WINTER 2016 F REPORT 20 The Blue Ridge Academic Health Group Synchronizing the Academic Health Center Clinical Enterprise and Education Mission in Changing Environments Members and participants Contents (August 2015 meeting) CO- C H A I R S FEATU RED PRESEN TERS Synchronizing the Academic Health Center Clinical Report 20. S. Wright Caughman, MD J. William Eley, MD/MPH Enterprise and Education Mission in Changing Environments Emeritus Executive VP for Health Affairs Executive Associate Dean Professor, Schools of Medicine and Public Health, and Emory School of Medicine Special Adviser, Government Affairs, Emory University Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Michael M.E. Johns, MD Maryellen Gusic, MD Interim Executive VP for Health Affairs, Emory University, Former Chief Medical Education Officer Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 and President, CEO, Chairman of the Board, Emory Association of American Medical Colleges Healthcare Jonathan S. Lewin, MD I. Academic Health Centers in Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Claire Pomeroy, MD, MBA Senior VP, Integrated Healthcare Delivery, and Professor and Chair of Radiology, Johns Hopkins Medicine President, Albert and Mary Lasker Foundation II. cademic Perspective: Educating for the Future in a A Charles L. Rice, MD M E MB E R S President Changing Health Care Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Jeffrey R. Balser, MD, PhD Uniformed Services University of the Health Sciences Vice Chancellor for Health Affairs; Dean, School of Medicine Vanderbilt University Mark Richardson, MD (see Members) III. Delivery System Transition: Disruption and Consolidation Pressures . . . . . . . . . . . . 8 David A. Spahlinger, MD Michael V. Drake, MD Executive Vice Dean for Clinical Affairs and Executive IV. Sizing for Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 President, Ohio State University Director, University of Michigan Medical Group Michael A. Geheb, MD Executive VP, Physician Planning and Operations, FA CILITATOR V. How Academic Health Centers Organize and Plan for Education Needs . . . . . . . . . 16 Oakwood Healthcare, Inc.; President, Oakwood Physicians Steve Levin Case Study: regon Health & Science University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 O Gary Gottlieb, MD, MBA Director, The Chartis Group CEO, Partners in Health Case Study: ohns Hopkins Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 J G U ESTS Darrell G. Kirch, MD Case Study: niversity of Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 U William N. Kelley, MD President, Association of American Medical Colleges Professor of Medicine, Perelman School of Medicine, Case Study: Uniformed Services University of the Health Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Steven Lipstein University of Pennsylvania President and CEO, BJC Health Care Trustee Emeritus, Emory University Case Study: University of Virginia Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Mary D. Naylor, PhD Charles H. (Pete) McTier President, Emeritus, Woodruff Foundation Marian S. Ware Professor in Gerontology Trustee Emeritus, Emory University VI. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Director, NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing Marschall Runge, MD Executive VP for Medical Affairs, University of Michigan References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Kenneth S. Polonsky, MD Executive VP for Medical Affairs; Dean, Biological Sciences Richard P. Shannon, MD Division & School of Medicine, University of Chicago Executive VP for Health Affairs About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Mark Richardson, MD University of Virginia Dean, School of Medicine Previous Blue Ridge Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Oregon Health & Science University STA FF Fred Sanfilippo, MD, PhD Anita Bray Director, Healthcare Innovation Program, Emory University Project Coordinator, Woodruff Health Sciences Center, Emory University Irene M. Thompson, MD Gary L. Teal President and CEO, University HealthSystem Consortium Chief Administrative Officer, Woodruff Health Sciences Mission: The Blue Ridge Academic Health Group seeks to take a societal Bruce C. Vladek, PhD Senior Adviser, Nexera, Inc. Center, Emory University view of health and health care needs and to identify recommendations for S EN I O R ME M B E R S ED ITOR academic health centers (AHCs) to help create greater value for society. William R. Brody, MD, PhD Ron Sauder Communications Consultant The Blue Ridge Group also recommends public policies to enable AHCs Irwin Jacobs Presidential Chair Salk Institute for Biological Studies to accomplish these ends. ED ITORIA L A N D D ESIG N CON SU LTA N TS Don E. Detmer, MD, MA Professor of Medical Education Karon Schindler University of Virginia Linda Dobson Woodruff Health Sciences Center, Emory University Arthur Rubenstein, MBBCh Reproductions of this document may be made with written permission of Emory University’s Woodruff Health Sciences Center Professor of Medicine, Perelman School of Medicine by contacting Anita Bray, James B. Williams Medical Education Building, 100 Woodruff Circle, NE, Atlanta, GA, 30322. Phone: University of Pennsylvania 404-712-3510. Email: abray@emory.edu. Recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of Emory University. This report is not intended to be relied on as a substitute for specific legal and business advice. Copyright 2016 by Emory University. Executive Summary The size of the patient population needed to innovative, science-based tertiary and quaternary produce enough patients to meet the various train- care. The new emphasis on coordinated, team-based Academic health centers (AHCs) are undergoing a The Blue Ridge Academic Health Group be- ing requirements for medical students, nurses, and care, and population health has implications for marked period of transformation as they migrate lieves it is time to focus specifically on the role of allied health professionals, as well as residents and undergraduate and graduate medical education, as from fee-for-service reimbursement, which led education in determining the optimal size, scope, fellows, should also consider the practice settings well as the many other health professions, including to a focus on episodic care, to value-based pay- and character of AHCs. needed to support coordinated, team-based health the new cadre of clinicians who will provide health ment methodologies that reward coordinated care There is no single right answer to determining professional training. care, policy development, and leadership in the and improvements in the population’s health.1-3 the ideal size for fulfilling an institution’s mis- Population health approaches will be more future. The impact of these changes will also affect Payment models increasingly embrace the “triple sion for health professional education. However, prevalent, even if the rate of change proves as the ability of AHCs to maintain centers of excellence aim”4,5 of improving the experience of care for one clearly wrong answer is to fail to address this nonlinear and unpredictable as one might expect for low-incidence disease and carry out clinical individuals, improving the health of defined question, since every institution needs to deter- from a study of the history of health care. Recent research that advances knowledge and produces populations as well as that of individual patients, mine the AHC’s required size and scale based on headlines, for instance, reveal ongoing challenges in new treatments and cures for these conditions. New and reducing per capita cost. In this new construct, its distinctive mission, communities of interest, ACA enrollment, as even “insured” consumers are opportunities to conduct population health and it is hoped that payment changes will encourage and rapidly changing environmental pressures. confronted with rising premiums, high deductibles outcomes research are now present and necessary providers to enhance the value of the community’s Mission—especially the commitment to the and co-pays, and unwelcome limitations in their to pursue. Such research conducted by the AHC can investment in health care through continuous im- preparation of the next generation of clinicians— networks.8 No matter what the pace and character of materially affect the shape of what might be called provements in safety, quality, and service that lead must be a driver of a system’s size and scale. health reform may bring, our teaching hospitals will the “New World” of health care which delivers dra- to better outcomes for individual patients, groups A factor of particular impact in defining be expected to continue to offer the best and most matically improved value. of patients, and the entire community. The goal is the desired size and configuration of the AHC’s for health care to be proactive rather than reactive, delivery system is the extent of its commitment to patient-centered rather than provider-centered, training in medical specialties. Specialty prepara- initiated by health systems actively engaging the tion demands access to millions of lives to ensure Recommendations patient, and delivered by interprofessional care adequate experience for training of residents and teams in many settings other than the hospital. fellows, including access to diverse low-incidence 1. linical networks, however they are sized, must C 4. ducation values and requirements must be key E Taken together, the changes under way portend and complex diseases. Meeting this requirement is produce enough cases, and enough of the proper considerations in planning the size and character significant change for AHCs, which are responsible sometimes taken to mean that AHC’s must control a mix of cases, to support the education missions of AHCs’ clinical delivery systems. It is especially for a substantial volume of health care delivery, as sufficient number of lives through owned networks of their associated health professional schools. critical to maintain access to a sufficient number well for as the education and training of the nation’s to ensure access to highly specialized training and The sizes of clinical networks may and will vary and diversity of complex medical and surgical future health care workforce and leadership. experience. However, dependable access to the enormously, while still being scaled appropriately cases to sustain specialty and subspecialty train- The transformation in payment models, accel- necessary number of patients with low-incidence to the needs and missions of their respective insti- ing programs. The most impactful requirement erated by the Affordable Care Act, is driving the diseases can also be accomplished through a variety tutions. There is no one-size-fits-all solution. may be the number of “rare” or low-incidence growing size and consolidation of payers, pharma- of means other than assuming total responsibility cases needed for subspecialty graduate medical 2. AHCs’ clinical delivery systems do not need to ceutical and device manufacturers, and providers, for coverage. In fact, it is likely impossible for most education (GME) training. completely “control” or “cover” all of the hun- who are building the capabilities to improve value AHCs to have control of a large enough population dreds of thousands