In this commentary, David Silbersweig, Chairman of the Department of Psychiatry and Co-Director of the Institute for the Neurosciences at Brigham and Women’s Hospital, and Stanley Cobb Professor of psychiatry and Academic Dean (Partners HealthCare) at Harvard Medical School, says that teaching hospitals provide vital care, research and training, but he believes they are under threat.
By David Silbersweig
Medicine is in an era of necessary process improvement and cost cutting — the confluence of two goals that aren’t always as synergistic as administrators would suggest. In academic medical centers, there is a third goal that is equally critical: preserving and enhancing the academic mission in this challenging context.
Teaching hospitals, together with medical schools in our universities, are places where medicine moves ahead. They are the envy of the world, and rightly so. For discovery happens there, whether in translational biomedical science or in systems and outcomes improvement. And extraordinary care is given there, combining the science and art of medicine, while training the next generation of pioneers and caregivers.
But our nation’s academic medical centers are under threat.
In a healthcare world increasingly governed by widely promulgated metrics, the difficulty is that there are no measures that truly capture the superlative medicine that happens there.
Infection rate at post-op day seven and patient satisfaction scores are vital for quality and safety. Diagnostic codes are needed for tracking and billing. “Pay for performance” indices encourage operational and outcome optimization. But how does one measure the incidence of getting the diagnosis right (let alone the costs, not just in unnecessary tests, of not getting it right)? How does one quantify the expertise that enables academic medical doctors and teams to treat the most complex, acute or refractory cases in a manner beyond the case mix index? How does one capture the reason why physicians in other settings routinely refer patients to teaching hospitals when they can’t figure out what is going on, when there are complications, or when they have run out of treatment options?
There is a reason why even those decrying the expense of teaching hospitals flock there when their own families are seriously ill. And they do this knowing that trainees will be part of the care team. They do this, despite the traffic and parking obstacles, even while receiving excellent routine care in satellite sites or non-academic settings. For they understand that the place where leading faculty and the brightest trainees come together in the most selective programs is the place where the most is known, practiced and taught concerning their conditions and how to treat them.
It is the place where new treatments and hopes are born.
There are legitimate incremental costs associated with the infrastructure, work and talent needed to support the teaching and research missions that accompany and critically enable the enhanced clinical mission of academic medical centers. But with NIH dollars uncertain and clinical reimbursements falling, with the prospect of reduced Graduate Medical Education government funding, and with reduced investment in discovery by big pharma, a perfect economic storm is threatening the foundations of our vital academic medical institutions.
The profits of health insurance company payors, for-profit providers, electronic medical records companies, myriad consultants, and device and pharmaceutical companies drive up cost and do not come to the academic medical center. In addition to enabling and supporting the academic missions, teaching hospitals often provide a larger share of unreimbursed and grossly under-reimbursed charity and safety net care, mental health care, buck-stops-here care, and costly emergency care and intensive care, in their communities.
Nevertheless, the academic medical center is the recipient of tremendous scrutiny and accounting pressure. This befits an accountable sector serving the public trust, and is even more the case during the current transition from fee-for-service to bundled care, population management systems. This also befits a medical education system in the midst of evolving, more demanding accreditation standards.
But while there is a need for oversight, in some political and journalistic quarters there are exaggerated senses of mistrust, attack, mixed messages (if not hypocrisy), and mis-aligned incentives. The coordinated care and economic imperatives of medical network expansion are often stymied by those fearing the growth of such centers in the marketplace (though they are far from the feared monopolies that seem to be allowed in other sectors, and such accusations are sometimes fueled by competitors). Ever-increasing regulation brings more and more unfunded mandates and documentation requirements, which while very important to a degree, require extensive amounts of organizational and personnel time, detracting from patient care and increasing professional burn out.
All of this has resulted in the corporatization of the culture at many teaching hospitals. Endless meetings and initiatives to make processes leaner and to remove waste may be imperative for the responsible, viable running of the teaching hospitals. But the relentless focus on these real concerns increasingly comes up against a point beyond which staffing and funding cuts endanger the academic mission, before endangering patient safety — the point no one wants to reach.
How can our academic medical centers survive, let alone thrive, alongside non-academic partners or competitors? Non-profit status and philanthropy are vital, but they form a foundation and a safety net, not the meat of a sustainable financial model, especially in the context of health care reform, which aims to increase access to care.
There need to be better ways to identify, quantify, value and communicate the benefits of the academic medical center to patients and families, to society, to policy makers. When a world-leading medical center is said to provide the same quality of care as a community hospital because they look the same on some process measure, something major is missing. When insurance providers are steering patients away and pundits are demanding price equalization, citing such measures, the academic medical centers, the patients and society all lose. When healing becomes commoditized and homogenized, something even larger is lost.
Alongside the appropriate cost cutting and reduction of unnecessary utilization and testing, there need to be creative, reasonable new ways to provide the support and revenue that our precious and vulnerable academic medical centers need. (Medical tourism for the wealthy of the world shouldn’t be the answer). While often perceived or portrayed as powerful, well-heeled interests, and while they need to reform, such centers are often harshly judged out of context and placed in no-win situations. And this by those who demand less expensive care for the general population, but usually want leading center (if not VIP) care for themselves and their loved ones.
What are some of the unique benefits that flow from academic medical centers, the confluence of medical schools and teaching hospitals? They are major life science and biotechnology incubators/attractors (sought-after ‘external innovation’ partners of choice and recruitment pipelines for the pharmaceutical and biotech industries), economic engines, large-scale job creators, and talent magnets for the cities, regions and states in which they reside. They are the place where the next generation of physicians and other clinicians are trained. This is particularly relevant in light of the aging population and the large predicted physician shortage by the year 2025. They are the birthplace of many latest scientific and technological discoveries, and their translation into improved care with near-term and long-term impact.
