THE NEW GLOBAL ECONOMY:
MODELS, MISSIONS, RISKS, AND REWARDS
International Forum 2009
Washington, DC
Highlights
Keynote: What We See in 2009
Victor J. Dzau, MD, chancellor for health affairs, Duke University, and president and CEO, Duke University Health System
The United Kingdom Establishes Academic Health Centers
Sally C. Davies, FMedSci, MD, director general of research and development, The Department of Health, National Health Service, London
Canadians Reassess Academic Health Centers
Glenn G. Brimacombe, president & chief executive officer, Association of Canadian Academic Healthcare Organizations
Pioneering a New German Model: Merging Campuses and Missions
Detlev Ganten, MD, PhD, former CEO, The Charité—Universitätsmedizin Berlin
The German Academic Health Center Enterprise
Ralf Heyder, vice CEO, Association of German University Hospitals (VUD)
Creating Academic Health Centers: The Dutch Strategy
Martin Paul, MD, PhD, vice president, Maastricht University Medical Center, and dean, faculty of health, Medicine and Life Sciences, The Netherlands
Hospital Reform in France: Understanding Change
Jean-François Rey, MD, président, U.MES.PE, Confédération des Syndicats Médicaux Français
The John P. McGovern Award Lecture: A Dialogue on the U.S. Healthcare Agenda
David Cutler, PhD, the Otto Eskstein professor of applied economics, Harvard University
Forces of Change in the Regulatory World
Christine K. Cassel, MD, MACP president and CEO, American Board of Internal; Deborah Nasdem, Joint Commission International
President’s Address
Steven A. Wartman, MD, PhD, MACP, president and CEO, the Association of Academic Health Centers
Health Reform Versus Global Agendas
Robert Kocher, MD, special assistant to the President for healthcare policy, National
Economic Council
Emerging Markets Perspective on Academic Health Centers
Tilman Ehrbeck, PhD, partner, McKinsey & Company, India
Understanding Health System Management
Lois Margaret Nora, MD, JD, president and dean, school of medicine, Northeastern Ohio Universities Colleges of Medicine and Pharmacy (NEOUCOM)
The Global Workforce: The Forgotten Agenda?
Peter Scherer, PhD, counselor, health division, Directorate for Employment, Labour,
and Social Affairs, Organisation for Economic Co-Operation and Development, France
Keynote: What We See in 2009
Victor J. Dzau, MD, chancellor for health affairs, Duke University, and president and
CEO, Duke University Health System
Dzau’s keynote address outlined the challenges and opportunities facing academic
health centers worldwide and provided new insights on organizing academic health
centers for the future. Dzau urged academic health center leaders to be “leaders of
innovation,” and “engaged with global missions,” for academic health center leaders
are the “ones who think about new paradigms.”
In a time of global economic crisis, U.S. academic health centers face challenges
from health care reform proposals, the stimulus plan (e.g., managing $10.4 billion in
new monies coming from the National Institutes of Health), congressional
investigations and interest in not-for-profit status and conflict of interest issues,
chronic underfunding of research, budget cuts, layoffs, and halted facilities
construction. The Obama Administration is proposing health reform with an
emphasis on primary care, medical homes, and financing through savings from
government entitlement programs.
Academic health centers have an opportunity to provide leadership to transform
medicine and health care reform, redefine the academic health center mission, and
help to address the fragmented health care delivery system with its misaligned
incentives, emphasis on late stage disease, and persistent health inequalities. Dzau
pointed to the new U.K. model of academic health science centers that also
highlights the mission to focus on world class research, teaching, and patient
care…and to “take new discoveries and promote their application.”
Academic health center systems should be leaders in creating integrated care
delivery, which is a seamless continuum of care from innovation to clinical delivery to
community health. Dzau showed how academic health centers can create aligned
organizations with vertical and horizontal integration for care delivery. Dzau focused
on the steps from discovery—to translation through clinical research—to translation
and adoption (in hospitals and practices)—to the final impact on populations and
global health.
The current timeline to move from innovation to care delivery is 10-25 years.
Academic health centers, including Duke University, are working to shorten that
timeline to 7-10 years through organizational changes that create an integrated
matrix of care delivery, research, and training and education. There is no single
perfect governance structure, and leadership is key to get commitment, trust,
responsibility, and accountability throughout the system.
