From the MIT Faculty Newsletter, Vol.
XVI No. 1, September 2003.
The following interview with Medical Director William Kettyle [WK] was conducted by the Faculty Newsletter [FNL] on August 6th of this year.
FNL: Let's start with a little background info, and how you wound up here at the Institute.
WK: I've been in practice in Cambridge for about 25 years. For the first 15 I was at Mt. Auburn Hospital, practicing internal medicine and endocrinology. About 10 years ago I came to the MIT Medical Department. I have had a long relationship with MIT via the HST Program where I've taught endocrine pathophysiology for 20-plus years. I had a long-term chronic job offer from the Medical Department and I finally took them up on the offer to come here. Although I came as a clinician, I've gradually become more involved in administrative matters. For the last three years I have been the medical director. My interests are in patient care and in teaching people how to take care of patients. I continue to teach in the HST program. Although I continue to see patients and to teach, much of my time is now spent on things administrative.
FNL: How many people do you administer? What's the staff?
WK: There are approximately 280 employees and about 100 contractors who work in the Medical Department.
FNL: Full-time positions?
WK: There is approximately 186 full-time staff. The care is provided by 150 full- and part-time clinicians physicians, dentists, psychologists, optometrists, nurse clinicians, and physician assistants.
FNL: Health services at the Institute, we believe, are viewed by many faculty and staff as one of the most, if not the most, important quality of life resource. And the consensus of concern seems to be the possibility of the Institute outsourcing health services . . . especially given the budgetary difficulties Institute-wide. What do you see as the broad picture for the future of health services here?
WK: Over the years we've tried to accommodate to the changes that have occurred at the Institute and, at the same time, to accommodate to the changes that have occurred in the medical world around us. The vast majority of care needs can be met here at our facilities. And if we can't meet the need, we try to facilitate the best care in the community around us. So it's important that we maintain good relationships with surrounding medical resources to back up our operation here.
The financial constraints that the Institute is under will have an impact, and are having an impact. They are requiring us to look carefully at the services we offer, so that we're focused on the services that the Institute needs. We need to be sure that we're using our resources as efficiently as we can so that we can maintain the availability of one-site, low-barrier, high-quality care.
FNL: Were you given a specific percentage for budget reduction that all of medical has to take?
WK: We were given a budgetary reduction target. The percentage was seven percent for FY04. A major question is seven percent of what number? A large amount of money goes through us and not to us. Money, largely Health Plan premiums, goes through us to pay bills for hospital and other services provided outside the Medical Department. The seven percent reduction was made on an expense base of approximately $28,000,000 and amounts to about $2,000,000. In addition,for a number of years the Medical Department has been over spending its budget and dipping into reserve funds. A significant part of our budget-related actions were to further decrease our spending in order to stay on budget. Over half of our expense budget is balanced with income from Health Plan premiums and fees for service. Approximately $12 million a year, or something of that magnitude, comes from the Institute to support the care of students, job site-related care, and community health activities. With about 10,000 students, we estimate that the cost for the care of students is about $1000 per student per year.
FNL: Do the students pay that, or does the Institute?
WK: Many schools charge a "Health Fee" to students. At MIT the cost of student health care is imbedded in the tuition.
FNL: So it's all rolled into the tuition, including the graduate tuition.
WK: Right. Supplemental insurance costs are not covered by tuition. This coverage pays for care that cannot be provided at the Medical Department. The cost of this supplemental coverage has gone up dramatically which places increased financial pressure on our students.
FNL: There's been a lot of concern about popular, well-respected doctors leaving the Institute. Lori Wroble in gynecology and Eric Schwartz in dermatology, to name two. So the questions are: are you replacing people, and why do you think they're leaving? Does it have anything to do with a tightening of resources or more work because of budget cuts?
WK: I think many of the personnel changes are the result of changes in personal life circumstances. For example, Dr. Schwartz moved to California and is now married. Other changes have been, for the most part, because of personal issues, lifestyle changes, moves, or something along those lines. However, I think I'd be less than frank if I didn't say that Lori Wroble's departure was in part related to the decrease in resource availability. We have and will maintain on-site services in dermatology and in obstetrics and gynecology. We are in the midst of working out ways of dealing with these issues. We are forging partnerships or recruiting to maintain these important services. Many of our clinicians have been here for many years, and our turnover rate is relatively low. Although that doesn't help make the person who has just lost their dermatologist or their gynecologist feel any better, but compared to other medical practices, our turnover rate is relatively low.
FNL: It seems that women faculty members are most concerned about the health care situation at the Institute, with the desire for more women doctors, for example. One would assume that's an issue aside from any financial question, although they are connected. What with the increase of women at the Institute and that traditionally more doctors were men . . .do you see that at all the direct need to hire more women?
