Interview with Dr. Robert Crone, former CEO of Harvard Medical International (transcript)

This is a transcript of a recent podcast interview.David Williams: This is David Williams, CEO of MedTripInfo.com. At the International Medical Tourism Conference in Washington, D.C. last week, I spoke with Dr. Robert Crone. He was, until recently, president and CEO of Harvard Medical International or HMI.Over the past several years, HMI has been involved in the development of world class health care facilities outside of the US, including Wockhardt Hospitals in India and Dubai Healthcare City. We spoke about accreditation, the impact of the globalization of health care on the US, and the Medical Tourism Association. Dr. Crone, thanks for being with me today.Dr. Robert Crone: It's a pleasure.David: Can you tell me what Harvard Medical International is, and what the relationship is with Harvard Medical School?Dr. Crone: Harvard Medical International was established by the Dean of Harvard Medical School in 1994. At that time I was invited to come start and develop it, and had been there for the past 13 years. I just recently left to go to the Huron Consulting Group. Harvard Medical International is a not for profit corporation, owned and operated by Harvard University. Its main goal was, and continues to be, to encourage high quality provision of health care, medical education, and biomedical research internationally, with the real vision to say that no citizen of the world should need to leave their own community in order to receive high quality health care. Over the past 13 years we worked with local and regional partners to develop regional centers of excellence, be they in medical education, research or in provision of care.David: And what forms have those partnerships taken? What's the length of involvement and the intensity of it and so on?Dr. Crone: It varies somewhat, but typically they are a minimum of five years in duration. Some are as long as 15 years in duration in terms of contractual relationships whereby we have very specific goals and objectives and inputs that are done on a regular basis, and are done on a fee for service basis. We have used in the past approximately 250 of the Harvard Medical School faculty per year to implement some of the very specific aspects of programs, and we have a team of about 60 to 65 professionals working full time at Harvard Medical International.David: Boston, Mass., where I live, is one of the highest cost places for health care in the world, and the Harvard system is certainly part of the excellence there but also one of the drivers of the high costs. When you talk about people being able to have access to the top quality health care within their local areas, how does that relate to resource constraints that would be present in most other places?Dr. Crone: Well this is really the interesting phenomenon, which has been occurring over the past decade. If one looks at the developing world, obviously it's not a monolithic look. If you look at what we would clearly refer to as the emerging economies where about two-thirds of the world population live, many of whom are in India, China, Southeast Asia, and certainly in Latin America as well, the purchasing power in the economies of those regions of the world is becoming quite strong. And therefore there is the opportunity to support a much higher level of health care.At the same time what we are trying to impart is quality, transparency, and a systems approach, but not necessarily at the same cost basis. So one is now seeing today in places such as India, for example, where one can get very high quality, very transparent health care at an equivalency of what one might find in the United States for one tenth of the price.David: And is the price difference just related to the level of economic development and therefore the costs of that area or is there something different in how the model is being set up? The reason I'm asking the question is to probe whether there any lessons learned from setting up a first class facility in a new area that we might be able to bring back to the US for cost reduction.Dr. Crone: It's a mix. There's no question that cost of living and salary rates for personnel probably is the major driver, but there are many others. In the United States it is nearly unheard of to create a greenfield project, namely building either a hospital, or a medical school or an academic medical center from the ground up. There is a cost to cobbling together legacy systems, in such a way that it is very difficult to do that without compounding the costs of the existing environment. Obviously many of the institutions in the US are in outdated facilities in downtown communities that are very difficult to access. All of this drives up cost.Also, as we compete for the very best professionals in the Untied States, that drives up costs; recruiting costs go up. Retaining people, the costs go up; union costs, liability costs all of these things are not major costs in many parts of the emerging economies of the world. That's not to say that ultimately that may catch up. I don't think they will ever catch up to what we have been able to develop here in terms of the costs of health care. But there will be an equalization over time, I think.David: When you look back at your time at HMI what would you point to as perhaps your greatest success and then maybe a shortcoming, something you wish could have gone a little bit better?Dr. Crone: I think that probably our biggest project which has not yet fully come to fruition is Dubai Healthcare City. This is a very interesting concept in the sense that it is an economic free zone, which in the past has really been devoted more towards manufacturing. But to apply this to the service industry, to create the regulatory environment that really encourages high quality, transparent health care has really been very, very fulfilling and at the same time it's still a work in progress so I can't say it's completely a success by any stretch of the imagination.I think that the biggest challenges that we've had in implementing programs overseas are always cultural differences, challenges of moving people and ideas around the world. And sometimes that works and sometimes it doesn't, frankly. So