Dzau urged that academic health centers voluntarily move from organizing as
centers to developing academic health sciences systems and then to accountable
health sciences care organizations—AHS-COs—that blend the “accountable care
organization” concept with an academic health sciences focus as the way to address
U.S. and global health needs.
The United Kingdom Establishes Academic Health Centers
Sally C. Davies, FMedSci, MD, director general of research and development, The
Department of Health, National Health Service, London
Davies focused on transformation underway in the structure and organization of the
National Health Service in the United Kingdom and the emergence of academic
health centers. Previous reorganizations had created barriers to the tripartite
mission of academic health centers: service had drifted apart from research and
education in the Thatcher years. The NHS lost a shared vision and clinical and
applied research suffered. The NHS still funds 40% of clinical posts in the UK.
Funding problems at key hospitals in England and the lack of support for research
drove the reassessment of health care institutions and the NHS and an experiment to
create an academic health center model in the UK. The advent of Lord Darsi as
health minister was the beginning of bringing the medical schools and hospitals
together. The initiative to designate academic health science centers in the U.K.
then emerged. Two models seemed to get the balance right - Hammersmith and
Cambridge - largely due to leadership and shared mission. Three years ago the NHS
created a virtual institute with competitive funding awarded based on new
shared/integrated partnerships.
It was recognized that some institutions might flourish and move at a faster pace in
terms of the integration of education, research, and service. These would be the
elite institutions in the vanguard of change. Criteria were developed for academic
health science centers along with an application process to receive such designation.
Efforts are based on clinical, educational, and research quality metrics. Leadership is
an issue. One consultant to the U.K. observed that the job of running academic
health centers is far more complicated than the leadership of most corporations.
Applicants for academic health center designation had to present a governance
model and also demonstrate financial sustainability. The U.K. has selected the first 5
institutions in the first round. Over time, the criteria for designation might change
although experts recognize that only a small number of universities have global
excellence in research. The NHS is pushing for networking to achieve comprehensive
scope. One challenge for the future is leadership, including training, for the young
clinical academics. Funding for the future in a time of economic crisis is also an
issue. It will also be interesting to see where institutions brand themselves despite
not actually getting the NHS designation.
Canadians Reassess Academic Health Centers
Glenn G. Brimacombe, president & chief executive officer, Association of Canadian
Academic Healthcare Organizations
Canada is closer to the U.K. and European system than to the U.S. in terms of its
health care system. Health care is regionalized with 40-50% of provincial revenues
dedicated to health care. Seventeen academic health centers are spread throughout
Canada. In the last 20 years, there have been 14 reviews of the health system but
not one with a particular focus on the role of the academic health center.
Last year, a new National Task Force on Securing the Future of Academic Health
Centers was established to look at the structure, alignment of missions, and how
they achieve their missions.
Universities and hospitals have separate governing structures in Canada. Currently,
80% of the nation’s research occurs at research hospitals. Translational research
also occurs within the hospitals, but it is not well funded and is a source of tension
between the universities and the hospitals.
With a government focus on funding for research as an engine for a new economy in
Canada, a lot of money is at stake for these institutions. A funder plays a key role in
defining the nature and scope of operations. However, three ministries fund the
academic health center complex and there is no mechanism for discussions across
silos. The task force has been addressing the issue and looking for new mechanisms
to increase liaison. Performance and continuous quality improvement are also top
issues for the task force.
Pioneering a New German Model: Merging Campuses and Missions
Detlev Ganten, MD, PhD, former CEO, The Charité—Universitätsmedizin Berlin
The Charité, one of Germany’s oldest and largest academic health centers, provided
a case study on the process of integration and the impact of mergers on the culture
and structure of an academic health center. Dr. Ganten reviewed the 300 year
history of the Charité, including four mergers since the fall of the Berlin Wall in 1989.
Added to traditional cultural differences between institutions, the Charité had the
added complication of having to blend socialist institutions of East Germany with the
western practices of West German institutions. These complex mergers were also
occurring concurrently with payment reform which saw a movement towards DRGs
and a significant drop in reimbursement rates.
