Academic health centers (AHCs) play a vital role in the health care system by training the next generation of health care workers; providing valuable clinical care for challenging medical cases in regional, national, and global communities; fulfilling a social mission; and researching new solutions to improve individual and population health.1–4 Further, AHCs are an economic engine, creating jobs and revenue for local communities, with far-reaching effects across states and regions in some instances.5 Reforms being implemented under the Affordable Care Act (ACA) and shifting economic patterns are threatening the financial sustainability of AHCs.6–9 Here we describe AHCs’ unique contributions to the U.S. health care system and possible strategies to address the financial challenges they face.
One of the primary missions of AHCs is to train health care professionals.2,4 Medicine is unique among professional occupations because it requires years of specialized education and clinical skill building within a health care environment that can provide a variety of training experiences.2 The intensity and diversity of training requirements contribute to higher patient care costs at AHCs than at nonacademic facilities because, compared with physicians in practice, trainees take longer to perform clinical tasks, use more diagnostic and therapeutic services per patient, and require faculty supervision in the provision of these tasks.10,11 AHCs’ educational activities can be viewed as a social good because the revenues from these activities do not make up for the costs, thereby requiring AHCs to finance the costs of providing training opportunities for medical students and residents through other revenue streams such as government subsidies, private foundation funds, research and educational grants, or profits from clinical services.10,11
In addition, AHCs do not have the flexibility of eliminating unprofitable clinical services if such services are required for graduate medical education (GME) and medical student instruction. The Accreditation Council for Graduate Medical Education establishes standards for residency programs. In meeting these standards, AHCs incur substantial administrative costs.12 Furthermore, the unfunded mandate to restrict working hours for residents, despite its potential to reduce medical errors, may lead to more costs in the form of hiring physician extenders to make up for lost work hours from residents.13
The need for physicians and other health care professionals in the United States is expected to increase because of several factors, including the aging of the population, increasing chronic disease burden, and the influx of newly insured patients into the health care market through health insurance exchanges and expanded government insurance programs under the ACA.14,15 The ongoing federal budget battles in Congress threaten GME funding, which presents a serious concern because GME is not a billable health service to health insurance providers or to patients paying out of pocket.16,17 Without a change to how GME support is financed, AHCs and hospitals may be limited in their ability to grow residency and fellowship program positions, or possibly be faced with reducing positions, which would exacerbate the physician workforce shortage.16,18
Treatment of complex cases
AHCs provide a disproportionate share of necessary but unprofitable services, such as complex trauma care, burn care, care for patients with complex diseases such as AIDS, and intensive care for patients with multisystem organ failure.10 Patients requiring these services in AHCs are disproportionately uninsured or quickly exhaust their insurance coverage.10 Furthermore, the risk of readmission increases with the complexity of the cases being managed in AHCs, which is a challenge because Medicare implements financial penalties for readmissions without regard to case complexity.19
AHCs compete in the medical care marketplace with nonacademic providers for revenue from insured patients’ co-pays and health insurance payments. Providers at AHCs provide a larger proportion of necessary but unprofitable care to poor and uninsured individuals than do their nonacademic counterparts. This, coupled with the low Medicare/Medicaid reimbursements for complex services (if they are even covered), can put financial strain on AHCs.10 As AHCs begin to establish accountable care organizations,20 new reimbursement and care models will emerge from these organizations and will require careful study on how these models affect the provision of complex clinical care in AHCs.6 New models of sustainably delivering these services are being researched through the Center for Medicaid and Medicare Innovation (the Innovation Center).21 For example, a demonstration project22 in Colorado successfully tested a comprehensive outreach trauma program that increased referrals of critically injured patients from outside the Denver metropolitan area while enhancing the social mission of the trauma center. This increase in outreach patients resulted in higher injury acuity of patients, more academic publications, and higher reimbursement at the AHCs.22 Continued work in this area will be needed.
