30th Bethesda Conference


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30th Bethesda Conference

  1. 1. Journal of the American College of Cardiology Vol. 33, No. 5, 1999 © 1999 by the American College of Cardiology ISSN 0735-1097/99/$20.00 Published by Elsevier Science Inc. PII S0735-1097/(99)00045-5 30th Bethesda Conference The Future of Academic Cardiology (1998) October 26 –27, 1998
  2. 2. Journal of the American College of Cardiology Vol. 33, No. 5, 1999 © 1999 by the American College of Cardiology ISSN 0735-1097/99/$20.00 Published by Elsevier Science Inc. PII S0735-1097(99)00045-5 BETHESDA CONFERENCE REPORT 30th Bethesda Conference: The Future of Academic Cardiology* Kenneth Lee Baughman, MD, FACC, Conference Co-Chair Michael H. Crawford, MD, FACC, Conference Co-Chair This Conference, sponsored by the American College of Cardiology, was held at Heart House, Bethesda, Maryland, October 26 –27, 1998. Participants JOSEPH S. ALPERT, MD, FACC JAY N. COHN, MD, FACC PATRICE DESVIGNE-NICKENS, MD Robert S. and Irene P. Flinn Professor of Cardiovascular Division Program Director, Heart Research Program Medicine University of Minnesota Medical School National Institutes of Health Head, Department of Medicine Box 508 –UMHC National Heart, Lung, and Blood Institute University of Arizona Health Sciences Center 420 Delaware St., SE Division of Heart and Vascular Diseases 1501 N. Campbell Avenue Minneapolis, Minnesota 55455 6701 Rockledge Dr., Suite 9158 Tucson, Arizona 85724-5035 Bethesda, Maryland 20894 C. RICHARD CONTI, MD, MACC NHLBI Representative Palm Beach Eminent Scholar, Cardiology KENNETH LEE BAUGHMAN, MD, FACC Professor of Medicine, Chief of Cardiology The Johns Hopkins University School of University of Florida College of Medicine Medicine P.O. Box 100277 BARBARA J. DREW, RN, PHD, FANN 600 North Wolfe Street 1600 Archer Road, M436 Associate Professor & Vice Chair, Department Blalock 536 Gainesville, Florida 32610-0277 of Physiological Nursing Baltimore, Maryland 21287 School of Nursing, N611Y Conference Co-Chair MICHAEL H. CRAWFORD, MD, FACC University of California, San Francisco Robert S. Flinn Professor and Chief of 521 Parnassus Ave. Cardiology San Francisco, California 94143-0610 GEORGE A. BELLER, MD, FACC University of New Mexico Health Sciences Chief, Cardiovascular Division Center Vice Chairman, Department of Medicine University Hospital ACC-5 University of Virginia Health Sciences Center 2211 Lomas Blvd. NE KENNETH A. ELLENBOGEN, MD, FACC Box 158 Albuquerque, New Mexico 87131 Director, Clinical Electrophysiology & Pacing Charlottesville, Virginia 22908 Conference Co-Chair Medical College of Virginia P.O. Box 980053 LARRY S. DEAN, MD, FACC Richmond, Virginia 23298-0053 JEFFREY S. BORER, MD, FACC Professor of Medicine Chief, Division of Cardiovascular 373 BDB, UAB Station Pathophysiology Birmingham, Alabama 35294 New York Weill Cornell Center of NY AVERY K. ELLIS, MD, PHD, FACC Presbyterian Hospital LINDA L. DEMER, MD, PHD, FACC Chief, Medical Service Weill Medical College of Cornell University Chief, Division of Cardiology Buffalo VA Medical Center (111) 525 East 68th Street Associate Professor of Medicine and Physiology 3495 Bailey Avenue New York, New York 10021 UCLA School of Medicine Buffalo, New York 14215 Room 47-123CHS, Division of Cardiology Box 951679 W. H. CAULFIELD, JR., MD, FACC Los Angeles, California 90095-1679 Executive Director ARTHUR M. FELDMAN, MD, PHD, FACC The Permanente Medical Group, Inc. HENRY DEMOTS, MD, FACC Harry S. Tack Professor & Chief 1950 Franklin Street Medical Director, University Medical Group Division of Cardiology Oakland, California Oregon Health Sciences University 200 Lothrop Street The Permanente Medical Group, Inc. 3181 SW Sam Jackson Park Road S572 Scaife Hall Representative Portland, Oregon 97201 Pittsburgh, Pennsylvania 15213 *The recommendations set forth in this report are those of the Conference participants and do not necessarily reflect the official position of the American College of Cardiology. Reprint requests and correspondence: American College of Cardiology, 9111 Old Georgetown Road, Bethesda, Maryland 20814. Attention: Educational Services Department (800-253-4636 ext. 694).
  3. 3. JACC Vol. 33, No. 5, 1999 Baughman and Crawford 1093 April 1999:1091–135 30th Bethesda Conference Participants MARC D. FELDMAN, MD, FACC REBECCA T. KIRKLAND, MD, MPH JOSEPH V. MESSER, MD, FACC Associate Professor of Medicine Professor of Pediatrics Professor of Medicine Associate Director, Cardiac Catheterization Lab Associate Dean for Curriculum Rush Medical College Director, Interventional Research Baylor College of Medicine Senior Attending Physician University of Texas Health Sciences Center of One Baylor Plaza Associates in Cardiology, Ltd. San Antonio Houston, Texas 77030 1725 West Harrison St., Suite 1138 7703 Floyd Curl Drive Chicago, Illinois 60612 San Antonio, Texas 78284 DAVID W. KOLSTAD Hewlett-Packard Co. ERIC L. MICHELSON, MD, FACC ARTHUR GARSON, JR., MD, MPH, FACC Imaging Systems Division Director, Cardiovascular Therapeutic Area Sr. VP & Dean for Academic Operations 3000 Minuteman Road Astra Pharmaceuticals Baylor College of Medicine Andover, Massachusetts 01810-1099 D-3N MC 1-4460, 6621 Fannin St. Hewlett-Packard Co. Representative 725 Chesterbrook Blvd. Houston, Texas 77030 Wayne, Pennsylvania 19087 President Elect, American College of Cardiology MARVIN A. KONSTAM, MD, FACC Astra Pharmaceuticals Representative Professor of Medicine NORA F. GOLDSCHLAGER, MD, FACC Tufts University ROBERT E. MICHLER, MD, FACC Professor of Clinical Medicine, UCSF New England Medical Center Karl P. Klassen Professor of Surgery Cardiology Division 5G1 Box 108 Chief, Division of Cardiothoracic Surgery San Francisco General Hospital 750 Washington Street The Ohio State University Medical Center San Francisco, California 94110 Boston, Massachusetts 02111-1533 N825 Doan Hall 410 West 10th Avenue AUGUSTUS O. GRANT, MD, CHB, PHD, Columbus, Ohio 43210 DAVID KORN, MD, FACC FACC Director, Intensive Care Unit Associate Professor of Medicine Mt. Sinai Medical Center ALAN B. MILLER, MD, FACC Duke University Medical Center 4300 Alton Rd. Professor of Medicine Box 3504 Miami Beach, Florida 33140-2849 University of Florida Durham, North Carolina 27710 Health Science Center 655 West 8th Street DAVID C. LEACH, MD GABRIEL GREGORATOS, MD, FACC Jacksonville, Florida 32209 Executive Director Professor of Medicine Accred. Council for Graduate Medical Director, Cardiology Consultation Services LESLIE W. MILLER, MD, FACC Education University of California, San Francisco Professor of Cardiology 515 North State St., Suite 2000 400 Parnassus Ave., Box 0327 Director, Cardiovascular Division Chicago, Illinois 60610 San Francisco, California 94143 University of Minnesota ACGME Representative 420 Delaware Street S.E., Box 508 JOHN W. HIRSHFELD, JR., MD, FACC Minneapolis, Minnesota 55455 Professor of Medicine CARL V. LEIER, MD, FACC University of Pennsylvania Director, Division of Cardiology GILBERT H. MUDGE, JR, MD, FACC Cardiac Cath Lab, University of Pennsylvania Professor of Medicine Brigham and Women’s Hospital Medical Center The Ohio State University Hospitals 75 Francis Street 3400 Spruce Street 669 Means Hall Boston, Massachusetts 02115 Philadelphia, Pennsylvania 19104-4283 1654 Upham Drive Columbus, Ohio 43210 JOHN NAUGHTON, MD, FACC ABRAHAM KARKOWSKY, MD, PHD Professor Medical Team Leader ROBERT I. LEVY, MD, FACC S.U.N.Y.