In addition, Dr. Ganten highlighted the many issues Charité faced in its decade-long
process of integration, including:
- Aligning and restructuring portfolios of overlapping services to meet regional
health care needs; - Designating appropriate and prompt decision-making processes;
- Juggling dual funding streams—a health insurance-funded budget for patient
care and a state-funded budget for research and education—that must be
kept separate; and - Generating value through innovative clinical research and partnerships.
The Charité has had significant success bringing technologies and enterprises to the
market. From 1996 to 2006, Charité members spun off 23 startup companies, only
two of which have become insolvent and several of which are either in the pre-IPO
stages or are already publicly traded.
The German Academic Health Center Enterprise
Ralf Heyder, vice CEO, Association of German University Hospitals (VUD)
Heyder offered a broader perspective of the 34 German academic health centers
nationwide, their evolution, and the challenges currently being faced. Heyder
highlighted a significant tension in the academic health center community and a
heated debate over the future governance of academic medicine. The state-owned
medical centers of German academic health centers are predominantly separate
institutions from the university, which still has jurisdiction over the medical faculty.
The shift to the paradigm of separating education from practice also marked the
beginning of a cultural divide between the more entrepreneurial administrative
perspective of the medical centers and the democratic academic nature of the
universities. In the face of these cultural differences and a perception of university
presidents that medicine is too strong and independent; some German academic
health centers are now pursuing integration of the clinical, research, and education
missions.
Integration in and of itself will be a difficult task, but it is further complicated by
payment reform, rising costs, demographic changes in the workforce, stiff
competition for federal research dollars, and a long-neglected medical education
system in great need of reform.
Creating Academic Health Centers: The Dutch Strategy
Martin Paul, MD, PhD, vice president, Maastricht University Medical Center, and
dean, faculty of health, Medicine and Life Sciences, The Netherlands
Maastricht provided a case study in cooperation between academic health centers as
well as across borders. The location of Maastricht University Medical Center—a bit
removed from most of the population of The Netherlands but much closer to
population centers and academic health centers in Belgium and Germany—has led to
strategic alliances across borders. There are only eight university medical centers
(UMCs) in the Netherlands, which is one of the most densely populated nations in
Europe in which patient care, research and education are all under central
government control.
The eight UMCs are centrally-organized in the Netherlands Federation of University
Medical Centers (NFU). The NFU allows all of the UMCs in the country to follow a
joint strategy in research, education and patient care. An example of the fruits of
this collaborative strategy is the pearl-string initiative—a cooperative project
involving all eight UMCs with joint national funding—which establishes a national
biobanking infrastructure gathering genetic and clinical data as well as tissue
samples. Eight large cohort studies using the biobanked data have been initiated to
examine chronic disease in the country.
Hospital Reform in France: Understanding Change
Jean-François Rey, MD, président, U.MES.PE, Confédération des Syndicats Médicaux
Français
Dr. Rey outlined the current French health care system and the reforms that have
recently been implemented in the country. In France, all citizens are covered with
basic insurance and have direct access to general practitioners as well as specialists.
However, basic fees are reimbursed at the same level whether they are delivered in
a public hospital or in a private setting. All medical care, both public and private, is
now managed on a regional level by 22 regional health authorities. Dr. Rey noted
that the defeat of the most recent reforms resulted from opposition from nearly all
the health professionals groups, and the perceived weakness of both the Minister of
Health and cabinet minister.
The John P. McGovern Award Lecture: A Dialogue on the U.S. Healthcare
Agenda
David Cutler, PhD, the Otto Eskstein professor of applied economics, Harvard
University
Cutler discussed the current U.S. healthcare agenda and noted the three principal
challenges of health system reform:
- How to expand coverage when upfront costs are significant and recovered
costs are diffuse and longer-term; - How to make the system work better by increasing value rather than simply
containing costs; and - How to improve community-based prevention efforts.
Cutler urged attendees to embrace his assertion that academic health centers are
the key to a more efficient health care system in at least three areas. He argued
that:
- The nation needs to get serious about prevention as an essential component
of health system reform; and - Academic health centers, as “de facto public health departments,” are the
only institutions with the resources and expertise to lead the effort.
