Essential Stewardship Priorities for Academic Health Systems

26 Pages·2014·0.54 MB·English

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Essential Stewardship Priorities for
Academic Health Systems
Victor Dzau, Gary Gottlieb, Steven Lipstein,
Nancy Schlichting, and Eugene Washington
September 2014
This individually authored perspective was developed as a contribution to the
Learning Health System Series of the IOM Roundtable on Value & Science-Driven
Health Care. The views expressed are those of the authors and not necessarily of the
authors’ organizations or of the Institute of Medicine. The paper is intended to help
inform and stimulate discussion. It has not been subjected to the review procedures
of the Institute of Medicine and is not a report of the Institute of Medicine or of the
National Research Council.
Advising the nation • Improving health
Copyright 2014 by the National Academy of Sciences. All rights reserved.
AUTHORS
Victor J. Dzau, M.D.* Nancy M. Schlichting, M.B.A.
President and Chief Executive Officer Chief Executive Officer
Duke University Medical Center and Henry Ford Health System
Health System
A. Eugene Washington, M.D., M.Sc.
Gary L. Gottlieb, M.D., M.B.A. Vice Chancellor, UCLA Health
President and Chief Executive Officer Sciences
Partners HealthCare System Dean, David Geffen School of Medicine
Chief Executive Officer, UCLA Health
Steven H. Lipstein, M.H.A. System
President and Chief Executive Officer
BJC HealthCare
The authors were assisted by the following individuals:
Ashley Abarr Rose M. Glenn Elizabeth Robinson, M.P.P.
Institute of Medicine Henry Ford Health System Institute of Medicine
David W. Bates, M.D., M.Sc. Michael Ritt Jaff, D.O. Devdutta Sangvia, M.D.
Partners HealthCare System Partners HealthCare System Duke University Medical
Center and Health System
Katherine Burns Elizabeth Johnston
Institute of Medicine Institute of Medicine Thomas Santel
Raising St. Louis, BJC
Lia Ramer Bygrave Anne Klibanski, M.D.
HealthCare
David Geffen School of Medicine Partners Biobank and PCORI
at UCLA Francesco Sergi
Isaac Lin, MBA
Institute of Medicine
William A. Conway, M.D. UCLA Health System
Henry Ford Health System Krishna Udayakumar, M.D.
Jennifer K. Lodge, PhD
Duke University Medical
W. Claiborne Dunagan Washington University in St. Louis
Center and Health System
BJC HealthCare
David R. Nerenz, Ph.D.
Neil Wagle, M.D.
Will Ellaissi Henry Ford Health System
Partners HealthCare System
Duke University Medical Center
Sandhya Rao, M.D.
and Health System
Partners HealthCare System
Timothy Ferris, M.D.
Joseph Rhatigan, M.D.
Partners HealthCare System
Partners HealthCare System
*Dr. Dzau is now President of the Institute of Medicine. His contribution to this Discussion Paper was
completed prior to leaving Duke University.
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ESSENTIAL STEWARDSHIP PRIORITIES FOR
ACADEMIC HEALTH SYSTEMS*
Victor Dzau, Gary Gottlieb, Steven Lipstein, Nancy Schlichting,
and Eugene Washington
In our leadership roles with Academic aware that these challenges provide the
Health Systems, we are simultaneously distinct opportunity for Academic Health
excited by the stunning potential we see for Systems to adapt through differentiation
health and health care and also sensitive to and build upon our unique strengths by
the strains that arise from the pace of changes increasing collaboration and innovation
underway in the organization, financing, so that we can fulfill our responsibilities
and delivery of health care in America. It is to the health system and the country.
critical that as the health system grapples From our experiences and what we have
with increasing pressures to improve observed, we have identified the shared
outcomes and to lower costs, the capacities aspects central to our missions here as
for innovation and building the workforce a list of essential stewardship priorities.
of the future are not lost. Given our unique
These 10 essential priorities serve as a
mandates to foster progress in real-time,
grounding framework for Academic Health
bench-to-bedside research while ensuring
Systems in order to maintain our charge
the excellence of the health workforce,
while establishing an ongoing capacity to
we recognize that Academic Health
ensure improved health through better
Systems hold much of the responsibility
care, innovation, and education. We offer
for leading the way to a continuously
examples of those experiences throughout
learning and improving health system.
the text and present full versions in the
The fact that Academic Health Systems corresponding document on Academic
also face economic challenges that call Health System Case Material. But, we are also
into question the effectiveness and aware of many other examples throughout
viability of current models might be a the nation and encourage the growth of this
positive development. Experiences at our inventory through contributions by others.
own institutions have made us acutely
DEFINING CHALLENGES
As the recognized stewards of innovation is equipped to use not only the skills,
and progress in research, education, and information, and resources available today
health care in the United States, Academic but also those likely to be available tomorrow.
