ver the past four years, on the strength of a thorough, center-wide strategic planning process, we have made some bold moves and pursued a number of exciting paths forward for the Woodruff Health Sciences Center. These include investing more than $200 million in new research space -- including a new 325,000-square-foot research building and a new 242,000-square-foot comprehensive cancer center. We are constructing a new nursing school building and will completely rehab the anatomy and physiology building as a new home for the medical school. We reinforced our commitment to the highest quality health care services in midtown Atlanta by undertaking a complete reconstruction and expansion of our Crawford Long Hospital. We have invested strongly in recruiting stellar new faculty in our schools and at Yerkes. And we have recruited extraordinary new leaders to head our school of nursing, our cancer center, our vaccine center, and Emory Healthcare. We consolidated our hospitals' administration and operations, taking millions of dollars in costs out of our system. We created Emory Healthcare and brought all of our clinical practice components within it.

But, as Robert Frost suggested, it is often the road not taken that makes all the difference. There were many paths along the way that we did not take. Sometimes it was because we benefited from studying the experiences of other institutions that had tried those paths. Often our well-grounded consensus strategy and leadership team approach brought varied perspectives to the table for consideration in all major decisions.

From the Director  /  Letters

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Nurses' Prescriptive Authority

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Among the roads we did not take are the following:

• We did not enter the home health care market, and we did not offer an HMO insurance product. Both of these were popular paths in the early 1990s for health systems looking for new ways to capture a larger share of patients in their locality and region. However, we saw both of these paths as potentially leading to serious problems: home health care because it was a model with which academic centers had little experience; insurance products because an owned insurance product would have had to compete with regional and national HMOs with far greater marketing and capital resources.
   
• We did not accept any capitation contracts, except in primary care. Capitation contracts generally provide a fixed payment per covered person per month. They require the provider, rather than the insurer, to assume the risks that the costs of care will outstrip the payments. Many providers grabbed such deals assuming they could manage their costs well. Our view, which has been borne out, was that only primary care was predictable enough for us to manage on a large scale.
   
• We abandoned an early plan to acquire a network of 350 primary care physicians. The idea was to acquire and "own" a large network of community primary care providers who would be a major source of needed referrals for subspecialty care. Emory started down this path, but we soon learned that the expense of buying practices outstripped the return in referrals. And nationwide, it was found that providers who sold and no longer owned their own practices quickly became less productive. We saw these trends early and quickly changed course, instead working to create a more friendly interface with referring physicians.
   
• We did not accept the first Columbia/HCA partnership proposal and did not accept other hospital merger/acquisition offers. Partnering with large regional and national managed care organizations through selling hospital and clinic facilities was very popular in the mid 1990s as health systems found themselves increasingly strapped for cash. Emory resisted this temptation. Four years later we consummated a partnering opportunity with Columbia/HCA that involved no sale of Emory assets. Instead, we formed an equal but limited partnership that draws on our respective strengths and is a win for both of us -- and our patients.

We will continue to face new opportunities and divergent paths as we make our way in this still difficult health care environment. We will do well to keep in mind that sometimes the best path is the one less traveled.

Michael M. E. Johns