–Buffalo Food and Drug Administration Senior Vice President, Science and Technology School of Medicine & Biomedical Sciences Division of Cardio-Renal Drug Products, American Home Products 128 Farber Hall HFD-110 5 Giralda Farms Buffalo, New York 14214 5600 Fishers Lane Madison, New Jersey 07940 Rockville, Maryland 20857 American Home Products/Wyeth Ayerst Research JOHN J. NORCINI, PHD Food and Drug Administration Representative Representative Senior Vice President American Board of Internal Medicine RICHARD J. KATZ, MD, FACC BARTON MCCANN, MD 510 Walnut St., Suite 1700 Professor of Medicine Health Policy Alternatives, Inc. Philadelphia, Pennsylvania 19106-3699 Division Director, Cardiology 444 North Capitol St., NW American Board of Internal Medicine George Washington University Medical Center Washington, DC 20001-1512 Representative 2150 Pennsylvania Avenue, NW Health Policy Alternatives, Inc. Representative Washington, DC 20037 CATHERINE M. OTTO, MD, FACC GEORGE A. MENSAH, MD, FACP, FACC Associate Professor of Medicine SPENCER B. KING, III, MD, FACC Medical College of Georgia Director, Cardiology Fellowship Program Professor of Medicine (Cardiology) Chief of Cardiology Division of Cardiology, Box 356422 Director of Interventional Cardiology VA Medical Center University of Washington Emory University Hospital One Freedom Way 1959 NE Pacific 1364 Clifton Rd., NE, F606 Augusta, Georgia 30904-6285 Seattle, Washington 98195-6422 Atlanta, Georgia 30322 Citizens for Public Research (CPR) & Association Executive Leadership in Academic Medicine President, American College of Cardiology of Black Cardiologists Representative Program for Women Representative
  4. 4. 1094 Baughman and Crawford JACC Vol. 33, No. 5, 1999 30th Bethesda Conference Participants April 1999:1091–135 GERALD M. POHOST, MD, FACC JAMES L. RITCHIE, MD, FACC DAVID D. WATERS, MD, FRCP, FACC Director, Institute for NMR Research & Director, Division of Cardiology Division of Cardiology Development University of Washington School of Medicine Hartford Hospital University of Alabama at Birmingham 1959 NE Pacific Street 80 Seymour Street 101 Boshell Diabetes Bldg. AA510 Health Science Building Hartford, Connecticut 06102-5037 1808 Seventh Avenue South Box 356422 Birmingham, Alabama 35294-0012 Seattle, Washington 98195-6422 J. JAMES ROHACK, MD, FACC HOWARD H. WEITZ, MD, FACP, FACC RICHARD L. POPP, MD, FACC Chair, AMA Council on Medical Education Deputy Chairman, Department of Medicine Sr. Associate Dean for Academic Affairs Scott & White Health Plan Director, Division of Cardiology Dean’s Office, Room M-121 2401 South 31st Street Thomas Jefferson Medical College 300 Pasteur Drive Temple, Texas 76508 1025 Walnut Street, Suite 403 Stanford University School of Medicine American Medical Association Representative Philadelphia, Pennsylvania 19107 Stanford, California 94305-5119 American College of Physicians/American Society of SIMEON A. RUBENSTEIN, MD, FACC Internal Medicine Representative 125 16th Avenue East MARC R. PRITZKER, MD, FACC Seattle, Washington 98112 Minneapolis Cardiology Associates American Association of Health Plans 920 East Twenty-Eighth St., Suite 300 Representative Minneapolis, Minnesota 55404 ROBERTA G. WILLIAMS, MD, FACC GEORGE W. VETROVEC, MD, FACC Chairman of Pediatrics Professor of Medicine 509 Burnett Womack PHILIP R. REID, MD, FACC Chairman, Division of Cardiology University of North Carolina School of Vice President Medical College of Virginia Medicine Eli Lilly and Company 1200 E. Broad St., W6 North, Rm. 607 Chapel Hill, North Carolina 27599-7220 Lilly Research Laboratories Lilly Corporate Center Virginia Commonwealth University Indianapolis, Indiana 46285 Richmond, Virginia 23219 Eli Lilly and Company Representative President, Association of Professors of Cardiology DOUGLAS P. ZIPES, MD, FACC ROBERT A. VOGEL, MD, FACC Distinguished Professor of Medicine DALE G. RENLUND, MD, FACC Herbert Berger Professor of Medicine Pharmacology & Toxicology Professor of Internal Medicine Head, Division of Cardiology Director, Krannert Institute of Cardiology & Division of Cardiology University of Maryland Hospital Division of Cardiology University of Utah Health Sciences Center 22 South Greene Street Indiana University School of Medicine 50 North Medical Drive Room S3B06 1111 W. 10th St. Salt Lake City, Utah 84132 Baltimore, Maryland 21201 Indianapolis, Indiana 46202-4800
  6. 6. Journal of the American College of Cardiology Vol. 33, No. 5, 1999 © 1999 by the American College of Cardiology ISSN 0735-1097/99/$20.00 Published by Elsevier Science Inc. PII S0735-1097(99)00045-5 30TH BETHESDA CONFERENCE Introduction Kenneth Lee Baughman, MD, FACC, Conference Co-Chair, Michael H. Crawford, MD, FACC, Conference Co-Chair Academic cardiology has been largely responsible for the and integration across divisions and traditional departments. medical advances which have resulted in the dramatic The product line integration would include all three mis- decline in death rates from cardiovascular disease over the sions of academic cardiology including patient care, research last 30 years in the United States. Changes in the health and teaching. The product line concept would allow a care environment including managed care, decreased phy- seamless transition of patients through the health care sician payment for patient care activities, diminished indus- system with an integrated approach eliminating duplication try support and a stringent regulatory environment have had of effort and allowing cost savings. Not only patient care a profound effect on the academic medical center. These resources, but also those used for teaching, research and changes have reduced funding for medical research and the administration would be consolidated. Traditional relation- training of physicians and have pitted the academic medical ships would exist between product line divisions and their centers against the private sector in competition for patients academic departments for promotion, teaching and taxa- and scarce health care resources. Most academic centers tion. However, some expenses previously supported by were ill equipped to deal effectively with these changes. departments would be assumed by the product line entity Consequently some have declared bankruptcy, and many are and taxation reduced appropriately. Product line develop- in financial crisis. The American College of Cardiology has ment could expand to other entities within the academic grown increasingly concerned about the effect of the current medical center such as gastroenterologic services and thor- environment on the nation’s academic cardiology programs. acic care. The 30th Bethesda Conference “The Future of Academic The conference participants strongly believed that the Cardiology” was convened to address these concerns. The traditional medical school expectations that faculty excel in conference organizers assembled cardiologists from aca- all three academic missions are no longer relevant in the demic medical centers and the private sector as well as current academic milieu. The expansion of the knowledge experts from organized medicine, industry, government and base in all three areas, the dedication necessary to make each payers. The purpose of the Bethesda Conference was not area financially self-sustaining and the effort required to stay only to define market force corrections necessary for the at the cutting edge of each of these endeavors make the survival of academic cardiology, but also to formulate a individual capable of succeeding in all