Academic Medical Centers: Too Large for Their Own Health?

Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study

BACKGROUND

Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit.

OBJECTIVE

To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization.

DESIGN, SETTING AND PARTICIPANTS

We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups.

RESULTS

Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction.

CONCLUSIONS

Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.

Trends in performance of hospital outpatient procedures and associated 30-day costs among Medicare beneficiaries from 2011 to 2018

BACKGROUND

United States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown.

METHODS

This observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status.

RESULTS

Of the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%-2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality.

CONCLUSIONS

There has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs.

IMPLICATIONS

The trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.

Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers : A Qualitative Analysis

BACKGROUND

Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs).

OBJECTIVE

To understand the impact of clinical growth on the educational mission for academic hospitalists.

DESIGN

Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level.

SETTING

Large AMCs across the United States that experienced clinical growth in the past 5 years.

PARTICIPANTS

Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs.

MEASUREMENTS

Themes and subthemes.

RESULTS

From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs' disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams.

LIMITATION

The study focused on large AMCs.

CONCLUSION

Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities.

PRIMARY FUNDING SOURCE

Society of Hospital Medicine Student Scholar Grant.

Building towards community-oriented policing: Forming an academic medical center partnership with local police

In the Spring of 2020, protective services for the Milwaukee Regional Medical Center (MRMC) Campus began a year-long transition process from the Milwaukee County Sheriff's Department to the Wauwatosa Police Department (WPD). This transition occurred during a time of focused local and national discourse regarding policing in diverse community settings. In response, the MRMC leadership formed the Ad Hoc Advisory Committee for the Transition of Protective Services (AATOPS). Over the course of six months, AATOPS members conducted site visits, developed a training manual, and divided into subcommittees to establish recommendations and key performance indicators in four primary areas: 1) Diversity and Inclusion of the WPD; 2) Psychological Evaluation of WPD Officers; 3) Use and De-Escalation of Force within the WPD; and 4) Communicating the Imminent Transition of Protective Services to MRMC organization employees, faculty, students, trainees, and patients. In this paper, we detail the process of organizing an accountable and collaborative approach to police and medical and academic campus relationships. At the end of the transition period, both the WPD and MRMC expressed commitment to a continued partnership to ensure the safety and security of all on the MRMC campus.

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives

INTRODUCTION

Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies.

METHODS

Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories.

RESULTS

Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified.

CONCLUSIONS

Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

CONTEXT

The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.

METHODS

Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.

FINDINGS

Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.

CONCLUSIONS

Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

COVID-19: Financial Stress Test for Academic Medical Centers

The coronavirus (COVID-19) pandemic is having profound effects on the lives and well-being of the world's population. All levels of the nation's public health and health care delivery systems are rapidly adjusting to secure the health infrastructure to manage the pandemic in the United States. As the nation's safety net health care systems, academic medical centers (AMCs) are vital clinical and academic resources in managing the pandemic. COVID-19 may also risk the financial underpinnings of AMCs because their cost structures are high, and they may have incurred large amounts of debt over the last decade as they expanded their clinical operations and facilities. This Invited Commentary reviews existing data on AMC debt levels; summarizes relief provided in the Coronavirus Aid, Relief, and Economic Security Act; and suggests policy options to help mitigate risk.

A proposal for the addressing the needs of the pediatric pulmonary work force

Unprecedented opportunities and daunting difficulties are anticipated in the future of pediatric pulmonary medicine. To address these issues and optimize pediatric pulmonary training, a group of faculty from various institutions met in 2019 and proposed specific, long-term solutions to the emerging problems in the field. Input on these ideas was then solicited more broadly from faculty with relevant expertise and from recent trainees. This proposal is a synthesis of these ideas. Pediatric pulmonology was among the first pediatric specialties to be grounded deliberately in science, requiring its fellows to demonstrate expertise in scientific inquiry (1). In the future, we will need more training in science, not less. Specifically, the scope of scientific inquiry will need to be broader. The proposal outlined below is designed to help optimize the practices of current providers and to prepare the next generation to be leaders in pediatric care in the future. We are optimistic that this can be accomplished. Our broad objectives are (a) to meet the pediatric subspecialty workforce demand by increasing interest and participation in pediatric pulmonary training; (b) to modernize training to ensure that future pediatric pulmonologists will be prepared clinically and scientifically for the future of the field; (c) to train pediatric pulmonologists who will add value in the future of pediatric healthcare, complemented by advanced practice providers and artificial intelligence systems that are well-informed to optimize quality healthcare delivery; and (d) to decrease the cost and improve the quality of care provided to children with respiratory diseases.