or millions of lives that are 5. AHCs’ clinical delivery systems must find or and gain access to a greater portion of premium to meet training requirements. required to produce enough cases every year for create room for value-based health professional dollars (notwithstanding cautions from industry However it is achieved, this imperative of ac- specialty and subspecialty training programs. A education to occur using team-based models of analysts that sheer size alone will not be deter- cess to teaching cases must be a key consideration variety of clinical referral and business arrange- education in the population health care delivery minative of success).6 The Wall Street Journal re- as AHCs develop strategies and actions to compete ments can be constructed to tailor the assumption settings of the future. Achieving this essential cently referred to a “health-care merger frenzy,” as in the changing environment. of risk appropriately to the size, resources, and requirement will be difficult in an era of dimin- both insurers and providers seek greater scale and Some AHCs have reacted reflexively to market character of any given AHC. ishing margins and commodity care, but it is efficiencies, with pending acquisitions that would pressures, rather than stepping back and remind- 3. ducators must be at the table in planning the E critical to the proper education and training of create three $100 billion insurance companies.7 ing themselves that education is the primary size and characteristics of clinical delivery sys- the generations of health professionals our nation These changes in the size and scope of health care reason they exist. Along with discovery-based sci- tems associated with AHCs. Education of health will depend on. While hospitals will continue systems bring with them cultural changes and ence and providing innovative clinical care, health care professionals is one of three foundational to be important sites for training, they will not challenges to management and governance, as professional education is a critical and indispens- and essential missions of the AHC, and it is the provide all of the appropriate settings for teaching well as risks and opportunities for the education able mission that AHCs perform uniquely well— one critical thing it does that no other part of the continuity of care. Other settings include nursing and training of health professionals, one of the and for which they must be held accountable by health care system can emulate. homes, home care, and still others, which will be defining missions of AHCs. health care’s various stakeholders. required to round out the training experience. 2 3 6. Academic health centers must make it clear by 12. cademic health centers should consider A perhaps even national level, depending on its and value-based health care delivery, we should their mission statements and in their strategic realistically what kinds of training programs mission, but also its own faculty, staff, students, seek to understand the contrast between health plans just how they benefit from, and contribute are available to them and make their plans residents, and fellows. The assessment of health needs as defined by the care delivery system vs. to, the larger university communities to which accordingly. For instance, statistics show that needs and the wants of the public are often health needs as defined by the health status and they belong. many states will not produce enough “rare” or surprisingly different from those developed by stated needs of members of the populations to low-incidence cases to support multiple organ AHCs, revolving around macro trends such as be served, including micro segments (subpopu- 7. Educators and AHC leadership must articulate violence control, obesity, nutrition, etc., rather lations) of our communities. transplant centers or multiple rare neurological clearly and convincingly that the academic mis- than organ-specific diseases and conditions. surgery programs, with adequate volumes to 16. The Center for Medicare and Medicaid sion of the AHC requires support and access to Understanding the full scope of needs and op- maintain excellence. There is significant oppor- Services should continue to include patients, cases, and care settings from their affili- portunities can lead to important conclusions, tunity for collaboration among AHCs and com- education needs in planning for Medicare ated clinical delivery systems and collaborating reinforcing the importance of public health, munity training programs; there is significant and Medicaid, especially with respect to partners, including community-based organiza- community health, and socioeconomic re- threat to the quality of training if all compete for reimbursement levels. Private payers also tions and other AHCs. searchers as valued contributors to the missions the same cohort of complex patients. should have a role to play in reimbursing 8. Not all education missions are or should be the of AHCs. As we devise education strategic plans their share of trainee costs. 13. he Accreditation Council for Graduate T same, despite the cookie-cutter feel of many for a new era dominated by population health Medical Education and its Residency Review mission statements; in fact, they should be even Committees should continue to work on more differentiated by scope, character, com- all residency areas to refine the milestone munity, and programmatic emphasis than they process and to quantify better how many are now. and what kinds of cases are required over the I. Academic Health Centers (AHCs) mission and strategic agenda. In many situations, the non-AHC components of the 9. Not all AHCs need to have identical kinds of re- course of a training program for all specialty in Transition university, which are essential to its identity lationship to their parent universities—quite the and subspecialty training programs. This is There are multiple dimensions of the rapidly and mission, are eclipsed in size and budget contrary, successful models show a wide range done relatively well now for most surgery changing landscape for academic health centers by the AHC. That is particularly true when of construction, from total ownership to arms’ programs but not nearly as consistently for (AHCs). Two have particular relevance for health the clinical delivery system—the hospitals, length affiliation, while still producing superb most medically based or hospital-based non- care education: clinics, and faculty practice settings—continue education and clinical care. The key common- procedural programs. n Health profession education changes: Preparing to be owned by the university. The attendant alities are wise governance, strong leadership, clinicians to deliver comprehensive, longitudi- 14. esearch must continue to validate the num- R uncertainties regarding the future funding and excellent management, guided by a shared nal care across a population requires changes bers, types, and outcomes of cases required of health care often lead to questions that understanding and commitment to mission in curricular content, education settings, and for the acquisition of expert competency. The go beyond issues of financial risk, size, and and values. expectations of graduates. Health professional old saw of “see one/do one/teach one” needs budget to include those of academic fit and 10. very health professional school should be E to be mothballed forever and replaced with schools are striving to produce graduates who reputation, and the roles of medical staff engaged in some kind of research that is real science. We need the best insights of will succeed in the delivery settings of the as faculty in greatly expanded health care appropriate to its size and mission, and that education psychologists, systems engineers, future. Health professional schools must main- systems. AHCs can and do bring great value to research should be an integral part of its edu- and health care faculty themselves, among tain an education environment that generates the university. They are often the best-known cation program. others, to study the acquisition and assess- and disseminates new knowledge, promotes and most-valued face of the university from 11. Education missions should provide clarity for ment of expert competency in a systematic professionalism, fosters an ethically informed the standpoint of many constituencies. The all parts of the academic health enterprise, not way. This approach must be applied to all approach to patients and colleagues, and as- significant philanthropy often provided by just undergraduate and postgraduate medical specialty training, whether procedural or sures clinical expertise. These are the hallmarks grateful patients illustrates this point. AHC education but also nursing, pharmacy, public non-procedural. of health professional education. Yet these missions should be aligned with those of health, and the allied health professions. Care professionals will practice and lead in settings their parent universities, while their strategic 15. s befitting a new era of value-based, popu- A delivery demands a team-based approach to very different from those that exist today and in plans should be particular to their own lation health, each AHC should continue to achieve highest value and outcomes—all profes- settings substantially different from those that distinctive characters, cultures, histories, and conduct research on the needs and desires of the sions must be included in the planning and their teachers were trained in as well. communities, making clear the full magnitude communities and populations it serves in order n niversity perspectives: Furthermore, AHC’s U of their unique contributions to the university’s execution of health care education. Additionally, to better understand matches and mismatches all settings in which the continuum of care is are a core part of the academic identity and education, research, and community service between what is being delivered and what is provided, such as long-term care facilities, rehab mission of most universities. The potential missions. By the same token, AHCs should being expected or needed. This research should centers, and community care centers, must be a benefits and risks of the changes in academic recognize the importance of other university include not only its patients, community mem- part of the education experience. health care and health sciences must be schools and colleges in enriching their own bers, and stakeholders at a local, regional, and considered in the context of the university’s academic culture and mission. 