three an anachronism. paradigm that would sustain academic medical centers into Likewise, the conference participants believed that the the next millennium. model which demands research faculty members make brief The tripartite mission of academic cardiology is to train appearances on the wards or in the clinic a few times a year adult and pediatric cardiologists, to conduct research in is not an adequate model for the training and patient care cardiovascular diseases and to provide secondary and tertiary missions of the institution. Nor is the clinician who per- patient care. Although all academic programs share these forms a few experiments funded by clinical earnings a useful missions, medical centers differ in their ability to support all model for advancing the science of cardiovascular disease. of the missions well. In addition, some are state supported, Specialization in one or two of the missions is required, and others are private institutions, and others are hospital-based consequently most medical schools have developed faculty training programs not associated with a university medical tracks such as the clinician– educator, the clinician–scholar center. Thus, not all of the recommendations put forth in or the research scientist. this document will be applicable to each academic cardiol- The conference participants believed that each of these ogy program. However, the conference did attempt to academic tracks should have its own criteria for evaluating provide basic principles that should guide the future devel- faculty performance, its own criteria for promotion and its opment of academic cardiology. Although the document is own concept of tenure or job security. The classic tenure primarily directed toward the future of academic cardiology, track also is anachronistic. Although the conference be- there may be aspects that would be of value to other lieved that some element of job security was important, the specialties and the academic enterprise. traditional tenure system should be reevaluated. A review To sustain academic cardiology in the future, a new policy to make sure that the faculty member is still perform- paradigm must be developed within the academic medical ing at the level that originally granted them tenure and center. This paradigm encourages product line development adjustment in salary or position retention based on this
  7. 7. JACC Vol. 33, No. 5, 1999 Baughman and Crawford 1097 April 1999:1091–135 Introduction review should be initiated. Also, faculty must be trained to volume of patients at the academic center to sustain its function as part of a team with other health care profes- missions by helping to support clinical activities in collab- sionals and workers. All on the team should be respected for oration with the academic center. An example of such an their unique contribution to the enterprise and a spirit of activity may be cardiac transplantation or a highly special- collegiality developed. Finally, those who attended the ized and investigational technique such as transmyocardial conference were very concerned that academic cardiology is revascularization. This collaboration should be accom- not attracting large numbers of women and minorities and plished in a fashion that allows all involved to benefit from believed that increased sensitivity to the special needs of the interaction, including the practitioner and his or her these groups needs to be taken into consideration in the patient. Some academic medical centers have developed future academic cardiology model. strong collaborative relationships with practitioners, includ- The survival of academic cardiology is dependent on the ing shared resource and clinical care business opportunities. operation of the entity as a business. Patient care revenues Although the conference participants realized that this which previously were used to support the teaching and collaboration with the private sector will be a challenge in research mission are no longer available. Specifically, bud- today’s highly competitive markets, they believed that this is gets must be developed to support teaching, research, the only system that would insure the sustained success of patient care and administration. Those components of the academic cardiology. mission most in jeopardy are teaching and the support of The academic medical center should be preserved by the young investigators. The teaching performed by the cardio- health care system and supported by academic cardiology. vascular faculty must be quantitated and segregated into that Although some of the research and teaching missions and which is integrated into, and that which is separate and much of the patient care can be accomplished in peripheral distinct from, patient care activities. The proportion of institutions, the academic medical center embodies certain Medicare Part A funds intended for faculty supervision of features that warrant its continuation and support. The patient care and teaching should be directed toward those academic medical center’s primary role is the maintenance performing these activities. Endowment funds should be of a milieu of research investigation, innovation and teach- raised specifically to fund young investigators and to pro- ing throughout all of its activities. This milieu and colla- mote dedicated teaching activities. There must be an align- boration has spawned many of the discoveries that have ment of the incentives between the cardiology sections, the dramatically influenced science and ultimately, patients. health care system and the academic hospitals. This align- This milieu cannot be maintained in a dispersed system that ment may allow resources to be allocated to cardiology does not support all three primary missions as core objec- sections to support appropriate activities which directly and tives. indirectly benefit the health care system. Finally, it is The American public, and many involved in health care important that the leaders of future academic cardiology finance, are unaware of the true cost of research and sections or cardiovascular institutes be trained as business education. It is important that the true educational cost persons capable of understanding the intricacies of health associated with the production of a cardiologist be accu- care finance. rately determined. The value of these trained cardiologists, A collaborative arrangement with physicians in the pri- most of whom will ultimately practice in the community, vate sector is important for all three missions of academic must be defined. The importance of the allocation of the cardiology. The academic cardiology section needs help cost of training to the public and payers must be justified by with teaching, especially that performed by accomplished the value to the community. Similarly, the rigorous nature clinicians in outpatient venues. Practitioners can help with of basic investigation and clinical research needs to be the recruitment of patients for clinical trials and other transmitted to the American people, who ultimately support clinical research activities that will not only increase the and benefit from research investigation. Only through such number of patients in the trials, but will bring new treat- educational efforts can the support that academic cardiology ments and procedures to a broader spectrum of subjects. sections have received in the past be preserved or enhanced Finally, private physicians can help maintain an adequate in the future.
