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Is the Mayo Clinic a Model Or a Mirage? Jury Is Still Out.

That, Mayo physicians said, has drawn doctors more committed to their professional obligations than to making high salaries by racking up procedures. "I didn't go to medical school to be the hardest-working guy in the room. I went to medical school to take care of patients," said cardiac surgeon Thoralf Sundt.

'In the Same Direction'

The emphasis on cost-effectiveness permeates the clinic. A single physician is assigned to coordinate each patient's care. A "clinical practices" committee preaches cooperation so that, for instance, vascular surgeons, neurosurgeons, cardiologists and radiologists agree on who would treat a carotid artery problem in the most cost-effective way.

The ethic is clear on the surgical floor, where schedules are organized so that patients spend as few days as possible waiting in Mayo hospital rooms. On a recent morning, colorectal surgeon Robert Cima assembled his 10-person team to review his four operations that day to ensure things would go smoothly. Nurses and other staff members tend to stay at Mayo for years, which also helps teamwork. "They know how I do it," Cima said. "Everybody knows what is going on."

In the transplant ward, 10 physicians, nurses and other staff members gathered for an hour that day to review patients. If Brooks S. Edwards, director of Mayo's transplant center, had a concern about potential infections, he could turn to the infectious-disease specialist in the room. "We're all rowing in the same direction," he said.

Mayo officials argue that smaller hospitals with fewer resources can follow suit. Gundersen Lutheran in La Crosse, Wis., for example, is known for its efforts to limit intrusive procedures at the end of life. Hospital chief executive Jeff Thompson cites one example of how its salary model keeps spending down: The hospital performs few Caesarean deliveries because its obstetricians are not worried about the number of cases they can get to and thus can wait out labor.

Staff members at the Marshfield Clinic, a network of 45 facilities in northern Wisconsin, have improved tracking of high blood pressure and other chronic conditions, saving Medicare $23 million this year. Under a pilot program, the hospital can keep $13.8 million of that savings.

"I'm skeptical of people who say, 'Only a few can do what Mayo does,' " said Mayo neurologist Mike Harper, who oversees its clinical practice. "It's not just our culture -- you can change culture overnight with the right incentives."

Demographics as Factor

It is a disparate group of skeptics that is taking on the Mayo mystique: federal health policy analysts, medical administrators and lawmakers in districts that would be hurt by the proposed Medicare reforms, and an informal network of health-care experts.

They agree that some communities milk Medicare with wasteful spending. But much of the low spending at Mayo and some other facilities, they say, is largely because they are dealing with a population that has fewer health-care needs: The Upper Midwest, for instance, has less poverty and lower rates of diabetes.

"If 98 percent of our patients were middle-class Scandinavians and no one was poor, we'd have low costs, too," said Cooper, from the University of Pennsylvania. "What happens is a poor person goes home and they don't have the support available that the average middle-class person has, and so they get readmitted at an astronomical rate."

Cooper and others note that Mayo's other facilities, in Jacksonville, Fla., and Phoenix, have total spending rates that are roughly proportional to those in other hospitals in those areas. And across the Upper Midwest, per-patient spending is low, including at centers where doctors are not on salaries.

Mayo's clientele is even more selective compared with other Upper Midwest hospitals. Its Rochester flagship accepts Medicare patients from outside Minnesota only if they are willing to pay a personal premium beyond normal Medicare coverage, a practice that screens out some who cannot afford to pay more -- and attracts patients deeply invested in their own care.

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