Becker, Bryan N. MD, MMM; Formisano, Roger A. PhD; Getto, Carl J. MD, MBA
Dinosaurs, the dominant animal on earth for 160 million years, often grew to great sizes, consumed large amounts of food, and still remained sensitive to climate and environmental shifts.1 Yet, despite evidence of dinosaurs' adaptability, only birds and diapsid groups, such as crocodiles, were left on earth after the Cretaceous–Tertiary extinction to carry on the legacy of these great animals.
Health care delivery at academic health centers (AHCs) can be compared to the dinosaurs. Both are complex entities, large in size, that consume vast resources. Unlike the now-extinct dinosaurs, clinical delivery must exist within the context of the AHC while remaining responsive to climate shifts, such as changes in payer mix, governmental policy and funding, and new predators and trends like private-sector competition and medical tourism. Although health care delivery at AHCs has manifested some traits suggesting social adaptation (e.g., membership in organizations such as the Association of American Medical Colleges [AAMC]), are the aforementioned reforms to the health care system cataclysmic enough to send clinical delivery at AHCs toward extinction like the dinosaurs?
Clinical Care as the Predominant Revenue Stream for AHCs
Clinical care is the most significant economic driver for AHCs. By examining faculty practice plan revenue, a measurable figure that is a reasonable substitute for clinical care revenue, we see what an important financial contribution clinical care provides for AHCs. According to the AAMC, practice plan revenue grew from $8.9 billion to $11.9 billion at public medical schools and from $11.5 billion to $16.6 billion at private medical schools between 2002–2003 and 2006–2007.2 Practice plan revenue accounted for 33.5% of all reported revenue at public medical schools in 2006–2007, surpassing total grant and contract revenue by $1.9 billion. It accounted for 42.1% of all revenue for private medical schools during 2006–2007, exceeding total grants and contract revenue by $4.5 billion. Together, then, revenue attributable to clinical care from hospitals and medical schools is the single largest economic driver for AHCs, providing incentive for sustainability if not growth of the clinical enterprise for the future.
Evolution of Clinical Care Delivery
When units within AHCs (e.g., a practice plan, hospital, or health system) impose clinical delivery objectives, service lines and interdisciplinary care environments develop. These interdisciplinary environments challenge traditional academic departmental boundaries. Revenue and cost-sharing, accountability for performance, and sources for reinvestment become more ambiguous.3 For AHCs to spur evolution in clinical practice and develop new modes of care delivery, these impediments must be overcome.
AHCs represent optimal sites to study the new types of care delivery through local demonstration projects and experimental clinics. Proposed health care innovation zones embody the AHC's core value of investigation.4 Such clinical research can also expand to investigate process or delivery system changes.5 Faculty engaged primarily in clinical work logically would have ideas to improve efficiency and outcomes. Such ideas deserve testing and reporting and represent acceptable novel research. By disseminating these ideas into a literature of practical significance, others can adopt and refine practices and, equally important, not repeat failures.
Individuals pursuing this “new” investigative work will need outlets for scholarship and professional interchange. Traditional health care management and medical journals might need to broaden their content to incorporate the innovation science of care delivery; otherwise, new academically rigorous venues, such as open access video journals focused on implementation and care systems engineering, will have to be created. Health care delivery innovation investigation coincides with the American Council on Graduate Medical Education mandates for process improvement and system-level care experiences for postgraduate training programs.6 Yet, the mentors and teachers directing such efforts often are new to these areas themselves. Thus, it is important to expand the number of individuals competent in clinical delivery innovation endeavors to successfully educate the future health care workforce.
Other forms of clinical research can be adapted to achieve synergy between the clinical enterprise and the AHC mission. Every willing patient can be a research subject for genomic, proteomic, metabolomic, long-term quality-of-life, and self-efficacy studies. Data from this large patient corps would provide natural links for computational mathematicians and social scientists to explore social networks and neighborhoods as nodes of health and health behavior investigation. Additionally, investigations of this dataset could inform higher-yield diagnostic and treatment decisions for the population.
How AHCs Can Compete With the Private Sector
The value proposition for patients in selecting an AHC is the expertise, reputation, physicians, and technology available at such an institution. As private-sector market forces encroach on these benefits, however, the attraction of the AHC can diminish. Cost, quality, and value drive competition. Health care consumers—patients and payers—demand value. AHC clinical care delivery will have to focus on the added value of its environment to win over health care consumers and have an opportunity to define and report new value metrics for the health care community.
Combination strategies to innovate clinical care (List 1) will likely yield the greatest value over time. Strategies that incorporate personalized predisease and risk factor management tools along with panel management can engage the present care population over a longer time frame and provide differential value to health plans. An emphasis on efficiently linking patient information flow with timely, appropriate testing will enhance patient-centeredness, efficiency, and satisfaction. Such strategies also increase patient population exposure to AHC procedures, technology utilization, and translational research.
Externally focused strategic alternatives highlight areas of excellence for regional, national, or international market development. These specialized services represent niche markets. However, by their nature, they integrate traditional science and clinical care and serve as a lure for parties who want to access a specialized service while simultaneously enhancing the AHC's research mission. This externally directed strategy has been readily adopted by some AHCs but contrasts with the locally focused mission and vision for other AHCs.
