(Editor’s note: As indicated in last week’s MCJ, the selection of Dr. John R. Raymond, Sr. as president of the Medical College of Wisconsin has sparked great interest and enthusiasm throughout the Milwaukee community, particularly among Black physicians and community leaders. His unique views on medical issues [particularly racial disparities] and commitment to diversity bodes well for the college and the community.)
Following is a one-on-one interview with Dr. Raymond conducted by MCJ Associate Publisher Mikel Holt.
Dr. Raymond: Milwaukee’s a great city and I’ve known about MCW for a long time. It’s a great story (with a unique history as a free standing medical facility).
Fabulous facilities on the regional medical complex, active faculty performing at an extraordinary high level. It compares to the best faculties in the country; small, but very good….there are world-class physicians here.
I was also aspired by Dean Jonathan Ravdin and (retired president) Michael Bolger’s vision that we should do a better job reaching out to the community; engaging the community with health care. So what’s not to like?
MCJ: In two speeches you have given since assuming office, I heard you mention the importance of diversity. Could you elaborate?
Dr. Raymond: I want to (enhance) an environment that is welcoming and nurturing to everyone who has something to contribute. We want to build a sense of pride in our community. That’s not self-interest, everything we give out to the community will come back to us multiplied many times over.
One of the real concerns in Milwaukee is health disparity, and the root causes of health disparities–poverty, which is a vicious cycle. Unemployment in some minority communities, whether its 33 or 50%, is really bad, tragic. I worry about our national competitiveness. If we have a segment of our society that can’t participate in the betterment of our country, because we didn’t give them opportunities, we’re not going to be able to compete on a world stage. How can we shut out a quarter of our community?
Diversity in its broadest sense, not just racial, brings in a way of approaching problems…looking through opportunities that we wouldn’t otherwise have. I want to see a richer environment.
I think we can try to create a wealthy environment, and if we want Milwaukee to thrive everybody has to take on a small piece of the solution. We would like to be more transparent, inclusive in our contracting.
We’re going to be putting up a new educational facility and we’re going to try very hard to have minority and disadvantage business involvement in that facility; that’s the way you really address the allegiance to Milwaukee; provide opportunities and build the talent base. When we can bring in (minority) general contractors who can say they worked on a $40 million project here in Milwaukee and they were both on the work side and in the boardroom during that process, that’s enhancing diversity through a mutually beneficial (paradigm). It’s not just about recruiting minority students and staff.
MCJ: The MCW has been applauded for its efforts to increase minority faculty and students, but in an overall sense, there has been a decline in the number of African American physicians serving the minority community in the last decade. It’s down to two percent nationally. The percentage of Black pharmacists is at nine percent.
Dr. Raymond: I think it’s very important to have more Black physicians than we have now, for lots of reasons. One is they can serve as role models for the community and inspire youth to pursue careers in science and medicine; which is good for us—America. I also think people feel more comfortable seeing a doctor that looks like they do; that’s just human nature…and if your choices are limited, maybe you’re not going to feel very comfortable at the institutions. That’s a very important consideration.
Our problem with African American male physicians–in particular in Milwaukee–I think a lot of them see better opportunities in other cities. It’s easy for us to say, but it’s harder for people to stay and be part of the solution. We have a brain drain. And for many years there were other professions that were more attractive to bright African American men, not just African Americans exclusively, but youth in general—they would rather work on Wall Street or be an attorney, or do venture capital or dot com work, elsewhere.
MCJ: That may tie in to the perceptions about Milwaukee. It’s been written that Milwaukee is one of the worst cities for African Americans in the U.S.—based on seven negative social indicators. South Carolina, where you are from, is considered one of the best places. What’s there, in Charleston, S.C., that’s not here?
Dr. Raymond: Warmer weather, for one. And because it’s a relatively new city, people think they will be more comfortable there and make their own name…perhaps here they think it’s not as much flexibility. There are also the perceptions…
MCJ: Do those perceptions have a direct link on why many, if not most, of your Black students leave Milwaukee upon graduation, or worse, don’t set up practices in central cities?
Dr. Raymond: As far as retaining graduates, our students leave here with a lot of debt, regardless of their ethnicity. (That factor provides disincentives) for a lot physicians who have to delay gratification for their families (to practice in underserved areas). Same goes for rural Wisconsin. There is a lot of pressure to get people to stay on our faculty…whether its majority individuals or underrepresented medicine. It’s not as (financially rewarding) to work on the faculty of a medical school. It’s more rewarding to some people, but it’s much more complicated. (As a staff member) you don’t just see patients, you have to teach students, and generate new knowledge (through research).
Adding to the problem is the fact that Wisconsin does not have a major health care provider or incentive program that provides debt forgiveness. Other states do, in South Carolina we have a loan forgiveness program that’s administered through the area health care council, not just for physicians, but dentists who show commitment to practice in underserved areas.
MCJ: Is the huge debt the reason so few Black physicians open practices in the central city? Most have to rely on Medicare and Medicaid, which have smaller reimbursements.
