The Future of Specialty Care within Academic Medical Centers

Healthcare reform and a patient-centered realignment are going to transform the healthcare system.  How these forces affect the academic medical center, and particularly their specialty services, will depend on the ability of these institutions to adapt to the new environment and to take advantage of new opportunities.

Healthcare reform promises to control cost, at least in part, by more appropriate use of specialty services.  According to the recent White Paper from the Institute for Healthcare Improvement, Reducing Costs Through the Appropriate Use of Specialty Services, as much as 30% of healthcare costs could be saved by correcting the overuse of services without reducing quality. The President and CEO of the IHI is Don Berwick who was recently nominated by President Obama to run Medicare and Medicaid.  Presumably, he will move the plans outlined in this paper directly into demonstration projects.

So, how will this effect specialty care provided at academic medical centers?  That depends on whether the center is a low-cost or a high-cost provider.  In 2005, the Commonwealth Fund published a study entitled Variation in Use of Medicare Services Among Regions and Selected Academic Medical Centers: Is More Better?  This study compared the 77 institutions rated by U.S. News & World Report in 2001 as the nation’s “best” hospitals for treating geriatric care, heart disease, cancer, and pulmonary disease.  When they looked at utilization of resources and costs they found that, per-enrollee, Medicare spending varies almost threefold among hospital-referral regions and academic medical centers.  The high-cost centers had more physician visits, more hospitalization days, more ICU days, more diagnostic testing and imaging.  They even had significantly more patients die in ICUs. The IHI and others have shown that academic medical centers with greater spending rates do not, however, provide greater quality of care.

So, in the future, it will be very important for high-cost academic medical centers, such as those in Southern California and Manhattan that were the focus of this study, to bring their costs into line with the lower-cost, high-quality centers.  Their physicians, particularly their specialists, are doing too much, without benefitting patients.  This from the summary: “In the long run, the most challenging problem will be finding mechanisms to clear regional markets of excess capacity.” That will not be easy, but academic centers should lead the way rather than sit on the sidelines and bemoan the passing of the good ol’ days.

And the realignment of healthcare around the needs and preferences of the patient will also require adaptability on the part of super-specialiists and academic medical centers.  As industry stakeholders, academic medical centers must reassess their processes and priorities toward customization for patients.  As outlined in a recent Pricewaterhouse Coopers’ Report all providers will need to assume more accountability for the coordination of care and begin to use electronic tools to help patients make better decisions.  A patient-centered approach is inevitable, as Gary Belfield of the NHS in England put it, “In an integrated world, no one provider owns chronic disease care.  The patient owns the chronic disease.”

The Commonwealth Fund concluded that self-directed care has been quite successful in a report from February 2010 entitled International Developments in Self-Directed Care.  The move toward self-directed care will have to start with an interoperable electronic health record that will allow the patient to take a collaborative role.  A patient-centered medical record will allow for better coordination of care.  Patients with rare, serious and chronic diseases particularly want and need their primary care physicians, specialists, social workers, therapists and pharmacists to have the same information and to communicate with each other and with the them when necessary.

Remote care holds a lot of possibilities for patients and physicians.  Mobile, networked tools for care at a distance are available already and will continue to improve.  Monitoring devices, safety devices, virtual visits with physicians, therapists and social workers are available and utilization will only increase.  Recently, some US states have been requiring insurers to cover telemedicine.  There are some barriers, such as state licensing limitations, but those can be overcome.  The Veterans Administration (VA) already has an electronic health record and some remote device services.  Free devices are enabling some patients more frequent monitoring.  The VA is reporting a drop in hospital admissions and shorter hospital stays as a result.  And in France, a home monitoring system is being credited with a reduced number of hospital days by 2.7 million between 2005 and 2008.  US academic medical centers should be actively pursueing these mobile and remote services because they stand to benefit by telemedicine more than most other institutions, because of the brand recognition that they command.

And along these same lines, in a Pricewaterhouse Coopers’ survey of global health leaders, “almost half said they thought medical tourism would increase in the next five years. The medical tourism industry will split between those shopping for low-cost and those searching for new science and value.”  Half of global consumers with chronic illness interviewed said it was easy or very easy to understand their medical condition, but that it was much harder to access a specialist than a primary care physician. These global consumers chose access to care as the top attribute that defines quality care.  A global shortage of specialists could be met by US academic medical centers.  Developing countries are also in need of medical educators and researchers. Distance care, in the form of consultation or second opinion, distance research and distance teaching all offer great opportunities for US academic medical centers.

Academic medical centers have not been known for their flexibility and adaptability. The definition of Ivory Tower on Wikipedia is a place “where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life.”  Many patients with rare, serious and chronic diseases depend on the highly specialized services provided by academic medical centers.  For their sake, I hope the Ivory Tower gets “connected” to patients, literally.

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