As the health care reform debate advances in Washington, concerns have arisen about its effects, unintended or not, on academic health centers (AHCs).1 AHCs for the last half of the last century focused their threefold mission of education, discovery, and clinical care on the leading diseases that have been responsible for the heavy burden of premature mortality and morbidity in the United States. The economic underpinnings of the modern AHC include large doses of National Institutes of Health (NIH) funding mingled with clinical care revenues, philanthropy, and government payments for graduate medical education. This formula has worked well, but its unintended consequences are the uncoordinated priorities of the NIH, donors, and government, as well as an emphasis on procedures and subspecialty care over diagnostic reasoning and primary and preventive care. Given current scientific and clinical care funding streams, there is scarcely an AHC functioning today that does not harbor or covet a cancer or cardiovascular institute. AHCs can be among the more costly elements of the U.S. health care system because of the expenses associated with their contributions to advances in clinical care and the scientific underpinnings of those advances.
Whether reform is successful or not, the health care landscape in the United States is destined to change. Bending the curve in the growth of expenditures has become an economic imperative. What will reform mean to AHCs as we have come to recognize them? Reform must seek to solve the principal problems of uneven quality, increasing costs, and inequitable access that afflict U.S. health care. While many proposals have addressed these issues, two structural solutions have also received some attention: accountable care organizations (ACOs) and patient-centered medical homes (hereafter simply “medical homes”). We believe both of these concepts present strong opportunities for AHCs. ACOs are integrated delivery systems that provide organizing connections among disparate parts of the health system and, in so doing, theoretically create efficiencies and reduce redundancies resulting in improved cost controls.2,3 Commonly cited examples of ACOs include the Mayo Clinic, Geisinger Health System, and Kaiser Permanente. However, few examples exist of academic health systems forming ACOs. Medical homes are primary-care-oriented practices that promote well-being through enhanced relationships between patients and members of a practice team, focusing care on the full range of cost-effective services for individuals and families—from prevention and acute care to chronic disease management.4,5 Medical homes are a relatively new concept in the United States, but systems of care built on advanced primary care medical homes have existed in health care systems in places as diverse as Europe and Asia.
We believe AHCs have a great opportunity to serve a pivotal role in advancing and uniting these two proposed solutions. In fact, AHCs, by utilizing the strengths of their scientific enterprise, are in unequaled positions to create ACOs that link medical homes both with community health resources and with the AHCs' tertiary and quaternary medical resources. AHCs, distributed throughout the 50 states, should serve as the organizing entities that bring the full spectrum of health professions education, research, and care to needs of local populations. This may require a change in strategy for some AHCs, but many are historically endowed with certain qualities that make this a natural outgrowth of their present and past.
AHCs are a reservoir of unparalleled biomedical research expertise. Many exist within university structures and, as a result, have significant social, political, and economic, as well as other scientific, resources immediately available. We propose that these resources can, and should, be brought to bear on the contemporary problems of our health care system. Imagine the possible experimental models that could be tested in AHC-directed ACOs in order to answer questions such as “Which delivery systems work best with which populations?” and “Which models deliver the right care at the right time at the best cost?” Government, as a major payer of care, should have a real interest in this research agenda and can serve to preserve and promote discovery in organizations that have structures and traditions of inquiry already in place. The AHC is the most appropriate and likely entity to advance this mission of discovery across the full spectrum of care from community to medical center.
Further, many AHCs are heirs to the early community missions that led to their genesis. While many AHCs have chosen to define “community” as broadly in geographic terms as they have focused narrowly their areas of clinical expertise, AHC-directed ACOs would have the opportunity to marry local population needs with their many education, research, and clinical care outputs. AHCs as ACOs can become the organizing force in the health of local populations. This will require change in the focus of mission content for some, but to the degree that disease does not respect geography, most of the existing infrastructures of AHCs should suffice—that is, just as disease occurs broadly, AHCs already have a wide range of available resources. One particular area (of several likely) to need attention, however, will be primary care. Most AHCs have not committed substantial resources to this underfunded part of the health care system. As payment reform ultimately needs to be a major piece of overall reform, opportunities exist for AHCs to play a facilitative role in enabling the existing and building a new primary care infrastructure through support for medical homes. Primary care has an important role to play in the translational research agenda of the NIH, and some AHCs have operationalized this through the NIH's Clinical and Translational Science Award initiatives. Practice-based research networks are likely partners in the bidirectional flow of research questions and data, and these networks, built around medical homes, should serve as translational research laboratories for AHC-sponsored ACOs. By advancing primary care practices as medical homes, AHCs can contribute to the renaissance of primary care envisioned by health care reform.
AHCs are also centers of expertise in health professions education, and, theoretically, through their ACOs, they could serve as laboratories for discovering best practices in implementing the team-based care models called for by the Institute of Medicine and other organizations.6 The rich tradition of learning found in AHCs can also facilitate the continuing education of health professionals across a wide range of disciplines needed in ACOs and advanced medical homes. The education mission of AHCs would serve a naturally facilitative role for the continuous professional education needs of ACOs, bringing the benefits of educational research and design to the delivery system and patient care. AHCs can help medical homes define and test the interdisciplinary work relationships possible in advanced primary care and specialty settings, and they can promulgate education curricula to meet defined professional needs.
At the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School and its AHC, work is advancing to create an affiliated ACO. This university-affiliated ACO will offer a range of services through partnerships with other stakeholders in the health care environment. These services include both practice transformation help to create advanced medical homes and technology linkages that will unite the care of patients in the affiliated community of primary and specialty care practices to the services of the AHC. The research and educational resources of the AHC will be used in support of the ACO. Most important, patients will benefit from the threefold mission of education, discovery, and advanced, seamless care that the AHC-affiliated ACO will provide. As a result, we anticipate that the missions of Robert Wood Johnson Medical School will enjoy the strong public support and transparency essential for continued funding and advocacy.
AHCs, if they are nimble and flexible, can begin to foster the agenda of health care reform tying their missions and areas of expertise to the needs of populations in order to help solve America's contemporary health problems. Serving as ACOs and advancing the agenda of medical homes are two new, but important potential actions AHCs can take. By fostering discovery, learning, and care through rational organizational structures that meet the needs of populations and bend the curve of growing health care expenditures, AHCs can lead health care reform in the 21st century.
The authors wish to thank Dr. William Owen, president of the University of Medicine and Dentistry of New Jersey (UMDNJ), Dr. Denise Rodgers, provost of UMDNJ, and the Foundation of UMDNJ for their support.
Support for planning the Robert Wood Johnson Accountable Care Organization is being provided by the University of Medicine and Dentistry of New Jersey.
The opinions expressed in this commentary are strictly those of the authors alone, and do not necessarily represent those of any other entity or organization.
Presentations regarding the Robert Wood Johnson Accountable Care Organization have been made to various parties internal and external to the university.