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274 Pursuing Excellence in Healthcare
These researchers suggest that using fewer hospital beds, less physician labor, and fewer high-tech treatments (such as intensive care beds and expensive imag-ing devices) could markedly decrease costs. Not surprisingly, they also found that integrated group practices, in which all physicians and the accompany-ing hospital are integrated into a single practice group and physicians’ salaries are based on their areas of specialization, are associated with the use of fewer resources [27].
Although the results of the Dartmouth study are intriguing, they raise as many questions as they answer. For example, how did the small class size of the medical school at the Mayo Clinic, demographics of its patient population, reimbursement structures for physicians, and the local malpractice environment influence physician behavior and resource utilization? The most important mes-sage to come from the Dartmouth study was [27]
The nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spend-ing can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care. The support of such research needs to be the responsibility primarily of federal science policy. It makes no sense for the government to invest in biomedical research…without complementary research aimed at determining how new and existing treatments affect the outcomes of care, the lives of patients, and the eficacy of clinical practice.
Thus, government must support new and innovative research studies; in par-ticular, those that do not fall under the traditional portfolio of the National Institutes of Health could be considered under the mandate of clinical and translational research. Lobbying Congress for the support of innovative new research in healthcare policy by collaborative groups of scholars from both busi-ness schools and AMCs might be one of the tasks of the national commission.
Building Infrastructure for the AMC
In order to stem the evaporating jobs and deepening recession, President-elect Obama promised to expand the opportunities for Americans to work by under-taking massive public works projects to improve the country’s infrastructure. Projects would include repairing or rebuilding aging roads, schools, sewer systems, mass transit facilities, dams, and electrical grids—as well as creating
Ensuring Governmental Support and Oversight of the AMC 275
alternative fuels, building windmills and solar panels, and replacing existing environmental systems with fuel-eficient heating or cooling systems.
Investing in the infrastructure of AMCs could also provide broad local and global economic opportunities. Many institutions have had to defer capital improvements to aging research and clinical facilities; others are struggling to support the debt service on buildings planned and built during the NIH “boom years” between 1997 and 2003, when the NIH budget doubled. In addition, individual investigators and collaborative groups have often been forced to make do with old and outdated laboratory equipment because of marked cutbacks in their NIH funding. At many AMCs clinical facilities are also in need of repair and capital is required to replace aging or outdated equipment—infrastructure support that can improve care, lower costs, and support the economic health of the community.
Perhaps the most important research “infrastructure” needed is talented young physicians and physician–scientists. At a time when most medical stu-dents graduate with six-figure debt, tuition reimbursement programs for indi-viduals who pursue careers in the clinical and translational sciences would be one means of providing a bulwark against the continuing attrition of talented physicians and physician–scientists.
references
1. Mayo, W. Rush Medical College commencement, June 15, 1910. 2000. Mayo Clinic Proceedings 75:553–556.
2. http://en.wikipedia.org/wiki/libby_zion
3. Myers, M. 1987. When hospital doctors labor to exhaustion. New York Times, June 12.
4. Colburn, D. 1988. Medical education: Time for reform? After a patient’s death, the 36-hour shift gets new scrutiny. Washington Post, Mar. 29.
5. Japenga, A. 1988. Endless days and sleepless nights: Do long work schedules help or hinder medical residents? LA Times, Mar. 6.
6. Segal, M. M., and Cohen, B. 1987. Hospital’s junior doctors need senior backup. New York Times, June 8.
7. Sullivan, R. 1987. Grand jury assails hospital in ‘84 death of 18-year-old. New York Times, Jan. 13.
8. Daley, S. 1988. Hospital interns’ long hours to be reduced. New York Times, June 10.
9. Horwitz, L. I., Kosiborod, M., Lin, Z., and Krumholz, H. M. 2007. Changes in outcomes for internal medicine inpatients after work-hour regulations. Annals of Internal Medicine 147 (2): 97–103.
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10. Volpp, K. G., Rosen, A. K., Rosenbaum, P. R., Romano, P. S., Even-Shoshan, O., Wang, Y., Bellini, L., Behringer, T., and Silber, J. H. 2007. Mortality among hospi-talized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. Journal of the American Medical Association 298 (9): 975–983.
11. Meier, M. 2008. Senators question financial ties between doctors and steel manu-facturers. New York Times, Oct. 17.
12. Berenson, A. 2008. Weak oversight lets bad hospitals stay open. New York Times, Dec. 8.
13. AAMC. 2004. Project Apacsor—What Americans say about the nation’s medi-cal schools and teaching hospitals, 1–36. Public and congressional staff opinion research project.
