Questions to Be Asked: What Health Systems Leaders Need to Know about Their Academic Counterparts
A recent report on how the changes in American health care could affect the teaching, training, and research efforts of health care centers suggests that leaders in health care systems – the “clinical enterprise” – may want to pose questions of candidates for academic health and medical posts if and when the opportunity arises.
Recently, the Blue Ridge Academic Health Group issued their twentieth report entitled “Synchronizing the Academic Health Center Clinical Enterprise and Education Mission in Changing Environments” (http://whsc.emory.edu/blueridge/publications/archive/Blue%20Ridge-2016.pdf). The title alone makes the point that the relationships between academic health centers (AHCs) and their mission of training and educating health-care providers, on the one hand, could become misaligned with, on the other hand, health care systems seeking to adapt to new payment models, different patient and population outcomes, and lower overall health-care costs. Coming on the heels of two or more decades of pressure to change, the challenge of keeping the two sectors “in synch” ought not be left to chance.
In this article, we offer suggestions to health care systems’ leaders – CEOs, COOs, CFOs, and CHROs – for what they may wish to look for in their counterparts on the academic side, especially to the extent that these leaders have the opportunity to weigh in on the recruitment of deans and department chairs. Patient care and well-being are shared values and concerns, but the incentives and imperatives of directing the business of health care and those of educating and training health professionals are not always or necessarily the same; hence, the importance of clarity of means and ends between the two leaderships.
The Blue Ridge Group’s report points to the demise of the fee-for-service payment model as the catalyst for change in health-care delivery, including:
• systematic and coordinated rather than episodic and isolated engagement with patients and defined populations;
• proactive instead of reactive care;
• on-going collaboration with other institutions, including, in some instances, other providers of care and agencies within communities, as well as across the health-care professions
These changes were underway in advance of the Affordable Care Act, but ACA’s passage “accelerated” the change in payment models such that the entire health sector, including the academic component, are having to adapt. And the challenges are significant. Consider the impact of population health management (PHM), generally seen as the alternative to what health care has been:
Not only will health care organizations have to embrace a new reimbursement model to support PHM, but they must also encourage their providers to adopt a new way of doing business, including how they are compensated to align with the new reimbursement models. Internal politics and competition with outside provider groups can also challenge collaboration, so leaders will need to anticipate how they will create the right cultures and environment for change. Further, health care systems will have to open lines of communication with public health agencies and other entities within their communities (Institute for Health Technology and Transformation, 2012, page 7).
The “business side” of health care – hospitals, health care systems, insurance providers - is hard at work looking for ways to respond to the pressures for change, most conspicuously, according to the report’s authors, by scaling up operations and creating national networks able to capture sufficiently large enough patient rolls to realize economies of scale.
These changes in the size and scope of health care systems bring with them cultural changes and challenges to management and governance, as well as risks and opportunities for the education and training of health professionals, one of the defining missions of AHCs (page 2).
The “opportunities and risks” are neatly summarized in the report’s Table 1 below.
Understanding the ways AHCs view these opportunities and risks, leaders of health care systems can do a better job of working to achieve the synchronicity both parties require to be effective in the changing environment. Working with their academic peers will go a long way toward making that possible. Weighing in appropriately when new academic leaders – deans, vice presidents, and the like – are recruited is also important and can build a foundation for real synergy.
What, then, is the state-of-affairs in health care education as that relates to opportunities and risks?
We begin with the opportunities.
• Educate health professionals to function in teams to manage care across the continuum and improve health status at lower cost.
Interprofessional education (IPE) remains a work in progress, even after its advent back in the late 1960s. While most AHCs can point to IPE courses and experiences, some observers such as Dr. Pippa Hall maintain that “immersion” in any one of the health professions produces specialization and not collaboration across the professions, while gender and racial issues often perpetuate status differences that complicate a true team approach.
In considering the sorts of academic counterparts health care executives will need to work with – chief nursing officer, chief medical officer, or dean of medicine – it’s worth the effort to inquire of candidates precisely how they perceive both interprofessional education and care. If it takes a village to raise a child, logic suggests it will require more than the efforts of one or even two health professions working together to prevent injury and illness and maintain good health status of patients.
How much experience have you had with interprofessional education and care? How well has the education prepared health care professionals to improve care and lower costs? What are the keys to making interprofessional education more effective in terms of care and costs?
• Improve the quality of research with access to large populations and more complete, integrated information.
