Alok Sharan, MD, MHCDS
Courtesy of Alok Sharan, MD, MHCDS


Published 8/1/2015
Alok Sharan, MD, MHCDS; Timothy E. Foster, MD, MS, MHCDS; Michelle Prince, MD, MHCDS

The Science of Healthcare Delivery

What we learned at Dartmouth

Health care in the United States is expensive—it accounts for one-sixth of the U.S. economy and is perhaps the greatest threat to the long-term solvency of both state and federal governments. The cost of health care is also a threat to U.S. companies trying to compete in a global economy while maintaining profitability. Despite this expense, many outcomes for the treatment of common diseases lag behind other industrialized nations.

Reforming the U.S. healthcare system to effectively deliver quality care using limited resources remains a challenge. Like many people, we (the authors) struggle to answer the question, “Why isn’t health care more efficient?” In the business world, generally the more money spent for a product or service, the better the quality of that product or service. But despite the massive outlays spent on health care in the United States, quality of care and outcomes continue to vary widely. The healthcare field is filled with well-intentioned, talented individuals, yet a tremendous waste of resources and mediocre outcomes remain.

To bring management and business techniques to bear on improving the healthcare delivery system, Dartmouth College created the graduate program Masters in Health Care Delivery Science (MHCDS). This program combines curriculum from the Tuck Business School with teachings from The Dartmouth Institute for Health Policy and Clinical Practice, creating a truly unique advanced degree.

The 18-month program is set up so that participants can maintain their surgical practices while competing the program. It requires a total of 6 weeks at Dartmouth, 1 week at a time every few months. In addition, participants regularly log in to live online classroom discussions, scheduled at specific times.

In our opinion, the MHCDS combines the best of business, leadership, and systems management training with an in-depth exploration of the measurement, organization, and improvement of health and health care. It is such a distinctive program that it is difficult to explain the degree. Some may consider it a medical MBA; others a Masters in Science with a focus on health care. As recent graduates of the program, we consider the MHCDS a useful tool to help prepare us to lead the way toward value-based healthcare delivery.

In business school, new MBA students quickly learn that the purpose of any organization or business should be to create value for its customers. Value is created when an organization can solve a problem or do a job for a customer in a more convenient, less expensive, faster, or higher quality manner. Businesses formed around selling products or delivering services that do not have clearly defined customers and those that have not been able to determine their value creation ultimately fail. Thus, value is more likely to be created when supply responds to demand (demand-induced supply).

However, the current U.S. healthcare system is an industry based on supply-induced demand (information-poor patients cannot make an informed decision and rely on the physician’s recommendations). Shifting to a more value-based system centered on the patient should lead to a more efficient state, in which the right care can be delivered to the right patient, using just the right resources, at a reasonable cost.

Clearly, making such a transition will require a deep knowledge of economics, finance, strategy, operations, management, leadership, and innovation—all in the context of delivering care to the patient. The MHCDS degree focuses on these skill sets as a means to create solutions for our failing healthcare system.

Three focal areas
In the first part of the program, we delved into problems with the current system. Many discussions centered on economic and financial issues and we took “deep dives” into understanding hospital budgets and the problems of high fixed costs. We saw the impact of misaligned financial incentives on the delivery of care. We learned how to understand and be critical of the various ways research data can be presented to support (or not support) practices.

The program then asked, “What does a value-based healthcare system look like?” To answer this question, we learned methods that other industries (such as hospitality and automotive) use to discover and deliver what is of value to their customers. We also examined highly efficient health systems (such as Shouldice in Canada and Aravind Eye Hospital in India) to see what we might be able to emulate.

Once organizations understand what is of value to the individuals they serve, determining how to deliver that value can be equally challenging. Using a clinical microsystem framework, this part of the program focused on the technical aspects of how to actually deliver value to the patient. In health care, value creation occurs not only at the provider-patient level, but also during interactions with other members of the team (when a patient calls to schedule an appointment, registers for the appointment, or pays the bill, for example). Bringing employees together around a shared vision is at the crux of delivering greater value to patients. Creating and conveying such a shared vision requires both leadership and team-building skills, courses that were also taught in the program.

Finally, the program centered on how to transition from the current system toward a more value-based system. Courses were dedicated to leadership, strategy, negotiations, and change management. Coming up with a sustainable model for present and future healthcare delivery is one monumental task! Moving out of traditional healthcare models will be an even greater challenge. MHCDS introduced us to some of the great mentors and voices of healthcare policy: Michael Porter, John Wennberg, Elliot Fisher, Elizabeth Teisberg, Paul Gardent, Eric Wadsworth, and Johnathan Skinner.

Shifting to a value-based healthcare system will clearly require mastery of information technology (IT); one entire course examined how a hospital’s health IT system can support its strategy. Because no discussion on change would be complete without a discussion on innovation, one of the final courses we took was on innovation in health care. How to execute innovation is sometimes harder than coming up with new ideas; MHCDS has prepared us for this challenge.

Consider MHCDS
The Dartmouth MHCDS was a transformative experience. Prior to enrolling, we saw ourselves as individuals who play small roles in delivering orthopaedic care within the healthcare system. After completing this program, we have skill sets that will help us become leaders in transforming U.S. health care. We highly recommend this program for individuals who would like to help lead this upcoming change.

Some institutions sponsor individuals or teams each year; we commend these institutions for being so supportive of the quest for “a better way.” We thank our home institutions and families for supporting us through our individual endeavors in this quest as well. We have no doubt it is a worthwhile investment.

Alok D. Sharan, MD, MHCDS, is a Washington Health Policy Fellow alumnus (2005) and chief of the orthopaedic spine service at Montefiore Medical Center, Bronx, N.Y. Timothy E. Foster, MD, MS, MHCDS, is a sports medicine orthopaedic surgeon for Partners Healthcare, and the chair of the orthopaedic department at Newton-Wellesley Hospital in Newton, Mass. Michelle Prince, MD, MHCDS, is a pediatric orthopaedic surgeon and pediatric orthopaedic division leader at Dartmouth–Hitchcock Medical Center, Lebanon, N.H.