14. www.acc.org
15. http://action.acscan.org/
16. Fuchs, E. 2008. Budget battles could last into 2009. AAMC Reporter 17 (6): 1. 17. www.aamc.org
18. http://www.democrats.org/a/party/platform.html 19. http://www.gop.com/2008Platform/HealthCare.htm
20. Mamula, K. 2008. UPMC outspends all U.S. hospitals on lobbying. Pittsburgh Business Times, Aug. 8.
21. Toland, B. 2008. Insurers spending millions on lobbying. Pittsburgh Post-Gazette, Sept. 7.
22. Flexner, A. 1973. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching, 346. Bulletin no. 4, New York (reprinted by The Heritage Press, Buffalo, NY).
23. Disraeli, B. 1877. Speech, Battersea Park. London Times, 10.
24. Krasner, J. 2008. State urged to review fees to elite hospitals. The Boston Globe, Nov. 20.
25. Kirch, D. The tough questions (www.aamc.org).
26. Cohen, B. 2008. Harvard Medical School to reduce student debt burden (http://harvardscience.harvard.edu/print/20205).
27. Wennberg, J. E., Fisher, E., Goodman, D. C., and Skinner, J. S. 2008. Tracking the care of patients with severe chronic illness. The Dartmouth Atlas of Healthcare, Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, NH.
Conclusion
As clearly demonstrated in the preceding chapters, there is little doubt that academic medical centers are threatened by a vast combination of factors, including
intense marketplace competition from private hospitals; decreased reimbursements from third-party payers;
a change in the demographics of the medical student population; increasing regulation from authoritative bodies governing requirements for
undergraduate and graduate education programs;
a shift of clinical research opportunities from the pubic to the private sector as well as from the United States to Europe, Asia, and South America;
the steadily increasing cost of a medical school education; draconian cuts in the NIH budget;
the global economic crisis; and
a general malaise among members of the academic faculty.
Although academic medical centers must begin to change in order to meet these many challenges, the philosophic structure around which change should occur has not been addressed since the publication of Flexner’s report in 1910. The goal of this book was to bring to public attention the great challenges faced by AMCs in fulfilling their societal responsibilities and to develop a new model that would allow academicians to have an initial construct around which to base their strategic plans.
Before beginning my research for this book, my impressions of what the AMC of the future would look like rested on a group of assumptions that were based largely on my own experiences. For example, I believed that the difference between a good and a great AMC was that the great AMC had a core focus on the “business of medicine” and that this helped to drive decision making as well as investments of time and money. The second assumption was that a medical
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278 Conclusion
school that did not have a substantial endowment and did not share positive margins with its afiliated hospital would probably be better off focusing on education and clinical care rather than struggling to support a research program; this was consistent with how businesses commonly focus only on what they do best. I also theorized that the separation of a hospital and its medical school would allow the physicians to leverage their autonomy and independence. Finally, I assumed that individual AMCs would have the best chance of survival if they could compete effectively in their local healthcare markets. Interestingly, my subsequent research led me to the realization that each of these initial assumptions was flawed.
For example, I found that good business practices were a necessary part of a successful AMC but were not suficient to make the AMC great. Indeed, making decisions based on “business” rather than basing each decision on what would be best for achieving excellence in patient care could lead an institution to renege on its societal responsibility. Without a core focus on providing outstanding patient care, no AMC could effectively compete in the future healthcare market or successfully teach the next generation of clinicians. I also found that research was a critical component of all medical centers, regardless of whether their goal was to train community physicians or clinician scientists. In conversations with residents, postgraduate trainees, and students, I found that those who had participated in research as medical students or between college and medical school were more adept at critically reviewing clinical trials in the literature, better able to think through complex cases, and far more likely to pursue careers in academic medicine. This information not only had an effect on the construction of the model presented in this book but also resulted in our developing a resident research program to improve the educational experiences in our department.
I also found that the most successful AMCs were not composed of economically and administratively separate units but rather were closely linked by an integrated structure. Finally, in contrast with my original belief that AMCs should focus on their regional environments, I found that outstanding AMCs today must develop regional as well as national collaborations and afiliations in order to provide the best possible care for patients. Thus, although each of the elements of structure, research, education, and business was necessary to support the success of an AMC, none was suficient in and of itself for an institution to achieve greatness. Only when these elements contributed synergistically to create an environment of outstanding patient care did an individual AMC excel.
Each of the four spheres that constitute the supporting structure of this book contains three chapters. These 12 chapters present recommendations for
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