These advances include more precise, earlier, personalized diagnostic tests and targeted treatments, based upon an increasingly mechanistic biological understanding of disease. Such developments form the foundation for early intervention and prevention strategies that can change health trajectories and save resources. They underlie new interventions for international epidemics. They offer real promise for fighting scourges such as Alzheimer’s disease, cancer, diabetes heart disease, depression and other conditions that bring so much suffering and expense. Also enabled are innovations in health care practice, in primary care medical homes and specialty care medical “neighborhoods.” Importantly, teaching hospitals care for the sickest, riskiest, costliest patients who other centers are unable or unwilling to treat, or who have suffered complications elsewhere.
The bringing together of clinical care, research and education may not be the most efficient endeavor, but is necessary for the vital cross-fertilization of ideas and transfer of knowledge that enable these critical contributions and elevate the level of practice. The academic medical settings in which this convergence occurs are not mutually exclusive with, or dismissive of, more routine or non-academic care, and they involve outpatient care and extensive partnering with community and even global health organizations.
How, then, can we save our academic medical centers, cutting costs and improving efficiency, without compromising the high caliber of care, patient safety, workforce development and discovery? How can we attract, educate, retain and develop our best medical talent, who have spent many years training while incurring crushing debt, and allow them to do their best work on behalf of society?
A different paradigm is needed. One in which there is an acknowledgment that it is the academics that underlie the clinical excellence of the teaching hospital. One in which there is not a disconnect or a zero-sum scenario between the clinical mission (with its economic imperatives) and the academic mission. One that views academic medical centers as health and wealth generators in the community, worthy of investment if not support.
Regardless of one’s politics or preferred health care model, and while healthcare spending increases certainly need to be controlled, is 18 percent or so of GDP really too much to pay for the health of a civilized society, even in the face of other important expenses and imperatives? Are we willing to pay the future costs of failing to train the next generation of physicians and other health care providers? Are we prepared to no longer lead the world in medical discovery at a time when advances offer such promise and are so desperately needed? Are we willing to lose our best medical centers by not truly recognizing and valuing what makes them the best?
Recent reports, including one from the National Academy (Institute) of Medicine, have grappled with these issues and suggested possible solutions. The evaluation of any solutions requires an understanding of the funding streams for undergraduate and graduate medical education. Teaching hospitals currently receive incremental federal and state support for residency training, mainly through the Centers for Medicare and Medicaid Services, the Teaching Health Center Graduate Medical Education Program associated with the Affordable Care Act, the Veterans Administration. There are additional incentives for the training of primary care physicians and physicians in rural/underserved settings, and there are considerations for foreign trainees.
All of these sources are appropriately under scrutiny, but there needs to be vigilance, education and advocacy to make sure that funding levels are adequate, and that caps or cuts are reasonable. There is pending legislation to try to address the anticipated shortage of physicians (the Resident Physicians Shortage Reduction Act and the Training Tomorrows Doctors Today Act). Innovative new ways of covering educational costs, and other public-private partnerships, perhaps involving other health sector stakeholders that benefit, need to be encouraged and evaluated. Industry supported fellowship positions are being re-examined, and there are mechanisms to insure that conflict of interest doesn’t arise.
Like teaching hospitals, medical schools are under tremendous pressure. And this at a time of excitement and promise in evidence-based educational innovation addressing the needs of today’s learners amidst an explosion of information. Patient cases are being discussed in groups, optimizing student-faculty time for deeper thinking and learning in an ever-changing professional landscape. Competency-based evaluations are gaining traction. Technology is being thoughtfully incorporated. Clinical experiences are being introduced earlier in the curriculum, allowing students to start to gain clinical skills and perspective, and permitting a greater integration of medical science following clinical exposure. Tuition and fees cover only a small amount of associated expenses.
Medical schools, like their associated teaching hospitals, are reliant upon philanthropy and asset management. Industry partnerships are no longer frowned upon, and can accelerate the clinical application of discoveries, though ethical conflicts must be avoided. Intellectual property can be generated, providing potential sources of income. Synergistic projects with other parts of universities, such as engineering schools, can create tremendous value. Joint initiatives with associated schools of public health, and other graduate schools, can offer wider impact, leveraging of resources, and integrated training. Win-win initiatives and arrangements with affiliated teaching hospitals and physician organizations can create new opportunities and resources. Research grants and contracts, and innovative public sector-private sector partnerships, are vital.
The reason to preserve and hopefully expand such sources of support is the realization that only academic medical centers can provide the environment and expertise that advance the practice of medicine, and ultimately the health of society. While such centers are not alone in experiencing resource constraints and the call for reform, they are particularly vulnerable, and the sorts of considerations and challenges described here need to be carefully managed.
If not, the academic mission, and its essential contribution to the clinical mission, will be diminished.
Teaching hospitals and medical schools in our academic medical centers provide everything from first breakthroughs to last-resort care. We must protect and support them while holding them accountable. For without education and research, there are no academics in medicine. And without academic medicine, there is no engine for healthcare, life-sciences advancement and societal well-being.
David Silbersweig is Chairman of the Department of Psychiatry and Co-Director of the Institute for the Neurosciences at Brigham and Women’s Hospital in Boston. He also is the Stanley Cobb Professor of Psychiatry and Academic Dean (Partners HealthCare) at Harvard Medical School.