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Commentaries

Academic Medicine’s Critical Role in the “Third Curve” of Health Care

Paz, Harold L. MD, MS

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doi: 10.1097/ACM.0000000000001165
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Abstract

With more than two decades of experience leading academic health systems and practices, I have watched the world of academic medicine steadily evolve against the backdrop of an enormous and unprecedented structural transformation of U.S. health care. Over the last several years, the health care landscape has changed at an unparalleled rate due to new economic and regulatory forces ushered in by the Affordable Care Act and the introduction of innovative technologies, such as personalized medicine, that are poised to open the door to consumer-driven health care. As a result, tremendous pressure exists on academic health centers and faculty practice plans to keep pace and rapidly evolve clinically while not abandoning their unique academic mission. The last massive transformation of academic medicine occurred a century ago following the Flexner Report.1 The circumstances today are much the same. The many segments of the health care system willing to innovate and take financial and strategic risk will be ready to join in the transformation, facilitating the opportunity for academic leaders to determine a path forward.

At the health system’s very core, we are finally, after decades of discussion, shifting from a physician-centric to a patient-centric paradigm that will serve to optimize health and wellness and create more healthy days for more patients. This, in turn, will enable us to address the rising costs of health care, drive quality, and offer new and innovative forms of access. Central to this strategy must be the creation of a holistic wellness experience for patients that engages all five determinants of health to offer the value proposition of improved care. From the public health movement in the early part of the 19th century, to the definition of health by the World Health Organization,2 the rise of community-based medical schools, the conceptualization of the biopsychosocial model of health, and measurement of social determinants of health, all in the latter part of the 20th century, the core elements of this transformation in our health system have been in place for years. The convergence of this work with new payment models distinct from fee-for-service medicine has brought us to a post-Flexner era of population health.

Plotting the Curve of the U.S. Health System

Health care delivery models can be seen as graphed curves that rise as they are widely adopted and then taper off as another model begins to take their place.3 As quickly as we have moved from Curve I (fee-for-service) to Curve II (population health), we are now crossing over to a new form of consumer-directed health care, or what I call the third curve of health care (Curve III). While the first two curves look at health from a provider and business perspective, the third curve places the individual in the center of a curated health ecosystem. Recognizing that patients, not physicians, own their health, new resources and tools will enable each individual to take more ownership, become more likely to adhere to care plans, and feel more empowered to take charge of his or her well-being. We must embrace these new tools and resources, such as mobile apps, telemedicine, home health, “urgicare” centers, and other technologies to improve the health of our patients. Physicians and health systems must be rewarded for quality over volume and must be able to address the interdependencies of behavioral and social health on physical well-being. Against the backdrop of higher deductibles, which give consumers greater incentives to think carefully about when and how they are using health care, Curve III is shaped by the recognition that health care is not immune to overall changes in consumer expectations driven by experiences with the Internet, social media, and information transparency in other sectors of the economy. Undoubtedly, all three curves will, for a time, coexist, but the convergence of large data sets and analytics with genomics and health information will certainly make good on the promise of patient-centered care in ways we can only begin to imagine.

In this new health care model, many new opportunities will exist for collaboration among academic health centers, payers, and other community health care providers. These relationships share a common goal of improving health outcomes, which will not only help each organization thrive in a new health care environment but will also improve the health of our communities.4

Training Physicians Who Can Adapt and Thrive

As a former medical school dean, I know that we have a responsibility to train students to succeed in this new world order of consumer-driven health care. Sadly, there is an overabundance of cautionary tales from other academic disciplines where graduate programs, such as law schools, faced significant challenges in transforming along with the massive restructuring of their professions.5

What makes medicine unique is that by 2025, we are projected to face a physician shortage of 90,000.6 While shortages generally predict increased demand, I believe that in Curve III things could take a different turn. Nature abhors a vacuum, and inevitably new solutions to the shortage will emerge, from new technologies to a broadened scope of practice across the health professions. This will give rise to the development of new pathways to improve health, further accelerating the move to a more patient-centric ecosystem. If the old physician-centered model of health care is in transition, and the impact of technology and analytics is growing, we must train future practitioners to embrace this change and function effectively in the world of consumer-driven health care.

What will the physicians of the future look like, and how will they operate? Physicians will play an important role where experience has not been automated. Computers do not offer compassion, and this will increase the pressure on academic medical institutions to look for and develop the personality and skill sets necessary to fill the void left by technology. The opportunity to address health and wellness within the context of not only physical health but also emotional and social health will be a priority. I am not suggesting that medical schools and residency programs diminish the importance of scientific knowledge and research. But at the same time, there must be an emphasis on preparing physicians to serve as leaders of teams of professionals that create a health and wellness experience for individuals that combines health care with data analytics and technology. The attributes of leadership, including empathy, trust, communication, determination, courage, integrity, and vision, are no different in medicine than in any other field. Collaboration will be the key to leading us into the future. If the doctor–patient relationship is to be preserved, physicians must be trained to serve as leaders to the greatest extent possible. With the capabilities, strengths, and challenges of all of the players in the health care system, I see a remarkable path forward if we all work together to ensure that patients come first, to embrace change, and to develop both hard knowledge and “soft” skills in our future medical professionals.

References

1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin no. 4. 1910.Boston, Mass: Updyke.
2. World Health Organization. WHO definition of health. 1948. http://www.who.int/about/definition/en/print.html. Accessed February 9, 2016.
3. Morrison I. The Second Curve. 1996.New York, NY: Ballantine Books.
4. Halfon N, Long P, Chang DI, Hester J, Inkelas M, Rodgers A. Applying a 3.0 transformational framework to guide large-scale health system reform. Health Aff (Millwood). 2014;33:20032011.
5. Campos P. The crisis of the American law school. Univ Mich J Law Reform. 2012;46:177223.
6. Dall T, West T, Chakrabarti R, Iacobucci W. The Complexities of Physician Supply and Demand: Projections From 2013 to 2025. Prepared for the Association of American Medical Colleges. March 2015.Washington, DC: IHS Inc..
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