by Karon Schindler

rom his earliest days, Bill Kelley has always been a player, in the game and part of the action. He is a deal maker, a risk taker, a man who by sheer force of energy, intellect, and courage has earned the reins of leadership in American medicine, not once, not twice, but three times and counting.

In February of last year, he left his position as executive vice president, dean of the medical school, and CEO of the medical center at the University of Pennsylvania, where he remains a professor of medicine. During his 10-year tenure, the school soared to new heights in research income and overall rankings, thanks in large part to Kelley's recruiting talents and ability to enliven his vision of Penn as the best there is. But the health system was losing money fast, and the prevailing mood called for retrenchment and redirection.

What had gone wrong? In a series of bold entrepreneurial moves watched with avid interest by his counterparts across the nation, Kelley presided over Penn's acquisition of three hospitals and hundreds of private practices. The measures were intended as preemptive -- to protect Penn's access to patients in a region where managed care's market share was dominant and growing. Without sufficient access to patients, there might eventually be no medical school and therefore no teaching mission to protect. Inaction was seen as irresponsible. And everywhere he had gone in his career, first at Duke, then at Michigan, and finally at Penn, Bill Kelley had been hired to be a change agent, to rattle the teacups and make things happen.

In hindsight, critics said, too much happened all at once. The business plan, arguably too broad and enacted too fast, took a beating from town-gown clashes that left it battered, bruised, and bleeding red ink. Positions and programs went through a series of cuts, as strategies were reevaluated.

Coincidentally, in the fall of 1999, there was trouble in other uncharted territory where Kelley had led a daring foray. The university's prestigious and groundbreaking Institute for Human Gene Therapy (the first such center of its kind anywhere) suffered a blow with the death of a young patient enrolled in a clinical trial.

Bill Kelley would have liked to have stayed on in his role at the helm and seen these problems through. "I'd prefer to be doing what I was doing, but I'm not," he says simply. But now, he has more time to reflect, to write, and to speak about issues that he has been immersed in for the past three decades. The problems in American medicine weigh heavy on his mind, and he has some strong convictions about what can and should be done.

He cited the "gigantic mess" in which health care now finds itself, with costs sky-high and physician morale low, and the feeling among doctors and patients alike that the interests of the latter are getting lost somewhere in the shuffle. He proposed a solution "from the bottom up" (so others "won't have to keep dreaming up ways to fix it from the top down"), and he placed responsibility for this task squarely on the shoulders of physicians. "We need to be, and to be seen by our patients and our payers, as part of the solution rather than as part of the problem. . . . We must stop being reactive and start being proactive, to help our patients and to help ourselves."

He believes a "small, piecemeal approach" can improve quality of care in this country by making it more uniform.

Quality of care isn't what it should be, in large part, he says, because patient care is so variable, a problem about to be exacerbated by the coming information onslaught from genomics. "There is simply too much important information coming too fast to expect a physician to practice effectively using old approaches. Practice variation has been a problem even before the genomic revolution. How will we deal with 100 times more information than we have now, coming 10 times faster?"

We have to do what industry has been doing for 100 years, he says: Figure out the best practice model, put it in place, and keep improving it as time goes on, eliminating components that don't work, improving ones that do, and continuously monitoring outcomes to determine which is which.

"We've already given up so much autonomy
in the wrong way," Kelley says. "Let's give
up some to get to the right way. In the long
run, having guidelines that we agree on,
that are sanctioned by our professional
organizations, and that are up to date is
a way to get some autonomy back. But
more important, it's a way to give patients
the best care we can."

"We put guidelines on an Intranet for the 30 most common diseases seen by primary care physicians. More than 200 generalists and 150 specialists used these protocols, and a special team reviewed and updated the modules regularly, as new drugs or information came to light. We applied this system to a population of more than 15,000 patients.

"We were beginning to see dramatic improvement in outcomes, such as a reduction in ER visits and admissions and enhanced patient and physician satisfaction," he says.

But the financial incentives, from Penn's perspective, were backwards.

Although the savings in health care costs promised to be tens of millions per year, these savings accrued not to the provider but to the payer and the patient. "Keeping people out of the ER and reducing admissions actually reduced our revenue," he says.

"The payers had little interest in subsidizing our pilot, regardless of the long-term value. And we were unable to continue subsidizing it ourselves. We generated about $1.5 million per year by marketing the pilot to other systems, but our direct costs per year were $6 million. So the costs were all ours, the savings accrued to others, and revenues were insufficient to offset costs -- a bad combination."

Penn also couldn't afford a $10 million to $20 million investment needed to implement corollary information systems, including an electronic medical record, a critical component to this project.

But it can work, Kelley says. And others could well take note and learn from this experiment.

Kelley argues for development of five to 10 pilots to test best-practice guidelines that could be implemented nationwide (much like the EBMsolutions.com project in which Emory is collaborating -- see the article in Winter 2001 Momentum).

"Based on our experience," he says, "$5 million to $15 million per year for five years would allow a pilot like ours to be developed and tested. Optimally, we should have five to 10 pilots nationally to evaluate several different models. Thus, we'd need a total investment of up to $1 billion over five years to develop models that could then be applied nationwide."

Kelley's proposal for testing pilots to dev-
elop guidelines for best practice would cost
less than 1% of the NIH budget, or less than
0.01% of the estimated $3 trillion annual
cost of illness.