Dr. Raymond: The MCW is able to take a handful (put on staff and partner so they can practice in urban areas). But for the most part, the days of independent physicians are coming to end. That’s the reality of the healthcare landscape. There are a lot of pressures (on independent urban physicians); a lot of them would rather be employees instead of independent contractors. That applies to both majority and underrepresented, and those who would rather work in underserved areas. There are reimbursement rates, administrative costs, and malpractice insurance rates (to consider).
Since I’m the president of the medical college I have to say we have to figure out how to reduce inefficiency. That includes tort reform—frivolous lawsuits—we probably need adjudication boards. Which is not to say people should not be compensated for malpractice, but we should have a better system for that.
We also need better incentives for preventive care, (greater) access for non-physician specialists. It’s not going to cost as much and would empower physicians.
Reform must also include the right for physicians to deny un-necessary (and expensive) treatments. Right now it’s very hard to deny a treatment; if you (patient) wants it, and physician can give it… right now, for the most part individuals have little skin in the game… they can say do it (unnecessary treatment) and not worry about compensation; insurance has to pay for it…
MCJ: Mr. Bolger was active in the educational arena beyond the MCW. He was at the vanguard of educational reform, started the Science Academy and was an integral member of PAVE, among other initiatives. Can we expect to see you following in his footsteps?
Dr. Raymond: I have joined the Science Academy board; that’s one step. Being on the board inspires me. I went to the campus soon after arriving; the students were happy, you could tell they felt safe in the environment. They made eye contact and wanted to engage (me). It was an unselected group of students who are really going to make a difference. The question before us (community and civic leaders) is how are we going to make a difference in our society?
That said, we want to work with MPS. Because of the sensitive nature (of educational reform in Milwaukee), you want to start with something that isn’t controversial; something that everyone can agree is beneficial. And I think mentorship programs are non-threatening… especially if you’re trying to inspire our youth to take up STEM disciplines, which should be a national priority. And it would be a priority because it inspires some students to be future doctors and researchers. I can’t imagine anyone would be against that.
I don’t want to get in trouble, but if you’re proposing educational reform, or having faculty from here take a leadership role in teaching or designing curricula…that could pose problems. But, I’m all for quality, whatever works, that’s what we should be doing.
We have an obligation to give back to the community, not just financially. We have a lot of talented people here and we want to inspire a culture. I think we already have faculty and students who are willing to donate their talents to make this (Milwaukee) a better place to live.
We’ll be working with community partners to build bridges. That will really rely on donated time from our faculty, and to the extent that the college can reward people for doing that we will. Again we don’t have a huge pot of money at our discretion to try to influence people’s behavior…health care dollars are going to be very restrained…we have our own financial challenges. Having said that, we can actually learn a lot and have doors open for us if we can have sustained partnerships with the community. And we will.
MCJ: There’s been little said from segments of the healthcare community during the debate on national healthcare initiatives. Some say its bad, while others say it is a Godsend. Few congressmen know everything that’s in the bill, and attempts are already underway to repeal it. Provide some insight, and the role of MCW.
Dr. Raymond: We have 1,500 faculty and they probably all hold different viewpoints. Institutions will take a pragmatic stance, but I start with the premise that we need health care reform…we spend too much on healthcare in this country.
There needs to be healthcare reform that rewards quality, efficiency and access. We have to be sensitive…the system needs to be streamlined. The current payment system doesn’t really provide incentives for good behavior. (If a patient is seen in a federally qualified health center, the government doesn’t give full reimbursement. People should be seen where the best expertise is, so more consistent remuneration for services is crucial) There should be incentives for preventive care. Incentives, to have systems partner with each other. (Expansion) of non-physician practices and also (greater utilization) of (federally connected clinics), truly integrated systems…we don’t have to merge, we just have to figure out how to cooperate.
The Veterans Administration (VA) works pretty well. It starts off with (fixed financial resources/budget) and has to take care of everybody with that money. What (that has) done over the years is forced an emphasis on preventive health care…inspired VA hospitals to use evidence based practices…doctors are evaluated not just on the number of patients they see, or if they ordered the right tests…but are patients put on medicines that the evidence tells you works.
The VA is a leader in using non physician providers–physical therapists, nurse practitioners, physician assistants–all playing major roles because you don’t have a different reimbursement scheme. They start with those providers…and if problems are complicated it gets bumped up to general practitioners. In private sector, your practice doesn’t get as well compensated; so there’s a financial disincentive to use other folks (to handle preliminary or non-physician based components).
Behavior is influenced by the overall payment structure. As much as we like it not to be, medicine is a business and everybody’s going to act to preserve their organizations health.
I don’t think the health care bill tells us what the financial incentives are going to be…and until you see those details, it’s hard to picture (the future). For systems to work, there has to be equalization of the payment structure, regardless of where patients are seen. There needs to be access to non-physician health care providers who would serve as first line of evaluation. Very few of the health care systems in Wisconsin are set up that way; it will take fundamental change in how we’re structured and how we deal with patients.
If it were economically feasible, our physicians would love to have care provided in the community instead of waiting until patients are very ill before they come to the emergency department. That doesn’t benefit anybody.