Treatment of the uninsured and underinsured
Traditionally, AHCs have served a disproportionate number of the uninsured or underinsured with an estimated cost of nearly $30 billion annually across all AHCs.23–25 As safety-net providers for many communities, AHCs currently receive Medicare Disproportionate Share Hospital (DSH) payments for serving a large proportion of the uninsured or underinsured.26 AHCs account for a large share of DSH payments.27 The ACA will substantially reduce DSH payments starting in 2014.26,28 The logic behind this ACA provision is that patients who previously received charity care will qualify for Medicaid or will be insured through the insurance exchanges, and therefore, less charity care will be required. Although the large number of individuals who are currently uninsured is expected to decrease substantially upon implementation of the ACA, a significant proportion of the population will not be eligible for insurance through Medicaid or the insurance exchanges, especially in states that reject Medicaid expansion.29,30 Therefore, these individuals will continue accessing services, but AHCs’ ability to offset this expense through DSH payments will be limited, especially AHCs in states that reject Medicaid expansion.27,31
Furthermore, the Emergency Medical Treatment and Active Labor Act (EMTALA), an unfunded mandate, requires federally reimbursed hospitals to provide care to patients needing emergency health care treatment, regardless of citizenship, legal status, or ability to pay.32 Under EMTALA, because AHCs typically have an emergency center, AHCs are disproportionately exposed to the most vulnerable patients lacking health insurance coverage, further increasing the financial burden on these institutions, especially with reduced DSH payments.27,31
AHCs conduct health research that generates new insights into the causes and treatments of illness.2,4,10 However, government funding for biomedical research has been flat over the past few years, which has made pay lines significantly more competitive.7,33 The National Institutes of Health (NIH) have recently revised financial compensation policies for researchers, decreasing funding awards in support of their salaries from level I to executive level II pay scale.34 The highly competitive funding climate was exacerbated by the 2013 federal budget sequestration and raises the question of how AHCs can sustain scientific research. Such a funding climate makes it difficult for AHCs to fulfill their mission of discovering meaningful medical knowledge and applications that promote and improve health and possibly could make it more difficult to recruit physician scientists if the extramural funding climate continues to be at risk.
Solutions to improve the financial health and viability of AHCs fall into three categories: economic, government intervention, and system reform.35,36 It should be acknowledged at the outset that some of the following solutions may be implemented quickly, whereas others may take longer to implement. Likewise, the following solutions have varying degrees of being within an AHC’s control, which will undoubtedly influence the likelihood of implementation. However, even solutions that might not be as feasible, such as solutions that require government intervention, should be discussed and debated because changes within the organization alone may not be sufficient to improve the financial health and future of AHCs.
Create reimbursement methods that more closely reflect the cost of services.
There is a need in hospitals to control costs and, at the same time, improve quality. The Diagnosis-Related Group (DRG),37 a system of classifying hospital cases for reimbursement purposes, is an example of a policy that exposes AHCs and other Medicare-recipient hospitals to significant financial risk because the true prices of services are not reflected in allowable billings to third-party payers. An alternative to DRG reimbursement would be to help AHCs address financial risk. For example, some components in the reimbursement model of critical access hospitals, such as allowing cost-based payments for some health care services, could be adopted for AHCs, as recommended by the Medicare Payment Advisory Commission.38 Another alternative would be to reimburse the first three days of each admission on a fee-for-service basis, with two per diems (one for “ICU days” and the other for “routine days”) beginning with the fourth day.37 The logic of this alternative formula is that cost and uncertainty are prominent at the beginning of each admission, whereas patient outcomes are likely to become homogeneous, regardless of incoming diagnoses, beginning on the fourth day. This approach could capture the case-mix feature of the AHCs better than the DRG and ultimately lower costs while maintaining quality. However, this formula was created based on data from a single AHC (the University of Michigan Health System)37 and should be evaluated further to determine whether it could be applied in other health systems.
Improve operational efficiency.
