Cohen, Jordan J. MD
Well, look at me. Here I am at 86 years of age in the year 2020. But, despite my age, I can still remember how things were'way back in the 1990s. I'm sure many of you do, too. Recall how everybody had become obsessed with runaway health care costs? The business community and, in their turn, the politicians were adamant that something be done. As a result, the whole health care industry found itself under unaccustomed and very intense scrutiny. People quickly became aware that practically no one in the health care enterprise had thought much about how to do their jobs more cost-effectively. They also realized that medical care could often be obtained more cheaply in settings unburdened by the costs of education, research, and indigent care. Calls for more accountability prompted a ton of new regulatory intrusions. Documentation suddenly seemed more important than performance.
But even more troubling, the intense scrutiny of the health care system revealed a lot more than high costs; it revealed a host of serious deficiencies that had gone unnoticed for years. Or, worse yet, noticed but willfully ignored. Let me remind you of some:
* Extreme variations in the way medicine was practiced in different parts of the country
* Failure of many physicians to incorporate proven medical advances into their practices.
* An astonishingly high rate of error, resulting not only in costly morbidity, but in many, many unnecessary deaths
* The virtual absence within the health care system of established quality improvement techniques, the likes of which had long since been adopted with great benefit by many other sectors of the American economy
* Wide disparities in health status as a function of race and ethnicity, which could not be explained simply by the availability of health insurance or by socioeconomic status
* Failure to place sufficient emphasis on health promotion and on the cultural, environmental, and behavioral determinants of preventable disease and disability
The root cause of many of these deficiencies was an intolerably inefficient system for actually managing the care of patients, particularly the care of the chronically ill, the aged, and the disabled. Why such an inefficient system? Several reasons:
* First, an archaic, paper-bound system for recording and communicating clinical information
* Second, an archaic financing system built to pay for discrete episodes of illness, rather than for the continuity and outcomes of care over time
* Finally, and most important, an archaic model of care itself, in which individual practitioners—widely dispersed and uncoordinated—were nevertheless the unit of accountability, rather than integrated teams of caregivers constructed to achieve better health outcomes at minimal cost
HOW ACADEMIC MEDICINE TOOK ACTION
Of course, the clinical faculties of medical schools—and the teaching hospitals in which they worked—were not immune to these problems. Fortunately, however, the leaders of academic medicine decided to take action. They realized that they had a fundamental responsibility to help chart a better health care future—not only for themselves, but for the country as a whole. They also realized that the public support crucial for sustaining their societal missions—education, research, and cutting-edge care for special populations—would remain in extreme jeopardy as long as policymakers continued to view medical schools and teaching hospitals as part of the problem rather than as partners in finding solutions.
Recognizing the enormity of the problems facing the nation's health care system, the leaders of medical schools and teaching hospitals wisely decided not to go it alone. Rather, they decided to collaborate with one another. To work together to close the gaps. To look beyond their local and regional concerns, and to align themselves with one another in a nationwide undertaking dedicated to solving the seemingly intractable problems that were plaguing the health care system. That decision was truly historic. It was the origin of what we recognize today, here in 2020, as the very centerpiece of the entire health care enterprise, the learning core of the system.
What we have now, after many years of painful but gratifying transformation, is an academic syncytium, a coordinated network of medical schools, teaching hospitals, and academically oriented health systems, along with their faculties, their staffs, and their many community-based partners. This powerful network, as you know, is acknowledged by all health care professionals, and by the public as well, to be the principal source of continuous improvement in the health status of our population. It is engaged explicitly in addressing prospectively identified problems of overarching national scope. Members of the network function in true alliance with one another—setting a national agenda, pursuing common goals, freely sharing information and best practices, benchmarking their performances across all of their missions, remaining fiercely competitive in the pursuit of excellence, but dedicated to working together to optimize their effectiveness—in education and in research, as well as in clinical care.
THE COLLABORATIVE CARE MODEL
One of the major successes of the coordinated network has been the launching and continued improvement of the Collaborative Care model of health care delivery, a model that is clearly destined to predominate in the future. As you know, the managed care model, which dominated the scene in the late 20th century, espoused a valid and forward-looking concept, but that concept was grossly distorted in the way it was implemented by market-driven, profit-seeking entrepreneurs. As a result, the market-oriented model of managed care was already on the ropes 20 years ago.
Happily, Collaborative Care came to the rescue just in time. Seizing on the public's dissatisfaction with managed care, the leadership of the newly formed network of medical schools and teaching hospitals constructed an alternative. In league with their many community partners, they designed a model of health care that adhered to the time-honored principles and values of American medicine, but that addressed directly the several deficiencies that had crept into the old system. They started with the premise that the core purpose of the health care system is not simply to make money; it is to achieve measurable improvements in the health of individuals and communities. And with that purpose in mind, they concluded that Collaborative Care must maintain an unwavering commitment to be cost-conscious, but must also be quality-driven, evidence-based, and above all, patient-, family-, and community-oriented.