Tenure Trends in Academic Emergency Medicine Departments in U.S. Medical Schools

OBJECTIVE

The objective was to assess the long-term trends in tenure status stratified by sex and underrepresented in medicine (URM) status among emergency medicine (EM) department faculty in U.S. medical schools.

METHODS

This study used the Association of American Medical Colleges Faculty Roster to study trends in tenure status of full-time faculty from 1989 to 2018. The numbers and proportions of faculty by tenure status were studied over the years and compared across sex and URM minority status. Two-independent-sample t-test and simple linear regression were used for statistical comparisons.

RESULTS

The number of EM faculty increased from 177 in 1989 to 5,237 in 2018, with the majority of increase in nontenured (from 120 to 4,485) rather than tenured (from 24 to 198) or tenure track (from 28 to 548) faculty. The proportions of tenure-line faculty increased briefly from 1989 (29.4%) to 1994 (32.5%) and decreased since to 14.2% in 2018. The decreases were greater among men (from 34.5% to 14.9%) or non-URM (from 32.7% to 14.1%) than women (from 24.8% to 13.1%) or URM (from 30.2% to 15.3%). Compared to other academic departments, EM departments had the second lowest proportion of tenure-line faculty in 2018.

CONCLUSION

Emergency medicine faculty size increased rapidly in the past 30 years, with the vast majority of growth in nontenured faculty, regardless of sex or URM status. This highlights the need to review career development and academic promotions for EM particularly among nontenured faculty.

Decentralize-Change-Recentralize Model of Drug Information Networks in Health Centers: Decentralized Drug Information Services

Large health centers usually decentralize their services to small self-sufficient sub-centers of care delivery. These small centers are part of an extensive network of practitioners who are connected. The drug information services of independent clinical pharmacists in a health center could be fragmented. Drug information centers thus need to have a new definition of the mode of operation. While maintaining autonomy in information exchange, professionals are integrated to form a large community of practitioners. Technological advancements in communication and access to resources enable efficient collaborations to happen. Immersed in patient-centered collaborative practice environments, networks of professionals integrate drug information services. Drug information networks thus hold a similar philosophy of health centers to decentralize-change-centralize its services. Further research is required to measure the impact of this model of drug information services.

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness

In 1939, British psychiatrist Lionel Penrose described an inverse relationship between mental health treatment infrastructure and criminal incarcerations. This relationship, later termed the 'Penrose Effect', has proven remarkably predictive of modern trends which have manifested as reciprocal components, referred to as 'deinstitutionalization' and 'mass incarceration'. In this review, we consider how a third dynamic-the criminalization of addiction via the 'War on Drugs', although unanticipated by Penrose, has likely amplified the Penrose Effect over the last 30 years, with devastating social, economic, and healthcare consequences. We discuss how synergy been the Penrose Effect and the War on Drugs has been mediated by, and reflects, a fundamental neurobiological connection between the brain diseases of mental illness and addiction. This neuroscience of dual diagnosis, also not anticipated by Penrose, is still not being adequately translated into improving clinical training, practice, or research, to treat patients across the mental illness-addictions comorbidity spectrum. This failure in translation, and the ongoing fragmentation and collapse of behavioral healthcare, has worsened the epidemic of untreated mental illness and addictions, while driving unsustainable government investment into mass incarceration and high-cost medical care that profits too exclusively on injuries and multi-organ diseases resulting from untreated addictions. Reversing the fragmentation and decline of behavioral healthcare with decisive action to co-integrate mental health and addiction training, care, and research-may be key to ending criminalization of mental illness and addiction, and refocusing the healthcare system on keeping the population healthy at the lowest possible cost.