4 5 Meanwhile, the migration of American health care education should be at the forefront II. Academic Perspective: patient experience with other experiences, such as health care toward population health, increasing- and a key driver for planning. simulation. While simulation has demonstrated ly organized through large, integrated delivery One of the key considerations must be Educating for the Future in a value, it cannot fully replace the unpredictability systems, changes the playing field, creating both selectivity—tailoring the decisions to the Changing Health Care Context and particularity of a living case from a pedagogi- new opportunities and new threats for AHCs in attributes of the AHC. As stressed in last year’s cal standpoint. When used at the graduate level, it transition (see table 1). Blue Ridge report, Refocusing the Research Health professional education is undergoing a may be appropriate in the early stages of learning, With real and potential changes in both Enterprise in a Changing Health Ecosystem,9 quiet revolution, or paradigm shift, driven by but it is not so in the later stages when proficiency education and delivery models (“Disrupters of this is not a time in which every institution the recognition that students need to be better is being established. Academic Health Centers,” page 14), it is obvious should seek to cover the waterfront. The prepared to care for patients in very different ways In this context, the role of the AHC faculty that strategic planning is mandatory. Key dimen- high-functioning AHC will identify its niche, and in different settings. As emphasized by the must be steadily maintained and preserved. In sions of that planning should include consider- acknowledge its boundaries and limitations, transformative work of Cooke and colleagues10 on almost every health care career of distinction, ation of the optimal size, mission, historical and and focus on its specific strengths and both undergraduate (UME) and graduate medical whether inside or outside academia, a professional current strengths, and needs of each institution’s opportunities. This is not a time to “be all education (GME), an increasing number of educa- can look back on a master teacher who set a stan- immediate and extended communities. Potential things to all people”; rather, it is a time for tors and specialty bodies are seeking ways to make dard of excellence that provided lifelong inspira- clinical and education partners as well as com- differentiated excellence and cooperation and the learning process more individualized, efficient, tion and vision. Just as there must be space and petitors should be assessed. Access to sufficient collaboration with other institutions, in both and competency-based.11 The new paradigm calls time for learning competencies to occur in the de- cases and appropriate patient care settings for traditional and innovative ways. for developing habits of inquiry and innovation, livery systems we are now creating, there must be the intentional formation of professional identity sufficient space and time for teaching faculty not on the part of the learner, and close integration of only to inculcate specific clinical expertise but also classroom-based knowledge and clinical experi- the values and vision that have infused American Table 1. ences. This new approach puts a premium on health professions at their best. Making sure these Opportunities and Risks for Academic Health Centers maintaining access to a large and diverse range of conditions exist, at both the UME and GME levels, Posed by the Migration to Population Health patients and settings, for both undergraduate and attests to the scope and culture of an AHC learn- graduate medical students.11 ing environment, apart from its given size. Opportunities Risks Similar changes are occurring in the education At core, the new paradigm for both UME and of other health professionals, including nurs- GME is aimed at teaching and assessing compe- E ducate health professionals to function in n oss of patients reduces the capacity L ing, public health, pharmacy, and others. Health n teams to manage care across the continu- available for education and research tency in learners through individualized path- um and improve health status at lower cost and damages economics due to market professional educators and those who will employ ways and under direct observation from master n I mprove the quality of research with access consolidation: their graduates, seek assurance that AHCs’ gradu- teachers. This requirement makes the process of to large populations and more complete, • Channeling of patients away from ates possess the skills needed to function as mem- assessment even more critical. As part of the mile- integrated information AHCs as competing health systems bers of interprofessional care teams12 and that they stone process being promulgated by the Accredi- attempt to retain patients in-network n D eliver more effective care across the con- have certifiable competencies that correspond to tation Council for Graduate Medical Education • Shift of “commodity care” for tinuum for disease episodes and procedures the education and training programs from which (ACGME) and its Residency Review Committees routine/common cases to lower-cost n I mprove health outcomes for defined settings they have been graduated. Increasingly, educa- (RRCs), there are both qualitative and quantita- populations, thus improving overall com- tion programs and accreditation bodies define the • Difficulties competing on price tive metrics—numbers and types of cases that munity health for payer contracts, especially quantity and quality of experience with different will be required for the successful completion of n B uild the market’s preferred delivery sys- given high levels of cost shifting kinds of patients and settings. This underlines the a residency program. An important development tem with the best outcomes and access to to cover constrained government the highest quality providers reimbursement and growing imperative of sizing and designing AHC networks in medical education is the recent integration of n D esign and implement new models of care research deficits properly to make sure these experiences can be the American Osteopathic Association and the by creating teams that leverage capabili- • Challenges with competing for encountered in the type and volumes needed for ACGME residency accreditation programs, with ties of different professionals to improve community physicians and hospitals health professional education at all levels. the goal of establishing a single set of high stan- seeking to join a larger health system outcomes, access, and patient satisfaction Because of limitations in some clinical net- dards for both allopathic and osteopathic medical n A ccess to new education sites improves works associated with AHCs, especially at newer school graduates.13 the diversity of the educational experience and smaller AHCs, there is the risk that residents In addition, many AHCs are responsible for may finish their residency in particular clinical training for a variety of health professions, and Courtesy of The Chartis Group disciplines without having seen the requisite num- the patient volumes and settings needed for their ber and types of patients called for by the relevant education must be included in clinical enterprise specialty bodies and accrediting groups. strategic planning. For example, a provision One approach has been to try to replace direct of the Affordable Care Act (ACA) authorized 6 7 a $200 million Graduate Nursing Education health systems assume responsibility for costs, Figure 1. Demonstration, with the objective of training processes of care, and some health outcomes The Move to Accountability in Health Care Delivery advanced practice nurses who can treat Medicare of defined groups of patients. The heightened beneficiaries in a wide range of primary care imperative for health systems to become more- settings. In the demonstration, five traditional expert at disease prevention, health promotion, Preparing for a Change Most AHCs medical centers were funded to partner with improved quality and safety metrics, risk analysis, Initial Pilots and in Delivery Modes, Completing Transition are in the multiple nursing schools and community and financial projection is clear and obvious, yet Payer Demonstrations Payment, and to a New Model membrane organizations, with a requirement that at least the capacity, expense of infrastructure, and exper- Workforce Operating Margin ($ in millions) 50% of the learning must occur in community tise needed to accomplish these new dimensions settings.14 of health care are not common components of First Moves traditional health care delivery systems. Fee for Service Well-timed In figure 1, delivery systems are shown mov- Transition III. Delivery System Transition: ing from the “Old World” (roughly, the familiar shore from which most AHCs are departing now), Disruption and Consolidation to “New Worlds” of value-based care. We believe Old World New World Pressures this transition may well take 10 years and perhaps longer in many markets (longer than some health These forces for educational change are occurring futurists and pundits would like us to believe). in a rapidly changing environment for U.S. health The pace of change will vary by geographic mar- Accountable Care Lagging care and in particular for the clinical enterprises ket, health system, and professional discipline. All Transition Zone Transition of AHCs. AHCs, like all clinical care providers, markets will not be moving at the same rate, and are grappling with the likelihood of transition- thus local realities must be taken into account in ing from fee-for-service to value-based, popula- managing the transition of a multitude of differ- Unknown Time Horizon tion health payment and patient care models. In ent but interconnected health services through Courtesy of The Chartis Group essence, this means AHCs must plan for moving the membrane. Going through too early will from a system where every procedure, examina- leave behind capital needed to invest in the new tion, and provider touchpoint with the patient demands of infrastructure and competencies; represents a fresh opportunity and occasion for going through too late could well compromise ery environments of today and tomorrow. Foundation. About 14 million people were added billing to a system where payment is based on the effectiveness and relevance of the AHC health In table 215 and figure 2,15 the Center for to Medicaid rolls18 at comparatively lower rates of an entire course of treatment and its outcome, or system in the new environment, including access Medicare & Medicaid Services (CMS) graphically reimbursement than traditional employer-based on the basis of defined pools or populations of to patients needed to support all elements of the depicts the migration of the Medicare system. All health insurance provides. Nonetheless, for those patients and their health outcomes over agreed- AHC’s mission. AHCs and all health systems in the country treat- systems that traditionally were providing care to upon lengths of time. What has been in the In some health systems, we may find that pro- ing Medicare patients are somewhere along this the uninsured, Medicaid expansion now provides “Old World” a source of greater revenue, such as cedure-based specialties, for instance orthopaedic continuum, but all of necessity must be migrating revenue that previously was not being realized. imaging, is likely to become (over a variable and surgery, remain on the left side of the membrane; toward the right. And, as in the past, it is likely A related trend, as noted earlier, is that of insur- as-yet-undetermined pace) a source of costs, if while primary care, for instance, has already that Medicaid programs and private insurers will ing individuals and families with plans that are the frequency and clinical appropriateness are not begun to migrate to the right side. Thus we are follow the same paths forged by