Animated, criss-crossing the auditorium and filling the room with praise, Michael Porter, Ph.D., seemed more like a coach pumping up his team before the big game, than a Harvard Business School professor delivering a lecture to a room of health care professionals and researchers. He uttered the words, “win” and “goal” about a dozen times during Wednesday’s faculty address.
Founder of the field of modern strategy, Porter coined the terms “competitive advantage” and “value chain,” and practically defined the American work ethic. Author of 19 books, he is one of the world’s most influential business professors. And yet here he was on the University of Utah Health Sciences campus delivering a cheerleader-like call to action to fix a broken health care system. While the complex and overwhelming nature of this task has ended the political careers of more than a few well-meaning folks, Porter remains undaunted. He framed the challenge and mapped out the winning play. “We see where we have to go and what we have to do . . . . Now we have to get it done.”
Porter has credited his involvement in sports for sparking his interest in competitive strategy. He played football, baseball and basketball in his youth, and led the NCAA championship golf squad at Princeton. So it is, perhaps, that he’s able to bridge high-level economic theory with more pedestrian strategies of tangible value to business leaders around the globe.
What Porter served up, though, was more than mere sports metaphor. Like any good coach, or CEO for that matter, he led by example, delivering inspiration grounded in evidence and cloaked in encouragement. “Why are we all here? To deliver value for the patient . . . and value is the outcomes we’re achieving relative to how much cost we have to expend to actually deliver those outcomes,” he said. What we need is absolute clarity on our fundamental goal. “If we can get everyone aligned on that . . . we’re 70 percent of the way.”
Porter didn’t sugar coat things. Everyone knows what’s wrong with health care and how to make it right, he said. Yet for decades, the industry has stubbornly defied strategies for improvement. From consumer-driven reforms and capitated payments to electronic medical records, none of our “magic bullets” has worked.
That’s because, while these are all good ideas, “they don’t get at the real problem, which is the fundamental structure of health care delivery,” Porter said. “Until we tackle that problem . . . all these things are incremental overlays. We’ve got to transform the actual way we deliver care. How you work, how you measure how you’re doing, and how you define success.”
Porter’s 2006 manifesto, Redefining Health Care, was challenged by his friend, Princeton health economist, Uwe Reinhardt as: “A utopian vision . . . that might occur to anyone possessed of a modicum of common sense but not too familiar with the real world of health care.” But increasingly, due to a growing body of examples of institutions succeeding, health care leaders are coming around to Porter’s way of thinking.“
At the core of Porter’s theory is the Integrated Practice Unit, or IPU – or moving away from organizing health care around specialties, departments and lines of service to organizing it around the patient’s problems. For specialty care this means organizing around episodes of care, and for primary care, it means organizing around groups of patients with similar needs. “Primary care for a healthy adult is completely different than primary care for the elderly and frail,” he said.
Few disagree with him outright. “The biggest pushback has been that it’s impossible to do, that it’s the right idea, the fright framework, but it’s impossible to do,” Porter said. Pick your impossible problem: The intransigent fee-for-service system, burdensome and unhelpful electronic medical record systems, overtaxed providers and patients who defy categorization by IPU’s. There has been no shortage of reasons why it can’t be done.
“It’s a journey, it takes time and it’s not easy, but we can get there,” said Porter, once again setting an optimistic and encouraging tone for his audience team. “You’re on the path,” he said. “These concepts are clearly taking root in Utah.” Just don’t get hung up on the payment system, he advised. “Yes it’s screwed up. But if you start moving to value, and measuring, and proving that you can deliver it . . . over time, you will be the organization that wins.”
Academia is hierarchical, a space where faculty are judged by the size of their NIH grants and research portfolios. But entrepreneurs can have just as great an impact on patient care and the bottom line – and who better to tinker and dream than students?
Nate Rhodes, a master’s student in bioengineering at the University of Utah, wondered if catheters, which are the leading cause of hospital-acquired infections, could instead be a solution to preventing infection. The thin tubes, used to deliver or drain fluids, are pervasive in medicine. Catheter manufacturers currently use chemical coatings to keep bacteria in check, and providers take care to insert them under sterile conditions and keep them clean. But the coatings aren’t durable; they wear off over time, says Rhodes. “We wanted something that was better at killing bacteria and that didn’t require such close monitoring, something that could be used anywhere in world.”
That is exactly the kind of thinking encouraged by Bench-to-Beside (B2B), an annual competition and incubator program at the U. that coaxes the inventions of medical, engineering and business students into marketable medical devices. “If you can develop a device that’s affordable to most of the world, but built to U.S. standards, you’re benefitting not just developing countries but helping to improve and lower the cost of health care in this country,” says John Langell, M.D., Ph.D., M.B.A., director of the U.’s Center for Medical Innovation.
Catheter-related infections not only compromise patient care, they are also costly. More than $400 million is spent treating the most prevalent, urinary tract variety each year. And now that Medicare is no longer reimbursing health care institutions for care related to preventable complications, such as infections, hospitals must pay the tab.
Rhodes and a team of engineering and medical students started by searching the academic literature for existing technologies but they didn’t find anything that could be adapted to a catheter. Then they stumbled across a study by a group in Glasgow who used visible light—one wavelength of it—to kill bacteria in burn wards. “They used it in the ambient lighting in the ceiling, and we thought, ‘Why hasn’t anyone tried this before with catheters?’” Rhodes said. “We decided, ‘Let’s be the first.’”
