American College of Cardiology

Contents Print a PDF Task 1 Task 2 Task 3 Task 4 Tables References < Previous Next > 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

Task Force 1: Clinical Care

Henry DeMots, MD, FACC, Co-Chair, Gilbert H. Mudge, Jr., MD, FACC, Co-Chair

CURRENT CHALLENGES

General Considerations

Although community providers are under the same ultimate financial constraints, the academic cardiovascular program has unique challenges that must be addressed. These include the following:

1. The funding mechanisms for medical education are unclear and differentially burden the cost of medical education to academic medical centers, yet all payers benefit from the products of this education process.
2. The current decision-making process in academic organizations is often bureaucratic, cumbersome and too slow for rapid response to changes in the marketplace.
3. Multiple agendas within an academic medical center and the multiplicity of priorities and commitments often make response to market forces slow and tedious.
4. The ability of each academic department within an academic medical center to delay or stall critical decisions burdens the deliberations.
5. Due to more limited and focused agendas, for-profit institutions and other health care systems without the academic medical center overhead and mission have more effectively invested resources in competitive strategies for clinical care.
6. Academic medical centers have traditionally relied on quality of care as a differentiating factor, but such quality is often difficult to measure and exists in the community.
7. The multiple agendas and missions within an academic medical center dilute the focus on clinical care. In many departments of medicine/pediatrics, for example, emphasis has been restricted to research productivity at the expense of developing appropriate clinical and teaching programs.
8. Rigid stratification of teaching techniques/paradigms also limits any advantage of an academic medical center.
9. The additional cost of training house staff and students is above and beyond the costs of medical care without a structure to finance this commitment.
10. Relationships between academic medical centers and community providers have often been strained and ineffective.
11. Academic medical centers strive to develop a profile of tertiary and quaternary care which inherently provides them with adverse selection, and high acuity of illness. In an environment of capitation and prospective payments, such adverse selection may be detrimental to the survival of the academic medical center.
12. Academic medical centers have often focused on care of the underinsured and fragile population, constituents of our society who are by and large ignored by the current forces of managed care and other payers. Research performed by the Association of American Medical Colleges[zzaq;7] suggests that the burden of this care in academic medical centers is increasing and may be of major consequence for the future of the academic program.
13. Current and proposed payment policies of the Health Care Financing Administration fail to recognize the unique role of academic medical centers in the delivery of health care services to Medicare beneficiaries and threaten the financial viability of institutions and programs that serve a critical public good.
14. Each academic cardiovascular program has a critical and minimal patient volume that is central to its missions, but cannot resort to historical strategies to maintain patient referrals fundamental to its teaching and research missions.
15. Traditional organizational schemes of academic departments have placed cardiovascular programs with less related specialties, rather than with specialties such as cardiovascular surgery, interventional radiology, cardiovascular anesthesia and pediatric cardiology.

Challenges to the Academic Cardiovascular Program

Academic medical centers have had increasing difficulty attracting sufficient patients, particularly in areas of the country in which managed care has achieved market dominance (7). Several factors render traditionally structured academic centers ineffective in the marketplace.

Shifting resources. The business of academic cardiovascular programs has historically relied on delivering high quality services and a monopoly in tertiary care of complex patients. However, they have succeeded in training outstanding physicians who have moved into the community. As high quality cardiovascular resources have proliferated in the community, academic cardiovascular programs have lost much of this traditional advantage to the community provider.

Separation from the community. Traditional academic cardiovascular programs have segregated themselves from their primary care feeder stream to pursue their tertiary and quaternary care goals and have had difficulty constructing the provider networks that are necessary to contract under managed care. Attempts by some academic programs to develop their own feeder programs have further alienated the community. The teaching model in which attending physicians were on service for only a month or two per year and most of the communication with referring physicians was conducted by residents often fails to establish the necessary relationships with community physicians that they deserve.[zzaq;8]

Noncompetitive structure. The structure of the academic medical center has failed to provide sufficient incentive in patient care and tends to inhibit collaboration among providers of related services outside the departments of medicine/pediatrics. Cardiology divisions have often been disproportionately viewed as the major revenue source for departments of medicine/pediatrics. The subservience of the cardiology division to the department of medicine often creates disincentives against profitable initiatives and may stymie appropriate collaboration with the hospital, with the cardiothoracic surgery division and with community-based physicians. There is often a lack of alignment between departments of medicine/pediatrics and divisions of cardiology, and economic structures may neither support academic cardiology nor foster profitability within divisions of cardiology. Because procedural revenue has decreased, this problem has become a major issue in most departments of medicine.