Health Systems (AHSs) hold primary With knowledge and tools in health and
responsibilities for ensuring that the medicine changing at an accelerating pace,
next-generation health care workforce and with the organizational and practice
*Suggested citation: Dzau, V., G. Gottlieb, S. Lipstein, N. Schlichting, and E. Washington. 2014. Essential stewardship
priorities for academic health systems. Discussion paper, Institute of Medicine, Washington, DC. http://nam.edu/wp-
content/uploads/2015/06/academichealthsystems.
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patterns in health care in a period of dynamic performing, coordinated health system
and competitive flux, the challenges that requires the simultaneous engagement
confront all in health care today impinge of innovation in the delivery of care,
acutely on the Academic Health System advancement of clinical research, and
community. AHSs find themselves fixed in a training and deploying a population health
crucible of expectations that they will deliver conscious, team-based health care workforce.
advanced expertise and performance, despite
Sustaining the ability of AHSs to contribute
the context of circumstances that place them
leadership in these arenas requires adapting to
at the bleeding edge of revenue streams and
changing economic circumstances
traditions that are neither nimble
nor easily adapted to{ The 10 essential }without sacrificing the
changing financial stewardship priorities reflect unique capabilities
the strategies that, in our that only AHS’s can
circumstances.
experiences, are central to contribute. Reports on
A health system the success of AHSs building the economic viability
grappling with upon their strengths in of Academic Health
increasing pressures the evolving health care Systems make it clear
to improve quality landscape that the status quo is no
while reducing costs depends longer an option. A 2014 report from
on the tools of innovation and workforce the Association of American Medical Colleges
effectiveness and efficiency to achieve the (AAMC) Advisory Panel on Health Care
triple aim of better care, lower cost, and reviewed in detail the challenges to the
improved health outcomes. The onus of sustainability of AHSs and identified eight
responsibility for development, validation, elements for close consideration, which were
and standard-setting for key components generally as follows: systems orientation,
often falls to AHSs, even as the funding geographically and clinically; governance
and resources that support them dwindle. strongly aligned with internal and external
Stewarding these capacities is critical to accountability; evolution in university
the future of American health, and that relationships to enhance the capacity to
function depends on the success and respond to change; new organizational roles
adaptability of Academic Health Systems. and skills for physician leaders; transparency in
clinical outcomes and financial performance;
Health care systems without these restructuring the operating model for cost
broader stewardship responsibilities have and quality; population health orientation
responded to cost pressures with a strategy and accountability; and candid ongoing
of consolidation and efficiency initiatives, assessment of strengths and weaknesses.1
counteracting thinner margins by spreading
fixed costs over a greater volume of activity Each of the AAMC report themes represents
and with acquisitions that diversify revenue a practical management priority important
streams to disperse financial risk over a to AHS operational and financial success
larger population base. However, a longer- moving forward. Our aim in this Institute of
term, system-wide transformation to a better Medicine Discussion Paper is to provide a
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complementary emphasis on the dynamics Together, these priorities represent a strategy
that must be addressed on the mission side of adaptation through differentiation, tailored
of AHS responsibilities, which are clearly to the unique AHS responsibilities, needs, and
central considerations for our business resources. What will be critical to success in
models. In this respect, we draw from making the necessary changes is a willingness
our various experiences leading different to develop meaningful partnerships, both
Academic Health Systems to underscore 10 with our stakeholders and with each
essential priorities, which are common to our other, as Academic Health System leaders
missions and which must be kept squarely in working cooperatively toward shared goals.
focus as we contend with the turbulent times.