Medicare. characterized by substantial co-payment require- managed for overall value and patient outcome. at a time of great change, in delivery modes and Of course, the root of this change is our na- ments and extremely high deductible levels. A It is important to note that most observers do not reimbursement, where there is variability from tion’s effort to “bend the cost curve” through recent report by the Kaiser Family Foundation expect the total disappearance of fee-for-service one institution to another and from one specialty the ACA and reduce the rate of growth of health showed that high deductibles have increased six payment models in the near term—perhaps not to another, within institutions. These changes spending, which stands at approximately one- times faster than wage growth for working Ameri- for decades. This uncertainty presents additional not only demand changes in the behavior of sixth of GDP.16 Even with these changes, projected cans since 2010, fueling consumer anxiety as well challenges as AHC providers must compete in the physicians, other health professionals, and health spending in Medicare is expected to increase by as decreased utilization of health care by many.19 current world (which for many is already very dif- systems but also place significant demands on the nearly 75% in the 10-year period from 2014 to The combination of markedly higher premi- ferent from only a few years ago) while preparing curricula, settings, and behavioral expectations 2024, from $500 billion per year to $866 billion ums, deductibles, and co-pays is not only raising for the unknown changes ahead. of the health professionals that AHCs are educat- per year.17 Pursuant to the ACA, the ranks of concerns about the direction and pace of health One immediate example of the change is the ing. It is our greatest responsibility as leaders of the uninsured have been cut significantly, from care reform,20 it also reinforces a trend toward accountable care organization (ACO), a demon- academic institutions that our students, residents, 16.2% in 2013 to an estimated 10.7% in the first consumerism and consumer-directed health care stration project created by the ACA, in which and fellows be educated for the health care deliv- quarter of 2015, according to the Kaiser Family that is characterized in part by discriminating, 8 9 demanding, and sometimes challenging “shoppers,” illnesses and injuries. The potential for cost savings, Figure 2.15 as well as “lowest cost” health service buyers who maintenance of health, and better outcomes in Target Percentage of Medicare Fee-for-Service (FFS) Payments Linked have little reliable data on the quality of care being acute and chronic disease management is obvious, to Quality and Alternative Payment Models in 2016 and 2018 provided. but perhaps equally obvious is that many tradi- tional systems of care have not been organized to Implications for AHC Clinical Strategies approach health care in this manner. All Medicare FFS (Categories 1-4) As part of the move to value-based population Adapting to the New World will require AHC FFS linked to quality (Categories 2-4) health, providers, including AHCs, are in an ongo- clinical delivery systems to develop new capacities Alternative payment models (Categories 3-4) ing transition in caring for patients on a continu- for dealing with risk. Many AHC delivery systems ing, rather than episodic basis, with a much higher will be compelled to assume financial responsibil- emphasis on prevention, wellness, and proactive ity for the costs and outcomes of care. 2016 2018 diagnosis and management of chronic diseases and Managing utilization risk at the patient or conditions, as opposed to episodic care of critical small population level will be an imperative to 30% 50% Table 2.15 Payment Taxonomy Framework Category 1 Category 2 Category 3 Category 4 85% Fee for Service— Fee for Service—Link Alternate Payment Population-Based 90% No Link to Quality to Quality Models Built on Fee-for- Payment Service Architecture Payments are based on At least a portion of Some payment is Payment is not directly volume of services and payments vary based linked to the effec- triggered by service All Medicare FFS All Medicare FFS not linked to quality or on the quality or tive management of delivery so volume is Description efficiency efficiency of health a population or an not linked to payment. From Centers for Medicare & Medicaid Services15 care delivery episode of care. Pay- Clinicians and organi- ments still triggered zations are paid and by delivery of services, responsible for the but opportunities for care of a beneficiary shared savings or two- for a long period achieve cost savings, given the near-term changes has options to build its networks with health sided risk (e.g., ≥ 1 year). in reimbursement. Actuarial (insurance) risk is a system partnerships of varying sizes as well as much bigger undertaking and will arguably be a with coordinated care organizations and other n Increasingly n ospital value- H n A ccountable care n E ligible Pioneer much less common strategy for the nation’s AHCs, emerging health care entities. In contrast, in limited number of based purchasing organizations accountable care even those with substantial reserves. The exper- highly competitive markets, such as Michigan, Medicare Fee for Service Medicare fee-for- n hysician value- P n M edical homes organizations in tise required is not currently within the manage- there are multiple academic and hospital system service payments based modifier years 3-5 n B undled payments ment structure of many AHCs or health systems. players that are all attempting to consolidate have no link to n eadmissions/ R n C omprehensive Many AHCs are finding they can best serve their their respective markets. quality. hospital-acquired primary care missions by maintaining their size of “controlled” Underlining the advisability of growing condition reduc- initiative tion program lives but growing the number of “influenced” or through collaborations and partnerships, n C omprehensive “attracted” lives that will be referred to them for rather than necessarily through mergers and ESRD model tertiary or quaternary care. acquisitions, was a recent column published n M edicare-Med- icaid financial An important strategy to ensure a sufficient by The Advisory Board which cautioned: “In alignment initia- number of cases is forming collaboratives and many cases, the best way to meet the market’s tive fee-for-service networks. See, for instance, the Oregon, Johns demands is through strategic partnerships model Hopkins, and Michigan case studies (pages where the network expands but the health 17-25), all of which use various versions of this system, as defined by balance sheet assets, From Centers for Medicare & Medicaid Services15 approach. For instance, in Oregon, a single AHC remains the same.”6 10 11 Implications for AHCs’ Education Strategies striking, however, that while the surgical RRCs Table 3.22 We need education and training systems that specify minimum numbers of types of procedures Neurological Surgery Case Log Defined Case Categories and Required can “skate to the puck in 2025”—not to where and case logs, the numbers and types of medical Minimum Numbers the puck is now. Our AHC clinical care delivery conditions for non-procedural specialty training systems are changing and will continue to change programs are much more general, or even absent. Defined Case Category Required Minimum Number dramatically, and therefore our education and What’s more, even though procedural specialties training of health care professionals—from medi- have established specific experience requirements, Adult Cranial cal doctors to nurses, pharmacists to dentists, validation that prescribed numbers and types DC1 Craniotomy for brain tumor 60 therapists to nutritionists—need to be reconceptu- of cases ensures competency in that discipline DC2 Craniotomy for trauma 40 alized and reorganized in accordance with future is often lacking. Nevertheless, given existing DC3a Craniotomy for intracranial vascular lesion 40 DC3b Endovascular therapy for tumor or vascular lesion 10 models of care. The AMA-ACE Consortium on requirements of procedural training, it is possible DC4 Craniotomy for pain 5 Accelerating Change in Medical Education, which to define the minimum population size needed to DC5 Trans-sphenoidal sellar/parasellar tumors (endoscopic and microsurgical) 15 recently expanded from 11 to 31 members with support subspecialty surgical programs. The Johns DC6 Extracranial vascular procedures 5 the shared goal of transforming medical educa- Hopkins and Michigan case studies (pages 19-22) DC7 Radiosurgery 10 tion through innovation, represents an important in this report show how those population require- DC8 Functional procedures 10 DC9 VP shunt 10 initiative toward this end.21 ments can be constructed. Total adult cranial 205 The pressures to develop new approaches to Table 3, for example, according to the ACGME, Adult Spinal manage risk and “control” populations through shows the case log needed to meet the procedural growth, acquisitions, and/or partnerships have requirements for Neurosurgery.22 DC10 Anterior cervical approaches for decompression/stabilization 25 DC11 Posterior cervical approaches for decompression/stabilization 15 myriad implications for the education respon- Knowing the numbers of cases that are re- DC12 Lumbar discectomy 25 sibilities of AHCs. For example, for subspecialty quired, how many years a residency will last, on DC13 Thoracic/lumbar instrumentation fusion 20 services and training programs that require average, how many residents will be supported DC14 Peripheral nerve procedures 10 a steady flow of low-incidence cases, both to in a given program, and the incidence of given Total adult spinal 95 maintain excellence and to meet minimum targets conditions in the population at large, it is possible Pediatric for residency and fellow training, the size of the to compute the minimum number of lives needed DC15 Craniotomy for brain tumor 5 population necessary to meet these training needs to meet the requirements of a given training DC16 Craniotomy for trauma (uses adult trauma codes) 10 will have to be considered as the clinical strategies program. This calculation should be one of the DC17 Spinal procedures 5 are designed and implemented. fundamental dynamics that drive the construction DC18 VP shunt 10 Total pediatric 30 Situations such as these raise questions about of AHC clinical networks. DC19 Adult and Pediatric Epilepsy 10 whether some system-level control, at either the However, several factors make network sizing Critical Care state or national basis, is required to guarantee to meet education requirements as much of an art DC20 ICP monitor placement 5 the robustness of subspecialty clinical and train- as it is a science: DC21 External ventricular drain 10 ing programs, such as neurosurgery and organ 1. lear metrics and case logs do not exist for C DC22 VP shunt tap/programming 10 transplant surgery. There simply are not enough many or most non-procedural specialties, DC23 Cervical spine traction 5 cases to support a multiplying number of referral whether ambulatory or hospital based. DC24 Stereotactic frame placement 5 centers. When demand is substantially less than 2. he numbers and types of