PROCEEDINGS
OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF
ACADEMIC CARDIOLOGY. BETHESDA, MARYLAND, OCTOBER
26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135
30th
Bethesda Conference:
The Future of Academic Cardiology*
Task
Force 1: Clinical Care
Henry
DeMots, MD, FACC,Co-Chair,
Gilbert H. Mudge, Jr., MD, FACC, Co-Chair
Academic
cardiovascular programs are currently defined
as subspecialty programs committed to advancing
clinical care, promoting innovative basic and
clinical research and fostering comprehensive
teaching of all health care professionals in cardiovascular
diseases. The unique integration of these commitments
distinguishes an academic medical center from
community hospitals, research foundations and
pharmaceutical companies and enhances the opportunities
to improve overall medical care. Academic cardiovascular
programs provide optimal patient care by applying
state-of-the-art technology, the most recent advances
in medical science and the medical expertise of
acknowledged opinion leaders and experienced clinicians.
Such programs may or may not be associated with
a university or a single teaching hospital, may
vary in relationships to community health care
providers and may or may not have single leadership,
but all remain committed as their primary purpose
to all three missions. A critical mass of both
expertise and clinical challenges in an environment
of questioning is central to its success.
Indeed,
academic cardiovascular programs have been highly
successful in achieving the goals of each of these
three missions. Over the past several decades,
academic cardiovascular programs have trained
large numbers of excellent clinicians who have
taken their expertise into the community, effected
major changes in the care of patients with cardiovascular
disease through innovative translational research
and developed high technology approaches to the
care of patients with cardiovascular disease,
resulting in improved outcomes with lower mortality
and morbidity and at decreased costs. Paradoxically,
it is these successes that in many ways have led
to the conundrum now facing the academic cardiovascular
program. Their success in training cardiovascular
specialists and appropriately exporting expertise
and technology to the community now makes it increasingly
difficult for academic cardiovascular divisions
to be differentiated from other providers on the
basis of quality of care and to compete on an
economic basis without differentiation despite
the costs of education and an increasing number
of indigent patients. To confront these assorted
pressures, some academic cardiovascular divisions
have attempted to increase clinical volume, which
has stressed traditional missions of teaching
and research. The necessary changes in staff requirements
or in academic expectations have not been made,
further confusing mission and long-term goals.
In
the earlier era of fee-for-service reimbursements,
cardiovascular divisions provided substantial
revenues for both the academic medical center
as well as for non-revenue-generating divisions
within the departments of medicine or pediatrics.
Furthermore, many academic centers had a virtual
monopoly on high technology services including
interventional coronary procedures and high risk
coronary revascularization. Professional revenues
as well as public resources were readily available
to support dedicated faculty, and to provide high
quality teaching and outstanding clinical care.
But revolutionary changes in the organization
and delivery of medical care in this country threaten
the integrity of the academic medical center,
necessitating recent restructuring of purpose
and redefinition of mission to be a more integral
component of health care delivery systems (1-4).
Recent catastrophic failures have resulted from
academic medical centers failing to establish
links, isolating themselves in an adversarial
managed care environment (5)
and being too late in recognizing the strength
of partnering with community providers.
Current
organizational structures of academic medical
centers compound the dilemmas of the current cardiovascular
academic division (6).
Diminished third party reimbursements, decreased
public funding for training and smaller profit
margins on high technology procedures have resulted
in substantial decreases in cardiology-based revenues.
Without an accompanying decrease in cost shifting
within the academic department of medicine/pediatrics,
divisions of cardiology are still held responsible
for subsidizing non-revenue-generating divisions
within the departments and are held accountable
to a different economic standard, making it impossible
for academic cardiology divisions to be competitive
with community specialists on an equitable footing.
Academic
cardiovascular divisions have also traditionally
had a monopoly on investigational drugs, biologics
and devices. They used superspecialized physicians
possessing a unique knowledge base compared with
the community, but this expertise has become more
readily available. Investigational device, drug
and biologic sponsors have found enrollment of
patients at times easier in the community hospital
with lower overhead, fewer bureaucratic impediments
and more ready access to patients and have moved
their studies to these new partners who have physicians
of comparable expertise.
In
the next decade, academic cardiovascular programs
must pursue business-like practices and compete
aggressively within the market if the traditional
mission is to be sustained. Such competition should
be in partnership with other colleagues within
the academic medical center or in community hospitals.
They must restructure relationships within and
outside the academic medical center to meet these
challenges. This will require modification in
external relationships as well as internal organization
summarized as follows:
External
relationships.
- Multidisciplinary
integration of programs and personnel that may
not always be in the division of cardiology
or departments of medicine/pediatrics aligned
with product line services.
- Effective
integration/coordination with nonacademic colleagues
to accomplish teaching, research and patient
care, redrawing the boundaries of academic cardiovascular
programs.
- Effective
relationships fostered by mutual respect of
individual contributions to a joint purpose,
where financial relationships may be but one
component of this relationship.
- Reconnect
with primary patient populations through excellence
of clinical products and fiscally sound relationships.
Internal
restructuring.
-
Development of cardiovascular units to include
personnel and programs separate from the departments
of medicine/pediatrics whose fiscal and governing
structure optimizes the likelihood of success.
- Leveraging
intellectual capital by developing new or more
effective business products (e.g., disease management,
faculty-owned companies or an expanded model
of clinical research).
- Active
support for development of clinical performance
measures and outcomes that result in benchmarks.
This
report will assess these opportunities, recognizing
the variation in needs from community to community.
Such long-term restructuring of academic cardiovascular
programs will be central to the success of all
cardiovascular specialists and will improve the
access of all patients to the best cardiovascular
care.
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