But the leadership understood that even a nationwide network led by academic institutions could not transform the health care system alone. It would need strong partnerships with many stakeholders, including the purchasers of health care services, in both the private and public sectors. And several large purchasers agreed to cooperate, at first by supporting a number of demonstration projects to test the validity and viability of the Collaborative Care model. They did so because they were convinced that aligning financial incentives to reward collaboration was far more promising than relying on price competition as the way to achieve ready access to affordable health care services of high quality.
What Collaborative Care promised—and delivered—was collaboration between doctor and patient, between generalist and specialist, between physician and hospital, between doctors and other health professionals, between hospitals and community-based facilities, between faculty and community-based practitioners, and, very important, collaboration between and among participating health systems.
One key to Collaborative Care's success was the rapid development and deployment throughout the network of a clinical information system constructed with the realization that modern health care is about providing information as much as or more than it is about providing hands-on, face-to-face services. This realization proved particularly prescient as the Internet evolved to become, as it is now in 2020, the veritable backbone of the entire health care system.
Another key success factor was Collaborative Care's commitment to fully integrating clinical research with clinical care. The leadership of the newly formed network of medical schools and teaching hospitals realized the golden opportunity they had to capitalize on academic medicine's unique responsibility not only to perform clinical research, but to immediately incorporate the knowledge gained from that research into measurable improvements in the processes and outcomes of patient care. That realization, too, proved prescient as investments in clinical research paid off handsomely by improving health while holding down costs.
But the biggest key to Collaborative Care's success was the restoration of trust. Having convinced the purchasers, and more important, the public, that it was possible, after all, for medicine to retain its fundamental commitment to providing affordable health care of high quality without yielding to commercialization and commodification of its services, a sense of trust once again permeated the health care atmosphere. Central to rebuilding that trust was the meaningful involvement of community leaders in the setting of priorities for the system. The barriers to forming functional partnerships with community-based providers quickly receded, and large numbers of patients eagerly enrolled to benefit from Collaborative Care's documented quality.
So, the power of collaboration, as evidenced by the success of Collaborative Care, has certainly produced handsome benefits for everyone, including academic medicine itself. Not the least of these is the unquestioned public support for medical schools and teaching hospitals now evident in Congress and throughout the policy-making establishment. Academic medicine is viewed no longer as a problem area, but as a reliable partner in anticipating and addressing quandaries in health care as they arise. As a direct consequence, Congress finally enacted the Shared Responsibility Fund, which the AAMC had advocated for many years. As you know, all public and private payers for health care services now contribute their fair shares to the Fund, which provides adequate, stable, and predictable support for all of the societal goods produced by medical schools and teaching hospitals.
BACK TO REALITY
OK, back to reality. Enough of fantasy time. It sounds wonderful, you say, but it's much too good to be true. Anyway, who's got time to daydream; we're too busy as it is just dealing with the problems of today.
I understand, of course. And I wouldn't suggest for a moment that anyone could afford to miss a beat in dealing with those immediate problems. But, by the same token, not carving out some time to begin thinking seriously about creating a better system is tantamount to acquiescing to an unacceptable situation. We should not accept without challenge what we know to be abominable just because it appears to be inevitable.
Besides, I'm not so sure what I've been talking about is all so fanciful. Just for fun, let me ask you to suspend disbelief for a moment. Let's just consider the central idea of collaboration. Is it so crazy to think that medical schools and teaching hospitals could form a truly collaborating network capable of unified, coordinated action in concert with others to solve a national problem of overarching significance? Why not?
Think about what we already do. Teaching hospitals, for example, have a long history of collaborating in the formation of purchasing coalitions, in the benchmarking of clinical care processes, and in the sponsorship of innumerable community services. Our researchers collaborate in countless ways, as well, sharing precious genetic reagents and other research tools, forming multi-center clinical trials, peer reviewing each other's work. Pediatric oncologists nationwide collaborate to ensure that most kids with poorly treatable cancers are entered into clinical trials, avoiding the premature introduction of unproven therapies into the market.
And our public advocacy efforts would be hamstrung without widespread collaboration across the academic medicine community and across many non-academic sectors as well. Our combined and coordinated efforts on behalf of the NIH budget, for example, are achieving veritable miracles at a time when virtually everyone else is being forced to curb their appetite for public support. Other examples of the power of collaboration include our success in blunting the impact of the ill-conceived PATH audits and our Herculean efforts to halt the debilitating effects of the Balanced Budget Act of 1997.