procedures given T DC25 CVP line placement 10 supply, the quality of training programs and the in table 3 represent the best professional DC26 Airway management 10 DC27 Arterial line placement 10 costs to maintain those highly specialized services judgment of RRCs, but it must be con- DC28 Arteriography 25 will be significantly negatively impacted. ceded that the science behind learning and Total critical care 90 competency assessment is not yet as mature Total all defined case categories 430 as one might want. A number of residency IV. Sizing for Education program directors indicated that they Reportable but non-tracked categories expect their residents to do substantially Craniofacial Sizing for Graduate Medical Education more procedures than the RRC minimum Spinal tumor/AVM guidelines to be considered competent in Miscellaneous/Unclassified As we consider how to size clinical networks to support GME programs, the numbers and types their field and successful graduates of their Copyright Accreditation Council for Graduate Medical Education, used with permission22 of cases specified in each program are the goal- residency programs. posts toward which the AHC has to advance. It is 3. hese cases can be shared between two or T 12 13 more residents, all of whom could be given schools have reduced the capacity available for tion care in the ambulatory care setting, new care share the authors’ concerns that such schools, like credit for varying roles. For instance, three U.S. medical student clinical experience by pay- models should deliberately plan for the partici- all medical schools, should ensure that trainees residents (assistant resident, senior resident, ing hospitals, private practices, and groups for pation of all levels and types of learners in these are fluent in the types of expertise that will be re- and lead resident) could scrub for any given placement of their medical students. new care environments. Students, residents, and quired in the clinical settings of the future, includ- case. Each of the three residents would be n Health systems are creating their own GME attending physicians should work together to ing bioinformatics and outcomes research. expected to assist the staff surgeon in some programs apart from medical schools. improve health care effectiveness, quality, and It is also important to keep in mind that one aspect of the case.23 n The menu of online education offerings contin- safety. Creative and thoughtful adjustment will be size does not fit all. Mission, communities served, 4. Finally, the move toward training teams as ues to grow for varying types of health profes- required to preserve our education missions and and financial realities all have to determine size providers means that the number of covered sions—though not, to date, for UME in the the production of a new generation of health pro- and strategy for any given AHC. Figure 3 illus- lives for neurosurgery must also consider United States, so far as we are aware. fessionals, in the midst of dramatically increased trates one way to think about the core issues. the training needs of a variety of students— Another disrupter is the increasing com- price competition. There is the consequent It is clearly the case that there are subpopula- nurses, pharmacists, technicians, etc., all of moditization of primary care in both AHCs and imperative that the education mission must be tions of patients who must be treated in larger whom will need exposure to neurosurgery community health systems due to inadequate adequately supported financially and throughout AHCs—both to ensure quality and to ensure case experiences to have a well-rounded reimbursement and insufficient numbers of the leadership of the AHC. enough cases for education. These subpopula- education. primary care providers. As practices are required tions should be directed to centers possessing In addition to the sheer numbers, of course, to become more efficient, there is less “space” Summary: Education as a Driver of Clinical the necessary expertise. Compelling models for there are many learning objectives that must be met for medical students, residents, and other health Enterprise Strategy this approach already exist in the form of NCI- in each training program. For GME, according to profession trainees, since their presence in the If AHCs are to have coordinated, integrated designated cancer centers, the national trauma ACGME accreditation standards, “residents must be ambulatory clinic may reduce the efficiency of the systems that accomplish the tripartite mission of standards of the American College of Surgeons, able to competently perform all medical, diagnos- practice, particularly for less experienced train- clinical care, research, and teaching, education and burn centers. tic, and surgical procedures considered essential for ees. A recent review article by Ellis and Alweis must be a driver of change, not just a passenger. Numerous studies have linked the mainte- the area of practice,” summarizes Maryellen Gusic, noted that several studies have found a decrease Only if education is part of the change process nance of adequate volumes with surgical profi- MD, former chief medical education officer for the in billing productivity when medical students or in health care delivery will the changes take hold ciency and good outcomes in referral centers. A AAMC. “Residents are expected to work effectively residents are incorporated in the clinical set- in the manner society demands. Competent, 2013 study at the University of Michigan by John in various health care delivery settings and systems ting; however, they also observed that “learning dedicated, and sufficiently supported educators Birkmeyer and colleagues30 showed that surgi- relevant to their clinical specialty.”11, 23 requires that clinical skills be attained through are thus the critical factor in producing the health cal skill of bariatric surgeons on videotape varied supervised provision of clinical care. Clinical care professionals of tomorrow. The education widely, as graded by peer reviewers, and that these Sizing for Undergraduate Medical Education teachers today are under intensifying pressure to and training for achieving success for tomorrow’s peer ratings of surgical skill could be correlated Students in UME must also be exposed to a wide increase clinical productivity and have less time care delivery requires that the appropriate educa- meaningfully with surgical complications and range of clinical cases. This range of cases is allotted to academic responsibilities.”27 tion environment puts a premium on lifelong patient outcomes. Such research serves to under- defined by each medical school’s faculty to meet Given both certification and experiential learning for faculty as well as redesigned pathways score the importance of training that happens their school’s specific mission. Going beyond requirements, student and trainee slots in the of learning for UME and GME students and all under the supervision of master surgeons, thus that, many medical schools recognize the need for ambulatory setting are critical for appropriate other health profession students and trainees. constituting a major reason to concentrate rare development of qualities and characteristics that education at both the UME and GME levels. In Thus the success or failure of education curricula and complex procedures to a few select places, may be uncaptured in accreditation standards but addition to the question of how medical students, will be determined by the excellence of educators’ rather than dispersing them more widely at the are still desirable or essential in health care profes- residents, and other health profession trainees fit performance in new roles, with new expectations, risk of mediocrity in both surgical outcomes sionals. Emory University School of Medicine into the ambulatory work flow, there is increased practice settings, and technology environments. and training. Population analyses suggest that in faculty, for instance, codified a list of Student questioning about the role and status of the fac- An issue of particular interest is whether order to have centers with appropriate expertise, Physician Activities for all students that would ulty providers who staff these clinical settings and and to what extent the nation may be creating a low-incidence diseases requiring specialized care include such soft criteria as managing time, iden- how much time and attention they can devote to two-tier system of medical education. A recent should be channeled to one or two centers serving tifying personal limitations and seeking assistance supervising, teaching, and evaluating the trainees. article by Arthur Feldman and colleagues29 notes a large population, e.g., one or two centers for when needed, and demonstrating trustworthiness Some AHCs are consciously reducing patient flow the founding of 17 allopathic and 19 osteopathic each 5 million people served in the region (as il- to patients and colleagues.25, 26 through certain clinics in order to make space medical schools in the past decade. Many of these lustrated by the case studies in this report). and time for instruction. One such example is have no relation to research universities, place their As the case studies show, there are many ways Disrupters of Education the Aliki Initiative at Johns Hopkins Bayview, a students in community hospitals rather than tradi- for AHCs that treat and train at the quaternary level AHCs, like all of higher education, face varying donor-funded curriculum to promote patient- tional quaternary institutions, and have small basic to achieve the requisite number of cases to main- categories of ongoing and potential disruption: centered care by residents and medical students.28 science departments. While these schools undoubt- tain their surgical excellence other than directly n For some years now, new and offshore medical Given the shift toward individual and popula- edly are responding to local and regional needs, we controlling or covering 5 million lives. While these 14 15 approaches have worked well for most AHCs in the Of course, there may well be times when AHCs past, current pressures will require reassessment of should voluntarily close clinical and/or education Figure 4.31 which approaches will suffice to meet AHC needs, programs that do not meet their goals. As required How Academic Health Centers (AHCs) Are Organized including clinical quality, financial sustainability, by the Liaison Committee on Medical Education, and education/training requirements. every medical school must demonstrate sufficient AHCs take many organizational forms. Consolidation and growth of health systems and These means include resources to sustain education quality. primary focus on system financial performance will put substantial stress on support of n ore networks, in which AHCs do indeed as- C AHC education and research missions, support of which are critical to AHC success. sume responsibility for assigned lives, including in ACOs and closed insurance products V. How AHCs Organize and Plan n linically integrated networks of providers and C hospitals for Education Needs Loose Degree of Integration Tight n ormal and informal partnerships with other F An old maxim with regard to AHCs stresses the institutions, including hospitals, nursing