’s called the preclinical block, a transition course for medical students that takes place at the very midpoint of their medical school experience, that all important segue between the first two preclinical and second two clinical years. The Mayo Clinic’s preclinical block is the longest and most comprehensive in medical education, spanning the breadth of healthcare—pediatrics, surgery, internal medicine, and a dozen other specialties.
Rosenman gives his students insights into new models of care, emerging technologies, and nontraditional medical school lessons about the realities of caring for patients in the 21st century. “Students at Mayo focus on topics that in real life are key to healthcare but are often absent from formal medical curricula—issues like intercultural and collaborative communication, leadership, even love. And thanks to my experience at MIT, I am looking to integrate system dynamics into the course as well.”
Rosenman is keen on keeping the methodology innovative as well. This year, he and his colleagues are exploring ways in which parts of the preclinical block can be “flipped” in the manner proposed by MIT Alumnus Sal Khan, who was the speaker at Rosenman’s MIT graduation. Khan believes that students might be able to concentrate better while listening to lectures at home on video, rewinding and reviewing as needed, while dynamic project-based learning could take place at school with classmates.
Rosenman also “flips” the student’s perspective about what’s important. “Regarding humility, we tell students, 'best to start now.’ There is some irony in the fact that the medical school application process invites and rewards evidence of personal and individual accomplishment, but the day medical students set foot into a clinical setting— especially at Mayo Clinic—the weight of these qualities takes a back seat to humility. Biomedical acumen is a critical prerequisite to being an excellent clinician, but it will get us doctors only so far. We tell students that they’ve chosen a profession of service and that they soon will be spending the better part of each day out in the world providing that service. As long as they remember to take care of themselves, a thoughtful awareness of others will go a long, long way.”
We’re already at work on the next MIT Sloan Fellows Program Newsletter. Please drop us a line at email@example.com if you have ideas about themes and news items for future issues.
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