Patient care is the main source of revenue for AHCs to cross-subsidize research and teaching. Thus, it is important and reasonable for AHCs to optimize allocation of resources. Various strategies have evolved to improve operational efficiency, among which are the use of incentives to stimulate efficient productivity by AHC staff members, including researchers.35 Additionally, focusing on clinical services that generate revenue is a strategy that may increase efficiency and reduce financial risk. However, dropping low-volume/high-risk clinical services (e.g., trauma units, burn units) may jeopardize an AHC’s commitment to education and research along with its institutional identity and commitment to social responsibility.37 Hence, it is critical for AHCs to strike a balance between provision of profitable health care services and delivery of uncompensated care, perhaps by specializing in a set of core competencies.
Government intervention solutions
As suggested by Blumenthal and Meyer,39 (p1813) “in states and localities that have little experience with competition and little prospect that it will develop (such as rural areas), the equivalent of government-operated single-payer systems may take hold.” Maryland is a successful policy lab for this ambitious government intervention through the Health Services Cost Review Commission (HSCRC), which is an independent state agency with the authority to set hospital rates.40,41 The HSCRC may set different rates for different hospitals after adjusting for their case-mix and social missions (e.g., education, charity care, bad debt) to better align the price with the cost, but the rates do not vary by payer. In Maryland, all payers, including public and private insurers and self-pay patients, pay nearly identical rates for hospital services. The rationale of Maryland’s policy is that the cost of the social mission should be treated as a common responsibility to be shouldered by all payers.40 More important, by spreading the cost of the social mission across all those who consume health care, serving social missions will not impair the financial viability of the hospitals, and the hospitals are encouraged to serve all patients in need regardless of their ability to pay. Finally, this system is fair because every insurer is paying the same rate, which reduces the incentive for cost shifting and price discrimination. Such a system helps to reduce the financial burden borne by AHCs as a result of charity care, leading to an increase in revenue that can help cover GME costs. There has been some evidence in the literature that the Maryland model has been controlling costs and improving health care quality.41,42
Subsidize the social mission and education.
AHCs are responsible for carrying out social missions that place them at a disadvantage in the competitive health care marketplace and may require government subsidy for financial survival.36,39 Medicare subsidizes GME primarily by making direct and indirect medical education payments to hospitals involved in training residents.26 It remains unclear whether GME reimbursements are sufficient to fully cover the cost of training residents and fellows, and the current payment system does not reimburse for the cost of training medical students.43,44 Increasing reimbursement for GME and initiating reimbursement for medical student education might be an option should policy makers consider medical education a priority. The ACA has provisions for increasing the number of residency training slots available for primary care training and also encourages the redistribution of unused Medicare-funded residency positions to hospitals that require them.45 The ACA also makes funds available for resident training outside the AHC setting.46
System reform solutions
Improve decision-making and communication processes.
All barriers to decision making among departments and hierarchies within an AHC should be evaluated. The organizational structure of AHCs includes various units, usually consisting of an academic arm (college of medicine/university), a teaching hospital, and a group practice plan. The level of autonomy and integration of these units varies among AHCs.47 The decision-making process in an AHC also needs to be consistent with its other organizational aspects, such as governance structure, organizational culture, and the strategic planning process.48 The organizational model used in AHCs could involve the integration of all units or a combination of units. For example, the University of Florida implements a fully integrated model whereby the hospital, academic arm, and group practice plan all fall under a single organizational structure.47 Decentralized and bottom-up decision making might not work effectively in vertically integrated systems with tight arrangements.49 However, a fully integrated model can be a challenge when state regulations of public-owned entities add cost and bureaucracy, thereby limiting the ability of the organization to be competitive within the market. The model adopted by any AHC should be the best one for achieving efficiency and effectiveness in the performance of its mission.
Improving communication within AHCs is important to solve problems, face challenges, and receive feedback more effectively and efficiently under dynamic circumstances.40 There is an ongoing drive to incentivize the application of information technology in the health care system to help reduce costs and improve communication.50,51 Improving communication is a key strategy to increase employee morale and consolidate organizational culture, which is critical to the survival of any organization.48 Personnel turnover can cost an organization more than 5% of its operating budget.52 The sense of being heard in the decision-making process is important to stabilize personnel and maximize return on investment.52
Utilize industrial management tools and models.