homes, high degree of local variation in how they are University University social services agencies, and the like. & SOM University University & SOM SOM organized, governed, and financed: “If you’ve seen & SOM & SOM n ffiliation agreements that facilitate referrals A one, you’ve seen one” (see figure 4).31 Governance n nformal relationships that facilitate referrals I Practice Teaching and leadership—the fundamental requirements Teaching Practice Teaching Practice Teaching Practice Teaching Practice n elations with VA and Department of Defense R Hospital Plan Hospital Plan Hospital Plan Hospital Plan Hospital Plan for success—are the essential commonalities in hospitals Independent Academic Separate Clinical Fully University of Enterprise Model Practice Plan Enterprise Integrated Figure 3. n Colorado School n Columbia University n University of n Indiana University n UCLA Health Academic Health Center (AHC) Models Imply Certain Strategies of Medicine n Washington Alabama Medicine Health n Emory | Woodruff n University of University School n Duke Medicine n Northwestern Health Sciences AHC strategies are a key input in framing the challenge. Each AHC’s aspirations for the Kansas Medical of Medicine n University of Medicine Center Center n Weill Cornell Virginia Health n Partners Healthcare n ohns Hopkins J three historical AHC clinical roles should be a key determinant of the numbers of patients Medical College System n University of Medicine to support education programs. n Yale School Pittsburgh Medical n niversity of U of Medicine Center Michigan Health n Stanford Health System Comprehensive Regional National/ Care n regon Health & O Population Health Referral Center International Science University Manager for Local for Complex Care Referral Center n Penn Medicine Community n Key provider of n Leading nation- n C ore provider high-end specialty al/international Adapted by The Chartis Group from Levine31 of hospital and care provider in select physician services Reliant on referrals n subspecialties n C ritical resources from independent n Low-volume any and all models of organization. Then one Oregon Health & Science University: for underserved physicians and business must tailor to mission and needs of those served. State-driven Strategies32 populations community hospitals Any of a variety of models can work—and a large The best planning begins with research and a variety are well established and are being devel- specific understanding of the communities to be oped. In addition, experimentation is ongoing. served and their particular needs and goals. Just as Implications: This is not a static universe. one size does not fit all, one format does not serve the needs of every community or mission. Large enough population needed Significant patient volumes needed to support undergraduate medical to sustain fellowships and specialized Case Studies As reported by Mark Richardson, MD,32 dean education, primary care, other core residency programs, e.g., neurosurgery, Following are five case studies of strategic plan- of the Oregon Health & Science University (OHSU) residency programs, and other health cardiothoracic surgery, pharmacists, ning undertaken by AHCs to create clinical net- School of Medicine, long-range strategic planning profession education programs advanced practice providers, etc works that are capable of meeting and sustaining there has resulted in a finely tuned plan to produce their education requirements. the volume and mix of graduates in medicine and Courtesy of The Chartis Group other health professional fields who will meet the expressed needs of that state and its communities. 16 17 Along the way, OHSU has cultivated and added in an integrated manner, the physical, behavioral, creasing medical school class size from 125 to 160 Hopkins faces in building its networks is, “How important partnerships of both private and public and dental health of all Medicaid patients, a group students, as well as expanding GME numbers and big is big enough?” entities and has gained access to new practice set- that was then newly expanded under the Afford- sites. The assumption continues to be that half of To answer that question, he says, it is critical tings that could serve as training sites for students able Care Act provisions to more than 1 million all graduates will stay in the state. This increase is to “start with the end in mind.” To support the and residents. individuals. The CCO mode, once demonstrated on track to meet the stated physician demand. education mission, Hopkins needs a robust clini- As Oregon’s academic health center, OHSU has as successful, may be applied to other patient OHSU has also redesigned its MD curriculum, cal delivery system that will provide a diversity a unique role in the state’s public university system, populations in the public sector, such as state educating MDs to work in the new, team-based set- of experiences and patients for its undergradu- as it is focused on health care delivery and educa- employees, eventually covering up to one-third tings that will characterize the future of population- ate medical students. Those experiences need to tion and serves as an “essential pipeline” for the of all Oregonians. based health care. “We need to meet the demand include settings that will prepare them to practice state’s health care workforce. The road to OHSU’s The CCOs have the flexibility to manage a from transformation of our state’s health care in the new population health model. current plan and configuration began in the 1990s, global budget to maximize population health, and system, but we must also help lead the transforma- For GME, in specialty and subspecialty train- when the state approved the right for it to become a this may include expenditures on non-traditional tion,” says Richardson. ing in “luminary” programs like organ transplant public corporation. This allowed OHSU to issue its items, such as gym memberships and nutritional Plans for the new curriculum were built on and rare neurological procedures, you need much own bonds and set its own compensation, among counseling. Each CCO must meet quality and nearly two years of survey work and consulta- larger networks that provide access to the required other things, while maintaining its mission respon- access metrics. OHSU helped to form one of the tion with a large number of stakeholders. While number of rare and complex diseases. The institu- sibilities to the state, including health care work- CCOs, serving on its Board of Directors, and is a everyone assumed OHSU graduates would be “in- tion needs enough volume to maintain its profi- force development. OHSU has a public Board of partner in several others. telligent” and well educated in science and medi- ciency, and trainees need to be able to see enough Directors appointed by the Governor. This change Oregon’s health care transformation presents a cine, what was surprising but critically important cases to become expert in the rare interventions gave OHSU the flexibility to respond to the com- “pivotal moment,” says Richardson, and consolida- was how highly OHSU stakeholders valued other and procedures required to treat them. In keep- petitive managed care marketplace and to partner tion among payers and providers is now under way, qualities, including collaborative ability, leadership ing with the tripartite mission, other, equivalently with public and private entities, maintaining tort a scenario which supports OHSU’s goal to form new potential, communication skills, and the ability to important objectives that must be balanced include protection as any state entity would. partnerships that help ensure its own stability while use data and apply new discoveries for the good of maintaining robust clinical trials and maintaining With this decision, the medical school con- supporting the state’s health care transformation the community. enough programs with positive funds flow to sup- tinued to be integrated with the clinical delivery goals and enhancing its ability to meet its education A major goal in meeting Oregon’s needs will be port education and research. system, along with the dental school, the nursing and research missions. producing primary care health professionals and Hopkins divides its clinical population into school, and other affiliated entities. OHSU was OHSU is essential to the supply of Oregon’s also encouraging OHSU’s trainees to practice in ru- three tiers: Its primary population, providing understood to have a unique role in the state’s pub- health care workforce, producing one-third of all ral and underserved areas. OHSU is addressing that the majority of its volume, is the basis for UME lic university system, as it focused on health care physicians and one-half of all dentists practicing goal through forming partnerships in rural areas and primary care training. Second, its expanded delivery and education and served as an “essential in the state. About one-half of OHSU’s MD gradu- of the state, providing care settings where medical populations, which are region-wide, reaching into pipeline” for the state’s health care workforce. ates and one-half of its medical residents remain in students and allied health professionals can work several adjoining states, provide enough rare and In 2012, OHSU adopted a new clinical en- Oregon to practice. In response to Oregon’s health in teams and where residents can train. Experience complex cases for subspecialty training. And then terprise strategic plan. Key elements of that plan care transformation and shifting workforce needs, says many of them will be inclined to stay there a third tier, consisting of international and “fly-in” called for its clinical delivery enterprise to reduce the university is both increasing the number of its after completing their programs. patients from distant areas out of state, enhances the cost of care, even while becoming a nationally graduates to meet state forecasts and redesigning both its renown for quaternary care and its positive recognized provider of choice and developing the its curriculum. Johns Hopkins Medicine: Sizing the Clinical financial margins. capacity to deliver population health in different As for numbers of physicians that will still be Enterprise to Support the Academic Mission33 Hopkins’ planning model showed that it needs geographic settings and throughout the full course needed, current forecasts by the state and OHSU About three years ago, Johns Hopkins Medicine about 1 million lives in its primary (core) market by of care. This plan reflected efforts by the state of analysts say that Oregon will need an additional adopted a strategic plan that led to the formation 2020 to meet all of its objectives, including fulfill- Oregon, which was then beginning to move aggres- 1,726 physicians, 332 nurse practitioners, and of the Office of Integrated Healthcare Delivery. ing its education mission in UME and primary care. sively forward with its health care transformation 168 physician assistants by 2020, although these Working with an Integrated Healthcare Delivery However, for specialty and subspecialty care and plan. The plan included the implementation of a forecasts have some challenges due to limitations Council, with representatives drawn from across training, the clinical networks of influenced lives in new delivery and