Cutler asserted the health system needs much better, and much more integrated,
access to information than we have now and suggested that academic health centers
are ideally situated to drive widespread adoption of interoperable community health
IT systems. He insisted that the nation needs better payment systems and
suggested that academic health centers have an essential role in piloting better
payment systems that reward performance.
Forces of Change in the Regulatory World
Christine K. Cassel, MD, MACP president and CEO, American Board of Internal;
Deborah Nasdem, Joint Commission International
Dr. Cassel noted that the U.S. model of board certification is attracting increased
attention from other countries, including China, Singapore, and European and Gulf
states, which have traditionally relied on alternative mechanisms for regulating
physicians. Board certification typically involves two components: initial certification,
which a physician earns upon satisfactory completion of a residency programs, and
maintenance of certification, which follows periodic, comprehensive assessment of a
physician’s knowledge, skills, and practice-based learning and improvement. Multiple
studies have shown that this process of board certification is correlated with better
health outcomes across a wide range of scenarios.
Dr. Cassel highlighted the efforts of the American Board of Internal Medicine and
other certifying boards to leverage certification to drive change in the health care
system. She noted that maintenance of certification activities can be tied to payer
initiatives to help align market, regulatory, and professional efforts to produce better
health outcomes.
Ms. Nasdem shared the perspective of Joint Commission International (JCI), an
international accrediting body that also works to build international consensus
around appropriate standards of care. Although JCI faced initial challenges in
bringing transparency and accreditation to health care organizations in different
parts of the world, it has been able to develop landmark standards for medical
records, infection control, fire safety, and advance directives. JCI has also developed
an array of staff management and clinical standards, all of which are compiled in one
standards manual, now in its third edition.
Ms. Nasdem noted that that the United States’ failure to adopt ICD-10 remains a
major obstacle to developing performance measures. She also commented on the
need to respond to the growing trends of medical tourism, increased mobility, and
cross-border telemedicine by developing standards that are knowable and available
to the public if not strictly uniform across different regions.
President’s Address
Steven A. Wartman, MD, PhD, MACP, president and CEO, the Association of
Academic Health Centers
Dr. Wartman addressed the global economic crisis arguing that the current situation
requires that academic health center leaders move forward on a collective and
collaborative international basis to improve the infrastructure for health and
education and also close the divide between science, practice, and the health of our
diverse populations through:
- Leadership;
- Regulatory improvement; and
- The healthcare workforce.
Dr. Wartman pointed out that “AAHC International™ can help ensure that academic
health centers have a voice in international matters affecting health, research, and
the economy, and, in so doing, help foster the concept of an international academic
health center community driven by the ideal of improving the public good.”
Dr. Wartman concluded the key to the success of AAHC International™ is the
development of an open, collaborative framework, and proposed the establishment
of an “Infrastructure Workgroup” to develop a roadmap for successful academic
health center development that not only serves the needs of institutions…[but also]
serves the needs of nations.” He noted that the goal is not just to survive, but to
bring real value toward the improvement of global health and well-being.
Health Reform Versus Global Agendas
Robert Kocher, MD, special assistant to the President for healthcare policy, National
Economic Council
Kocher discussed the NEC’s role in the Obama Administration’s health reform efforts
and how the reform debate is expected to unfold. Citing the belief that the cost of
inaction is greater than action, he reiterated the Administration’s intention to move
forward on major initiatives relating to employment, health, education and energy.
Kocher expressed confidence that health reform will be enacted this year, with
highest priority placed on addressing cost concerns, because slowing the rate of
growth in health care costs is a prerequisite to affordable expansion of coverage and
access.
Kocher indicated the Administration’s goal is not a perfect health reform plan, but a
sensible plan that can be refined over time, expressing some concern about the risk
of weighing down reform by trying to address too many issues in the first iteration.
He insisted the academic health centers’ role in the overall system is highly valued,
but that some rationalizing of that role may be necessary, for example, with respect
to payment for services where there is no strong academic interest (e.g., low acuity
routine procedures). He also suggested that health reform was likely to see a
rationalizing and reallocation of residency slots because the current allocation has
been frozen in place while the health system continued to change and the continued
use of immigration policy to fill less attractive slots is unsustainable.