  8. 8. Journal of the American College of Cardiology Vol. 33, No. 5, 1999 © 1999 by the American College of Cardiology ISSN 0735-1097/99/$20.00 Published by Elsevier Science Inc. PII S0735-1097(99)00045-5 TASK FORCES Task Force 1: Clinical Care Henry DeMots, MD, FACC, Co-Chair, Gilbert H. Mudge, Jr., MD, FACC, Co-Chair PURPOSE OF CLINICAL CARE IN have not been made, further confusing mission and long- THE ACADEMIC MEDICAL CENTER term goals. In the earlier era of fee-for-service reimbursements, Academic cardiovascular programs are currently defined as cardiovascular divisions provided substantial revenues for subspecialty programs committed to advancing clinical care, both the academic medical center as well as for non– promoting innovative basic and clinical research and foster- revenue-generating divisions within the departments of ing comprehensive teaching of all health care professionals medicine or pediatrics. Furthermore, many academic cen- in cardiovascular diseases. The unique integration of these ters had a virtual monopoly on high technology services commitments distinguishes an academic medical center including interventional coronary procedures and high risk from community hospitals, research foundations and phar- coronary revascularization. Professional revenues as well as maceutical companies and enhances the opportunities to public resources were readily available to support dedicated improve overall medical care. Academic cardiovascular pro- faculty, and to provide high quality teaching and outstand- grams provide optimal patient care by applying state-of-the- ing clinical care. But revolutionary changes in the organi- art technology, the most recent advances in medical science zation and delivery of medical care in this country threaten and the medical expertise of acknowledged opinion leaders the integrity of the academic medical center, necessitating and experienced clinicians. Such programs may or may not recent restructuring of purpose and redefinition of mission be associated with a university or a single teaching hospital, to be a more integral component of health care delivery may vary in relationships to community health care provid- systems (1– 4). Recent catastrophic failures have resulted ers and may or may not have single leadership, but all from academic medical centers failing to establish links, remain committed as their primary purpose to all three isolating themselves in an adversarial managed care envi- missions. A critical mass of both expertise and clinical ronment (5) and being too late in recognizing the strength challenges in an environment of questioning is central to its of partnering with community providers. success. Current organizational structures of academic medical Indeed, academic cardiovascular programs have been centers compound the dilemmas of the current cardiovas- highly successful in achieving the goals of each of these cular academic division (6). Diminished third party reim- three missions. Over the past several decades, academic bursements, decreased public funding for training and cardiovascular programs have trained large numbers of smaller profit margins on high technology procedures have excellent clinicians who have taken their expertise into the resulted in substantial decreases in cardiology-based reve- community, effected major changes in the care of patients nues. Without an accompanying decrease in cost shifting with cardiovascular disease through innovative translational within the academic department of medicine/pediatrics, research and developed high technology approaches to the divisions of cardiology are still held responsible for subsi- care of patients with cardiovascular disease, resulting in dizing non–revenue-generating divisions within the depart- improved outcomes with lower mortality and morbidity and ments and are held accountable to a different economic at decreased costs. Paradoxically, it is these successes that in standard, making it impossible for academic cardiology many ways have led to the conundrum now facing the divisions to be competitive with community specialists on academic cardiovascular program. Their success in training an equitable footing. cardiovascular specialists and appropriately exporting exper- Academic cardiovascular divisions have also traditionally tise and technology to the community now makes it had a monopoly on investigational drugs, biologics and increasingly difficult for academic cardiovascular divisions to devices. They used superspecialized physicians possessing a be differentiated from other providers on the basis of quality unique knowledge base compared with the community, but of care and to compete on an economic basis without this expertise has become more readily available. Investiga- differentiation despite the costs of education and an increas- tional device, drug and biologic sponsors have found enroll- ing number of indigent patients. To confront these assorted ment of patients at times easier in the community hospital pressures, some academic cardiovascular divisions have at- with lower overhead, fewer bureaucratic impediments and tempted to increase clinical volume, which has stressed more ready access to patients and have moved their studies traditional missions of teaching and research. The necessary to these new partners who have physicians of comparable changes in staff requirements or in academic expectations expertise.
  9. 9. JACC Vol. 33, No. 5, 1999 DeMots and Mudge 1099 April 1999:1091–135 Task Force 1: Clinical Care In the next decade, academic cardiovascular programs education to academic medical centers, yet all payers must pursue business-like practices and compete aggres- benefit from the products of this education process. sively within the market if the traditional mission is to be 2. The current decision-making process in academic or- sustained. Such competition should be in partnership with ganizations is often bureaucratic, cumbersome and too other colleagues within the academic medical center or in slow for rapid response to changes in the marketplace. community hospitals. They must restructure relationships 3. Multiple agendas within an academic medical center within and outside the academic medical center to meet and the multiplicity of priorities and commitments these challenges. This will require modification in external often make response to market forces slow and tedious. relationships as well as internal organization summarized as 4. The ability of each academic department within an follows: academic medical center to delay or stall critical deci- sions burdens the deliberations. External relationships. 5. Due to more limited and focused agendas, for-profit ● Multidisciplinary integration of programs and personnel institutions and other health care systems without the that may not always be in the division of cardiology or academic medical center overhead and mission have departments of medicine/pediatrics aligned with product more effectively invested resources in competitive strat- line services. egies for clinical care. ● Effective integration/coordination with nonacademic col- 6. Academic medical centers have traditionally relied on leagues to accomplish teaching, research and patient care, quality of care as a differentiating factor, but such redrawing the boundaries of academic cardiovascular pro- quality is often difficult to measure and exists in the grams. community. ● Effective relationships fostered by mutual respect of 7. The multiple agendas and missions within an academic individual contributions to a joint purpose, where finan- medical center dilute the focus on clinical care. In many cial relationships may be but one component of this departments of medicine/pediatrics, for example, em- relationship. phasis has been restricted to research productivity at the ● Reconnect with primary patient populations through expense of developing appropriate clinical and teaching excellence of clinical products and fiscally sound relation- programs. ships. 8. Rigid stratification of teaching techniques/paradigms also limits any advantage of an academic medical center. Internal restructuring. 9. The additional cost of training house staff and students ● Development of cardiovascular units to include personnel is above and beyond the costs of medical care without a and programs separate from the departments of medicine/ structure to finance this commitment. pediatrics whose fiscal and governing structure optimizes 10. Relationships between academic medical centers and the likelihood of success. community providers have often been strained and ● Leveraging intellectual capital by developing new or more ineffective. effective business products (e.g., disease management, 11. Academic medical centers strive to develop a profile of faculty-owned companies or an expanded model of clin- tertiary and quaternary care which inherently provides ical research). them with adverse selection, and high acuity of illness. ● Active support for development of clinical performance In an environment of capitation and prospective pay- measures and outcomes that result in benchmarks. ments, such adverse selection may be detrimental to the survival of the academic medical center. This report will assess these opportunities, recognizing 12. Academic medical centers have often focused on care of the variation in needs from community to community. Such the underinsured and fragile population, constituents of long-term restructuring of academic cardiovascular pro- our society who are by and large ignored by the current grams will be central to the success of all cardiovascular forces of managed care and other payers. Research specialists and will improve the access of all patients to the performed by the Association of American Medical best cardiovascular care. Colleges suggests that the burden of this care in academic medical centers is increasing and may be of CURRENT CHALLENGES major consequence for the future of the academic General Considerations program. 13. Current and proposed payment policies of the Health Although community providers are under the same ultimate Care Financing Administration fail to recognize the financial constraints, the academic cardiovascular program unique role of academic medical centers in the delivery has unique challenges that must be addressed. These include of health care services to Medicare beneficiaries and the following: threaten the financial viability of institutions and pro- 1. The funding mechanisms for medical education are grams that serve a critical public good. unclear and differentially burden the cost of medical 14. Each academic cardiovascular program has a critical
