Socially Accountable Academic Health Centers: Pursuing a Quadripartite Mission

Abstract

Academic health centers (AHCs) in the United States have had a leading role in educating the medical workforce, generating new biomedical knowledge, and providing tertiary and quaternary clinical care. Yet the health status of the U.S. population lags behind almost every other developed world economy. One reason is that the health care system is not organized optimally to address the major driver of health status, the social determinants of health (SDOH). The United States’ overall poor health status is a reflection of dramatic disparities in health that exist between communities and population groups, and these are associated with variations in the underlying SDOH. Improving health status in the United States thus requires a fundamental reengineering of the health delivery system to address SDOH more explicitly and systematically. AHCs’ tripartite mission, which has served so well in the past, is no longer sufficient to position AHCs to lead and resolve the intractable drivers of poor health status, such as unfair and unjust health disparities, health inequities, or differences in a population’s SDOH.

AHCs enjoy broad public support and have an opportunity—and an obligation—to lead in improving the nation’s health. This Perspective proposes a new framework for AHCs to expand on their traditional tripartite mission of education, research, and clinical care to include explicitly a fourth mission of social accountability. Through this fourth mission, comprehensive community engagement can be undertaken, addressing SDOH and measuring the health impact of interventions by using a deliberate structure and process, yielding defined outcomes.

The U.S. health system is expensive and suboptimally effective compared with other health systems of developed-world economies.¹ In the beginning of the 20th century, the chief causes of U.S. deaths were communicable diseases, resulting in large comprehensive medical centers built to centralize, isolate, and address individual care. Over the ensuing 100 years, the main causes of death have shifted gradually to chronic diseases largely determined by health-related factors commonly referred to as social, behavioral, and environmental determinants of health. Addressing these factors requires a new model of care. Academic health centers (AHCs) have achieved significant successes in driving health care excellence and innovation; stimulating new biomedical discoveries and medical technologies; and advancing our understanding of human biology; however, they must now embrace a more appropriate conceptual framework if they are to optimally improve population health.^2–6

As a country, we must adopt a new, more comprehensive approach toward improving the health of our nation, one that focuses on strategies to optimize the integration of medical care; public health; and the social, environmental, and community conditions of living that are necessary for people to be healthy. AHCs must partner with communities to engage in collaborative solutions that address underlying causes of disease, rather than getting caught in the fragmented loop of addressing symptoms alone. The purpose of this Perspective is to propose a framework that enhances the current missions of AHCs and also provides an impetus for the improvement of our national health status.

Determinants of Health

Social science, public health, behavioral health, and health services research consistently conclude that the major determinants of health are 50% social (socioeconomic status, employment, education, food and housing security, racism, etc.) and behavioral (food choices, exercise, and substance use); 10% environmental (lead exposure, unsafe or polluted living conditions); 15% genetics (family history, inherited conditions); and 25% medical care received.^7,8 Thus, the overwhelming preponderance of U.S. health status (60%) is not related to medical care but, rather, to environmental and social determinants of health (SDOH). High-quality medical care alone often cannot protect against poor health outcomes. In fact, living conditions, socioeconomic factors, and health-related behaviors account for 60% of all premature deaths, 33% of all acute disability, and 66% of all chronic disability in the United States.⁹ This reality is starkly evident in New Mexico, where the indigenous population has some of the best screening and treatment for diabetes in the country, yet has the highest death rate from diabetes.¹⁰ AHCs comprehensively engaging the community—the “process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people”¹¹—is key, and research shows that authentic collaboration between academic and community partners can enhance health outcomes.^12–15

The Importance of AHCs

AHCs are defined by the Association of Academic Health Centers as “academic institutions that include a medical school, one or more additional health professional schools or programs, and an owned or affiliated hospital/health system.”^16,17 Despite significant variability, all AHCs have in common the tripartite missions of education, research, and clinical care. There are currently 151 AHCs in the United States, and as a group, they have contributed significantly to improving the health status of this nation.^2–5,18 AHCs, however, have the capability—indeed, the obligation—to do more.