reimbursement model focused on of underlying data. The forecasts include multiple the system, the office strives to align quality, value, its expanded market must be much, much larger. both individual and population health. scenarios, says Richardson, including ones in and financial performance to support the institu- For instance, only about 2,655 heart trans- The state set up 16 coordinated care organiza- which MD requirements are attenuated by team- tion’s tripartite mission of research, education, plants are done per year in the country. Based on tions (CCOs—a modified version of ACOs), each based care and/or in which enhanced utilization and patient care. those incidence rates and on typical transplant with defined patient populations (initially Med- of electronic health records and other technologies Jonathan Lewin, MD, senior VP for integrated center volumes of 15 to 40 cases per year, Hopkins icaid enrollees only) and per-capita based global slows the rate of health workforce growth. healthcare delivery and chair of radiology,33 says calculates that it needs to have access to 1.7 to 4.4 budgets. The CCOs are charged with managing, In response to these forecasts, OHSU is in- one of the most fundamental questions Johns million “influenced” lives per year to maintain 18 19 clinical proficiency and a training program capable bigger; tell me how big you need to be to support of cases they believed UM’s networks needed to termine the rates at which relevant cases occur per of producing expert graduates. your mission.” generate to meet training needs. By and large, they 100,000 lives.34 Based on the number of residents The same kinds of calculations for kidney and David A. Spahlinger, MD, the senior associ- reported that their programs’ training volumes in each program, he was then able to compute how liver transplants show that the institution needs ate dean for medical affairs and executive director were in the 75th percentile nationally and that was many lives per resident would be needed to pro- expanded networks of 1.4 to 2.8 million for these of the University of Michigan Medical Group,34 where they wished to stay. duce the required number of cases in each specialty programs. said he came to appreciate the force of that chal- Spahlinger then used patient data provided by and subspecialty area. That also gave the number With a core network projected at only 1 million lenge over the course of planning. “That question the Health Care Cost and Utilization Project of the of lives needed overall to maintain each training by 2020—and in the face of rapid consolidation in was much more difficult than I thought when we Agency for Healthcare Research and Quality and program. (See table 4.) the market—how can such large networks be cre- started. I was naïve.” the Michigan Health & Hospital Association to de- Having large-enough networks to maintain ated and maintained? But it turned out that the question was answer- Lewin says Hopkins is working on many fronts: able, and the answers pose a challenge that now will n hysician networks P shape the many directions in which Michigan will Table 4. 34 n ffiliations and partnerships: for instance, in ex- A grow and develop, both by itself and in conjunction Population Needs for Selected Residency Programs change for providing pediatric surgery coverage with other partners and affiliates. for a community hospital, create a linkage that The strategic planning in Michigan, like virtual- at University of Michigan Medical School34 facilitates access to future transplant and other ly everywhere else, is driven by fundamental forces Department Index ACGME Per Resident Rate per LIves Per Number of Lives quaternary referrals of change in the state health care marketplace: Procedure Minimum National Average 100,000 Resident Residents Needed n ully integrated partnerships: for instance, acqui- F n he rise of consumerism, bringing with it a new T Normal 200 273.0 667.5 29,963 179,775 sitions and mergers degree of transparency into real costs of proce- Obstetrics & deliveries n mployer/payer relationships: for instance, mak- E dures: For example, a company called Castlight Gynecology Cesarean 6 145 228.0 400.1 36,239 217,436 ing agreements with large corporations that the Health has a contract with Blue Cross/Blue deliveries institution will provide all of a certain type of Shield. Enrollees contemplating a colonoscopy Hysterectomy 70 117.0 214.1 327,884 54,647 procedure, such as joint replacements, for their can compare real costs (based on actual BC/BS covered lives contracts) and see in advance what they will owe Hip 30 93.2 193.1 48,265 289,590 Orthopaedic replacement All of this is taking place against a background in out-of-pocket costs, co-pays, and deductibles Surgery of “shifting sands,” says Lewin, with rapid con- across the available range of providers. 8 Fractures/ solidation in the provider market place, growth of n ew forms of payment, in the form of bundled N dislocation -- 66.7 108.5 61,474 491,797 hip/femur consumerism linked to the increasing prevalence payments for an entire course of care: For in- of high-deductible insurance policies, and all kinds stance, hip replacements are now bundled in 75 Mastectomy & -- 35.2 169.5 20,649 123,894 of disruptive forces and technologies. Furthermore, markets in Michigan, in a trend that is moving lumpectomy each micro-market has a distinctive mix of needs with surprising speed. Overall, the market is General Colon Surgery -- 57.9 123.4 46,172 277,033 and preferences. The north side of Baltimore may moving from group to individual purchasing of resection 6 be very different from suburban Washington D.C., coverage, with narrow networks, high-deductible Cholecystec- -- 122.7 131.4 35,190 211,141 and networks need to be constructed accordingly plans (thus allocating more cost-sharing to the tomy in each place. consumer), reference pricing, and transparency. Pancreatec- -- 10.0 2.32 448,430 2,690,580 However they may be achieved, Lewin con- n ultiple medical schools in the state (and local M tomy cludes, “‘hardwired’ relationships with patient political or economic issues that favor still more), Peripheral populations are increasingly necessary to support with a finite number of rare cases and lives to nerve decom- 10 72.0 128.6 56,250 112,500 the education and research missions and to remain provide the necessary volume for top-tier clinical Neuro- pression financially strong.” and subspecialty care and education programs surgery Craniotomy, 2 In calculating the number of cases needed to 145 292.0 41.3 707,021 1,414,044 adult University of Michigan: Sizing the support UM’s specialty training programs, Spah- Spinal Clinical Enterprise for GME34 linger consulted the case minimums established by 5 35.0 292.0 13,687 27,375 procedure When the University of Michigan (UM) Health RRC’s for the ACGME. Clear numbers of minimum System began revisiting its strategy for network cases were available for virtually all the surgical Transurethral 100 205.0 172.0 119,186 476,744 Urology 4 sizing a year ago, the leaders of the project were programs of interest but not for most of the medi- Nephrectomy 30 99.0 22.0 450,000 1,800,000 given a memorable challenge by the university’s cal programs. He also talked to program directors president: “Don’t tell me how you are going to get throughout his school to determine the numbers Data sources: ACGME 2014, HCUP 2012, MHA 20 21 proficiency and training programs in organ trans- ceeded in building understanding and support for Planning to support the mission is compre- the required volume and mix of cases for their plant is a particular concern, given the limited its clinical enterprise plan and objectives from the hensive and driven by complex algorithms that various programs. number of organs and procedures nationally. university’s leadership as it walked through the define the parameters of expected need. MHS plans Despite its complexity, granularity, and Table 5 shows the national rate per 1,000 lives, the process of matching size and scope to mission. are written to support Defense Department plans, meticulous detail, “this is at best imperfect,” says volume needed, and the lives needed, accordingly, which in turn are derived from the Quadrennial Rice. “Nobody can anticipate every circumstance.” to produce the volume. The numbers needed in Uniformed Services University of the Health National Defense Review. Every requirement for Because of those unpredictable elements of life, he the top four transplant areas range from 3 to 6 Sciences: Workforce Planning for Societal staffing grows out of a particular “driver,” which has says, it is an important advantage to have trained million lives. Need36 been vetted by a higher order of command. medical personnel in the Ready Reserve, who can UM’s strategy calls for it to remain both a Based in Bethesda, Maryland, the Uniformed Ser- For instance, staffing for wartime medical be called on if needed in a crisis. Still, year in and comprehensive provider of care in the state and a vices University of the Health Sciences (USUHS) requirements grows out of standard assumptions year out, MHS represents an outstanding example national referral center in a number of specialty embodies perhaps the clearest, most emphatic about the population at risk, anticipated casualty of getting the right numbers of students and areas. Accordingly, it projects that it needs about example of rationalized planning, from the top rates, and other planning factors. A more recent trainees in the pipeline, by specialty and subspe- 400,000 covered lives in its primary service area, down, to produce health professionals in specific dimension of operational planning involves cialty, using historically based assumptions and and 3 to 4 million covered lives overall to ensure specialty and subspecialty areas to meet defined readiness to undertake humanitarian missions, projected needs. enough specialty cases to meet both its clinical societal needs. The university has a school of since long-term instability in developing coun- enterprise and education needs. medicine, graduate schools of nursing and dental tries can destabilize indigenous governments University of Virginia Health System: To accomplish this, it is working across a wide science, and graduate programs in biomedical and health care systems and foster the breeding Population Health—A New View of range of channels, including partnering with two science that are of military significance, including grounds for terrorism. Community Partners38 large, Roman Catholic systems, Ascension and psychology, emerging infectious diseases, neuro- MHS planning is based on a series of equations The transformation associated with payment Trinity; affiliating with a number of independent science, and molecular and cell biology. and projections that encompass both the peace- reform is having significant impact on both hospitals; taking an equity position in the 14-coun- As Charles L. Rice, MD,36 president of USUHS, time requirements of attending to the medical academic and community care providers. The ty, nonprofit MidMichigan Health System; and puts it, in comparison with many aspirational and needs of 9.6 million active military and military dynamics differ based on diverse geographic creating a network within physician organizations. abstract