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Health Care Reform: The Missing Piece of the Puzzle

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By Laurie H. Glimcher, M.D.

Amid the deafening rhetoric around health care reform there's a silence that should concern all of us. While the Supreme Court considers challenges to the Affordable Care Act (ACA) on a variety of grounds, no one is talking about what health care reform will mean for medical education and biomedical research, an essential element in the quest for more efficient and effective care. It's a critical piece of the reform puzzle that has fallen off the table.

Dr. Laurie Glimcher

Health care reform as currently conceived doesn't pay much attention to supporting the mission of academic medical centers, but it does put in place financial incentives and organizational innovations (such as accountable care organizations) that may be good for the health care system as a whole but harmful to academic centers.

When it comes to providing care at as low a cost as possible, academic medical centers are at a considerable disadvantage compared to hospitals and medical groups that are not responsible for educating new physicians or for making groundbreaking research discoveries. The mission of the academic medical center is unique. Training physicians and scientists with modern techniques and tools is costly, and its impact is not always immediately measurable. An investment in a medical student's experience today might result in the creation of a skilled practitioner or elegant clinical investigator decades hence.

Consider, for example, the costs of training a medical student. Data from the American Association of Medical Colleges show that only a small percentage of medical school revenues come from tuition. For all 126 fully accredited medical schools in the U.S. only 3.6 percent of revenue comes from tuition and fees. The remaining funding for education, patient care and research — all necessary for the training of students — comes from clinical practice, grants and philanthropy. As grants and patient revenue decrease, cost-shifting for education of students becomes increasingly challenging.

Weill Cornell public health professor Lawrence Casalino, M.D., Ph.D., and other researchers have shown that financial incentives aimed at improving the quality and controlling the cost of care may have the unintended consequence of harming organizations with special missions and/or special patient populations.

In thinking about stewardship of the academic medical center, I consulted with Joseph J. Fins, M.D., chief of medical ethics at Weill Cornell, and he reminded me of the late Daniel Patrick Moynihan's consistent, stalwart defense of academic medicine. During an earlier round of health care reform, the senator reminded Washington's elite of "…the manifest fact that American medicine is in a heroic age of discovery" and that these discoveries "are taking place in our academic health centers and in our pharmaceutical industry, as well."

Moynihan warned that, "Whatever we do, we are under a solemn obligation to do no harm to, indeed to facilitate, these centers." We would hope that present-day leaders would take note and appreciate the danger that narrow market-based reforms pose for academic medicine and its broader humanitarian mission.

It is a critical time for academic medicine. Making health care leaner will fundamentally change the financial structures that make medical education and research possible. Experts suggest that even the most efficient of centers will see reduced funding under President Obama's Patient Protection and Affordable Care Act. This financial shift, coupled with a National Institutes of Health (NIH) budget, projected to be flat or reduced in real dollars, will place academic medicine under considerable strain.

This needs to be fixed. In the past, Senator Moynihan sponsored the Medical Trust Fund Act, so as not to "…bring a premature end to a great age of medical discovery, largely made possible by America's exceptionally well-trained health professionals and superior medical schools and teaching hospitals."

This generation of leadership must do the same. Funding must remain in place for the complex training of physicians as well the research that leads to improved clinical therapies. We must preserve that unique combination of training, research and patient care that inspired Moynihan to call academic medical centers the "jewels in the crown" of the health care system — a "public good" that "everyone benefits from."

But much of this is at risk. Dr. Fins importantly cautioned that metrics that quantify the success of the new models of health care delivery mandated by the ACA do not factor in the latency of a superb medical education. Nor do they account for the "unproductive" years of medical research that typically precede an important discovery. Neither can be measured by the fiscal year, and holding academic medical centers to account — as if one could — is to ignore a critical part of their mission.

I am not suggesting that the new financial incentives and organizational innovations being introduced via health care reform should be abandoned because they are not well-suited to academic medical centers. Nor do I suggest that academic centers should be free from accountability, that nothing should change, and that policymakers should give us lots of money and leave us alone. But I do believe that academic medical centers are a crucial element of U.S. society — an area where the U.S. has an important comparative advantage over other countries. Policymakers should seek to provide a stable source of revenue to these centers to support their special missions, and policymakers and academic medical center leaders should work together to seek ways that academic medical centers can demonstrate accountability.

Both tasks will require a good deal of creativity. The tasks are urgent. These great institutions took a century to create, but they could be eviscerated in a decade if we do not act.

Altruism need not be the motivation for action. Support of academic medical centers is also highly cost-effective and good for a flagging economy. A recent report by the Association of American Medical Colleges noted that in 2009, research funds awarded to academic medical centers and teaching hospitals generated approximately $45 billion for the U.S. economy and that each NIH dollar invested yielded a return of $2.60.

Moynihan's voice, and those of other proponents for biomedical science like Senators Edward Kennedy and Arlen Specter, is sadly absent from the current debate over health care reform. But their historic and enduring advocacy reminds us that responsible health care reform must also be accountable to the future.

As we strive for present-day value, our leaders must ensure a bright future for academic medical centers — uniquely American medical institutions, which have done so much to foster human good. It is simply a question of stewardship. The President and the Congress should emulate the bi-partisanship of the past and work together to ensure their continued strength and viability.

Our academic medical centers are the envy of the world; let's not place them at risk. To replace these "jewels in the crown" would be beyond our means, and entail a societal and moral cost no nation could ever afford.

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