The Mayo Clinic has an international reputation for the quality of its care, but few people know that it's also one of the most efficient health care systems in the country.
President Barack Obama has suggested that Mayo could be a possible model for a new way of structuring care. He told members of Congress last month that Mayo manages to provide some of the best health care services in the nation at half the cost of some of its competitors with lower quality care.
Before surgeon Dana Thompson can begin her first surgery of the day, she previews all of her cases with her surgical team.
Mayo requires its surgical teams to have these morning briefings. They're designed to help staff members think about all of the possible issues they might encounter in the operating room that day.
Thompson relies on her team to help her catch anything that could trip them up once surgery begins.
On this day Thompson's colleague Amy gets a gold star for thinking ahead.
"Did you want any Mitomycin or Kenalog available for any of these patients today?" Amy asks.
"No," Thompson says.
Thompson says that's an example of something she might not have thought of.
The question is not, “Can you be the Mayo Clinic?” Can you use principles that we've established or implemented here and apply them locally to make a difference?Dr. Michael Joyner
"Since they know my routine," she says, "they're asking do I need the medication whereas if I did need it and we're in the middle of the case that's like what, how long does it take to get it from pharmacy."
Amy says Mitomycin can take 20 to 30 minutes to get from the pharmacy.
A delay waiting for medication means more time under anesthesia which costs money and can cause complications. Anticipating these problems is important because it can potentially avoid unnecessary care and expense.
In surgery, Thompson is paired up with the same crew every day - so her colleagues are familiar with her work style and are better able to anticipate what she needs during surgery.
But if you ask Thompson what distinguishes her employer most from other clinic and hospital systems, she'll tell you it's all about philosophy.
"I think when you work somewhere where the needs of the patient comes first, it really allows you to practice medicine without putting other things in to clouding your judgment," Thompson says.
What Thompson means by "clouding your judgment" is that her medical judgment is not influenced by pressure to pad the bill with extra tests or unnecessary treatments. Her fixed salary won't increase by performing more treatments.
Mayo's salary system is quite different from what you'll find in many other health care systems where specialists from different group practices have privileges at hospitals but usually work for themselves.
In that environment there often is pressure to treat as many patients as possible because that's how physicians and hospitals make the most money. That, however, does not always the best health care.
A group of Dartmouth researchers has found that in regions of the country where the most money is spent on health care, those patients often do not have better outcomes. In some cases, they do worse. The Dartmouth data show that Minnesota hospitals are more efficient than many of their counterparts elsewhere.
Few can claim the type of savings that Mayo has been able to demonstrate.
At Mayo a team of researchers is constantly looking for better ways to give critical information to doctors. The clinic's annual research budget is just over $500 million. Part of the money comes from a huge federal grant from the National Institutes of Health.
Mayo uses its research money to improve its care and drive down unnecessary costs. On one project the clinic system saved $60,000 in just three months by getting doctors to do fewer blood transfusions.
Dr. Ognjen Gajic, who oversees the computer software that resulted in 1,000 fewer transfusions during that period, says Mayo's technology is only there to give doctors a helpful nudge when they need it.
"It is the minimum, just to steer them the right way and they can decide," he says.
Before the computer system, doctors frequently made the decision on whether to give a transfusion based on a patient's hemoglobin level, but the hemoglobin number isn't always the best indicator of whether a transfusion is really necessary.
Gajic says Mayo programmed its computer system to ask the ordering doctor a question.
"We just added one hoop...for the provider to order the transfusion, they have to pick why. They have to say active bleeding, peripheral ischemia, symptomatic anemia. They can even say 'other' and put 3x if they want, it would allow them to, but they have to think."
Adding that one computer question helped Mayo cut its blood transfusion complication rate in half, from 6 percent to 3 percent.
But being one of the most efficient health care providers in the country, doesn't make Mayo one of the cheapest places to get care.
Mayo officials said they don't know how all of their individual procedure prices compare to their competitors, but some Minnesota health plans don't reimburse as much for care at Mayo in large part due to what the clinic charges.
Mayo anesthesiologist Dr. Michael Joyner is an at Mayo says decisions like that are short-sighted because Mayo does save patients money in the long run by giving them better care and making it less likely that they'll have complications.
"Even if in specific examples where it might cost more here, we think the total lifetime cost would be lower," Joyner says.
To many patients around the state and around the world, it is worth it to spend more to travel to Mayo for care.
But for many others, especially those without health insurance, it's not an option.
Still, Joyner says the solution to the nation's health care problem isn't to bring more patients to Mayo. He thinks more hospitals and clinics should adopt Mayo's principles of care.
That might sound impossible to some health care systems that currently operate under a very different financial model and don't have a huge research budget, but Joyner says it's not an all or nothing proposition.
"There's a lot of reasons to say, 'We can't be the Mayo Clinic.' But the question is not, 'Can you be the Mayo Clinic?', can you use principles that we've established or implemented here and apply them locally to make a difference?" Joyner says.
"And I think to the extent somebody has tried that, every time they've tried it it works."
It's probably not realistic to think that very many health care organizations will be able to implement a Mayo-style salary system.
Bits and pieces of Mayo's model are already in place at a number of Minnesota hospitals and clinics, but only Mayo and the University of Minnesota have the enormous research budgets that enable them to examine everything they do.