  10. 10. 1100 DeMots and Mudge JACC Vol. 33, No. 5, 1999 Task Force 1: Clinical Care April 1999:1091–135 and minimal patient volume that is central to its problem has become a major issue in most departments of missions, but cannot resort to historical strategies to medicine. maintain patient referrals fundamental to its teaching Cardiology divisions at risk. With the development of and research missions. high cost procedures such as interventional cardiology, large 15. Traditional organizational schemes of academic depart- clinical revenues were available to support cardiology divi- ments have placed cardiovascular programs with less sions and departments of medicine. With the expansion of related specialties, rather than with specialties such as interventional and bypass programs to community-based cardiovascular surgery, interventional radiology, cardio- hospitals, academic cardiology divisions have been placed at vascular anesthesia and pediatric cardiology. risk. This has been further influenced by these community Challenges to the Academic Cardiovascular Program hospitals having cardiology and interventional training pro- grams, which increases the competition from the commu- Academic medical centers have had increasing difficulty nity with additional available practitioners. Furthermore, attracting sufficient patients, particularly in areas of the with falling reimbursements and increasing costs of these country in which managed care has achieved market dom- technical innovations, it may be more cost-effective to shift inance (7). Several factors render traditionally structured less complex procedures to the community, further reducing academic centers ineffective in the marketplace. revenue to the cardiology division, departments of medi- Shifting resources. The business of academic cardiovascu- cine/pediatrics and ultimately the academic medical center. lar programs has historically relied on delivering high Changing environment. The forgiving environment of quality services and a monopoly in tertiary care of complex state support and fee for service medicine has been replaced patients. However, they have succeeded in training out- by declining revenues, the uncertain future of managed care standing physicians who have moved into the community. and the progressive loss of government support. This As high quality cardiovascular resources have proliferated in threatens not only the health but, in some cases, the survival the community, academic cardiovascular programs have lost of academic medical centers. much of this traditional advantage to the community provider. Primary care emphasis. Current economic forces tend to organize delivery of health care around primary care physi- Separation from the community. Traditional academic cians. Academic medical centers have traditionally focused cardiovascular programs have segregated themselves from on specialty care. Patients are often channeled away from their primary care feeder stream to pursue their tertiary and academic medical centers in newly integrated health care quaternary care goals and have had difficulty constructing delivery systems. Building new relationships with the phy- the provider networks that are necessary to contract under sicians in the region when these relationships have been managed care. Attempts by some academic programs to strained in the past is difficult and many times impossible, develop their own feeder programs have further alienated particularly in geographic areas with heavy penetration of the community. The teaching model in which attending managed care contracting. This problem may also exist physicians were on service for only a month or two per year within an academic medical center when primary care and most of the communication with referring physicians physicians provide an inadequate referral base for cardiovas- was conducted by residents often fails to establish the cular programs. necessary relationships with community physicians that they deserve. Internal structure. Many of the challenges to academic medical centers are internal, however, and must be solved by Noncompetitive structure. The structure of the academic the center. These include a faculty structure in which each medical center has failed to provide sufficient incentive in department functions with little accountability to the whole. patient care and tends to inhibit collaboration among Whereas competitors have a focus on efficient health care providers of related services outside the departments of delivery, academic medical centers try to excel simulta- medicine/pediatrics. Cardiology divisions have often been neously in research, teaching and patient care. The impact disproportionately viewed as the major revenue source for of this approach is substantial and it may not be tolerable. departments of medicine/pediatrics. The subservience of the cardiology division to the department of medicine often Performance measures. In the past, academic medical creates disincentives against profitable initiatives and may centers have considered effective management of difficult stymie appropriate collaboration with the hospital, with the cases as a quality indicator, whereas the managed care cardiothoracic surgery division and with community-based industry and government define quality as adherence to physicians. There is often a lack of alignment between Health Plan Data and Information Set indicators. Thus, departments of medicine/pediatrics and divisions of cardi- statistical comparisons do not accurately reflect quality when ology, and economic structures may neither support aca- applied to tertiary and quaternary patients in academic demic cardiology nor foster profitability within divisions of medical centers. This is best reflected in the number of cardiology. Because procedural revenue has decreased, this patients who are transferred from community hospitals and
  11. 11. JACC Vol. 33, No. 5, 1999 DeMots and Mudge 1101 April 1999:1091–135 Task Force 1: Clinical Care other tertiary care centers for high risk interventions or ADVANTAGES OF ACADEMIC MEDICAL CENTERS surgery. This information is not available on current stan- Despite considerable challenges confronting academic med- dard databases and underscores the importance of the ical centers in the immediate future, such centers have development of better measures of clinical performance and unique capabilities/strategic advantages that should be used outcomes with resultant benchmark criteria. to confront the challenges. These advantages can enhance Teaching models/mission. Academic medical centers the opportunities for integration of research, teaching and have historically developed models for teaching and at- clinical care while providing incentives for potential rela- tempted to adapt them for patient care rather than the tionships with community providers. reverse. The structure of these services follow guidelines Expertise. Academic medical centers are capable of pro- imposed by residency review committees and often are ill viding a broad spectrum of expertise that should provide for suited for clinical care. Placing specialty patients on general unique capabilities in innovation of clinical care. Some teaching services requires an attending physician who may subspecialists may be used in the evolution of critical not be suited to provide specialist care. The quality of pathways, product line development and restructuring of patient care can be supported by liberal use of consultants, clinical care models (8). Moreover, the depth of expertise but precious hours and dollars are lost in the process. may make reorganization across product lines more feasible Trainees in the outpatient clinic can also produce ineffi- in an academic medical center than in the traditional ciency and patient dissatisfaction if the teaching model is context of specialty health care providers. In many locales, not well constructed. In addition, variation in practice academic programs offer unique expertise in high risk patterns from one physician to another is as prevalent in angioplasty, congestive heart failure/transplantation, elec- academic medical centers as in community counterparts. trophysiology, adults with congenital heart disease and Following a single care path with a new contingent of cardiac genetics. residents each month is challenging. Furthermore, aca- demic cardiologists are sometimes removed from more Application of basic research to clinical practice. The highly remunerative activities on the cardiology services opportunities for translational research from basic science to the bedside represent enormous growth opportunities for to treat noncardiac patients on the general internal academic medical centers. Indeed it is the opportunity to medicine service. link sophisticated investigator-initiated biological research Faculty expectations. Faculty members who chose aca- with clinical expertise that most strongly differentiates the demic careers in another era are often disgruntled because academic medical center from community providers and the expectations have changed and their ability to meet their industry. Recent basic research discoveries have led to novel career goals is threatened. Meeting the goals of the institu- therapies that include, but are not limited to, brachytherapy tion with people who are dissatisfied, and who often have for restenosis, percutaneous transmyocardial laser revascu- tenure, is a major challenge to the medical school and larization to stimulate angiogenesis and vascular endothelial therefore the academic medical center. In cardiology, tal- growth factor (VEGF) for peripheral vascular disease, and ented clinicians and proceduralists are often underappreci- the promise of gene transfer technology presents unique ated during promotional reviews and are instead attracted to opportunities for academic medical centers to expand their community-based opportunities. Clinical contributions are clinical responsibilities. Alignment between industry and not measurable by classic academic scales and are not as academic medical centers in translational research provides central to promotion as education and research contribu- enhanced opportunities for academic medical centers to tions. Furthermore, cardiologists are often held to a pro- market themselves as the providers of true quaternary care to ductivity standard that is different than that of other a knowledgeable and discerning patient population. More- department of medicine members. In addition, for those in over, the American patient population continues to demand the clinical arena, tenure consideration during promotion is access to specialists who are capable of the most sophisti- often of lesser value. cated medical care. The alignment of the academic medical center to industry represents an important strategic advan- Reimbursement/documentation. The future holds more tage in this regard. challenges. New documentation requirements of the activity The academic medical center needs to be more aggressive of the faculty imposed by the Health Care Financing at protecting and developing the intellectual property of its Administration are costly to implement. In addition, faculty. This will clearly be a source of future revenue during changes in the Practice Expense component of the this time of rapid growth in biomedical and genetic engi- Medicare fee schedule will disproportionately affect neering. If patents can be licensed to companies in the same specialty-laden faculties and especially cardiology divi- geographic region as the academic medical center, that can sions. Continued pressure on reimbursement is likely, be of benefit to the local community. If faculty are encour- and the appetite for cost containment of the nation has aged to develop companies so that patents they develop can not yet been sated. be licensed back to faculty companies, additional methods