CONTRIBUTORS TO HEALTH PROGRESS
Academic Health Systems represent a Delivery of complex services to high risk
critical and distinctive component of the populations
nation’s health enterprise. Also known as
The complexity of the patient population
Academic Medical Centers, AHSs represent
served by Academic Health Systems is well
partnerships between accredited higher
beyond that served elsewhere. AHSs tend
education institutions, health professions
to provide services that are less common
schools, and health care providers. As both
and more specialized than in non-teaching
clinical and academic leaders, AHSs serve
hospitals, and they also disproportionately
a critical role in the national dialogue on
serve populations at higher risk. With respect
health and health care. They also hold
to services, 87 percent of teaching hospitals
responsibility for educating and training the
provide psychiatric emergency services,
future health workforce and often represent
compared to 25 percent for non-teaching
an essential link in the bench-to-bedside
hospitals.2 Similarly, teaching hospitals
progression of clinical research. Many of the
provide 63 percent of our nation’s pediatric
most transformational opportunities and
intensive care.3 AHSs have traditionally
innovations in the health system are focused
played a critical role in community health
on integration and coordination, from
and expanding access to care, and, in 2013,
bridging research and practice to developing
Academic Health Systems represented 6
fluid data streams to enhancing resource use
percent of hospitals but provided 40 percent
across different care sites in a community.
of the nation’s charity care and received 40
Academic Health Systems therefore offer an
percent of transfers for complex care.4
ideal venue for research, development, and
training around technologies and approaches
Training the health and health care workforce
that stand to benefit from interdisciplinary
perspectives and a culture of learning and
With health and health care comprising more
experimentation. Some of the ways in which
than 17 percent of the national economy
AHSs hold unique and disproportionate
in the United States, the workforce needs
societal responsibilities are highlighted
in health and health care are substantial
below.
and dynamic.5 The estimated current U.S.
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health workforce of nearly 12 million people Academic Health Systems are also expected
extends well beyond the approximately to serve as sources of counsel and, as
800,000 physicians, 2.7 million nurses, appropriate, as test beds for demonstration
300,000 pharmacists, 300,000 laboratory and validation of new models and new
technicians, and other licensed health care approaches for the delivery and improvement
professionals in active practice.6, 7, 8, 9, 10 AHSs of care processes.
yearly graduate nearly 17,000 new physicians
Developing instruments of evaluation,
as well as about 20,000 nurses who graduate
with bachelor’s degrees.11, 12 Approximately accountability, and data management
5,000 pharmacists and 6,000 physician
Just as critical as their roles in developing
assistants also graduate annually, and some
new approaches and new models, faculty
110,000 medical residents are in training
within Academic Health Systems are often
programs approved by the Accreditation
sources of leadership in the assessment and
Council for Graduate Medical Education.13,
measurement of care costs and outcomes.
14, 15 Along with professional societies and
The drive across the health system toward
the relevant government agencies, Academic
improved outcomes and lower costs requires
Health Systems serve as the vehicles through
better metrics and better tools for assessing
which the health workforce pipeline needs
and improving in real time as well as for
are assessed and addressed.
identifying and communicating the return
Leadership in clinical practice and quality on investment of research activities. Of
special importance in this respect is the
AHSs are responsible not only for the expectation that AHSs will provide leading-
numbers in the health professions pipeline edge expertise in the development and use
but also for their skill sets and, again in of the digital infrastructure for care delivery,
partnership with professional societies and assessment, and improvement—a particular
relevant government agencies, for adherence challenge since a sizable proportion of
to training and practice standards. With AHS patients are referrals from outside the
the continuing focus on care outcomes and system, requiring interfaces with multiple
continuous improvement, the development of information technology (IT) platforms.
evidence-based clinical guidance continues
Biomedical and clinical research advancement
to be an important tool for improving care
and translation
quality. Currently, nearly 2,600 clinical
guidelines are contained in the National
Academic Health Systems are positioned to
Guidelines Clearinghouse maintained by the
generate new knowledge and to discover new
Agency for Healthcare Research and Quality.
approaches to overall health improvement.
16 AHSs are not as large as many mega multi-
With an estimated public and private
state health systems and multi-specialty
investment totaling $120 billion in 2012, the
physician organizations, yet AHS clinicians
U.S. remains the largest source of biomedical
serve disproportionately in key roles in the
research in the world, and much of this work
production of those guidelines as well as
is conducted in Academic Health Systems.17
in their implementation and assessment.