Emerging Markets Perspective on Academic Health Centers
Tilman Ehrbeck, PhD, partner, McKinsey & Company, India
Dr. Ehrbeck’s presentation focused on the opportunities for AHCs seeking
partnerships in Asian markets. He noted three broad categories of potential AHC
interest in Asian markets:
- Medical Education—AHCs can help to accelerate the training of national
workforces, while at the same time accessing a foreign talent pool to help
offset shortages in the U.S. - Medical Research—By building partnerships for research, AHCs can
conduct affordable clinical trials with relatively less expensive local staff and
patients and gain access to large populations and DNA pools. - Healthcare Provision—AHCs can export best practices in clinical care as
well as organization and management. Foreign partnerships also provide an
opportunity to advance promising medical technologies and identify complex
cases for medical travel to the U.S.
Asia should be considered in a differentiated way that takes account of individual
countries’ relative economic status and relative medical sophistication, according to
Ehrbeck. For example:
- Bangladesh and Indonesia have low economic status and low medical
sophistication. - India and China have low economic status but relatively high medical
sophistication. - Singapore and Korea have both high economic status and high medical
sophistication.
Relatively advanced foreign markets offer the potential for partnerships involving
high-end medical education programs, advanced research, and joint development of
knowledge and technology. Less advanced foreign markets offer an opportunity to
build on comparative advantages. Potential partnerships in these markets include
exchange programs for doctors, large-volume and low-cost clinical research trials,
and co-branded specialty programs. Dr. Ehrbeck noted that there have so far been
no successful partnership between AHCs and less economically advanced Asian
countries.
Three key factors for successful partnerships:
- Stress-test the viability of partnership/venture, including an assessment of
local market conditions; - Ensure upfront alignment between partners by outlining respective
contributions and metrics of success; and - Pick the right partner, one with the ability to get things done domestically
while abiding by relevant international regulations.
Understanding Health System Management
Lois Margaret Nora, MD, JD, president and dean, school of medicine, Northeastern
Ohio Universities Colleges of Medicine and Pharmacy (NEOUCOM)
NEOUCOM is a small, community-based, academic health center, which nevertheless
has a complex organization and governance structure, and offered many
comparisons to academic health centers in developing areas.
NEOUCOM comprises 15 teaching and affiliated hospitals, two Boards of Health, and
four university partners. All four of the university partners are public and must
compete with one another for resources. In recent years, Dr. Nora has been
refocusing the institution on its core missions of education, research, and clinical
care, including a research visioning process that led to a doubling of NIH funding.
Under Nora, a school of pharmacy was established. She also spearheaded an effort
to transform the medical curriculum to focus on interdisciplinary education. Politics
are also at issue and NEOUCOM is working towards obtaining a legislative mandate
to include Cleveland in its service area.
Among the lessons learned from the NEOUCOM transformation are:
- Understand and give clarity to the mission;
- Remember the institution works for the patients and the community;
- Don’t waste a crisis, which often provides opportunity to facilitate change;
- Ensure processes focus on relationships and communication;
- Understand the importance of culture in the governance structure; and
- Don’t underestimate leadership and personal courage.
The Global Workforce: The Forgotten Agenda?
Peter Scherer, PhD, counselor, health division, Directorate for Employment, Labour,
and Social Affairs, Organisation for Economic Co-Operation and Development, France
Scherer offered insights on health workforce trends in OECD member countries. He
observed that education and training policies have resulted in slowing physician
workforce growth in almost every OECD country, with the slowdown in France
especially severe; a similar pattern is also occurring in other health professions, such
as nurses. As a result, there has been a growing reliance throughout OECD
countries on foreign-trained doctors to meet training shortfalls. Most OECD
countries, like the U.S., are primarily importers, but a few OECD countries (e.g.,
Ireland, New Zealand, and to a lesser extent Great Britain) are both high importers
and high exporters. Many smaller OECD countries import from other OECD
countries, but the U.S., U.K. and France import mostly from outside the OECD
countries.
Scherer indicated that the pattern in medicine is similar to patterns across all highly
skilled technical professions. It is less a function of relative earnings potential at
home compared to abroad than the ability of the training country to afford to pay
salaries that are high relative to GDP resources: many net exporting countries can't
afford to pay their physicians to stay even at salaries far below the standard in
developed nations.