  12. 12. 1102 DeMots and Mudge JACC Vol. 33, No. 5, 1999 Task Force 1: Clinical Care April 1999:1091–135 will be created to fund research as well as maintain faculty in central to the long-term success of health care providers. the academic medical center. The integration of information systems with clinical care, Academic medical centers that have successfully part- medical management and any prospective payment system nered with community physicians possess a unique oppor- will occur. Academic medical centers may be in the unique tunity to enroll large numbers of patients in industry- position to take a leadership role in the evolution of such sponsored trials. Academic medical centers often possess the information systems that integrates inpatient and outpatient opinion leaders who provide the impetus to these trials, and activity and larger system approaches. In the short term, whose participation in the design, implementation and data community providers may have more relevant information analysis of these trials is of importance. Better marketing of systems that address their day-to-day needs. The academic these two advantages by the academic medical center to medical center also has had a traditional mission to provide industry can also serve as a revenue source in the future. access to computerized reference services and innovative However, when industry is the initiator of new drugs, educational material, but the widespread availability of biologics or devices, the academic medical center is often Internet services has deeply discounted this traditional role. not the partner they currently seek for initial patient trials. Recognized expertise is in the community, the overhead POTENTIAL SOLUTIONS/OPPORTUNITIES costs are often lower and bureaucratic obstacles are typically less burdensome. The academic cardiology division cannot Academic medical centers are poised to redefine their afford to surrender this traditional relationship with industry relationships with the community and the departments of and must continue to compete for clinical studies generated medicine/pediatrics in a fashion that can be instrumental to from basic science work performed in industry. their long-term viability (6,9 –11). Geographic differences and rapidly moving market forces make a standardized Organizational structure. The organizational structure of approach impossible, but a number of different strategies academic medical centers might suggest that there can be a have already proven to be successful. Whatever solution or closer alignment of purpose between faculty, hospital and opportunity is identified, academic medical centers must be medical school than in the community hospital with com- proactive in its initiation. munity specialists. This potential alignment is not often strategically explored, as traditional agendas have been External Relationships perpetuated. Acquire primary care practices. The acquisition of pri- Administrative structure. An important advantage of the mary care practices has clearly channeled specialty care to a academic cardiology program is that the practitioners within number of academic medical centers. This has allowed them the academic medical center have defined leadership and are to maintain a high census during times of declining specialty used by a single entity. This structure is in marked contrast care needs. However, such acquisitions have been a financial to nonacademic medical centers that must contend with burden, and are now being reconsidered by a number of multiple group practices and which often have unwieldy integrated health care systems. Moreover, shifting an ac- bylaws requiring a majority vote to enact any new practice quired practitioner from a private practice model to a staff patterns or to establish contractual relationships with insur- model for remuneration purposes has consistently resulted ers. Furthermore, it provides a mechanism by which physi- in reduced provider productivity. Academic cardiovascular cians can be given incentive to maintain a relatively consis- programs have benefited from these department/ tent practice pattern and to comply with new practice institutional initiatives, but should not rely on them as their guidelines. sole future strategy. Brand equity. The American population will continue to Develop primary care networks. Although such networks demand access to specialty care. This is manifest by point- have usually been directed toward the development of a of-service options, plateau enrollment in heavily controlled system capable of accepting large managed care contracts, managed care plans and continued requests for subspecialty their intended consequence has also been to rechannel services. The brand equity that academic medical centers specialty care to the academic medical center associated with bring to specialty care has not been sufficiently exploited by such networks. Moreover, the investment in the infrastruc- many centers. Patients will never want to be excluded from ture of such networks has primarily benefited the primary the “court of last resort,” and academic medical centers are care physicians and only indirectly the specialists. in the unique position of providing such quaternary care. In Subspecialty care clinics/outreach programs. Establish- addition, evidence of patient concern about not being able ing subspecialty clinics in conjunction with community to choose their own physicians is responsible for the physicians has been welcome in many regions. Although negative backlash against Health Maintenance Organiza- some community specialists will certainly view this as direct tions appearing in recent U.S. congressional campaigns. competition, the ability of academic specialists to work Information systems. Whatever occurs in the evolution of closely with community physicians will often be perceived as American medicine, information system capabilities will be enhancing the capabilities of community physicians. The
  13. 13. JACC Vol. 33, No. 5, 1999 DeMots and Mudge 1103 April 1999:1091–135 Task Force 1: Clinical Care academic medical center benefits because new sources of Purchase of cardiology practices. Due to falling reim- potential patient referrals are created. These relationships bursements and excessive numbers of cardiologists in the can often be established based on “goodwill” without formal community, high quality community cardiologists may con- contracts. This is in keeping with traditional referral pat- sider being purchased by academic medical centers. In terns that are based on mutual respect and personal rela- exchange, they expect regional exclusivity within the aca- tionships and not exclusive contracts. However, it is impor- demic cardiology network and full membership in any tant to note that one means of changing referral patterns is network products. They are also provided with long-term providing financial incentive. Moreover, inviting commu- contracts with minimum salary guarantees. Once purchased, nity specialists to participate in other missions of the these groups include the academic center as a site for academic medical center (teaching, clinical research proto- interventional procedures. Because most academic medical cols) serves to enhance their participation/affiliation/ centers expect minimal numbers of interventional proce- allegiance to the long-term mission of academic medical dures to be performed in their facilities, these purchases centers. increase the academic centers’ interventional patient vol- Partnering of community hospitals and academic special- umes and associated inpatient admissions. Once these ists serves a similar need. This outreach provides community physicians develop relationships with other academic spe- hospitals with sub-subspecialty care that might not other- cialists including electrophysiology or congestive heart fail- wise be available to them. ure/transplantation, additional referrals to the academic medical center may occur. However, preexisting referral Subspecialty carve outs. There are a number of potential patterns may abrogate the ability of purchased practitioners carve-outs that may emerge in managed care for subspe- to move their cases to the academic center if the groups cialty care and will depend upon the degree of managed care referring primary care physicians demand that their patients penetration. Such carve-outs might include diabetes, hyper- remain at the nonacademic medical center. tension, end-stage renal disease and congestive heart failure. They offer the ability of an academic cardiovascular program Internal Restructuring to offer cardiology capitated carve-out products as managed care evolves. This model requires the ability to offer regional The future success of the academic cardiovascular division cardiology services, which can be capitalized by the large depends on its ability to leverage a number of the potential academic medical center, and provides high quality practi- market advantages that it possesses in a business-like fash- tioners for managed care providers. It