Big Myth: Academic medical centers — that is, universities that have a medical school, teaching hospital, faculty practice plan, and receive substantial research funding from the US government — provide the best care at the lowest price.
Wrong. They provide great unique care — for example, treatment of rare diseases or complications — and they provide reasonable care for common diseases but at a very high price. For more common syndromes and diseases, you are better off going elsewhere for your money; places like Intermountain Healthcare in Utah and Advocate in Illinois.
Unlike Intermountain, Advocate — Carolinas, Kaiser, Geisinger, Group Health and Fairview Health, too — which measured and balanced their clinical quality and cost-of-care for years, most academic medical centers are barely getting started measuring anything. Their measure of success is research funding per year; and I mean that quite literally. AMCs have long measured their success by the amount of research funding they receive each year, particularly from the National Institutes of Health. You could argue that higher research funding implies better research (even that’s a stretch) but even if you accept that argument, there is no denying that it typically takes several years at best for that research to translate into meaningful and better care for most patients.
By accident or by design, I’m not sure which, the Obama administration is the first to shine a spotlight on this disparity between cost and quality at AMCs. Now, they have a rocky road ahead to change their culture, quickly. If AMCs traded in stocks, I’d rate them a “Sell” right now.
This Feb 17, 2011 article from the New England Journal of Medicine is a good overview of the cultural challenges ahead for AMCs. Note that Johns Hopkins (discussed in this article) has its own insurance company, which makes it very unique among AMCs. Because by managing its own insurance company, Johns Hopkins must manage both the cost of healthcare and the quality of healthcare that it delivers, otherwise placing its own insurance company in financial peril. That’s the key point: AMCs must feel the financial pressure to deliver better care, in general. Right now, they really don’t.
jbormel says
Dale, Great post. I appreciate your commentary, as well as the link. Here’s my take.
JD Klenke divided the inpatient world into three, neat buckets: AMCs, For-Profits, and Not-For-Profits. Your “Unlike” paragraph above does capture the measurement model that uniquely characterizes AMCs. It’s worth noting that the training, cross-subsidies, and patient mix at AMCs also makes their tasks different, as well as their operations and measurement challenge.
My affordable care / accountable care organization (ACA, ACO) thinking follows a framework from the HealthCare Advisory Board (http://www.advisoryboardcompany.com/) and consists of five domains. I would argue the most AMCs have distinct issues with each:
1) Network Interconnectivity of EMR (inpatient, outpatient and their patient summary and exchange capability, critical to clinical integration.) This is compatible with the clearly contrasting organizations you cited. Name three organizations, AMCs, FP, and NFPs who were sending out ePatientSummaries before 2009?
2) Clinical Knowledge Management (few AMCs invest in this, as evidenced by their public and private measurement data you cited.)
3) Financial Operations – AMCs have cost accounting systems but no significant ability to manage multi-stakeholder payment and outcomes. The better organizations struggle with Balance Scorecard Dashboards.
4) Population Risk Management – AMC’s have multiple adverse selection issues. Think “county and inner-city hospital.”
5) Patient Activation (including networked PHRs.) My personal experience as an advocate for a patient receiving care from one of the named AMCs is that AMCs can be upside down. By that I mean that, for example, they send patients to a different facility for their anti-coagulation clinic (different location,date and time) than their pulmonary and cardiac clinics. This is more than a need for multi-resource scheduling. This is a need for geographically-sensitive care coordination. Too often, AMCs are the last to get on the patient-centeredness bus. Whether affluent or indigent, sick patients need their travel burden minimized. That doesn’t happen by accident.
Dale, thanks again. Provocative post and thoughtfully constructed.
Dale Sanders says
Thank you, Joe! You always have such great perspectives and insights; I genuinely appreciate what I learn from you.
I am keen on the Advisory Board framework you reference as a means of describing the specific adjustments lying ahead for the AMCs. God bless the AMCs for what they do well– e.g., rare diagnoses and highly complicated surgeries– but start-to-finish patient service and chronic disease management are not their forte.
We need to either change the culture of the AMCs to align better with ACOs, or change our expectations of AMCs in the future. But if we change our expectations of AMCs to one that alleviates the pressure of functioning like an ACO, what type of medicine will they be teaching to students? The core mission of the AMC is to develop students who can lead and function in the future of healthcare. AMCs have basically ignored the best business & clinical practices from places like Intermountain and Kaiser. I don’t mean to sound overly harsh when I use the term “ignore”– AMCs have never felt a compelling need to pay attention until now.
Interesting times ahead! Many thanks, Joe…
flpoggio says
Dale and Joe,
Excellent posts…brought back fond (maybe not-so-fond) memories. As a former AMC facility exec many years ago I used to describe the AMC as the ‘three headed monster’. That’s because they have three distinct and frequently conflicting organizational objectives. They are:
– Research
– Teaching
– Patient care delivery
If you put these in a vend diagram there is a cross section sweet spot…but rarely is it realized. Typically the research docs wants/needs patients for the data they bring (a la grants), the teaching doc sees patients as teaching fodder for the students & interns, and the true clinician sees the patient as a ‘customer’. A customer orientation for one out of three ain’t good and finding a faculty MD that can keep all these in balance is extremely difficult.