Kelley says that getting used to guidelines in daily practice would take time. "Changing the routine of busy practitioners reduces their efficiency, at least for a while." And he agrees that physicians would lose some autonomy, although any guidelines obviously would have to accommodate exceptions to the rule. "But we've already given up so much autonomy in the wrong way," he says. "Let's give up some to get to the right way. In the long run, having guidelines that we agree on, that are sanctioned by our professional organizations, and that are up to date is a way to get some autonomy back. But more important, it's a way to give patients the best care we can."

Practice guidelines, he says, are the logical extension of what various specialties have been devising for a long time. "Oncologists have used protocols almost since the birth of the specialty, and cardiac surgeons have minimized variation, as have orthopedists and anesthesiologists. Virtually every professional society has developed guidelines for managing specific illnesses common to their discipline -- even HMOs have developed guidelines." But implementation has been slow to nonexistent.

"We must get on with it. We've been a cottage industry with a guild mentality, artisans who trained, taught, and practiced like our carefully selected mentors. We feel comfortable with our tradition, but its days are threatened.

"We need to stimulate a unified front among physicians, perhaps involving a much greater commitment from some of our professional societies, if they are willing. Perhaps there are foundations ready to help. We need a careful evaluation of not only what works and what doesn't, but an evaluation on purely economic grounds of the cost benefit of improved quality."

According to Kelley, the cost of illness in this country is estimated at $3 trillion per year. If the NIH budget next year is $20 billion, it would be well under 1% of the cost of illness. His proposal for testing pilots to develop guidelines for best practice would cost less than 1% of the NIH budget, or less than 0.01% of the cost of illness.

"Economists project that a 20% reduction in death rate from either heart disease or cancer would be worth $10 trillion, or more than the annual GDP," he says. "And a $200 billion war on cancer would be cost-effective if it reduced cancer deaths by as little as 1%." The pilot programs he described likewise would have an impressive return on investment measured in dollars, not to mention the benefits from improving health.

"Practice variation has been a problem even
before the genomic revolution. How will we
deal with 100 times more information than
we have now, coming 10 times faster?"

Kelley never considered any choice other than medicine (as a kid, he used to accompany his father, Oscar Kelley, 39M, in his Model A Ford on house calls), and his talents and passion for the profession were evident early on. By his late 20s, he'd already served a stint in genetic research at the NIH and helped discover the cause of a rare rheumatologic disorder that later was named the Kelley-Seegmiller syndrome.

Next, he was tapped to join the faculty at Duke, where his scholarship continued to garner attention (and he, a long list of prestigious awards) and where he was given opportunity to prove his skills in leadership. He became chief of rheumatic and genetic diseases (it was he who added the "genetic diseases" part to the name) and in seemingly short order built his division to become one of the top five rheumatology programs in the nation.

In 1975, after seven years at Duke, Kelley, then 36, went to the University of Michigan to chair the department of medicine. His mandate? To take a department in the doldrums soaring to the top.

Like a brash young American in a Henry James novel, still too much an outsider to the established power structure to be daunted by naysayers, too bull-headed (and too naive) to let outmoded or irrelevant traditions stand in his way, he did what others said couldn't be done. He stormed the halls of academe and surpassed even his bosses' most optimistic expectations. By the time he left Michigan in 1989 after 14 years as chair, research funding had increased more than 20-fold, bringing the department from 42nd to fourth in the country in NIH funding. And he had implemented a medical service plan that increased clinical income more than 20 times over.

Michigan (where his son, Mark, is currently a resident in medicine) was where Kelley honed his skills in leadership, where he began to feel the full measure of responsibility for increasingly far-reaching decisions. He had to steel himself, as any player does, against the certainty that he couldn't afford to worry about being liked or disliked, that he couldn't afford agonies of indecision.

He needed to keep moving forward, his focus on the ultimate goal. Faculty who didn't like the new world order of increased emphasis on the bottom line (rankings in education, research recognition, clinical income) would need to find a new venue. Some gold would be lost with the dross, but that was a price that had to be paid. He had a job to do, a vision to enact.

He was the first, for example, to implement a bonafide "integrated delivery system" (translation: a health care system, in this case at Penn, encompassing a network of physician practices, hospitals, and other clinical settings to ensure continued access to a wide swath of patients, including the least and most ill, the chronic and acute, the young and old, the insured and uninsured).

Kelley was also the first to act on his long-held convictions about gene therapy (he had said for decades that gene therapy would be as important in the 21st century as immunization was in the 20th). He not only nurtured careers in the new field of clinical genetics but provided them a venue at Penn, not just to test endless theories but to actually help human patients in need.

Kelley also helped breathe real life into the still-budding field of bioethics, directing resources for a center at Penn and recruiting leadership whose credibility elevated bioethics to new levels of appreciation and whose opinions are sought around the world.

In taking steps like these, Kelley lent courage and confidence to others to blaze trails of their own, at the same time alerting them to pitfalls to avoid.

"Many of the creative improvements in health care and in research have come from academic centers. What's happening now is they're so stressed by their financial problems that they're having to cut the programs that made them different. It's like a patient with metastatic cancer who is beginning to lose some weight. The prognosis isn't obvious to the casual observer, but when you look back years from now, you're going to ask, 'What happened to that great academic medical enterprise in this country that was the leader in the world in setting the standard in almost every aspect of education, research, and patient care?'"

Rebuilding those enterprises after they've been dismantled may take years, maybe even a century, and will cost a lot of money, he says.

"It's almost as if no one has taken the time of late to appreciate or articulate how much an academic health center really is worth. And we do so now, as is so often the case in life, only when faced with the prospect of losing it."