WK: Absolutely. And one of the issues that we're trying to address now is finding the best way to meet the health needs of women in our community. We had a very interesting meeting with representatives of the women faculty. The meeting was sparked largely by the changes that are occurring in the Obstetrics and Gynecology Service. The changes are fiscally driven at some level, but at another level it's, I think, a process of making sure that we are using our resources in a way that best serves this community. In the OB/GYN area it is largely an issue of scale. The birth rate has been relatively stable and relatively low and the fixed costs of taking care of a relatively small number of deliveries are great. And what we need, I think, is to forge a partnership with a group that can spread out some of the fixed costs of coverage. The goal is to continue to have on-site obstetric services and to also have the staffing to meet the GYN needs of our community. During the discussion with members of the women faculty it also became very clear that there was an important need for enhancement of primary care services for women in our community. We are in the process of thinking together with the women in our community, among ourselves here and with colleagues in the medical community around us, about designing a system that would meet the health care needs of women. Delivering babies is clearly important, but it is one part of the care need. Rebalancing our spending on obstetrics will allow us to redirect resources in a way which I think will enhance the care of women in the MIT community.
FNL: I don't believe there's been a permanent replacement for Dr. Schwartz yet.
WK: We have not been able to find a permanent replacement.
FNL: So it's not for lack of looking.
WK: It is not for lack of looking.
FNL: So why do you think that is? And have there been other people in areas other than dermatology who have come in recent years? And if not, why not? And what can one do to make it more attractive?
WK: We have several new clinicians who have joined us over the last several years. Some join our department as contractors, as opposed to employees. We've been shifting away from hiring very part-time employees. When the care needs require the services of a very part-time clinician (less that 50 percent) we try to meet the clinical need with a clinician who provides services as a contractor - paid for time worked, without benefits. We can often control costs and provide service in a more plastic way by use of contractors. When the need supports more time, greater than 50 percent, regular employment is the preferred route.
FNL: And we don't have those people now? Or are you trying to get more people in?
WK: We have about 150 employed clinicians and about 100 contractors who provide services here at MIT Medical.
FNL: Are those cheaper?
WK: Contractors may be less expensive largely because we don't have to pay benefits for them. The hourly rate or the contractual rate is, in large measure, market driven. Our commitment to them and theirs to us is relatively less than an employee. In spite of this we have had many very long-term contractual relationships with some of our clinicians.
FNL: That 50 percent figure is important.
WK: Exactly. You need 50 percent effort to become benefits eligible. Retaining good people is something that we're very concerned about and want to be sure that we're making this a comfortable place to work. Workplace environment (an area highlighted in our strategic planning process) has been an important focus of several activities in the last couple of years. With regard to dermatology, the competition in the outside world is significant. Many dermatologists can make very large amounts of money doing cosmetic things like tucks, laser treatments, and this and that. The competition is great for skilled dermatologists.
FNL: So that particular one you're going to replace. But in pediatrics, for example, my understanding is that people have left and that they're not going to be replaced.
WK: The issues in the Pediatrics Service are also issues of scale. The number of children served in the population is relatively small and we felt, as we reviewed things, that we had the capacity to care for our population of children with a slightly reduced force of pediatricians.
FNL: So the flip side of that point is what about gerontologists? Have we got one?
WK: We have one. You're looking at him.
FNL: You're the gerontologist. Do we need another one?
WK: [LAUGHTER] Most of our internists are very comfortable with the geriatric age group. But there is only one of us who is board certified in geriatrics.
FNL: There has been a lot of discussion the last several years about people who would love to teach at MIT but don't feel they can afford to - the cost of living, the necessity of living further away from campus, what about their kids. Have you found anything like that in the hiring, that people are hesitant to relocate around here?
WK: The Massachusetts Medical Society provides information that suggests that Boston, and Massachusetts in general, are less desirable places for physicians to work, because of salaries, because of cost of living, because of some issues of job satisfaction, malpractice costs, etcetera. In spite of this, I don't think that it has been a huge factor in our hiring.
FNL: Have you hired mid-career positions or have they been more at the entry level?
WK: We have hired more in the mid-career level than at entry level.
FNL: Do you feel you're able to fill the need with the contractors for example, in dermatology? Someone could make an appointment to see a dermatologist here. You're not going to send a patient to a private physician somewhere else, are you?
WK: Patient care is obviously the most important thing. To the extent that we can provide the services here, we will make every effort to do that. But when we do have staff deficiencies, we will try to make them up in the community.
FNL: Prospective graduate students and undergraduates are often told when they apply that the medical department is a real resource that other places don't have. From your perspective, would you say that's an accurate statement?
WK: Yes, I think so. I think we have a breadth and depth of services on campus that is at the top of the heap of comparable institutions. Harvard, Yale, and Stanford are the places we compare ourselves to most frequently. In addition to caring for students these universities also have an HMO or provide medical services for faculty and staff and their families.
FNL: Do those other places have a hospital or infirmary, as we do?
WK: Harvard has an infirmary. Yale has an infirmary. Stanford uses the Stanford Hospital.
FNL: Stanford's is right on campus, though. Let's tie this into the gerontology question. The infirmary seems to be an incredibly important facility for retired and older faculty. But it's something I would think that's particularly vulnerable.