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Of the approximately $31 billion budget for research, development, and training
of the National Institutes of Health (NIH) around technologies and approaches that
in 2012, three-quarters went to AHSs.18, 19 stand to benefit from interdisciplinary
The pharmaceutical and biotech industry perspectives and a culture of learning and
invested nearly $70 billion in biomedical experimentation.
research in 2012, and although much of
Catalyzing attention to population health
that was intramural research, a substantial
opportunities and priorities
share of the investment was shaped through
professional interaction with members of the
A natural corollary of the advantageous
Academic Health System community.20 AHSs
capacity of AHSs for interdisciplinary study
continue to produce new insights about
and practice is the growing need for them to
individual variation in disease susceptibility,
serve as a source of leadership and guidance
diagnosis, and treatment. Perhaps the most
for population-wide health improvement
rapidly emerging tool in biomedical and
efforts. In acknowledgement of both the
clinical research is found in the many forms
potential and the necessity for population
of the developing digital infrastructure
-based initiatives for health improvement,
and the concomitant opportunities to draw
the Patient Protection and Affordable Care
lessons and knowledge from data sets of
Act (ACA) contains a number of provisions
unprecedented size.
to strengthen the national population health
Fostering interdisciplinary perspectives and improvement agenda. As sources of expertise
programs and data for population health, AHSs
find themselves with new demands and
One compelling research avenue for which opportunities for alliances and partnerships
Academic Health Systems are also uniquely in the provision of health and health care
positioned is that of interdisciplinary programs that can meet the needs of diverse
research. An important limiting factor of communities and the populations they serve.
previous research activities has been the lack
Maintaining ties to global issues and
of capacity to assess the ways in which many
perspective
factors—biological, social, environmental,
and behavioral—intersect to affect disease
Communication, commerce, and travel
occurrence and treatment. With the
patterns have substantially changed
developments occurring now in biology
perspectives, horizons, and interactions so
and information technology, the capacity to
that the need and the opportunity to share
study and understand those intersections
information and progress globally is becoming
is greater, but there are few places outside
a practical reality. Historically, the academic
of the university and Academic Health
health arena, through initiatives that are
System environments in which the necessary
binational, multinational, and international
scientific disciplines can be assembled into
in nature, has been the leading focal point for
teams to conduct this important work.
these relationships. Those links—particularly
As a result, Academic Health Systems
institution-to-institution collaborations—
currently offer the most promising venue
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have increased substantially in the wake it is likely that many AHSs will still bear
of new communication capabilities, and, disproportionate responsibilities for action
although these communications are likely on the global scene to share best practices
to become more diversified and networked, and improve care across the world.
THE CHANGING LANDSCAPE
Along with overall forces for change at interest. Increasingly, health systems are
play in the American health system— being challenged to develop models that
consolidation and reform in the insurance shift care out of the hospital setting, moving
market, concerns about escalating the locus of care to the outpatient setting,
costs, incentives and practices around the home, and the workplace where the
IT implementation, stronger focus on emphasis can also shift to prevention, early
outcomes and accountability, requirements detection, and longitudinal care management
for transparency, and information available of chronic conditions. The special challenge
to consumers—Academic Health Systems for AHSs is moving the locus of its activities
are also facing changes in the revenue (care delivery, education, and research)
stream prospects related to support for without compromising either innovation or
health professions training and biomedical the need to provide care across the entire
research. Highlights follow for some of the continuum. Similarly, the pressures for cost
developments and trends with particular discipline and efficiency are coming at a
importance to the landscape for AHSs. time that coincides with the need to better
understand and apply emerging scientific
Nature of the care process
insights about opportunities for tailoring
clinical interventions to individual patients
Whether economic, managerial, scientific,
and to responsibly introduce data from
technical, or cultural, the care process is
personal mobile sensors into diagnostic
the common conduit for the influence of
and decision processes. Relatedly, the care
the various forces in play, and many of
process is beginning to be altered by the
these forces can contribute positively to the
growing culture around patient and family
evolution of the care process. Recognition
involvement, through developments such
and concern about substantial shortfalls
as patient care portals, decision aids, and
in the efficiency and effectiveness of care,
access to Web-based information. Given
including in Academic Health Systems,
their stewardship of the frontiers of health
creates pressures for change that can
care, AHSs bear a special obligation to keep
be difficult to accommodate from an
abreast of evolving opportunities and to help
institutional perspective. But, if the result is
guide their appropriate assessment and use.