also potentially ion to maximize their impact. These include: provides for cost saving, since a single employer is identified Broad clinical strength. Community hospitals often pos- so practice patterns can be uniform and respond quickly to sess cardiologists with skill and technical expertise equal to the rapidly changing environment of health care reform. the faculty in academic divisions. However, academic pro- Additional cost savings can also be realized because this grams often have greater breadth of expertise with sub- model allows shifting of procedures such as stress tests, subspecialists in congenital heart disease in the adult, echocardiograms and diagnostic catheterization to commu- electrophysiology, congestive heart failure/transplantation nity hospitals where they may be able to be performed at and outcomes analysis. lower costs, while shifting more complex procedures to the academic medical center, fostering mutual benefit. Such Align incentives. The academic medical center should carve-outs by definition require a broad geographic distri- foster an environment that is conducive to alignment of bution of academic center–related cardiologists and are an incentives among physician groups (e.g., cardiology and important outgrowth of long-term specialty outreach strat- cardiothoracic surgery divisions) and between physicians egies. and hospitals. Such alignment may be instrumental in augmenting revenue and managing down institutional costs Leasing arrangements. Full-time interventional faculty or to maximize profitability of the entire system. These sub-subspecialists in the academic division of cardiology are factors—academically credible clinical strengths and an leased to community clinical cardiologists who wish an environment conducive to aligning incentives—are often affiliation with the academic medical center but do not wish not adequately leveraged by academic centers, in large part to be purchased. The community cardiologist pays a portion because of bureaucratic obstacles, a lack of mutual trust of the academic salary and in exchange, the academic among the various parties and fear, on the part of depart- clinician/interventionalist receives patients for interven- ments of medicine/pediatrics, of losing control. tional procedures or clinical care. The academic medical center gains new referrals and associated referrals to other Become cost-competitive. It is imperative for survival that cardiology services while the patient is in hospital. The academic medical centers provide care at costs that are community cardiologist can then legally receive part of the competitive with surrounding community hospitals. The professional fees from the interventions or other procedures academic medical center faces this challenge with a number performed, since the academic cardiologist is a part-time of intrinsic disadvantages and some advantages which have employee of the community practice. not been adequately developed and deployed. In many
  14. 14. 1104 DeMots and Mudge JACC Vol. 33, No. 5, 1999 Task Force 1: Clinical Care April 1999:1091–135 instances the faculty practice only at the academic hospital, cardiovascular disease each year. Legal concerns about and practice at the academic hospital is dominated by restraint of trade are usually articulated as justification for faculty members. This facilitates aligning financial incen- lack of action. This fact, more so than any other, has tives to reduce cost. When patients’ length of stay is negatively affected the economics of cardiovascular care in reduced, the reimbursement to the physician correspond- the U.S. and might well contribute to the actual or perceived ingly drops. But the physician effort required to produce the overuse of cardiovascular services in many geographic re- shortened length of stay may increase. If physician and gions. Although many academic cardiovascular programs hospital incentives are allowed to conflict, improvement in have substantially restricted the number of fellows that are performance can be achieved only by imposition of rules, enrolled each year in their cardiovascular training programs, guidelines and threats; and success will be limited. In nonacademically affiliated and smaller training programs creating a funds flow process in which the academic depart- have failed to alter their enrollments. In fact, any reduction ments benefit as the hospital thrives it becomes possible for in the smaller training programs threatens their viability the faculty member to provide the extra effort required for with regulatory bodies and the institutional purpose that good fiscal results. Because the faculty may be employees of they serve. Furthermore, many of these community-based the health system, novel financial arrangements may be training programs barely meet or fail to meet the basic constructed between the hospital and the academic practi- requirements provided by the American College of Cardi- tioner. Cost-competitive care can be delivered by other ology. Their clinical volume often precludes adequate train- means; the academic medical center is an ideal environment ing in sub-subspecialty areas, including electrophysiology, to standardize purchasing and inventory items; physician preventive cardiology, heart failure and cardiac transplanta- involvement can produce substantial savings through bulk tion and adequate six-month research experience resulting purchases of high-end technical equipment. in scholarly publications. Although there are many examples of excellent non– university-affiliated programs that meet Minimize variation in practice patterns. Variation in these requirements, many more cannot. Since such training practice patterns increases cost of medical care without is a requirement of certification, it is imperative that the measurable influence on quality. Although one can argue academic cardiovascular programs, the American College of which group of physicians is offering procedures at the Cardiology and the Accreditation Council for Graduate “correct” frequency, there is rarely evidence that the general Medical Education address this issue. health of the population treated with the higher number of procedures is better. Academic medical centers might prefer Nonphysician extenders. Academic cardiovascular pro- to consider their practices evidence-based, but this may not grams have often been slow to optimize the value of always be the case. The same clinical history, stress test physician extenders to improve efficiency of clinical care. result and stenosis identified by coronary angiography may Residents and fellows are traditionally integrated into the trigger variations in coronary intervention or medical ther- continuum of clinical care as part of the teaching mission, apy. whereas community providers have markedly improved The value of variation in patterns of acceptable practices their efficiency with nurse practitioners, clinical nurse spe- must also be readdressed. The educational mission tradi- cialists or physician’s assistants. It now becomes a challenge tionally requires proof that more than one direction of care to the academic program to incorporate these valued non- is acceptable. A standard approach to care may reduce physician colleagues in a fashion that compliments the inventory costs and provide routines that allow nursing and educational mission. technical personnel to become very skilled and efficient in providing care. However, such an approach is viewed by Advocate change in payment policies of the Health Care many as antithetical to the academic environment in which Financing Administration. Current and proposed pay- the trainee is traditionally thought to benefit by observing ment policies of the Health Care Financing Administration multiple paths to the same end. The trainee is considered to should be revised to diminish their adverse effects on clinical be in a better position to judge the best way after this varied practice at academic medical centers. Specifically, the poli- experience. This precept must be reconsidered, for this cies should: educational approach is prohibitively expensive and scien- ● Recognize uncompensated care as a legitimate physician tifically flawed. To propose that the educational “best way” practice expense. can be determined by a trainee based on uncontrolled ● Provide adjustments to the outpatient prospective pay- experiments in which patients vary, entry criteria are not ment system to recognize the added costs of teaching and defined and end points often are not collected or analyzed providing care to populations with a disproportionate except in an anecdotal fashion is inconsistent with our share of Medicaid recipients. collective scientific heritage. ● Extend the exception for teaching physician supervision Define training/workforce. Unlike our colleagues in many of residents to all specialties that provide evaluation and of the surgical subspecialties, adult cardiologists have failed management services. to limit the number of physicians that are trained in ● Provide payment to teaching physicians for the services of