Our efforts on behalf of gender, racial, and ethnic diversity in medicine would have gone nowhere without the close collaboration of many diverse communities.
And how about medical education? I would argue that collaboration has been a major driver, propelling medical education in the United States to the pre-eminent position it now enjoys throughout the world. Without the willingness and the ability of medical educators to collaborate in setting tough standards for themselves, in sharing information freely, in agreeing on the goals and learning objectives that students must achieve, and in celebrating each other's successes—without those collaborative activities our educational system could not have dreamt of achieving world pre-eminence. And with it all, we have not been inhibited from competing with one another for the best students.
So, why not collaborate in developing a comparably world-class model of health care for our country? It doesn't mean we would be any less free to compete our brains out for patients. But it would mean we'd have a shot at getting our country's health care system out of the gutter and back on the high road—and while we're at it, getting ourselves out of a terrible bind.
THE FORK IN THE ROAD
We have reached what even Yogi Berra would recognize as a fork in the road. One choice is to continue to struggle for survival as the environment around us gets harsher and harsher. Left unchecked, Darwinian market forces will continue to transform the system through the survival of the fittest competitors. Now, I don't think academic medicine, relatively speaking, would fare all that badly if we stayed on the Darwinian fork. Most of our institutions would find ways to adapt, one way or another. We're smart, we're politically well-connected, and we're highly respected in our communities—not only for all the good things we do but also for the large number of jobs we provide for the local economy. So, in the aggregate, we'd do OK. But in the process of adapting to the harsher environment we now live in, some wonderful institutions will almost certainly become extinct. Many more will undoubtedly be mutated beyond recognition, with atrophied vestiges of their former academic missions providing scant reminders of their more robust histories.
If we don't relish that prospect, there's only one other fork we can take. The only alternative to struggling for survival against a harsh environment is to fix the environment. And we should know by now that no one is going to fix it for us. Who might one even consider as candidates for the fix-it job? Congress? State governments? Managed care organizations? Insurance companies? Employers? Foundations? Help me here, I'm running out of candidates. There isn't anyone else. If we in academic medicine don't engineer a better health care environment for ourselves and the country, no one will. Period.
I don't mean we in academic medicine can do it by ourselves. Of course not. But I do mean that our institutions, by virtue of their unique strengths, are uniquely positioned to lead the effort. You know those strengths as well as I do. First is our strong tradition of leadership itself, which permits, if not obligates, us to take affirmative action on our own to address the present deficiencies. Second is our reputation for quality, which enables us to credibly aspire to improve our health care mission. Third is our commitment to discovery and innovation, which offers the only hope for achieving the improvements we seek. And last, but certainly not least, is our core purpose—improving the public's health—a value-laden purpose that is all but invisible in our current market-oriented system and that is most in need of restoring.
Despite the strengths inherent in our institutions and in our traditions, no single academic medical center, no matter how influential it is in its community or region, could make a splash on the national scene sufficient to force the issue for the country at large. But just imagine what medical schools and teaching hospitals across the country might accomplish if they began to function in true alliance with one another, if they came together—along with their community partners—to form a truly collaborating network committed to pooling their talents for the purpose of developing the Collaborative Care model I fantasized about a few minutes ago. Frankly, I relish the thought of what we could do under such a scenario.
WHAT WE COULD DO
For openers, we would start with certain knowledge of what a better health care system would look like. It would not take a group of experienced people very long to set down the specifications of a system that would run circles around our current non-system of health care delivery. I sketched those specifications earlier in describing Collaborative Care: More quality-driven, more attentive to identifying and learning from errors caused by system failures, more evidence-based in decision making, more oriented to patients, families, and communities, more reliant on teams of caregivers, better supported by clinical information systems, and financed in ways that reward achievement of better health outcomes.
But, of course, listing specifications is a far cry from drawing actual blueprints; and farther still from constructing a working model. But there's cause for optimism here. First, we already have more than theoretical knowledge of what we want; indeed, many of the elements of that better system—elements needed to address the major health system deficiencies that I highlighted at the beginning—are already in operation in one or more places around the country.
* We know that the widespread adoption of established clinical guidelines and disease management programs can dramatically reduce variations in clinical practice.
* We know that electronic clinical information systems can be designed to provide automatic reminders and updated information to physicians and other caregivers at the place and time of decision making. Such systems can routinely inform decision makers about the latest evidence and can greatly reduce if not eliminate errors of omission and comission resulting from such irreducible human frailties as faulty memory and fatigue.
