During the past decade, the leaders of academic medicine’s institutions—medical schools and teaching hospitals—have been forced to confront a number of major challenges to the continued viability of the patient care, education, and research missions of their institutions. In responding to those challenges, many adopted new approaches for organizing and financing their mission-related activities. And some responded in a more dramatic fashion by entering into various kinds of partnership arrangements with other institutions, including full-asset mergers. Needless to say, not all of the strategies that were adopted turned out to be successful.
This issue of Academic Medicine presents a collection of articles that describe how some institutions responded, at least in part, to the challenges facing them, and the degree to which the strategies they adopted were successful. Taken as a whole, the articles provide insight into the scope, magnitude, and complexity of the challenges that the leaders of academic medicine’s institutions have faced in recent years. Since there is no reason to believe that challenges to the institutions are a thing of the past, the articles should have value for years to come for those who currently hold leadership positions in medical schools and teaching hospitals and for those who aspire to those positions.
The articles by Corwin et al. and by Chatman et al. describe how certain institutionally based strategies improved the performance of the institutions in which those authors work. Specifically, the strategy adopted by the New York-Presbyterian Hospital—an institution resulting from the merger of two large teaching hospitals in New York City—for consolidating the clinical services provided by the two merged hospitals has proven so far to have a positive impact on the institution’s financial performance. Similarly, the alliance between Meharry Medical College and the Vanderbilt University Medical Center in Nashville has produced significant benefits for both institutions. But the article by Mallon, which describes the merger of the Penn State University’s Hershey Medical Center and the Geisinger Health System in Pennsylvania, strikes a cautionary note. Unlike the experiences in New York and Nashville, the Penn State-Geisinger merger was not successful, and the de-merger resulted in significant costs to both organizations.
These articles describe not only what happened at the institutions involved, they also provide important insights into the reasons why the institutional arrangement either succeeded or failed. In doing so, they offer important lessons for those who may consider entering into similar arrangements in the future. In reflecting on the lessons to be learned, it is important to be attentive to the specific circumstances affecting each of the institutions involved and to recognize that a strategic approach that may be successful in one situation may well fail in another.
Also in this issue is an article by Ruedy et al. that adds to the growing body of information about mission-based management, a key strategy for changing the way the mission-related activities of academic medicine’s institutions are financed. The authors describe the ten-year experience with mission-based budgeting in a Canadian medical school. The favorable experience at that school is important because it demonstrates that the principles embedded in the mission-based management concept apply equally well in Canada despite the very different approaches that exist in the United States and Canada for funding clinical care and education. The article by Longnecker et al. gives a great deal of information about the strategies adopted at the University of Pennsylvania and the Johns Hopkins University to provide more effective management of the faculty practice plans at those institutions. That information is relevant to the implementation of mission-based management, since the clinical revenues generated by faculty are of increasing importance to the successful pursuit of the academic missions of medical schools and teaching hospitals.
Those who might be inclined to believe that the challenges facing academic medicine’s institutions can be addressed successfully simply by focusing on improving the management of the institutions as they currently exist should be disabused of that notion by reading the article by Snyderman and Williams and the one that follows by the Academic Medical Center Working Group of the Institute for Health care Improvement (IHI). The authors of those two articles argue that to be successful in the long run, academic medical centers cannot simply focus on improving the management of the clinical services they provide today, but also must change in very fundamental ways the approaches they use for providing clinical care. The implications of what they propose for medical schools and teaching hospitals are quite profound.
Snyderman and Williams suggest that the current approach for providing health care needs to be dramatically transformed. They argue that the focus of the care given to the growing number of adult patients with chronic diseases must shift from one that concentrates on the episodic treatment of complications of a disease to one that concentrates on the prevention of those complications, beginning at the earliest stages of the disease. This approach has implications not only for the way that patients are cared for, but also importantly for the ways we educate doctors and other health professionals to provide care. Academic medical centers will be severely challenged to make the kinds of changes that are needed to put in place the systems of care envisioned by Snyderman and Williams. And the IHI Working Group calls for academic medical centers to become much more actively involved than they are now in developing and implementing approaches to care aimed at improving at every level the quality of the care being provided. Their call to action is clearly in keeping with the positions advanced by the Institute of Medicine’s Committee on Quality Health Care in America.
So what should those concerned about the future of academic medicine take away from the collection of articles that appear this month? I believe those articles provide another wake-up call for those who hold leadership positions in academic medicine’s institutions and for those holding leadership positions within the academic medicine community. In one sense, the articles validate some of the concerns expressed in the reports issued by the Commonwealth Fund Task Force on Academic Health Centers and the Institute of Medicine’s Committee on the Roles of Academic Health Centers in the Twenty-First Century. Those reports are critical of the ways that academic medicine’s institutions are meeting their responsibilities to the public in the conduct of their patient care, education, and research missions.
The critiques of academic medical centers included in the reports make it clear that the leaders of academic medicine’s institutions must do a better job not only in managing their resources, but also in deciding to what end the resources available to them should be committed. It will not be enough to ask for more resources as a precondition for responding to the concerns of those who have been studying the state of academic medicine’s mission-related activities. Public expectations for academic medicine are changing, and it is important that the leaders of the academic medicine community recognize this and act. If they don’t exert bold leadership, the public may look elsewhere for solutions to the problems that concern them. Would that be a good thing? I don’t think so.
Michael E. Whitcomb, MD