What makes AHCs so important to the U.S. health care delivery system? First, AHCs are uniquely organized under their integrated tripartite missions. The intersection of these missions creates synergies that drive and augment interdisciplinary innovation, learning, and the discovery and application of new knowledge, all of which can translate into the highest quality of care. Second, although AHCs represent only 3% of nonfederal, acute care hospitals in the United States, they care for 33% to 40% of the uninsured and account for almost 33% of national health-related research funds. Additionally, they produce approximately 22,000 medical school graduates annually; are the dominant providers of graduate medical education (GME), sponsoring 60% of all GME programs in the United States; and graduate about 15,000 nurses and 6,000 public health professionals.^19–21 AHCs have a disproportionate and significant impact on the nation’s health care delivery system and, consequently, its health status.^18–21 The challenge, however, is that overall improvements in U.S. health status have been underwhelming because the U.S. health care delivery system has lacked a systematic and organized approach to addressing the main driver of health status, SDOH.

AHCs and Population Health

The dramatic disparities in health status that exist between communities or population groups are due primarily to variations in the associated SDOH. Addressing the challenges associated with eliminating health inequities and improving the health of vulnerable populations thus requires targeted innovations and strategic interventions related to these determinants.²² Confining AHCs’ contributions to the achievement of excellence in education, research, and clinical care is suboptimally effective for addressing the nation’s health status. Often, these three missions have become ends in themselves rather than activities that support a common purpose, such as the health improvement of a population. Research cannot and should not be a mission by itself, nor should education or clinical care.² All three mission areas must act synergistically to advance a common purpose—that of a healthy future for all.⁵ Given their disproportionate impact on the nation’s health care delivery system, AHCs are both uniquely qualified and strategically positioned to contribute beyond medical care optimization, and they can and should play a leadership role in transforming population health.^2–5,23 It will require a mission update to do so.

AHCs can make a unique contribution to improving population health in three important ways.

First, AHCs are the entities within the health care delivery system that are well equipped to (1) enable collaborative identification of community or population health needs; (2) facilitate identification and understanding of underlying causes, mediating factors, and mechanisms of action leading to population health challenges; and (3) participate in the design and implementation of requisite innovations and strategic interventions to meet these challenges.

Second, AHCs are well equipped to function as a member of a broader societal (interprofessional) team in which the development of innovative solutions, the application of community interventions, and evaluation of impact on targeted populations occur in collaboration with key non-health-care-sector community stakeholders—community and corporate leaders, businesses, social services, transportation, and government, along with members of the community itself. The AHC intra-health-professional team is well positioned to interact with the interprofessional team of the broader society.

Finally, over and above the tripartite mission, AHCs are major contributors, directly and indirectly, to the economic health and development of local and regional communities. The latest available data indicate that AHCs contribute more than $562 billion annually to the national economy and $22 billion annually in state tax revenue, while also supporting 6.3 million jobs (1 out of every 30 U.S. wage earners), paying more than $387 billion in aggregate annual wages, salaries, and benefits.^24–26 Furthermore, 75% of AHCs are located in underserved communities with the capacity, opportunity, and obligation to serve the public good by addressing health equity and elimination of health disparities. This opportunity is reinforced by the Affordable Care Act and Internal Revenue Service (IRS) regulations, which require nonprofit organizations to demonstrate “community benefit” by developing community service plans jointly with community partners.¹² AHCs have significant potential to influence and benefit local community economies and therefore have a legitimate voice at the community table, independent of their role and contributions in health care.

Conceptual Framework for AHCs to Address SDOH

To address SDOH systematically, AHCs need a conceptual framework within which to work. The concept of social accountability for medical schools was introduced two decades ago. It is defined as

the obligation of medical schools to direct their education, research, and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, healthcare organizations, health professionals and the public.²⁷

This concept provides a framework for assessing institutional accountability and commitment relative to addressing societal obligations. Over the last decade, the social accountability of medical schools has garnered considerable interest, and a number of medical schools worldwide have adopted it. It has been the focus of a broad range of initiatives to advance its development as a strategy to address health inequality.^28–31

The principles of social accountability call for an explicit three-stage engagement: (1) identification of society’s priority health needs and challenges; (2) adaptation of the institution’s programs in education, research, and clinical care to address priority needs and challenges; and (3) assessment of the impact of the institution’s efforts. The two defining elements of this engagement are (1) developing a structured and purposeful partnership between the institution and key community, regional, and national stakeholders; and (2) external assessment of the impact of institutional interventions on meeting the needs and challenges of the population of interest and the society as a whole.^28,29 Social accountability, therefore, moves beyond awareness and intentions to address a community’s or society’s needs. This concept demands the articulation of measurable results and tangible outcomes where the focus of program evaluation is impact. Application of the concept of social accountability has been directed almost exclusively toward medical schools and has focused primarily on educational mission outcomes and workforce development.^30,31 Application of social accountability to the research and clinical missions is considerably less well developed or described. The concept of social accountability applied to AHCs has broader implications and greater potential for significantly impacting population health than does the application of this framework to medical schools in isolation. The application of the social accountability framework to the AHC enterprise represents an opportunity for community health status transformation.

