What Do You Do First?


Leonard Zwelling

There’s a lot to be done at MD Anderson. Making a problem list for this newly freed patient (the cancer center) doesn’t take the best resident in the class.

First, there’s the money. How does one guarantee a positive revenue stream in a large, academic cancer center in 2017? With over 20,000 employees and millions of square feet of air conditioned space, the fixed costs are staggering and the revenue stream is always variable depending on both patient volume and reimbursement per unit of work. That’s a knotty problem to approach in any business. In specialized academic health care, it’s doubly challenging when grant revenue is falling and the overhead on grants doesn’t really bear the actual cost to the institution of doing the research. From a financial point of view, education is a loss leader and so, largely, is prevention.

Then there is the question of strategy. MD Anderson has moved from a niche market, product differentiation strategy in the 1980’s, doing the specialized cancer care of Texas, to a necessary broad market low cost leader strategy because the paying agencies have curtailed reimbursement. How does a super-specialized place for care delivery survive when competing with lower cost rivals that do not have the burden of research and educational missions? That’s also a tough one.

Let’s add faculty and employee morale at an all-time low. Well, not really. It’s better than it was under the last administration and Hicks and Hahn have done a great deal to improve morale, but as ad interim leaders, they can do just so much. The new, permanent leader will have to build upon the good will engendered by the temp help and that will also be a tall order.

If you add in the problems of ameliorating a top-down governance system, restoring confidence in the ethics of the leadership, eliminating the ludicrous drive to base the future financial stability of MD Anderson on the profits from commercialization of research, and the greatest challenge of all, that of cancer itself, Dr. Pisters’ challenges are broad and deep.

But what do you do first?

Number one will be to emphasize the critical nature of the shared governance structure to make sure that everyone has a stake and a say in how MD Anderson moves forward.

Number two is to restore patient care to its rightful place as the primary activity of MD Anderson. That means rewarding people who do it well. It means making sure patients’ phone calls are answered by a real person 24/7, and it means increasing the efficiency with which patients are cared for in the clinics. It will mean better outreach to referring physicians. A greater consideration of the cancer problem as it applies to the Houston community—particularly cancer prevention and screening–is also in order.

Number three, what is the strategy? Will MD Anderson continue to see every single cancer patient that wishes to be seen there or will there be some prioritization for those patients who the institution can uniquely help or who qualify for a research protocol? There’s no right answer to that one, except not answering it clearly is the wrong answer.

Finally, the new leadership, and there needs to be a lot of new leadership, needs to articulate the plan and behave accordingly. Talk the talk and walk the walk. That means no grandiosity and no fancy couches.

I am sure you can think of many other problems I have forgotten. Communicate your thoughts to your faculty and staff leaders. The one thing I am sure of is that one person cannot do it all and that MD Anderson will do best when the entirety of the faculty and staff is engaged in solving its problems.

Leonard Zwelling