Academic health centers today: are we reforming without changing?
Academic health centers have led the nation in advancing health-care delivery, biomedical and behavioral science research, education of health professionals and scientists, and community service for more than half of the past century. These centers are uniquely positioned to make such advances because many of them encompass within one campus colleges of medicine, nursing, dentistry, pharmacy, health professions and veterinary medicine, along with teaching hospitals and clinics. The centers fulfill three interdependent missions: discovery of new knowledge (research), transmission of knowledge (teaching) and application of knowledge (patient care).
Despite the many impressive achievements of academic health centers, significant flaws and inequities still exist in safety, quality, cost and access to care, and the efficiency with which practical new health research is pursued and applied. Access to and quality of health care vary widely across regions and populations.
Two recent reports from the Institute of Medicine identified significant problems with patient safety and the quality and consistency of health-care delivery. Managed care has severely eroded reimbursement to health-care providers, hospitals and clinics. We are challenged to do more and become better with increasingly limited resources. Today, health-care consumers and private and governmental insurers who pay for health services are demanding evidence of efficacy as well as quality and consistency of care.
Traditionally, clinical care in these health centers has been characterized by the work of independent physicians and health-care providers with unique and highly specialized interests. These individuals often are renowned for their knowledge about a particular disease or skill in performing a limited set of highly technical procedures.
Yet some of today’s most pressing health problems, including cancer, diabetes, cardiovascular disease and dementia, are very complex and chronic conditions. Understanding the multifactor causes of these conditions and delivering effective treatments requires a multidisciplinary team of researchers and practitioners who work in specialized research and clinical facilities. Such facilities must be able to deliver unique, highly efficient services to more people and to rapidly apply new knowledge to patient care — all within a stringent economic environment.
Academic health centers face similar challenges in research. The traditional paradigm for a successful university research program focused on an independent scientist studying a specific problem, sometimes one with what apparently limited or obscure practical impact. He or she worked in a self-contained laboratory, often with few collaborators. Today’s pace and complexity of research is astounding. Private corporate research enterprises compete with universities for scarce research funding. Today’s technology is obsolete tomorrow. Our egocentric research model will struggle to compete.
Traditional teaching and clinical training programs at these centers also have been based on the authoritarian, egocentric and didactic lecture-type approach. Particularly in the clinical realm, the maxim of “see one, do one, teach one” prevailed. The senior practitioner’s experience and authority took unchallenged precedence over the application of contemporary scientific evidence. Little attention has been paid to the unique needs and learning styles of our adult students.
Educational research has shown that this must change. Today’s medical and health science students demand a new approach. They learn in small independent groups through self-directed inquiry, and they demand relevance.
Thus, at the beginning of this new century, academic health centers find themselves in organizational, professional and financial turmoil. Our organizational structures and management approaches must change to adapt to new challenges. Some are trying different approaches to change. Examples include university hospital mega-mergers (Stanford-UCSF); acquisition of networks of large primary-care “feeder” practices (University of Pennsylvania); aggressive cost reductions at owned/affiliated hospitals (Allegheny); consolidation of hospital and university administrative functions (University of Kentucky); implementation of corporate-style productivity goals and incentives (Baylor University); and entry into the insurance business by creating health plans (Harvard).
Some of these changes have resulted in the unintended consequence that faculty and staff are buffeted by shifting and sometimes conflicting professional and institutional expectations. Emphasis on clinical service productivity has challenged the faculty’s ability to pursue research and teaching under traditional paradigms. Faculty and staff are beginning to question whether there has been an irreversible drift away from the traditional three-part academic mission toward a focus on corporate productivity.
Academic health centers, now more than ever, face insufficient resources and are unready for the changes. Traditional structures and management processes are becoming ineffective — if not obsolete. To achieve success, these centers must develop new values that preserve the key purposes of university departments, such as discipline-specific training, support and protection of faculty research time and freedom of inquiry.
Research progress is best achieved through interdisciplinary collaborative programs rather than by independent and isolated investigators buried inside academic departments. Contemporary examples on our campus include the McKnight Brain Institute, the UF Shands Cancer Center, the UF Genetics Initiative, and bio- and nanotechnology initiatives.
Tomorrow’s health center will create new mechanisms through which clinical departments can align interests and optimize resource use to maximize research and clinical performance. Aligning teams of clinical providers with hospital managers and creating common goals and incentives across university departments and hospital departments will be key. Centers will be organized by disease or demographic-specific care such as cancer centers, cardiac institutes, spine and diabetes centers, child health-care centers and geriatric centers. Each must be more patient-centered than the traditional multidepartmental approach. They will require specialized facilities to meet the needs and expectations of those they serve.
Care delivery is increasingly constructed on three pillars: solid scientific evidence, well-designed and cost-effective delivery systems, and an unwavering focus on patient-centered care. The best examples of interdisciplinary care in today’s academic health centers are the cancer centers, especially those with National Cancer Institute designation as comprehensive cancer centers, which combine the best in advanced care, research and training. They bring together experts across traditional academic disciplines. They consolidate diagnostic and treatment resources across inpatient and outpatient environments. They allow faculty and hospital leaders and staff to develop systematic approaches to the disease and customized approaches to individual patients. They foster development of interdisciplinary teams of care providers focused on patient needs. They create opportunities for subgroups of faculty and staff to develop new ideas and test them through rigorous peer-reviewed research.
Despite these compelling reasons for academic health centers to organize their clinical activity around centers and institutes, this is not the standard model within our health center today. Why? Important factors include limited federal funding and a payer reimbursement system that does not recognize or reward collaborative care. Nationally, academic health centers must advocate for policy reform that leads to greater federal support for establishing patient-centered and disease-specific efforts and aligning payments with desired practices and outcomes.
We need to become better at assessing, measuring and improving quality and outcomes in health care.
At our health center, we can create motivators such as evaluation and incentive programs that reward collaborative efforts. We can base budget allocations and space distribution on the development of interdisciplinary programs. We can translate clinical strategies into real reforms in service delivery. Inpatient and outpatient units focused on specific diseases and patient groups can replace generic one-size-fits-all facilities.
To do all of this, we need a nimble response to change. We need to maintain a rigorous commitment to be accountable, and we need to celebrate and reward innovation and success. We also need to find ways to align incentives for success between our academic colleges and our health system’s hospitals and clinics.