that patients are receiving more of the care
they need and less of the care they do not
and that what they receive is delivered more
efficiently, then the result is in the patient’s
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Role of patients and families and pressure to reduce Graduate Medical
Education funding through the Medicare
A number of developments are under way that program increases the strain at a time when
may lead to fundamental change in the roles the number of medical schools has increased
played by patients and families in health care. by about 15 percent.21 The administration
Access to scientific information in health and has proposed reducing GME support by
medicine is open to the public not only via about $11 billion over the coming 10 years.22
availability and retrieval on websites but also The limitations are examined further in
via patient portals and mobile monitoring the recently released IOM report Graduate
devices. Patients and families have ready Medical Education That Meets the Nation’s
access to sources of information important Health Needs.23 Outside of the clinical and
to their care. As patients and families become direct patient care arena is the considerable
more fully and actively involved, their roles need for more informaticians. Both the
as fully functioning partners in the care team Office of the National Coordinator for Health
becomes more a reality, with substantial Information Technology and the Bureau of
implications for the effectiveness of care. Labor Statistics are predicting substantial
shortages—between 35,000 and 50,000
Again, change of this potential magnitude
people by 2020—in the supply of health
offers opportunity and a mandate for AHSs
information managers. 24 Although few would
to understand and lead the change process
question the need for a studied assessment of
of predictive, personalized, and integrative
the health workforce needs—profiles, skill
health care models for patients and families.
sets, and strategies—creativity will clearly
be important in the years ahead, and some
Changing workforce needs and the prospect of
AHSs may be able to get ahead of the curve
reduced support for training
by expanding their focus beyond physician
Greater dependence on information education to create more interdisciplinary
management technology to track, mobilize, programs with other health professionals
and effectively apply the exploding body of in growing areas such as population health
scientific information; changes in the nature management and clinical informatics. 25
of the care process; and an emphasis on care
Biomedical research funding
teams all require adjustment in the culture
and content of health professions training.
Acute challenges to the core activities of
The success and sustainability of coordinated
many Academic Health Systems derive
care will require a balanced workforce.
from the prospect of reduced funding for
Opportunities for inter-professional
biomedical research. Currently, the revenue
education will be critical to building the
supporting AHSs comes from several key
capacity and competencies necessary
sources: Medicare, 21 percent; Medicaid, 17
for effective teamwork in the health care
percent; commercial insurers, 33 percent; and
setting. Our “call for attention and action”
grants and contracts, 12 percent; with various
is accentuated by the prospect of reduced
other sources making up the balance.26 Of
support for training. Increasing scrutiny of
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these, the only category expected to shift as they are both with the analytic capability
dramatically is the share coming from grants and with the foundational philosophical
and contracts, with a projected decline of commitment to openness and truth that
nearly 25 percent between 2010 and 2020.27 represent the basis for the establishment
This reflects projections based on the nearly of the universities with which most are
22 percent decline in purchasing power from identified.
2003 to 2012 as a result of NIH expenditures
on biomedical research remaining essentially Health sector consolidation
flat in the face of recession and inflation.28
The dominant strategy for health systems
As a direct corollary, the NIH study section
seeking financial security under changing
scores required for funding grant applications
circumstances has been acquisition and
have tightened substantially, which has, in
consolidation, forming bigger, more
particular, placed younger investigators at
inclusive care delivery and population health
a disadvantage.29 AHSs will need to forge
management systems. Academic Health
partnerships with each other and with those
Systems require a more nuanced approach
holding private sector research resources.
to adaptation that balances the efficient
New research capacities and funding streams
delivery of care against the responsibility to
can take advantage of patient care and related
support clinical research and educate the
data systems as tools in developing novel and
next generation of clinicians. The pace of
accelerated clinical research and knowledge
AHS consolidation is accelerating, and the
translation strategies.
pressures for expansion and scale through
Transparency, accountability, and value merger and/or acquisition are undeniable.
The report of the AAMC Advisory Panel
Throughout health care, there is a strong and on Health Care concluded that AHSs have
growing emphasis on the importance of—and four options: form a system, partner with
need for—transparency, accountability and others in a collaborative network, merge
better outcomes in health care. Because the into a system, or shrink in isolation.30 In
health system as a whole has been relatively recent years, many AHSs have expanded
opaque in its processes—not to mention their clinical faculty and expertise in clinical
its costs—external pressures now demand care and health services delivery in order to
the inevitable movement toward increased better leverage their size, unique services,
transparency for collecting and reporting and market prominence. Still uncertain are
outcomes data. Academic Health Systems the implications of these dynamics for the
should be well-positioned to provide the unique AHS stewardship roles for teaching,
model for performance reporting, equipped research, and care innovation.
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