The Societal Obligation of AHCs and Justification for a Quadripartite Mission

What obligates AHCs explicitly to step forward and lead the effort to improve the health status of the United States? First, the health professions in general and AHCs in particular have a moral and ethical contract with the general public that transcends ideology or financial considerations and speaks to societal expectations of the health professional. Second, AHCs already have a disproportionate and significant influence and impact on the direction of the nation’s health delivery system as well as its personnel, as discussed above. Third, based on mission, infrastructure, and expertise, AHCs enjoy substantial and disproportionate benefits from federal public funds (e.g., National Institutes of Health, Centers for Medicare and Medicaid Services, etc.) for mission-specific activities; they also receive regulatory exceptions (e.g., Stark law, IRS) under the assumption of public benefit and societal gain. Over the last decade, federal and state governments have allocated approximately $100 billion to support education, research, and clinical care activities as well as Disproportionate Share Hospital funds and enhanced Medicaid funding for the poor and uninsured. Much of this funding has gone to support the activities of AHCs.¹⁹ This has provided AHCs with significant public revenue streams and public support, which obligates a return on investment to the public. Lastly, AHCs are often recipients of local and regional public-sector investment in support of special infrastructure, expertise, and health-related assets for the purpose of providing specialized services (e.g., burn units, trauma), safety-net functions (e.g., indigent care tax revenues, local tax abatements, other public support), and other health-related activities not otherwise available in the community.

What we know today about SDOH and the pressing unmet societal needs relative to health is that it is no longer acceptable to consider population health as an aspirational by-product of excellence in the traditional tripartite missions. The significant public funding, the societal obligations of AHCs, and the extraordinary health care assets associated with these institutions must be juxtaposed against the unmet health needs of our society. Considering the special institutional and organizational status of AHCs, they have an opportunity to lead in solving the unmet societal needs of our current health care delivery system and improving our national health status.

The traditional tripartite mission of academic medicine is therefore inadequate for addressing population health and SDOH. AHCs must adopt a quadripartite mission that includes explicit metrics and impact measures that drive accountability for population health improvement. We recommend that the fourth mission be social accountability. Adoption of the social accountability mission would obligate AHCs to direct their expertise, resources, activities, and missions to addressing, collaboratively, the mutual priorities and health needs of the communities they have a mandate to partner with and serve. Social accountability moves AHCs from establishing awareness and intentions to address a community’s or society’s needs, to producing outcomes for which success is measured by community impact (Figure 1). This means that to accomplish national health status improvement, AHCs would have to move from a three-legged stool (tripartite mission) to a four-legged table (quadripartite mission) so that the community can sit equally at the table. The involvement of community in this process cannot be overestimated. AHCs should take a major role in convening and informing the community-based interprofessional team. These interprofessional teams (community health collaboratives), co-led by AHCs and respective community partners, could mutually develop metrics and measures to determine what needs to be accomplished and how, as well as how success should be defined and assessed.^12,15,32,33 The synergies of AHCs’ collective quadripartite missions of education, research, clinical care, and social accountability can fuel the effort to mitigate the recalcitrant health and social problems in the United States, and AHCs are already well positioned to and capable of doing so.^5,34

Figure 1: Academic health centers’ current tripartite and proposed quadripartite mission.

Addressing Challenges and Enablers of Incorporating Social Accountability

Multiple challenges exist for the adoption and implementation of a new mission for AHCs and academic medicine. To be successfully adopted and sustainably implemented, a new mission needs to address the issues of organization, leadership, and value. Reorganizing the AHC enterprise is essential to incorporating a new mission. Although reorganizing the AHC enterprise is essential to incorporating a new mission, nonetheless, as often cited, “Every system is perfectly designed to get the results it gets.”³⁵ Furthermore, since AHCs are at present organized around the operation and delivery of products associated with the three traditional academic medicine missions, reorganizing would entail development of a new mission-specific area of authority and responsibility. Identifiable and responsible leadership would be another tangible manifestation of organizational commitment to redesign and mission effectiveness. Most current AHC leaders are outstanding at managing the tripartite mission of academic medicine. Likewise, this new model will require accountable executive-level leadership (e.g., a vice president or vice dean) for the social accountability mission with programmatic responsibility for population health. Finally, commitment to a new mission would necessitate redeployment of existing resources or mission-specific investment. In any case, a clear value proposition would need to be established in support of implementation and financial sustainability.