So now the government (which historically has significantly underwritten all three roles) says…become an ACO…get more patient focused…what a challenge for the AMCs. A Medical School Dean I used to work with described the balancing as ‘herding cats’. Good luck to all AMCs.
Gerry Higgins says
Dale Sanders-
I agree that chronic disease management is not the focus of NIH-funded AMCs. However, I do have to say (I now consult for the NIH and have served as a Section Chief there in the past) if you are funded by the NIH as a physician-scientist, you will know the “bleeding edge” of your discipline better than any other physician. Only 5-7% of grant proposal submissions are funded by the NIH, and this represents the cream of the crop. If I had a deadly form of cancer or degenerate neurological disease, I would go to a large AMC, because my odds of survival would be better. You can look at the data from the Association of American Medical Colleges for confirmation.
Kind regards – Gerry Higgins
Dale Sanders says
Hi Gerry,
Yes, I think, in general, I agree. If I suffered from an unusual disease or syndrome– what I call the small n diseases– I would probably seek treatment at an AMC. But, an IDS like Intermountain and Kaiser have fairly impressive outcomes with the small n diseases, too, along with a good track record of chronic disease management with complex co-morbidities. Dollar for dollar, at the macro-economic level, I feel that an IDS provides a better overall return on investment for the healthcare dollar. Johns Hopkins would be at the top of my list if I were desperately searching to treat an unusual small n condition, but I would make sure that I was being treated directly by one of the veteran research staff, and not his/her proxy resident.
I’m ENORMOUSLY grateful for and proud of my past position with an AMC. That said, there is always room for reflection and improvement– it’s time for the AMCs to start borrowing concepts of clinical operation from the integrated delivery systems…or maybe we should simply change our expectations and let AMCs focus exclusively on the small n.
Thank you, Gerry.
Dale
jbormel says
Dale,
Consider this comment (i.e. one month past your original post,) to be a real test of who chooses to use RSS comment feeds!
I think the lumping and splitting over “what AMCs are good for” has gone too far.
I contributed to that, so I’ll apologize here. And offer a better framework for consideration.
Elsewhere, I have written about my daughters care at four AMCs, seeking a diagnosis and therapeutic intervention for one, fixed, congenital issue requiring pediatric orthopedic intervention. The post was titled “Reality and Relativity.”
By the end of the story, the four AMCs delivered not just a second opinion or a third, but a total of four, different opinions and resulting recommendations. Two of the those four were using relevant pre- and post- surgical experience (evidence); those two were the same that had strong financial endowments. The reimbursement system does not pay for gait lab studies that is critical to collect the objective measurements that underlie adequate assessment. The AMCs closest to my home, as a result reimbursement and no endowments for gait labs didn’t offer gait lab services. Those with endowments, more than a dozen centers, each do between 500 and 1,000 patient assessments per year, and they’ve been doing so for more than a decade. The science goes back to the 1940s and computerized measurement was being done since at least 1973. My daughter got a great result, because of three factors: a) a highly dedicated and disciplined pediatric orthopedic surgeon; b) an AMC with unusual vision clarity around patient needs; and c)an adequate endowment to support the mission.
Bottom line: The question, AMC or not AMC is the wrong framework.
What’s the right framework, then? It’s those same three factors above.
In the 2000 HBR article “Will Disruptive Innovations Cure Health Care?” by Clayton M. Christensen, Richard Bohmer, and John Kenagy, an objective that caught my attention was this:
“Create—then embrace—a system where the clinicianʼs skill level is matched to the difficulty of the medical problem.”
I have participated in care delivery in about a half dozen AMCs, often particiing at the highest level of a medical license (to use of currently popular phrase). I have advocated for patients and family members in several more AMCs, as well as several very well tuned non-AMCs. As Christensen, Bohmer, and Kenagy describe, it’s the
1) the matching of clinician skill to the complexity of the problem,
2) the “organization’s organization,” i.e. is it truly patient centered, and
3) the impact of the reimbursement model that make the difference.
AMCs can impact all three; those focused on using adaptive design can and do consistently outperform any delivery system, AMC or not. AMCs that fail to address each of those factors deliver flawed processes and outcomes.
Each of those three is worthy of it’s own blog post to elaborate! Thanks again for drawing us into a useful dialogue, Dale.
-Joe
Dale Sanders says
It’s worth noting on this topic, a new article by Consumer Reports that finds Academic Medical Centers are poor performers when it comes to avoiding bloodstream infections developed while on central-line catheters or tubes.
http://bit.ly/kuVPUC