Issue link: https://beckershealthcare.uberflip.com/i/267523
55 Some AMCs have already recognized the impor- tance of expanding their reach beyond a single tertiary care center. For example, BJC HealthCare, parent of Barnes-Jewish Hospital in St. Louis, oper- ates 13 hospitals throughout Missouri and Illinois, the majority of which are community-based orga- nizations with 400 or fewer beds. Pittsburgh-based UPMC has more than 17 contracts with "commu- nity service providers" to better coordinate the care patients receive outside of its hospitals, including skilled nursing, home health and rehab services. In July 2012, Iowa City-based University of Iowa Health Care joined with three other health systems in the state to form the 52-hospital University of Iowa Health Alliance. Each system within the alli- ance will remain independent but will collaborate on research initiatives, benchmarking and best practice implementation, as well as cost sharing and IT accessibility. Rethinking the mission Even though AMCs have an incredible aggregate of talent and capabilities, they have been relatively slow to make decisions — their academic culture makes them largely consensus-driven organizations. "Today and into the future, we face more formi- dable competitors when it comes to cost, quality, service and technology. Why? Because they can do it cheaper and faster," says Dr. Pescovitz of UMHS. "AMCs have higher cost structures, incapacitating bureaucracies and two critical components of our enterprise that we subsidize. We are unable to be sin- gularly focused, and we're not as nimble or flexible." Dr. Ziskind agrees. "Community competitors re- spond more rapidly to market change," he adds. "I think it's absolutely essential that academic medical centers change their mindsets from hold- ing steady and trying to protect their price pre- mium to actively engaging in and implementing a culture change [that empowers speedier decision making and responsiveness]." Rethinking care delivery If the future of healthcare delivery means coor- dinating care and taking on risk for population health, which many believes it does, AMCs must be guided by a strategy that moves the organiza- tion away from a focus on complex, acute care to- ward one that delivers the right care, at the right place, at the right time, to all types of patients. Many academic health systems, like the Univer- sity of Michigan Health System, have launched accountable care organizations or similar mod- els. UMHS operates a Medicare Shared Savings organization, and a recent ACO-like partnership between UMHS and Blue Cross Blue Shield of Michigan resulted in $155 million in savings in its first three years. At Montefiore Medical Center in New York City, 50 percent of patient revenue is at risk through vari- ous ACOs and shared savings/risk arrangements. Successfully adjusting to this new imperative for care delivery will be critical for the survival of AMCs, but, unfortunately, it only impacts one area of it's tripartite mission — patient care. Rethinking education Many AMCs may continue to borrow from their operating margins to fund shortfalls in medical ed- ucation and research. Successfully moving to risk- based reimbursement could improve margins just enough to sustain research and education under this approach. The most innovative AMCs, though, aren't satisfied with this remaining the only option. In 2008, Ochsner Health System in New Orleans partnered with the University of Queensland in Brisbane, Australia, to open the University of Queensland - Ochsner Clinical School, a program that offers students from the U.S. the opportunity to receive the equivalent of a doctor of medicine de- gree. Ochsner offers more than 20 residency and fel- lowship programs, but did not have its own medical school, and saw the joint program as an opportunity to help attract more physicians to Louisiana. Stu- dents in the partnership program spend two years in classroom-based training in Brisbane, then come to Ochsner for clinical training. The program's 2012 class received a 100-percent residency match rate, says Warner Thomas, Ochsner's president and CEO. Perhaps in one of the more creative bits of legisla- tion for GME to date, the Florida legislature ap- proved a bill that would allow insurers in the state to provide funding for GME. Florida insurers who do not hit their medical loss ratio require- ments now have an option to take money that would otherwise be refunded to policyholders and dedicate it to a fund that will be used to sup- port GME in the state. The Herbert Wertheim College of Medicine at Florida International University in Miami, part of the 12-campus State University System of Florida, has proposed a demonstration project in which it will establish a psychiatry residency program in partnership with a Federally Qualified Health Center in Miami-Dade County, supported by the state GME fund. A larger question, though, is whether the federal government and AMCs themselves should be the only parties supporting physician training during an era of physician shortage. There are multiple exchanges of dollars on a medical student's jour- ney to becoming a physician. Medical students of- ten take on high levels of debt for medical school tuition, earn moderate salaries during residency and fellowship, and then receive salary increases that may be up to four times the amount of their salaries during training. Medicare pays teaching hospitals for some training costs, and the hospi- tals absorb the rest. Perhaps a different exchange of dollars is in order. A different model would be difficult to sell, but could significantly help improve the economic challenges surrounding medical education and training. "Residency training costs are significant, more than $13 billion total for the 110,000 physicians in training each year, and Medicare pays less than 25 percent of the direct costs," says Dr. Conroy of the AAMC. "Many hospitals are already supporting residency positions over the amount of Medicare support they receive. This pattern is not sustain- able for hospitals if they are to meet the demand for more physicians." Rethinking research Patient care and education aren't the only areas ben- efiting from creative approaches. How basic and clinical medical research is funded is also changing. Gone are the days of relying solely on government and other grant-making organizations. "There needs to be a lot more partnering between industry, i.e., medical device and drug companies and AMCs," says Mr. Thomas, who indicated Ochsner has several research-focused industry partnerships in the pipeline. "We know more partnership has to happen in the clinical care of medicine, but it also has to happen in the research and education parts of medicine." Dr. Conroy agrees. "There are so many innova- tions borne in our research labs," she says, add- ing that while academia is great at discovery, it isn't known for quickly bringing new products to market. Under a partnership, once an innovation has legs, it can be leveraged in more traditional research and development setting, supported by industry partners. In a more creative approach, Tulane University School of Medicine in New Orleans decided to bypass traditional research funding by using crowdfunding to finance several proposed re- search projects. It partnered with crowdfunding platform Microryza to launch a website that al- lows anyone, anywhere in the world, help fund the school's research. The Future of the AMC The next five to 10 years are sure to bring great change to AMCs in the United States as they ad- just to new market and environmental conditions impacting the three distinct, but interrelated, parts of their missions. Because the future is uncertain, so is how to best respond. Yet, we know differentiation is often the key to remaining competitive in a crowded market. With so many hospitals currently struggling to keep up with their objective of "being everything to everyone," perhaps it's time for AMC leaders to reflect on their organizations' strengths, and focus strategy and decision-making around one or two characteristics — affordability; the high- est level of quality; top-notch service; seamless, coordinated care; or the best health maintenance capabilities, etc. — and work today to ensure their organizations' culture supports this strategy. "Academic medical centers have excelled at the innovation. Creativity is in our DNA. Where we need to improve is in our ability to be more nimble, more flexible and more adaptable. That requires a culture that is prepared to evolve," says Dr. Pescovitz. "We're not as adaptable or respon- sive as our competitors." But AMCs have something their competitors don't: the greatest minds in medicine with the ability to offer the most specialized care in a breadth of specialties. What they do with that is up to them. n