  15. 15. JACC Vol. 33, No. 5, 1999 DeMots and Mudge 1105 April 1999:1091–135 Task Force 1: Clinical Care medical students provided under direct physician super- both privately and publicly, have had substantive effects on vision. the care of patients with malignancies and have provided ● Reduce the physician presence requirements of the teach- multidisciplinary and collaborative centers allowing for out- ing physician rules for private practitioners willing to standing levels of patient care, rapid transition of new teach residents in their offices. technology to the patient and interdisciplinary collaborative ● Provide adequate payment to support the care of children research. These stand-alone facilities compete effectively for and adults with congenial heart defects. patients with community hospitals and practitioners and in some ways exist as economically independent entities. By Any future discussion of payment of graduate medical having administrative responsibilities to a larger health education by payers other than Medicare should recognize system, they are able to bypass much of the academic that the current level of funding may be inadequate. In other bureaucracy that has slowed the ability of these academic words, some of the contributions to the funding of graduate divisions to respond to change. medical education by payers other than Medicare should be A number of different and successful models should be in addition to, not as a substitute for Medicare funding. considered by the academic cardiology division. Cardiovas- Relationship between the academic cardiovascular divi- cular specialists at the Washington Hospital Center have sion and the departments of medicine/pediatrics. The developed a superb organization structure for cardiovascular academic mission of the departments of medicine/pediatrics care outside the traditional department of medicine. Their is essential, but academic cardiology programs have a clinical trials in interventional cardiology are leadership traditional relationship with their department of medicine investigations, their commitment to basic research is ex- that needs to be reexamined. Although the departments of panding and their outreach/merger with other institutions medicine/pediatrics continue to be central for academic or individuals makes them competitive with the most recruitment and credentialing, there are other constituents prestigious institutions in the mid-Atlantic States. In other and partners for the academic cardiovascular programs, regions, for-profit ventures in cardiac catheterization have which include hospital leadership and integrated networks proven to be fiscally sound and serve as an example to among others, whose needs must be addressed. A restruc- academic cardiology programs for their efficient business- tured academic cardiovascular division will ultimately be of like clinical care. more benefit to a department and its other subspecialty Several cardiovascular centers have been successfully in- divisions than the current fragmented approach. tegrated into the academic mission of their respective The present alignment of the various subspecialties into institutions; Mount Sinai Medical Center’s Cardiovascular departments of medicine, pediatrics, surgery and obstetrics Institute and the Cardiovascular Institute at the University and gynecology dates back to the late 1800s, a time when of Pittsburgh Medical Center are perhaps the most com- cardiologists’ primary tools were their hands and their pelling current examples. Common characteristics of these stethoscopes. However, like all of medicine, the practice of efforts include advisory boards responsive to the governing cardiology has changed dramatically. Indeed, cardiologists health care system, horizontal multidisciplinary integration are sub-subspecialized with independent board certification across clinical care and all research endeavors and indepen- in at least two of these highly specialized areas, electrophys- dence from their traditional departments to forge new iology and interventional cardiology. Furthermore, the pri- community relationships and to develop marketing and mary point of service is more often an interventional philanthropic strategies while maintaining fiscal responsi- laboratory than an outpatient clinic, and the practice of bilities to and academic credentialing by their respective cardiology has far more in common both intellectually and departments and medical school. technically with the surgical subspecialties than with tradi- tional medical subspecialties. Despite these differences, OPERATIONAL CHANGES cardiology divisions are still expected to support less remu- nerative divisions of the departments of medicine/pediatrics, There are a number of operational changes that might be and meet more robust productivity standards. However, this considered by academic cardiovascular programs. disparity is far from novel. Over the past several decades, Hospitalists similar disparities existed between the goals of the surgical subspecialties and those of the department of surgery, The evolution of hospitalists may in fact improve the resulting in the development of departments of otorhino- efficiency and use of patient resources. Full-time individuals laryngology, neurosurgery and cardiothoracic surgery. Even committed to inpatient care should result in reduced length in schools of medicine, divisions of neurology and derma- of stay and hospital costs. However, the evolution of tology have become independent departments. However, academic hospitalists will require substantial restructuring of perhaps the most relevant models for the cardiology pro- traditional academic/clinical roles. The early involvement of grams of the future are the 50 centers of excellence in an attending physician who can direct care in a way that oncologic disease that have been developed at academic moves the diagnostic workup in the most expeditious centers across the U.S. These centers of excellence, funded manner, and institutes therapy and discharges the patient at
  16. 16. 1106 DeMots and Mudge JACC Vol. 33, No. 5, 1999 Task Force 1: Clinical Care April 1999:1091–135 the earliest reasonable moment is essential. This requires remote from the institution. Therefore, regular meetings of that alternative strategies must be created for training a group of cardiologists to present patient cases for discus- programs which benefit from a more leisurely hospital sion to develop common practice patterns will be of impor- course. tance. An example would be weekly conferences for the Academic medical centers can provide care with low interventionalists in the catheterization laboratory. They mortality and with acceptable lengths of stay when consid- may decide to develop consistent strategies for a given eration is given to the severity of illness found in patients at stenosis morphology, a specified IIb-IIIa antagonist only for an academic medical center (12). In many instances the angiographically identifiable clot, and they may choose a costs of this care are still higher than in the community. single “workhorse” balloon (from a single vendor) for the These higher costs could be due to higher utilization or most straightforward stenoses. Such an approach is prefer- other inefficiencies or cost shifting from the educational able to having such decisions imposed by a hospital admin- mission and from the care of indigent patients. To the istrator and can drive down operational expenses. extent that they are the former they must be addressed. Clinical Pathways Advantages of a Product Line Structure Practice patterns can be standardized by using clinical Restructuring the delivery of cardiovascular services into a pathways, practice guidelines and algorithms. The design “product line” consistent with its academic mission and and implementation of these tools is difficult and time- goals represents one mechanism for advancing the academic consuming but, if properly performed, can produce im- cardiovascular division toward a more competitive position. provements in outcomes and reduction of cost. Resistance is Furthermore, product line development links cardiologists often encountered by condemning these efforts as “cook- with the most appropriate academic colleagues: those spe- book medicine.” They should never be used as an excuse for cializing in cardiothoracic surgery, pediatrics, interventional failing to meet the special needs of a patient or providing radiology and cardiac anesthesia. Such a structure might appropriate variation in care when the clinical situation have the following characteristics and advantages: demands it. Appropriate use, however, provides reminders for the implementation of care, a time-conserving set of 1. Strengthened fiscal and operational ties among physician standard orders that can be modified to fit the clinical groups that provide related clinical service, in a structure situation and a template from which variation can be that provides incentive for revenue-seeking and cost- recorded. The greatest value of pathway development may cutting behavior. accrue from the act of development in which experts and 2. Alignment of incentives between hospital and physi- other providers come together to research current practice cians. patterns in the hospital and agree on a uniform approach 3. Facilitation of initiatives toward maximizing quality based on best evidence. Usually these groups can agree on a while minimizing cost. best approach, but when legitimate disagreements occur it 4. Facilitation of specialty-oriented risk contracting, serving provides a basis to compare the financial and clinical to network the academic cardiovascular division and outcomes of patients treated in different ways. community providers by adding value through initiatives In cardiology there are a number of conditions that are to a) reduce cost internally and b) implement medical suitable for pathway development such as chest pain, myo- and disease management programs system-wide. cardial infarction, pacer implantation or pulse generator 5. Increased use of clinical care teams, including nonphy- change and coronary angiography for stable angina. Other sician health care extenders. conditions such as congestive heart failure will be more Product Standardization difficult, because the clinical course of a patient may be driven by a number of comorbidities that are found in these Product standardization is difficult to implement, because patients. In many complex conditions found in an academic specialists tend to cling to their favorite device or imple- medical center the best guidance may come from practice ment. In many instances the faculty members may have guidelines or algorithms which apply branching logic at key participated in the development of a device or performed decision points rather than the linear course provided by a crucial research to validate or improve a device or drug. clinical pathway. When a hospital is forced to stock numerous brands of the Communication of the pathways and guidelines is a same device it raises inventory costs for the hospital and it challenge for academic medical centers because of the prevents the hospital from participating fully in volume inclusion of fellows and residents in the care model. Geo- discounts or in buying consortia that reduce costs. Academic graphical concentration of like patients allows nurses to cardiologists will be faced by requests from hospital admin- become important promoters and educators of the residents istrators to use predominately a single brand of pacemaker, in standard procedures. Storing materials on easily accessi- defibrillator or angioplasty catheter to offer their services to ble and user-friendly electronic media or web pages com- an adequate volume of patients. In some instances their plete with references, tables, diagrams and preprinted orders choices will be limited by a buying consortium that is promotes use of the path and offers an educational resource