Cardiology divisions at risk. With the development of high cost procedures such as interventional cardiology, large clinical revenues were available to support cardiology divisions and departments of medicine. With the expansion of interventional and bypass programs to community-based hospitals, academic cardiology divisions have been placed at risk. This has been further influenced by these community hospitals having cardiology and interventional training programs, which increases the competition from the community with additional available practitioners. Furthermore, with falling reimbursements and increasing costs of these technical innovations, it may be more cost-effective to shift less complex procedures to the community, further reducing revenue to the cardiology division, departments of medicine/pediatrics and ultimately the academic medical center.

Changing environment. The forgiving environment of state support and fee for service medicine has been replaced by declining revenues, the uncertain future of managed care and the progressive loss of government support. This threatens not only the health but, in some cases, the survival of academic medical centers.

Primary care emphasis. Current economic forces tend to organize delivery of health care around primary care physicians. Academic medical centers have traditionally focused on specialty care. Patients are often channeled away from academic medical centers in newly integrated health care delivery systems. Building new relationships with the physicians in the region when these relationships have been strained in the past is difficult and many times impossible, particularly in geographic areas with heavy penetration of managed care contracting. This problem may also exist within an academic medical center when primary care physicians provide an inadequate referral base for cardiovascular programs.

Internal structure. Many of the challenges to academic medical centers are internal, however, and must be solved by the center. These include a faculty structure in which each department functions with little accountability to the whole. Whereas competitors have a focus on efficient health care delivery, academic medical centers try to excel simultaneously in research, teaching and patient care. The impact of this approach is substantial and it may not be tolerable.

Performance measures. In the past, academic medical centers have considered effective management of difficult cases as a quality indicator, whereas the managed care industry and government define quality as adherence to Health Plan Data and Information Set indicators. Thus, statistical comparisons do not accurately reflect quality when applied to tertiary and quaternary patients in academic medical centers. This is best reflected in the number of patients who are transferred from community hospitals and other tertiary care centers for high risk interventions or surgery. This information is not available on current standard databases and underscores the importance of the development of better measures of clinical performance and outcomes with resultant benchmark criteria.

Teaching models/mission. Academic medical centers have historically developed models for teaching and attempted to adapt them for patient care rather than the reverse. The structure of these services follow guidelines imposed by residency review committees and often are ill suited for clinical care. Placing specialty patients on general teaching services requires an attending physician who may not be suited to provide specialist care. The quality of patient care can be supported by liberal use of consultants, but precious hours and dollars are lost in the process. Trainees in the outpatient clinic can also produce inefficiency and patient dissatisfaction if the teaching model is not well constructed. In addition, variation in practice patterns from one physician to another is as prevalent in academic medical centers as in community counterparts. Following a single care path with a new contingent of residents each month is challenging. Furthermore, academic cardiologists are sometimes removed from more highly remunerative activities on the cardiology services to treat noncardiac patients on the general internal medicine service.

Faculty expectations. Faculty members who chose academic careers in another era are often disgruntled because the expectations have changed and their ability to meet their career goals is threatened. Meeting the goals of the institution with people who are dissatisfied, and who often have tenure, is a major challenge to the medical school and therefore the academic medical center. In cardiology, talented clinicians and proceduralists are often underappreciated during promotional reviews and are instead attracted to community-based opportunities. Clinical contributions are not measurable by classic academic scales and are not as central to promotion as education and research contributions. Furthermore, cardiologists are often held to a productivity standard that is different than that of other department of medicine members. In addition, for those in the clinical arena, tenure consideration during promotion is often of lesser value.

Reimbursement/documentation. The future holds more challenges. New documentation requirements of the activity of the faculty imposed by the Health Care Financing Administration are costly to implement. In addition, changes in the Practice Expense component of the Medicare fee schedule will disproportionately affect specialty-laden faculties and especially cardiology divisions. Continued pressure on reimbursement is likely, and the appetite for cost containment of the nation has not yet been sated.