Recommendations for New Models of Care Delivery
As we move into an era defined more by Atul Gawande and less by William Carlos Williams, using the same delivery system to care for more individuals with more comorbid conditions in a more compressed time frame isn't practical. Though possibly iconoclastic, AHCs should explore new constructs of care delivery, including
* restructuring clinical care delivery into different workday templates—laboratory review, patient contacts, group visits, individual patient sessions, panel management sessions, and care continuum planning—to avoid overlap and improve focus in each area,
* teaching panel management to interdisciplinary provider teams,
* examining whether evaluation/management specialists might become primary care givers for certain medical homes with a concentrated patient base, and
* developing effective methods and valuation for placing stem cell and genomic-based research into clinical practice.
Regardless of the experiment, AHCs should report on the new procedures and policies that have been implemented and the subsequent outcomes. Some experiments will fail. Such data should be disseminated to enhance understanding of optimal care delivery. Although successful models will be “owned” by the AHC, the AHC is still obligated to disseminate the findings while considering how to mix innovation with business in marketing successful novel models of care.
Challenges in Care Coordination and Workforce Facing AHCs
Continuity and care coordination at AHCs are two issues consistently raised by patients, caregivers, health care providers, and health policy makers that have yet to be resolved. The layers of communication needed to accomplish continuity of care for patients referred into an AHC are complex. Telephone calls and discharge summaries are seemingly antiquated in an information age that allows real-time access to medical information across continents. AHC clinical practices will need to develop systems that integrate referring physicians into read-only aspects of a medical record or video links into patient rooms for inclusion as part of the care team. Such practices encourage patient-, family-, and referring-physician-centered clinical care.
A shift in workforce is another challenge facing AHCs. Different attitudes suffuse Generation Xers and Millennials in the medical workforce.7,8 Workflows, resources, and schedules are all subject to transformation to fit the lifestyle and interests of this future workforce. The National Institutes of Health decision to allow K award recipients to pursue research via a part-time institutional appointment is an important step in meeting the needs of a changing workforce.9 Generation Xers and Millennials also have facility with information technology. New job descriptions and task management should access these skills, merging them with population- to patient-based workflows, to more fully engage this new workforce demographic.
What of the “baby boomer” providers' migration out of direct care provision?10 Clinical practices at AHCs can craft positions for these physicians with distributed responsibilities and defined roles while cultivating team skills and keeping generational shifts in mind. The benefits of such efforts should improve physician satisfaction11 and retention. Yet, for such changes to be effective, they also have to translate into higher-quality or more-innovative care delivery.
Developing Leadership in AHCs
AHCs must identify leaders who promote their mission, manage the health care business, and work to adapt their institutions to the changing environment. Frequently, individuals at AHCs tapped for leadership roles have reached that career milestone through individual successes. Opportunities to exercise skills in team building, stakeholder analysis, and strategic management built on a crafted vision are limited. AHCs need to identify how to foster these experiences beyond just management programs. Succession planning and identification of high-potential future leaders, even if such individuals are not stellar researchers or educators, is paramount to finding the right leadership team to balance the AHC mission with leading exemplary innovative care delivery.
AHCs are embedded within the academy, which is not a negative quality, as scholarship and intellectualism are foundations of biomedicine. Yet, the ethos of the academy can be internally focused and individualistic. Principles of autonomy and faculty governance can detract from a global sense of clinical mission, efficiency, and care delivery. Faculty practice plans can partially alter that perception. However, they often exist as parallel structures to traditional academic departments. This separation can lead to negotiation between the practice plan and departments as to clinical effort, accountability, and incentives. The “group practice” can be truly at odds with departmental structures, uncovering tensions related to resource allocation and cross-subsidization in the absence of clear strategic direction.
Clinic models, such as the Mayo and Cleveland Clinics, have advantages in this context. Their genesis and primary emphasis derive from care delivery. Their academic productivity primarily (although not exclusively) developed around a care delivery foundation. Clinical trials, process improvement, informatics, and health outcomes research are part of their research portfolios. This work is both academically laudable and serves as internal research and development for their own environments. Should university-linked AHCs gravitate to such work to achieve greater financial and research impact from their clinical enterprise?
If so, AHCs will need to place research with a primary clinical emphasis within promotional criteria. AHCs' willingness to accept collaborative research in the context of promotion has set a precedent. Yet AHCs can intensify recognition of scholarly clinical practice, even for individuals in a traditional tenure track. Some AHCs are moving in this direction. Translational research can easily embody clinical innovation that concomitantly contributes to the practice environment's growth and success. By making this shift, AHCs can integrate promotional standards with criteria that could also help identify future clinical leadership.
How to Prevent AHCs From Going the Way of the Dinosaurs
AHCs must act now to develop, share, and implement new modes of clinical care delivery to thrive as health care undergoes multifaceted reform. To prevent extinction, AHCs must
* develop academic venues for clinical management and care delivery research,
* formalize interdisciplinary process improvement research,
* develop new funding mechanisms similar to the Clinical and Translational Science Awards to examine mechanisms of health care delivery,
* investigate the sociology and effectiveness of shifts in workforce demographics,
* develop novel partnerships with private-sector business, information management, technology, marketing, and engineering entities to explore innovative care delivery,
* implement health information technology systems that are linked with alternative personal media,
* study organizational dynamics within AHC clinical delivery constructs,
* formalize new organizations to disseminate knowledge about clinical care delivery with leadership development opportunities (e.g., the AAMC's Group on Faculty Practice and Chief Medical Officer's Forum development of a clinical leadership fellowship program similar to the AAMC's Council of Teaching Hospitals Fellows Program), and
* incorporate many of these survival recommendations into health professional education to encourage examination of multiple models of care delivery.
These suggested steps are only a sampling of the possibilities to enhance the development of clinical care delivery within AHCs.