If health care is to provide compelling evidence as to the efficacy of care in a given population, data of far greater variety and from many more sources (some not engaged in health care per se) will be needed to tease out the effects using powerful statistical techniques which, in turn, require large data bases to warrant inferences.
Collaboration with researchers in another health care system is part of the tradition of academia, but sharing such information may not be a “natural” action by health care systems.
To what extent does research of all types in your current organization rely on data from sources other than those within the organization? What sorts of arrangements and understandings to you have with those “outside” sources?
Inquiring of candidates for leadership of health professions just how expansive and open potential deans or directors may be when it comes to sharing data can be a useful way to anticipate what practices may be forthcoming from those new leaders.
• Deliver more effective care across the continuum for disease episodes and procedures.
This may be something of a challenge for medical and other health care specialists, but most of those in the academic side of the enterprise and especially primary care providers will welcome the opportunity to work with patients over longer periods of time, especially when the patient’s behavioral changes are critical to improving health status. Those on the business side of health care would thus serve themselves well by promoting the opportunity to “follow” patients through significant portions of their lives
How does your current organization enable “tracking” patient information and care over time while maintaining data security and privacy?
• Improve health outcomes for defined populations, thus improving overall community health.
Noted earlier, population health management is a concept that, at an intuitive level, makes ample sense, but delved into, becomes definitional quicksilver and elusive to pin down in operational terms. Nevertheless, the concept and its implementation are keys to the sorts of change that health care in the United States will be required to make.
o Defining the population the health of which will be managed (e.g., first-pregnancy teenage women in a given jurisdiction or community) and, in the process, identifying the “partners” such as public health agencies, schools, employers, and the like that also affect individual and population health.
o Identifying care gaps in the population
o Stratifying risks within the population, some of which will change over time
o Managing care provided the population
o Measuring the outcomes of care
The goal of PHM is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests, and procedures. This not only lowers costs, but also redefines health care as an activity that encompasses far more than sick care. While PHM focuses partly on the high-risk patients who generate the majority of health costs, it systematically addresses preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or exacerbates their illnesses (Institute for Health Technology and Transformation, 2012, page 7).
The Blue Ridge Group makes a strong case for academic leaders to be “at the table” when decisions are made about the populations whose health will be managed, especially as it affects the scope of experience that can be afforded students in training.
Equally important will be the diversity of settings in which patients will be treated since the hospital will likely not be the primary facility in which care is delivered for some populations.
And it is worth the asking to inquire of academic leaders what experience they have had working with organizations that do not deliver health care per se but nevertheless have impact and sometimes profound impact on patients’ health.
Describe the process by which your current organization and any affiliated organizations went about defining the population(s) whose health at both the individual and community levels would be managed. What would you change about that process? How did academic needs factor into the decision?
• Build the market’s preferred delivery system with the best outcomes and access to the highest quality providers
The Blue Ridge Group’s report does a good job in describing the nature of change now being called for and already underway. All clinical care providers, including AHCs, are having to move “from a system where every procedure, examination, and provider touchpoint with the patient represents . . . [an] opportunity and occasion for billing to a system where payment is based on entire course of treatment and its outcome, or on the basis of defined pools or populations of patients and their health outcomes over agreed-upon lengths of time.” Not every aspect of fee-for-service will undergo the transition, but that serves to complicate further an already unknown and untested delivery system.
Moreover, sufficient variation exists among patient populations to give pause in deciding which delivery system actually works best or whether there are one or two delivery systems that perform well across most patient populations.
The result is, as the Blue Ridge Group notes, health care providers will need to assume a fair measure of risk (see also below). On the other side, academicians are trained to be skeptical and are not generally noted for taking risk. Knowing a candidate’s appetite for risk on the education and training side of the clinical enterprise could be very valuable to those who have to manage that enterprise, so asking questions of the candidate about risk-taking – either past or prospective – is more than conversational etiquette.
How far has your current organization gone in transitioning from the traditional fee-for-service model delivery of care? Based on that experience, what do you see as the three most important factors in effecting a good transition?
• Design and implement new models of care by creating teams that leverage capabilities of different professionals to improve outcomes, access, and patient satisfaction.
This opportunity was addressed in part earlier on, albeit, more in the context of interprofessional education enabling interprofessional care. The new models referred to here need not evolve out of shared educational experiences of different health care professions. Instead, by focusing more on the patient and his/her needs and rethinking standard operating procedures so as to produce better patient outcomes and satisfaction, it may well be possible to develop better models of care for given populations.