I think that over the 13 years that I was involved with this I think we learned a great deal. I think that Harvard University was very prescient in putting this together. At the same time, there've been changes in leadership at Harvard University and their priorities are changing. So, whether this is going to continue under the current set of circumstances remains to be seen.David: What's your view on the concept of medical tourism in general and also the relationship between medical tourism and what Harvard Medical International has been doing?Dr. Crone: I see it purely as an unintended consequence of developing regional centers of excellence. Frankly speaking, it has never been our intent to create a globalized health care system, but at the same time, it reflects the fact that there are regional centers of excellence at a global standard. If that's the case, then patients will start shopping around, both in terms of quality and cost. This requires outcomes reporting, it requires global standards in terms of what facilities and providers do and how they do it. So, it really is a reflection of the success of the development of these regional centers.David: What's your view on accreditation and how does accreditation, for example preparing for JCI accreditation, relate to the sort of work that HMI would be doing?Dr. Crone: I think accreditation is critical, but I also see it as the floor and not the ceiling and that is it is the minimum standards that are in an institution to meet a global standard. I think that putting in place the processes and going through the exercises that need to be gone through on a continuous basis is really what quality is all about. What I've seen, frankly, internationally is that many of these institutions are corporately financed and corporately run. These institutions are willing and able to institute a culture of quality from the beginning as opposed to being dragged along kicking and screaming, which is what has happened in the United States and elsewhere.So, that philosophy of imparting and improving the quality culture from the very beginning, I think is absolutely critical and one of the critical success factors of these institutions. But it's not just accreditation for health care delivery that's going to be important. It's going to be universal standards for accreditation for education and for certification for providers and for global standards for research, which are going to be also critical, so that we really truly are health care providers as citizens of the world as opposed to our own communities.David: A high percentage of physicians in the US were either born overseas or educated overseas or both and that's both in the leading academic medical centers in places like Boston, and then also in the more rural areas. What's the impact of the development of new regional centers on the supply of health care workers in the United States?Dr. Crone: Although this is just beginning, I think it will adversely impact the workforce supply that we have here in the United States. There is a global workforce shortage in health care of nurses, physicians and allied health professionals if one looks at the United States. I'm on the Board of the Educational Commission for Foreign Medical Graduates and in fact, 25% of practicing physicians in the United States today are international medical graduates, 5% of those are nonresident Indians. If, in fact, those individuals either stop coming to the US or stay home, that will have a profound impact on both the availability of physicians and the cost of recruiting and retaining physicians in the United States. So, I think it will potentially adversely impact the US health care system by driving up cost even further.David: You talked about Dubai Healthcare City. Can you talk about some of the challenges that they face and some of the key success factors to actually realize the vision?Dr. Crone: Yes, there are a couple. I think that first of all, it is challenging to get individuals from that community to become health care providers. So, just getting the raw material, the human resources. It's somewhat of a "chicken and egg." There have not been resources available. So, that's not been the inclination of families in the region to have their children go into health care. So, that hopefully will evolve as the facilities and the programs and opportunities increase. So, that's certainly one.The second is that this is a very, very young, modern society. It's obviously a very old culture, but going through an enormous amount of transformation at the present time. Although it's very easy to build buildings overnight, it's very difficult to build institutions overnight. Just creating the culture of institutions will be challenging. It's doable, and I think it will be done, but it is an issue.David: You've been involved in the founding of the Medical Tourism Association in the US, and I'm wondering if you could comment on your role there and what future you see for that association?Dr. Crone: I must say that I really viewed myself as an innocent bystander in watching this phenomenon. I don't have any really personal stake in medical tourism, per se, other than I find it a very interesting phenomenon. So my willingness to participate in this was to be part of where it goes. I also would say that I'd like to see it done well, and I think there are a number of issues that need to be resolved.I think the first and foremost is the continuity of care. There needs to be the creation of partnerships between US health care provider systems and international health care provider systems, so that we create a safe platform for patients to be able to be evaluated pre-procedure, maybe have their procedure overseas or having their postoperative care provided. This should be done in a systematized way.There are other issues. There are legal issues, there are regulatory issues, all of which need to be worked through and I just find that interesting from an academic perspective more than from a commercial, or other perspective.David: I've been speaking today with Dr. Robert Crone, Managing Director of Huron Consulting Group, formerly President and CEO of Harvard Medical International.Dr. Crone, thank you for your time today.Dr. Crone: My pleasure.