This is a summary accompanied by some personal comments of a very recent Viewpoint report(Academic medical centers.Too large for their Own Health?) published in JAMA (june 17,2019,E1,E2) by S.Claiborne Johnstone (Dell academic medical school,university of texas,Austin)
1) fully accreditated medical schools(141) in the US not only educate medical students but they mainly „operate clinics and own hospitals“ defined as „Academic Medical Centers“ (AMCs)
It would be interesting to know how the accreditation procedure works.Who decides about the qualification of the teaching personnel and about the scientific quality of the publications? Deans of medical faculties are judged on the basis of the „quality“ of researchers they are able to hire The researchers are judged on the basis of their publications and of their funding.However there is no way to check the quality of the scientific production independent of the scientific journal lobby. More and more researchers within AMCs have not studied medicine.They can not even judge the real impact of their research on medical pathology.
2)56% of the AMCs have annual revenues greater than 500 million dollars.
The crucial question raised by the author is : „have some AMCs grown to large to survive a changing health care system,much less to lead the change required?“
In other words can the AMCs lead the necessary structural(dimension ) reduction by reducing the number of treatments to those really needed?
Or do the economical and occupational constraints dominate the scientific knowledge which seems to suggest that less is more for the comunity?
3)„AMCs generate an estimated 6.3 million jobs and contribute an estimated 562 billion dollars to gross domestic product“
That is to say that each employee contributes with his medical insurance fee to the maintenance of the largest employers in many cities hosting AMCs.
4)„At the same time, academic medicine has contributed to the creation of a suboptimal health system.“
5)„The World Health Organisation ranks the US health care system 37th among countries worldwide,just above Cuba“
6)„and life expectancy has declined in the United States during the last 3 years“.
7)„health care costs in the united states are 25% greater than the second most expensive country and 14-fold greater than Cuba`s“.
That is to say that „scientific progress“ contributes to increased expenses for the health care system but not to prolong life expectancy in a country with the most expensive health care system which, however, ranks just above that of Cuba, still a comunist country. On the contrary,decreasing life expectansy may be also because of an „aggressive“ DRG-based health care system mainly working for profit „.
8) „AMCs are major sources of health care in nearly every US metropolitan area,and costs of care at virtually all AMCs are particularly high“
9)„so there is no denying that they have contributed to the health care system that currentlx exsists“
This is a polite way to express the concept that AMCs,which are supposed to path the way for the rest of the health system by mainly contributing to the medical guidelines, instead of becoming more and more restrictive, are developing toward a growing business branch.This of course influences the consideration given (mostly by the CEOs) to less aggressive and chipper diagnostic and therapeutic procedure in comparison to more aggressive and more expensive tools with a disavantage for the patient. In fact,if the system can not be made responsible for the reduction of life expecatncy,it does not seem to be able to stop this trend.
10)„the shiftng balance of the three major missions of AMCs-education,research, and clinical care-underlies the current challenge“
This is a crucial point. Education and research , existing within the same structure,can not be other than dominated by the economical constraints of clinical care,which forces to rewrite physiology , pathology,diagnostic and therapy toward profit oriented SOPs(standard oerating procedures) combined with ultra short permanence in the clinic.
Internal medicine has become much less important than surgery.
11)„however, the proportion of medical school funding derived from research has declined more recently,with federal grants making an average of 14% of medical schools revenues (Figure),with industry and foundation funding accounting for another 9%.“
12)“ from this perspective,funded research is actually a modest function of medical schools and their associated AMCs.Clinical revenue dearly is the dominating source of revenue at virtually every AMC.“
What we really would like to know is how many AMCs are in private hands,and how much private funding influences non private funding by lobbying work into the review system.How much is the educational system including scientififc society meetings,therapeutic tryials and scientific journals influenced by private interest groups? The continous advertising within the health care system does not make it different,if not even worse than other commercial branches with little possibility of defence for the „consumer“,in this special case, the sick patient.
13)„As greater and greater margins were realized from these faculty clinicians with revenue exceeding costs,more were hired and clinics and hospitals were constructed to support them“
14)“ These trends have accelerated during the last 20 years,with many faculty devoted nearly to clinical care“
At the same time the scientific world is asking itself why is the figure of the physician scientist within the AMCs disappearing ?
15)„Thus many of today`s AMCs are similar to huge tankers loaded with health care services,and research and education are merely passengers“.
The consequence of this developement is much worse.As mentioned above, the chief of administration are the true deus ex machina.They decide about who is going to be hired und who is „disturbing“ the business within the clinical teams. Honest medicine is in the middle of two enemies, the industry and the administrators of the clinical every day life.
15)„there is the crux of the issue :any changes threatening the margins from clinical care will affect the intire mission of an AMC“.
This consideration does not take into account that part of the revenues of the clnical care goes into the pocket of private investors at total disavantage of the fee-payers. This money influences the fate of „honest“ medicine.
16)„Academic medical centers tend to do well in negotiating reimbursement rates from insurers,and they tend to admit patients who require more expensive and invasive interventions.“
This assumption goes back to the time where medical knowledge about tissue damage leading to organ dysfunction was poor and patients with acute or with terminal organ insufficiency made the bulk of the patient population. Conservative medicine has however made giant progresses and many invasive procedures (even oragan transplantation) are much less necessary than it was 20-30 years ago when patient presented with more advanced disease stages.
17) „Thus by necessity,the majority of AMCs are inclined to stay the course of the current health care system.“
18) “ A move to value-based care is more than just risky;it is counter to their best interests unless a clear line of sight to new payment models exists.
In fact so far using the DRG-system no attention was paid to quality of medical treatment as it is not considered by the reimbursement system. For this reason number and quality of the persons involved in treatment was less important than costs.
19)„In the fee-for-service payment system, preventig illness and reducing wasteful diagnostics or unnecessary treatment could reduce the income of AMCs (as well as other medical centers)“.
20)„Although many reports that have described the need to reallocate resources toward prevention,population health, and value-based care come from medical school faculty, the leaders of the AMC clinical enterprise will tend to resist change because it puts the entire institution at risk“.
21)„Faculty can discuss population health and value,but may be stymied from making important progress“.
22)„In this way,academic medicine is not fully aligned wih society´s interest in optimizing health outcomes or in reducing waste.“
23)„To better align with society´s interests,AMCs must reduce their reliance on fee-for -service medicine and the associated pressures to retain market share,raise prices,and increase consumption of health care.“
24)„Instead,they should leverage their expert leaders to develop and coordinate new models of care,focusing on solutions that enhance value„.
25)„If payers are reinbursing for value,the planning and coordination role naturally payed by AMCs could produce revenues that exceed costs.“
26)„Academic medicine could then lead in innovation and coordination of new models of care,being paid for value without necessarily owing all components of the system“.
27)„Academic medical centers should be optimized to enable rapid innovation in health that aligns with society´s interests.“
28)„Getting this alignement right will not be easy,particularly in an industry that has rewarded the traditional fee-for-service model with fairly reliable margins“
29)„Similar to a nimble schooner,an AMC that can alter course quickly and test new waters may be more valuable to society than megatanker,particularly given the narrow straits ahead“.
This would however mean reduction of the number of beds and of the number of employees,which is politically very inconvenient.