But development of such models takes imagination and a willingness to experiment and almost invariably have direct and indirect implications for staffing, facilities, and other “logistics” of health care that involve the business side. So, again, leaders on the business side will want to explore with academic candidates whether and what sorts of alternative ways of delivering care they have developed and deployed.
Describe team-based models involving the active engagement of persons from all or most of the health professions with which you are familiar. How long from conception to implementation did the effort to operationalize such teams require? To what extent and by which criteria would you assess the efficacy of such teams? In retrospect, what do you see as ways to either expedite the development of teams and enhance their effectiveness?
• Access to new education sites improves the diversity of the educational experience
The traditional hospital is a 20th-Century monument to the scientific and technological genius to create controlled environments in which to deliver health care. But science and technology do not cease enabling innovation, so we are beginning to see health care being delivered at and in sites quite different from the hospital setting. Couple those forces with the power of economics and finance and you have the makings of transformation.
How many and what types of sites is care delivered in at your current organization? Have the types of sites increased, remained the same, or declined and, regardless, what do you anticipate will be the case in the next 3-5 years? What sorts of challenges have sites other than traditional ones posed for your organization?
Table 1 depicts the move to population health management creating opportunities for AHCs. The change also carries risk, most of which is brought about by the “loss of patients, thereby reducing the capacity available for education and research and damages economics due to market consolidation.” The four sources of risk for losing patients are already present and having effects on AHCs and care providers not engaged in education and training and it is possible that some unaffiliated providers will remain so because having students present in clinical sites may slow the delivery of care and thereby adversely affect efficiency and productivity.
Care settings are now the proverbial “doc in a box” as well as pharmacies and grocery stores.
The Blue Ridge Group’s report notes that the consolidation of health care networks is already well underway and at least one of the primary motives behind mergers and acquisitions is to use scale and sheer volume to reduce cost and price, undercut other providers, and thereby cope with lower reimbursements. Signs are few that consolidation and the creation of national networks will slow.
Ultimately, these risks are only likely to be mitigated by a successful strategy of competition: save for health care organizations in remote, rural areas, all care providers will have to compete for patients and employees. Competition is not a stranger to academicians, but the terms by which an organization competes are sufficiently different at the aggregate population level of health chosen for management to require at least some rethinking by those on the academic side of the house.
At your current institution, what types of competition are the more potent ones and how is your institution addressing the competition? Were you to join us, what do you see as the primary competition to us and how would you propose we be successful in competing?
The Blue Ridge Group’s 20th report closes on a sobering note: “Medical education in the future must evolve to reflect fundamental changes in science, medical knowledge, information management, patient/consumer requirements, medical sector dynamics, and most fundamentally, the notion of what it means to be a healer.” Add to that formidable list of requirements for change the opportunity - if not the mandate - to work more closely with those on the clinical enterprise or business side such that as much alignment as possible can be achieved between those who lead the education, training, care, and research missions and those responsible for administering and managing the enterprise itself. Much is at risk, but much can be achieved.
Questions to Be Asked
1. How much experience have you had with interprofessional education and care? How well has the education prepared health care professionals to improve care and lower costs? What are the keys to making interprofessional education more effective in terms of care and costs?
2. To what extent does research of all types in your current organization rely on data from sources other than those within the organization? What sorts of arrangements and understandings to you have with those “outside” sources?
3. How does your current organization enable “tracking” patient information and care over time while maintaining data security and privacy?
4. Describe the process by which your current organization and any affiliated organizations went about defining the population(s) whose health at both the individual and community levels would be managed. What would you change about that process? How did academic needs factor into the decision?
5. How far has your current organization gone in transitioning from the traditional fee-for-service model delivery of care? Based on that experience, what do you see as the three most important factors in effecting a good transition?
6. Describe team-based models involving the active engagement of persons from all or most of the health professions with which you are familiar. How long from conception to implementation did the effort to operationalize such teams require? To what extent and by which criteria would you assess the efficacy of such teams? In retrospect, what do you see as ways to either expedite the development of teams and enhance their effectiveness?
7. Describe team-based models involving the active engagement of persons from all or most of the health professions with which you are familiar. How long from conception to implementation did the effort to operationalize such teams require? To what extent and by which criteria would you assess the efficacy of such teams? In retrospect, what do you see as ways to either expedite the development of teams and enhance their effectiveness?
8. How many and what types of sites is care delivered in at your current organization? Have the types of sites increased, remained the same, or declined and, regardless, what do you anticipate will be the case in the next 3-5 years? What sorts of challenges have sites other than traditional ones posed for your organization?
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