* We also know that sophisticated information systems, properly designed, can provide a comprehensive source of data for clinical research, permitting large-scale studies of clinical effectiveness and outcomes, all of which can be linked seamlessly to continuous improvement in the documented quality of care—especially important for reducing the overuse of services of unproven benefit.
* We also know that clinical research into the causes of health system dysfunction is key to our gaining a better understanding of the root causes of the persistent racial and ethnic disparities in health status in America. The absence of such data continues to thwart our efforts to narrow this equity gap.
* And, finally, we know what can happen when we hold multidisciplinary teams of caregivers responsible for effecting measurable improvements in the health status of the patients under their care. In addition to boosting patient satisfaction scores, patient education programs flourish, compliance with routine preventive measures improves dramatically, and modification of unhealthy behaviors becomes a top priority.
What we need to do is take advantage of what we already know, and of the many things yet to be discovered, and put them all together in one package. And do so on a scale that can demonstrate superior performance to payers and to the public, including, of course, superior financial performance.
Don't most of us believe that a better health care system would be a less expensive health care system? I do. I believe that coordinating the care of the chronically ill, eliminating overuse of unneeded services, reducing errors through improved support systems, minimizing preventable disease and disability, and extracting all the benefits embedded in modern information and communication technologies would not only hold down health care expenditures but reap other economic benefits for our country as well.
It is the task of testing that belief that requires, in my judgment, the collaboration that I'm envisioning—the syncytium of medical schools and teaching hospitals and their myriad community-based partners.
WE CAN DO IT
I can already hear the corridor conversations. Naïve, utopian; Pollyannaish; impractical; doesn't he understand how massive the problems are in the present system? No way academic medicine could possibly lead us out of this mess; the financing aspects alone are monumental, if not absolutely insurmountable; besides, who's got the time to tilt with windmills? We're having enough trouble as it is just getting through the daily hassle; does he really think that by coming together we can close the colossal gaps in this crazy system?
The answer is, Yes, I do.
I know how hard it is to look beyond today's pressing horizon. But don't we owe it to ourselves to see if there is a way out of our present circumstance? I also know how vague the Collaborative Care concept is as I've presented it. My intent is merely to plant a stake in the ground, to suggest a starting point for charting a course to a better destination.
I have no illusions about how difficult it will be. For sure, transforming our culture from its long-standing predilection for independent action to a genuine fondness for collaboration—especially at a time when everyone is totally preoccupied with just staying afloat—is not going to be an easy job. But I also have no illusions about our vulnerability if we fail to recognize and exploit the power of collaboration that is within our grasp. Without meaning to sound melodramatic, I think our circumstance is not unlike the one facing Ben Franklin when he said, “We must all hang together, or assuredly we shall all hang separately.”
And it will assuredly take courage of Franklinian proportions on the part of many to foment the revolution I am calling for. Investing time and intellectual capital in an unproven venture without guaranteed benefit, no matter how enticing, is a dicey proposition under the best of circumstances. Doing so when the immediate demands of the daily struggle are so all-consuming calls for a gigantic leap of faith. I know.
Nevertheless, I hope at least some of you will agree with me that the risks of making the attempt are, at worst, no greater than the risks of continuing on our present course. What's more, it's not a matter of “either/or.” By all means, we must continue to compete and adapt to the current environment. Collaborating, at times and in places where it makes sense to do so, does not nullify the critical importance of maintaining one's competitive edge. And I pledge to all of you that the AAMC is not about to diminish its efforts to compete on behalf of academic medicine to ensure the success of our institutions and their societal missions.
But, while we soldier on together, let's not lose the opportunity to get above the fray, to capitalize on our deep reservoir of social conscience, on our unique legacy of leadership, and on our special talents for innovation. We are an exceptional group. And we are living through exceptional times. There is no reason why we can't do exceptional things. But we must find a way to do them together.
What we need to get started is a core group of visionary and gutsy medical school and teaching hospital leaders who are willing to take up this challenge, who can think out of the box, who will take some time away from today's turmoil to indulge in a longer view. The AAMC staff and I are ready and eager to help.
I see our role as catalyst—
* to solicit interested constituents,
* to help them develop an agenda,
* to facilitate communication,
* to assist in hammering out a template for change,
* to broker alliances with key, non-academic stakeholders,
* to propose demonstration projects,
* to hustle the government and foundations for the funding that's certain to be required, and
* to seek out institutions that are prepared to mount collaborative “pilots.”
There's an awful lot of hard work to do. But the task boils down to this: using the power of collaboration to unleash the unlimited creativity and wisdom that we have. Rather than accepting the limits of today, let's harness that creativity and wisdom to explore the possibilities for closing the gaps for a better tomorrow.