mission statements expressing the tripar- retirees and their families. (The MHS, however, considerations. Strategies that may be effective The UM health system is also embracing some tite objectives of civilian academic health centers, is separate from the Veterans Administration.) for large urban based AHCs may be less available of the potential disrupters; for instance, partner- the USUHS is more sharply focused. Working from a Medical Operational Support to AHCs serving statewide and rural geographies ing with CVS Minute Clinics and developing Requirement, which is the total number of medi- where distance compounds the universal issues of “virtual care” capabilities through telemedicine, “The mission of the Uniformed Services University of cal personnel needed on active duty, the MHS then access, affordability, and quality. patient portals, and smart phone apps, as it seeks the Health Sciences is to educate, train, and prepare calculates the annual “sustainment” numbers that All AHCs support the construct of the triple to improve access on nights and weekends and uniformed services health professionals, officers, and are needed to maintain full strength given annual aim, but the most potent of the three imperatives increase price transparency to patients. leaders to directly support the Military Health System attrition rates. (See table 6.36) in the early days of payment reform is the pressure According to Spahlinger, “the most critical [MHS], the National Security and National Defense The result is a grid of requirements broken to reduce costs. These forces have disproportion- thing is to connect to the mission of the univer- Strategies of the United States and the readiness of down by surgical and medical specialties and sub- ately affected community and rural hospitals, sity.” And, he said, the UM health system suc- our Armed Forces.”36 specialties, along with the number of postgradu- where scale is limited and reduced occupancy ate training years required for each specialty. The driven by a move to more ambulatory-based care military maintains its own internships as well as is eroding economic fundamentals. Yet a vibrant Table 5.34 residencies at Walter Reed; Portsmouth, Virginia; community hospital network is essential not only Complex Care Mission and Population Needs San Antonio (Texas) Military Medical Center; to access and affordability but to the health of the and elsewhere. Currently, MHS has 182 residency regional AHCs that serve as tertiary and quater- Procedures Use Rate Volume Lives Needed (millions) programs representing 2,889 residents, with a nary providers. The University of Virginia (UVA) per 1,000 first-time board pass rate of 98%. In addition to Health System has adopted a strategy of partner- Liver transplant 0.02 50-75 3-5 the military’s own sites, residents are currently ing with payers and community providers to cre- doing rotations in the National Capital Con- ate regional systems of rational community based Kidney transplant 0.05 150-200 3-4 sortium institutions in the greater Washington care. The partnership, while driven by efforts to Bone marrow D.C.-Baltimore region and in medical schools and create affordable access at reduced costs, can be 0.05 200-300 4-6 VA medical centers in North Carolina, Georgia, transplant aligned with the education and research missions Cardiac 0.02 45-60 3-4 Florida, California, and Texas, among others. of the AHC. transplant Reaching out to other partners to place resi- In sweeping discussions with all community University of Michigan Medical School dents is the best way to make sure the they see hospital systems throughout Virginia, UVA deter- 22 23 Table 6.36 A consequence of declining activity in the training sites using UVA clinical faculty assigned Calculating GME Trainees Needed by Specialty community setting is the inability to recruit and to those settings. It allows patients to remain close retain skilled providers. UVA plans to assist in to home and yet have access to the expertise of to Meet Medical Readiness Needs of US Military building a community health workforce by chan- the AHC. Finally, it affords the AHC with a high- Sustainment—Basic Training Equations neling UVA trained physicians and other health quality, low-cost community setting that facilitates DEMAND professionals into the community network. Key the focus of the AHC on tertiary and quaternary DESIG NOBC PSUB SPEC MOSR TPPH SPEC# LRATE TLEN GOAL PGY1 PGY2+ GME to the success of this effort is a critical assessment care mission. of patient needs and consideration of the regional GMO and not just the local marketplace. Providing a 2100 0102 15F0 GMO 292 9 301 0.38 115 1.00 1.00 115 VI. CONCLUSION 2100 0107 16U0 UM 92 3 95 0.30 29 1.00 1.00 29 workforce for the region, as opposed to exclusive- 2100 0110 15A0 FS 296 9 305 0.31 95 1.00 1.00 95 ly for the local community, is critical to economies Medical education in the future must evolve to of scale. In addition, it is important that these reflect fundamental changes in science, medical GMO TOTALS 680 21 701 239 community providers be UVA faculty in order to knowledge, information management, patient/ SURGICAL maintain ties to the regional center and to afford consumer requirements, medical sector dy- 2100 0214 15C0 SURGERY 245 7 252 0.23 58 4.00 0.80 46 140 186 regular opportunities for these providers to return namics, and most fundamentally, the notion of 2100 0118 18B0 ANEST 199 6 205 0.22 46 3.00 0.80 37 74 111 to the AHC to build and maintain competencies. what it means to be a healer. Education and its 2100 0150 15M0 PATH 34 1 35 0.20 7 4.00 0.80 6 17 23 2100 0224 15D0 NEURO 21 1 22 0.26 6 7.00 0.80 5 29 34 In turn, the clinical department at the AHC can evolving needs must be drivers of AHC strategic 2100 0229 15E0 OBGYN 79 2 81 0.27 22 3.00 0.80 18 35 53 provide backup in the community. Importantly, planning for its clinical enterprise. AHCs also 2100 0234 15G0 OPHTHAL 22 1 23 0.24 6 3.00 0.80 5 10 15 the concept of partnership, not ownership, al- must ensure training for teams of providers 2100 0244 15H0 ORTHO 143 4 147 0.29 43 4.00 0.80 34 104 138 2100 0249 15I0 ENT 31 1 32 0.27 9 5.00 0.80 7 29 36 lows control to remain locally governed by an to coordinate clinical services for individual 2100 0269 15J0 UROL 33 1 34 0.23 8 4.00 0.80 6 20 26 agreed-on set of operating principles derived from patients across the care continuum, while also regional care needs. Therefore, UVA’s education improving outcomes for specific populations of SURGICAL SUBTOTAL 807 24 831 164 458 622 mission has become a fundamental currency in patients under their care. These will include a MEDICINE the creation of the JOC. range of populations, such as diabetics and more 2100 0101 16R0 IM 223 7 230 0.26 60 2.00 0.80 48 48 96 The model creates an opportunity for the AHC narrowly, those requiring complex interventions 2100 0105 16V0 PEDS 78 2 80 0.20 16 2.00 0.80 13 13 26 to consider these regional community partners as such as transplantation. 2100 0108 16Q0 FP 252 8 260 0.18 47 2.00 0.80 38 38 76 2100 0109 16P0 ER 113 3 116 0.20 24 3.00 0.80 19 39 58 2100 0110 15A1 FS 36 1 37 0.29 11 3.00 0.80 9 18 27 2100 0111 16N0 DERM 21 1 22 0.19 5 3.00 0.80 4 8 12 2100 2100 0115 0121 16X0 16T0 PSYCH NEUROL 80 16 2 0 82 16 0.18 0.20 15 4 3.00 3.00 0.80 0.80 12 3 24 7 36 10 References 2100 0131 16Y0 RAD 40 1 41 0.24 10 4.00 0.80 8 24 32 1. Blue Ridge Academic Health Group. 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Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, accelerating-change-in-medical-education/innova- mary_of_the_Agreement_between_ACGME_and_ Carlin AM, Nunn AR, Dimick J, Banerjee M, Birk- tions.page#developing-expand. Accessed December AOA.pdf. Accessed December 9, 2015. meyer NJO. Surgical skill and complication rates 11, 2015. after bariatric surgery. N Engl J Med. October 10, 14. Quinn WV, Reinhard S, Thornhill L, Reinecke P. 22. ccreditation Council for Graduate Medical Educa- A 2013;369:1434-1442. Available at http://www.nejm. Improving Access to High-Quality Care: Medicare’s tion. Neurological Surgery Case Log Defined Case org/doi/full/10.1056/NEJMsa1300625. Accessed Program for Graduate Nurse Education. AARP Categories and Required Minimum Numbers. Avail- December 14, 2015. Public Policy Institute; June 2015. Available at able at http://www.acgme.org/acgmeweb/Portals/0/ http://www.aarp.org/content/dam/aarp/ppi/2015/ 31. Levine J. Considering alternative organizational PFAssets/ProgramResources/Final%20Defined%20 improving-access-to-high-quality-care-revised.pdf. structures for academic medical centers. Washing- Case%20Categories%20and%20Required%20Mini- Accessed December 9, 2015. ton, DC: Association of American Medical Colleges. mum%20Numbers.pdf. Accessed December 14, Academic Clinical Practice. Summer 2002;14:2. 16. Centers for Medicare & Medicaid Services. Better 2015. 26 27 About the Blue Ridge Academic Health Group Previous Blue Ridge Reports See http://whsc.emory.edu/blueridge/publications/reports.html. The Blue Ridge Academic Health Group studies and reports on issues of fundamen- Report 19: Refocusing the Research Enterprise in a Changing Health Ecosystem. 2015 tal importance to improving the health of the nation and our health care system and Report 18: A Call to Lead: The Case for Accelerating Academic Health Center Transformation. 2014 enhancing the ability of the academic health center (AHC) to sustain progress in health Report 17: Health Professions Education: Accelerating Innovation Through Technology. 2013. and health care through research—both basic and applied—and health professional Report 16: Academic Health Center Change and Innovation Management in the Era of Accountable Care. 2012. education. In 19 previous reports, the Blue Ridge Group has sought to provide guidance Report 15: The Affordable Care Act of 2010: The Challenge for Academic Health Centers in Driving and Implementing to AHCs on a range of critical issues. (See titles, opposite page.) Health Care Reform. 2012. For more information and to download free copies of our reports, please visit Report 14: The Role of Academic Health Centers in Addressing the Social Determinants of Health. 2010. www.whsc.emory.edu/blueridge. Report 13: Policy Proposal: A United States Health Board. 2008. Report 12: Advancing Value in Health Care: The Emerging Transformational Role of Informatics. 2008. Report 11: Health Care Quality and Safety in the Academic Health Center. 2007. Report 10: Managing Conflict of Interest in AHCs to Assure Healthy Industrial and Societal Relationships. 2006. Report 9: Getting the Physician Right: Exceptional Health Professionalism for a New Era. 2005. Report 8: Converging on Consensus? Planning the Future of Health and Health Care. 2004. Report 7: Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century. 2003. Report 6: Creating a Value-driven Culture and Organization in the Academic Health Center. 2001. Report 5: e-Health and the Academic Health Center in a Value-Driven Health Care System. 2001. Report 4: In Pursuit of Greater Value: Stronger Leadership in and by Academic Health Centers. 2000. Report 3. Into the 21st Century: Academic Health Centers as Knowledge Leaders. 2000. Report 2: Academic Health Centers: Good Health Is Good Business. 1998. Report 1: Academic Health Centers: Getting Down to Business, 1998. 28 29