Building a Better Delivery System

Dr. Kevin Curtis, director of Dartmouth-Hitchcock Medical Center’s emergency medicine residency program, is among the first recipients of Dartmouth College’s master’s degree in health care delivery science. (Valley News - Jennifer Hauck)

Dr. Kevin Curtis, director of Dartmouth-Hitchcock Medical Center’s emergency medicine residency program, is among the first recipients of Dartmouth College’s master’s degree in health care delivery science. (Valley News - Jennifer Hauck)

Hanover — Nearly a quarter of the patients who show up in Dartmouth-Hitchcock Medical Center’s emergency department don’t have a primary care doctor.

Dr. Kevin Curtis saw this as a problem in need of addressing.

So a year and a half ago, he enrolled in a new master’s program at Dartmouth College where he could explore the issue as part of a course project. The system he and his classmates developed to help ER patients get a primary care doctor has been in place a year now.

“Using that system over the last 12 months, about 300 people have been successfully referred to a primary care doctor,” said Curtis, who is the director of Dartmouth-Hitchcock’s emergency medicine residency program.

Last month, Curtis was among 45 health care professionals to complete their studies as part of Dartmouth’s Master of Health Care Delivery Science program. Officially, this inaugural class won’t graduate until June, but its members have already begun to change health care practices using what they’ve learned.

Dartmouth has gained renown for its studies on health care, but the master’s program was designed to go beyond academic conversations and instead give health care professionals, lawmakers, policy experts and others the skills to go back to their jobs and implement the kinds of changes that will address the quality and cost concerns in the U.S. health care system.

“If (changing health care) didn’t happen, then we will have failed,” said Robert Hansen, a senior associate dean at Tuck School of Business who helped develop the program. “We need an army of change leaders.”

The United States spends more on health care than any other country, and yet trails several nations in quality of care . In 2000, the World Health Organization ranked the U.S. 37th in overall efficiency, behind much poorer nations such as Morocco, Costa Rica and Saudi Arabia. The WHO did not rank countries in its 2010 report, but a separate study that year by The Commonwealth Fund suggested the U.S. still lagged its peers. Of the seven industrialized countries examined, the U.S. ranked last in health system performance.

Launched in July 2011, Dartmouth’s health care delivery science master’s was one of Jim Kim’s major initiatives during his brief tenure as president. The program steps outside the normal boundaries of medical education for a hybrid approach, marrying the expertise of the business world with health care. Professors from the Tuck School of Business joined researchers at The Dartmouth Institute to develop a curriculum and teach classes.

The program was far from traditional. Most of the coursework was taught online, with students visiting the Dartmouth campus only a handful of times over the 18-month-long program. The remote instruction was necessary because the students were still holding down day jobs where they applied the lessons they were learning.

Students in the class of 2013 were mostly mid-career professionals, with an average of 23 years of work experience, according to the program’s website.

Three quarters of the students came from hospitals or some other kind of health practice, but the class also included students from state government, the insurance industry, higher education and the military. They were also geographically diverse, coming from 17 states, France and India.

One of Curtis’ classmates was Robin Lunge, who is spearheading Vermont’s push toward a single-payer health care system. She began her job as Vermont’s director of health reform only days before she started the master’s program.

What she learned about health economics at Dartmouth influenced how health benefits were structured in Gov. Peter Shumlin’s budget proposal, she said. Starting next Jan. 1, Vermont will implement its health insurance exchange, through which individuals and businesses may buy insurance. The plans offered through the exchange will replace state-run programs such as Catamount Health.

Part of Lunge’s job was to set standards for the kinds of plans that would be offered in the exchange. Rather than replicate what was offered in Catamount, Lunge applied her economics lessons to set premium costs and deductibles at levels that were affordable to as many people as possible.

“Having that consumer economics background gave me a different perspective,” she said.

Cleveland-native Bret Anderson came to the program after spending several years as a health care consultant, most recently with Booz Allen Hamilton. Anderson, a 2005 Dartmouth alumnus, said he was hoping to get practical and in-depth instruction that would help him solve the problems he’d encountered with his clients, which included the U.S. military health system.

One of his specific interests was to help health care providers improve communications with patients. But he also picked up some business acumen.

“The financial management was something I definitely picked up on,” he said.

Anderson is now pursuing a masters in business at Tuck and will spend his summer interning at the Cleveland Clinic.

When Jim Kim left Dartmouth last year to lead the World Bank, some in the college community worried that the initiatives he supported would lose steam and perhaps even disappear. To date, the health care delivery science program has remained intact.

The class of 2014 includes 46 students from equally diverse backgrounds and locations, including 16 states, Sweden, Kosovo, Rwanda, Singapore and China, according to the program’s website.

Vicki Loner is part of the class of 2014. Among her responsibilities at Fletcher-Allen Health Care in Burlington is involvement in the rollout of a new partnership between her hospital and Dartmouth-Hitchcock. The partnership, called “OneCare Vermont,” is an accountable care organization that joins Vermont hospitals and doctors throughout the state as they coordinate to lower costs, improve efficiency and maintain a high quality of care.

One of the questions Loner hopes to explore at Dartmouth is how to help doctors use patient data to improve their practice.

“One of the biggest challenges has been how you integrate data to help inform the practitioners on how they’re doing,” she said.

The master’s program continues to evolve, but Dartmouth faculty and administration are “fully committed” to its development, said Katy Milligan, the program director. Everyone understands that something needs to be done to resolve the crisis of health care in the United States, she said. This is one way of going about it.

“The time is right for this program,” she said.

Chris Fleisher can be reached at 603-727-3229 or