Tools widely used in other industries, including hedging, risk pooling, creating logistical and financial buffers, developing forecasting and information systems, and cultivating sophisticated scheduling strategies, can help AHCs better manage their risk.36 Initiating a department focused exclusively on risk management is also an option.36 Mission-based management that aligns revenues with strategic initiatives can also help AHCs use financial resources more efficiently.48
Increase internal cooperation.
Given the trend of a greater percentage of NIH funds being awarded to a declining number of institutions,53 most AHCs must find new ways to sustain funding for their research endeavors. Breaking down barriers among departments and increasing cooperation among basic science, clinical research, and public health have great potential to improve competitiveness for large multidisciplinary grants.54 Moreover, operational efficiency can also be achieved from sharing facilities and personnel among departments and colleges, which will increase the cost-effectiveness of research. For example, institutions such as the University of Florida are able to better translate research into clinical application because there is internal cooperation between its research centers and institutes and its clinical teams.47 Hence, medical innovations discovered in the research lab (e.g., new drugs or treatment protocols) can be tested in the clinical setting of AHCs according to specified guidelines, thereby achieving synergy and maximizing return on investment. This would likely be incentivized if promotion and tenure policies recognized team-based science and commercialization of research.
Increase external cooperation.
In addition to encouraging internal cooperation, AHCs may also want to increase cooperation with external institutions (including other AHCs) to further benefit from operational efficiencies in patient care, with the additional possibility of benefiting the AHCs’ research endeavors. This might include pooling resources and facilities. A recent model of strategic partnership is between AHCs and rural primary care clinicians. The University of New Mexico Health Sciences Center created a partnership with primary care clinicians in underserved areas to deliver complex chronic disease care using telemedicine technology.55 This partnership resulted in a significant increase in patient consultations in rural areas, with high ratings on patient satisfaction scores among users and providers.
Besides using internal resources more efficiently for research, AHCs should make efforts to reduce their financial dependence on NIH funds and seek alternative external funding sources. A promising strategy to promote both research and clinical services is for AHCs and corporations to affiliate.56 The partnership between General Electric medical systems and New York-Presbyterian Hospital serves as an example.43 In such partnerships, AHCs can benefit from a negotiated price for corporate products and services, while the corporation benefits from a stable contract and shared research product. AHCs have a unique advantage to participate in this type of affiliation, with both laboratory and clinical space.39 Such an affiliation can facilitate the translation of research findings into clinical practice, creating a synergy between academic products and economic benefit. However, this public–private partnership should be in line with ethical and other prescribed guidelines to avoid conflicts of interest and unfair exploitation of AHC patients and faculty. Nonetheless, the timely translation of research to clinical practice also helps AHCs demonstrate to the public that they are meeting their social mission to improve community health and generate innovations that benefit society.2,4,10
The pivotal role of AHCs as trainers of health care professionals and providers of expert care to various sectors of the population, including complex and indigent patients, is a significant benefit to society. Furthermore, as innovators pioneering and nurturing the development of novel treatment techniques and medical products, AHCs play a critical role in the U.S. health care system. However, increased competition for profitable clinical services, fulfillment of a social mission, and recent federal legislation are putting an increasing financial strain on AHCs, thereby jeopardizing their economic sustainability. The clinical services that are currently profitable may change significantly under the ACA as compensation models change. Services that are currently well reimbursed on a fee-for-service basis, such as cardiac stenting, will be reimbursed under global reimbursement models that would include a range of treatment options to improve patient outcomes. Devising solutions to the evolving problems of AHCs is crucial to improving health care delivery in the United States. Most likely, a combination of market, government, and system reforms will be needed to improve the viability of AHCs and assist them in fulfilling their social and organizational missions.
Acknowledgments: The authors wish to thank John Adams, Bradley Britigan, and Sue Nardie for their valuable input on earlier drafts.
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