WK: The infirmary is a wonderful resource. It's a place where any one of a number of different types of care can be provided. End-of-life services can be very nicely done there. Immediate post-operative recovery after an operation we can do very comfortably there. We also serve the care requirements of students who may be living in a dormitory or independent living group. For example, a student with mononucleosis, if he or she lived nearby, could go home for a few days and get care. If they live in Cleveland or if they live in Karachi, they can't go home so easily we can provide the care here.
The Inpatient unit provides a range of very valuable services for our community. The use of the inpatient unit, however, is at a level that makes the cost per case relatively high. This is a function of the fixed costs of running the facility and a relatively small volume of people using it. Is it the best use of our resources? I think it is a good use of resources. In my view the care benefits trump the cost, but we clearly need to be sure we are using this resource as effectively as we can. One possibility is to decrease the size of the Inpatient Unit to the size that will just meet the needs of students and a few post-operative patients. When we analyze that option we find that the gain is mostly in space and very little in dollars because of the relatively high fixed costs of 24/7 staffing around the year. Another option is to think about whether we could use the facility for patients from other educational institutions. On the one hand that has a lot of charm; on the other hand we don't want to dilute our commitment to this community. The Inpatient Unit is an expensive resource but it's a wonderful resource, a valuable resource.
FNL: Do you view this facility in any way being in danger of being outsourced by the institution or severely cut back in some way, or can the faculty be at least somewhat comforted by the thought that the director would say that this is a resource that all the highest levels of the Institute people appreciate, and is likely to be preserved for the indefinite future?
WK: I think that we will endure for the indefinite future. We play an important role in the life and care of the Institute. But I don't think that this immunizes us from the need to responsibly use our resources. We need to be sure that our costs are realistic and that our services meet the needs or our community.
FNL: So do you anticipate the rate going up for the MIT Plan or the Flexible MIT Plan?
WK: Rate increases are in many, many ways a function of our outside costs, of costs that we don't have a whole lot of control over. Because we are buying many of the services we need for our community in the same medical community in which Blue Cross and the Tufts Health Plan are doing business, we are faced with similar costs for hospital services. The other large driver is the increasing cost of pharmaceuticals. Unfortunately, there will be an increase in our rates. We are working hard to keep that increase as small as possible. Success at some level is a smaller increase. No increase is unrealistic.
FNL: What about the Lincoln Laboratory Medical Center? It's beautiful, but is it cost effective? Are you the director there as well?
WK: Yes I am.
FNL: What fraction of the 280 employees are out there as opposed to here?
WK: There are about 15 clinicians and support staff who spend time at the Lexington facility. Some of these are there for only one session a week or less. There are four to six staff members there on a daily basis. We've always provided on-site job-related care at Lincoln Lab, and so with the opening of this center three years ago, we augmented the services available there. Our hope was that it would build the Health Plan membership. And we have seen some growth in Lincoln Lab-related Health Plan membership. But the volume there is relatively low. And from simply an economic point of view, it's not very cost effective. From a care point of view, from a community point of view, and from the point of view of our important relationship with Lincoln Laboratory, it has been very successful, but at a high cost.
FNL: What about the changes in psychiatric care? That's been in the news for the last couple of years, the increase in psychiatric attention to the students primarily.
WK: The use of mental health services by students has increased significantly both here and across the country over the last several years. The need for psychiatric care is quite clear and was underscored by the report of the Mental Health Task Force. Their report pointed out a need for more outreach, and called for more easily available mental health services. We have been working hard to try to respond to their suggestions and to meet the mental health needs of our community. We have increased our mental health staff by about four people over the last year, increasing our outreach efforts, and increasing our hours of availability for mental health services.
FNL: But isn't it all one pie, so if you increase that by four, aren't there four other medical people that cannot get a chance to be hired?
WK: We requested additional fiscal support and with a salary supplemental were able to increase the Mental Health staff. So the pie has indeed gotten a little bigger.
FNL: What about the increase in the pharmaceutical co-payment? Is that supporting anything else besides the drugs?
WK: We have a three-tier pharmacy formulary system. These arrangements are designed to nudge patients and clinicians toward lower cost options for drugs. Brand name and heavily marketed drugs are available, but usually at a higher cost to the patient. Our three-tier formulary system is not at all a revenue generating endeavor. It has, however, effectively helped us contain the rapidly rising costs of pharmaceuticals for our Health Plan and for our patients.
FNL: Is there anything else you'd like to add before we close?
WK: We want to preserve the services and the on-site availability that we provide on this campus for students, for faculty, for staff, for everyone who is a member of the MIT community. We need resources to do this. Our resources come from well-run and cost effective health plans and from the support of the Institute for the care of students, employees, and for community health activities. In addition to needing adequate resources we must be sure that we are deploying them in responsible, cost effective ways that meet the needs of our community. We want to focus our efforts and resources where they are most needed and can be most effective. We are both part of and insulated from the medical community around us. Medical costs are rising relentlessly. The challenges are significant and the need for focus and continued monitoring of the needs of our community is great.
I realize that some of the changes that are happening and that we are making are having a significant effect on many members of our community. Changing clinicians and changing jobs is never easy. We are trying to keep the changes to a minimum and the service to our community at a maximum.
FNL: Thank you very much.