Value Proposition of New Mission

It would be unrealistic to expect a reorganization of the AHC enterprise and the successful incorporation of a quadripartite mission without a clearly delineated value proposition. It is particularly important to demonstrate value in an environment of increasingly limited resources. There is a strong “business case” for implementing the social accountability and population health mission of AHCs. The conventional wisdom is that an emphasis on population health, with specific focus on SDOH, will negatively impact AHCs’ bottom lines. This is a belief based on an analysis of the current situation but does not account for the rapid shift in demography, changes in payment models, the unsustainable rise in health care costs, or improvements in medical and information technology. The U.S. payment model is anticipated to move toward more value-based pricing, and the aging generation of baby boomers is sure to cause a surge in the need for health care services. While advances in medicine and addressing SDOH may diminish the need for health care related to chronic diseases such as hypertension and diabetes, an increased life span will initiate a demand for treatment of other illnesses such as cancer and dementia. Thus, although the impact on AHC revenues from addressing SDOH is not known with certainty, it is likely to improve in a value-based payment model.^5,36–39

Effective implementation of the social accountability mission would have other direct financial benefits to AHCs. Moreover, it would significantly increase the attractiveness of AHCs to public agencies relative to public investment. This would be particularly true for AHCs that engage in a substantial safety-net function. Renegotiated value-based contracts, with payers emphasizing population health, particularly in vulnerable populations where addressing SDOH is most challenging and most needed, can indeed be financially sustainable. Addressing “upstream” determinants subsequently impacts downstream use of health care services. Accordingly, targeted upstream interventions in communities that disproportionately contribute to uncompensated care would decrease financial losses of AHCs by decreasing both the number of uncompensated patients requiring health care services and the intensity of services used by these patients. An additional benefit of addressing upstream determinants that would impact all members of these communities is the improvement in therapeutic outcomes expected to occur when untoward effects of social determinants on these outcomes are mitigated. Optimizing therapeutic outcomes will become increasingly important to the bottom line as we evolve to a value-based environment.^5,36–39 Current attempts to account for the influence of SDOH on health outcomes are largely carried out by population-centered statistical risk adjustments, based on demographic factors. Addressing underlying social determinants would allow us to move from statistical risk adjustment to actual adjustment of population risk—essentially moving from simply forecasting health outcomes to better monitoring, evaluating, and positively modifying health outcomes, overall resulting in an enhanced impact on the health of the population. AHCs whose focus incorporates social accountability will therefore seek to demonstrate measurable societal impact. Demonstrable improvement in the economic, physical, social, and/or mental well-being of defined communities would be a direct benefit of this augmented mission and, most important, will be beneficial to the health of the nation.^5,40–42

Takeaways and Next Steps

This Perspective has five takeaways for our community of AHCs. These takeaways concretely address health inequities and vulnerable populations. They also provide the initial steps in population health transformation that will enhance the social accountability of AHCs as instruments for sustainable health reform.

1. SDOH are the major drivers of poor health status in the United States.
2. The concept of social accountability—an institutional mission that requires a formal structure, process, and outcomes for assessing comprehensive community engagement as well as the associated metrics for measuring population health impact—must be further developed and adopted by AHCs.
3. The current AHC tripartite mission encompassing only education, research, and clinical care is insufficient for improving the nation’s health status in the absence of a new fourth mission.
4. The proposed fourth mission—social accountability—facilitates the integration of the “triple threat” (research, education, and clinical care) with the “Triple Aim” (better care, better population health, and lower per capita costs).⁴³ Thus, necessitating the transition of AHCs from a tripartite to a “quadripartite” mission for AHCs.
5. Identifiable and responsible leadership of the social accountability mission would be another tangible measure of organizational and operational commitment to redesign and transform AHCs effectively.

Conclusion

By adding social accountability as a new fourth mission for AHCs, with associated and agreed-on metrics and measures of success, we can establish a tangible mechanism to realign interdependent components of SDOH for populations and achieve a healthier nation. As AHCs, we have a mandate and an obligation to do so. There is no better time than now.^36–43

Acknowledgments:

The authors are grateful to Anil N.F. Aranha, PhD; Lynn C. Smitherman, MD; Allison Guilliom, MLitt; Kristin Copenhaver; and Kevin Sprague, MD, of Wayne State University School of Medicine for efforts rendered with preparation of this manuscript.