B2B is unique in that it’s an incubator for new ideas rather than just a competition. With philanthropic support it provides seed funding for student teams. Its professional and faculty mentors represent diverse fields, from business and law to medicine and biotechnology. “No one else in country offers anything like it,” Rhodes said. His team was coached by experts on 3D modeling and given legal advice on how to file patents. Business faculty gave them crash courses in how to value a company that doesn’t have a sales record, and the optimal time for hiring a CEO.
Their invention: The bacteria-killing LIGHT LINE Catheter is being tested in the lab. Early results show the device, equipped with a high-intensity narrow spectrum light, is harmless to human cells, but kills 99.99 percent of bacteria. The startup company they created, Veritas Medical LLC has secured more than $100,000 in cash prizes and grants from national competitions. They’re in negotiations with a major device maker to commercialize the property and hope to get it FDA approved and to market by 2016. And every penny Veritas earns goes to its founders who were all undergraduate students when they started the project. “This is how we nurture tomorrow’s inventors and speed discovery of life-sustaining technologies while lowering health costs. It’s how we improve health care through innovation,” Langell said.
With nearly 50 teams now competing, up from 14 in 2011, B2B is the most popular program at the 3-year-old Center for Medical Innovation (CMI). Roughly 600 students have gone through the program, producing 87 technologies and 21 spin-off companies. But B2B is just one of CMI’s programs designed to nurture entrepreneurs—students, residents and faculty. BioInnovate is a master of bionengineering degree track attracting dozens of tech venture-minded graduate and post-doctoral students each year. This spring also marked the inaugural Games4Health Challenge, a design competition focused on therapeutic video games. Also under construction is a “gap lab,” or simulation center, where gamers can test their designs on patients. The market for health games and apps is huge; Price Waterhouse Coopers pegs its value at $4 billion. Peruse the app store and you’ll already find a glut of apps that promise to help you lose weight, avoid exerting yourself on “bad air” days, or manage your blood sugar. “Consumers have lots of choice, but they have no real way of determining which game is best, or clinically works. The Food and Drug Administration isn’t regulating them,” says Langell. “We’re studying these games, doing research, which the university is really good at, and giving them efficiency ratings.”
By the Numbers
The Center for Medical Innovation, which has grown five-fold since created three years ago, has a two-year return on investment of 285 percent, based on acquired research grants and philanthropic underwriting. Here’s a recap of accomplishments:
19 faculty patents filed
57 student patents filed
10 University patents licensed
3 clinical trials
25 tech ventures from CMI-facilitated technologies
Suleika Jaouad's future was exceptionally bright. She had just graduated from Princeton, moved to Paris and was on her way to northern Africa to launch her dream of becoming a foreign correspondent. Then came three unexpected and terrifying words: “You have cancer.” After five different opinions during her 22-month medical odyssey, the results of a bone marrow biopsy confirmed the dream-crushing diagnosis for the 22-year-old: Acute Myeloid Leukemia and a rare blood disorder called Myelodysplastic Syndrome.
“No one is ever prepared for those three words,” said Jaouad. “But cancer doesn’t care who you are or how old you are. It doesn’t discriminate,” Jaouad told the audience of medical professionals at the 2014 AAMC annual meeting in Chicago. Instead of reporting on foreign revolutions, Jaouad ended up “reporting from the front lines of a different kind of revolution: one that was taking place inside of me.”
“I thought that I would be behind scenes and tell others stories,” said Jaouad “It never occurred that story would be my own.” But as she begin looking around the waiting room in the oncologist’s office and browsing the cancer section at Barnes & Noble, she felt like nothing addressed her as a cancer patient. Nothing spoke to her. There seemed to be no one like her. She was inspired by broadcast journalist Amy Goodman’s definition of a journalist: “The role of reporters is to go to where the silence is and say something.” Jaouad decided that she could shine a spotlight on a group of people too often voiceless—the 70,000 young adults diagnosed with cancer every year.
At 23, she launched her Emmy Award-winning column, “Life, Interrupted” as part of the New York Times Well blog, reporting from the front lines of the bone marrow transplant unit at Memorial Sloan-Kettering Cancer Center. “Cancer is not something that makes you want to share,” said Jaouad. “It did not come naturally.” Inadvertently, she became a patient advocate, which was a cathartic experience for her personally, and also created a community—online and offline—to combat the intense loneliness she felt.
Jaouad finished her last cycle of chemotherapy in April and says she’s “deeply grateful to say that I’m finally cancer free.” Two weeks ago, she had her port removed and appreciated her doctor’s joke: “Congratulations, you’re being deported today.” She realizes now that she has been deported from land of disease to survivorship, which she admits has not been an easy transition. She references Susan Sontag’s metaphor for illness: “Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.” She adds that there is a no man’s land between those kingdoms where patients like her—who don't have active disease but feel far from well—live. “There is no map to guide you back to the land of the well,” she says. But she has a new mantra: “Health is about adding life to years, and not years to life.”
Panel moderated by Marsha D. Rappley, M.D., Dean, Michigan State University College of Human Medicine.
How can the field of medicine eliminate waste when students aren’t being trained on the best practices to do so? Vineet Arora, M.D., (@FutureDocs) tells us about the Teaching Value Choosing Wisely Challenge: a contest that involves everyone from medical students to department chairs in improving patient care at lower costs.