In a medical career spanning 30 years, one intractable case has preoccupied James Mongan. He's worked in Washington, Kansas City and Boston, for the federal government and for publicly funded hospitals. But through all the moves, the goal remains: to help find a way to ensure that all Americans receive the medical care they need.
Mongan, '63, MD '67, acknowledges that his prognosis for the country's health care system is mixed. Thirty-seven million people have no health insurance, and policymakers have failed to expand Medicare because funding is a political hot potato. Still he fights on, convinced that the money crunch has the positive effect of forcing hospital administrators and physicians to work together. Mongan says they need to find cost savings before less judicious market forces beat them to it.
This is the job he's come to do as president and chief operating officer of Massachusetts General Hospital. "Somebody once said that it seems as if I've devoted my life to losing causes," he quips. But to Mongan, 55, the brief is straightforward. "You have to see if you can develop a system where the decision making can be left in the hands of the physicians as opposed to some clerk at an insurance company telling you whether or not you can have surgery."
On a recent Friday, Mongan was at work in his small, uncluttered office in the two-story brick Bullfinch Building where New England's first hospital and the country's third began 186 years ago. Here, beneath a copper-plated cupola known as "The Ether Dome," surgeons performed the world's first ether operation, a radical circumvention of human pain.
He's up early each morning, driving in from Brookline's Chestnut Hill, where he lives with his wife, Jean. At work, he spends much of his time huddled with physicians and administrators, crunching numbers.
Mongan grew up in San Francisco in what he describes as a liberal Democrat Irish-Catholic family. After earning his MD at Stanford in 1967, he was lured away from clinical care by his growing interest in health policy. "I liked biology and medicine, but I really liked politics, too," he says. "I was struck early on by the potential, at the intersection of the two, to be able to magnify the impact you might have."
He spent more than a decade in Washington, first as a Senate staffer and then as assistant surgeon general in the Carter White House, fighting for expanded Medicare coverage and a universal health insurance proposal that went down to defeat. When Ronald Reagan came into office, Mongan left Washington to head the 380-bed Truman Medical Center in Kansas City, Mo., an urban public hospital where 30 percent of patients had no insurance.
Truman took him away from the abstract realm of policy and challenged him to make his ideas work on the ground. Mongan stayed for 15 years and turned the hospital's bleak finances around, partly by convincing voters to approve a $9 million annual tax levy. "I believe there is, locally, an understanding of the importance of having some place for people to go who have no other alternatives," he says.
Four years ago, he turned down the post of assistant secretary in the Department of Health and Human Services. The job would have placed him at the forefront of President Clinton's push for expanded health care coverage. Mongan says he didn't want to uproot his family, but he also feared the proposal was doomed.
"I'm pessimistic about the indigent care picture nationally," he says. Of the derailment of the Clinton effort, he says: "In part, it's because of three decades of anti-tax rhetoric, playing to self-centeredness. But times and seasons have a way of changing, so it might not be permanent."
Mongan's move to Mass General brought him closer to his children--John, 22, at Yale, and Sarah, 20, at Bates in Lewiston, Maine--and gives him a "bully pulpit" for his views on universal coverage. It also presents a new challenge: finding ways to manage the managed-care squeeze.
"When you talk about managed care, frankly, all Americans have issues to deal with, not just the 37 million uninsured. I'd like to work on all of those issues."
With his quiet, diplomatic style, Mongan has won broad backing for the hospital's Operations Improvement Program (OIP), which aims to save money and improve care. One recent success: The consolidation of six blood labs reduced the number of vials drawn from each patient, cut down paperwork, and will save $1.5 million a year. "It was hard to make that happen because each lab represented someone's domain," says Elizabeth Mort, MD, director of the program.
Another innovation is known as "clinical pathways," a series of steps to standardize treatment for 80 different illnesses and procedures and to establish target discharge dates to avoid unnecessary delays. "It used to be that pathways were viewed as cookie-cutter medicine," Mongan says. "But it really makes sense for doctors as well as patients that two people with the same condition would be treated in the same way."
Doctors and nurses in this 25-acre mini-city--with 66 buildings, 900 beds, a $750 million annual budget and 11,700 employees--appreciate Mongan's inclination to put people, both staff and patients, ahead of pocketbooks. W. Gerald Austen, surgeon-in-chief and head of the hospital's physicians organization, says: "He's really gotten the trust of the physicians. He recognizes that for the hospital to succeed, the doctors should succeed also. His approach is 'this is a job that we need to do, let's get it done,' rather than worrying so much about saving four cents. The result is that everyone works a little harder to make sure things work out."
Nurse Manager Marie LeBlanc, who's been at Mass General for 25 years, concurs. "He's been very available, very visible. We never had direct access before. It's been a very refreshing atmosphere for me and the nursing staff."
After a morning of meetings, Mongan breaks away to attend a lunchtime panel about the emotional bonds between caregivers and patients. He listens intently as staff review the case of a cancer patient whose wife believed alternative therapies could cure him. She had vented her frustration on several nurses, who recount how they were hurt by her abuse but empathetic with her situation.
Later, Mongan observes that the case underscores the emotional component of healing: "You have to pay attention to the numbers, or the place falls apart, but if you pay too much attention, you don't have an institution you can be proud of." He turns back to his work, clearly proud of the institution he now runs.
Bob Goodman is a freelance writer working in Boston.
