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Committee on the Roles of Academic Health Centers in the 21st Century
Linda T. Kohn, Editor
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THE NATIONAL ACADEMIES PRESS · 500 Fifth Street, N.W. · Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropri-
ate balance.
This study was supported by Contract No. 01-267 and 20010609 between the
National Academy of Sciences and The Rockefeller Brothers Fund, with additional
support from The Commonwealth Fund, the Institute of Medicine, and the Na-
tional Research Foundation. Any opinions, findings, conclusions, or recommenda-
tions expressed in this publication are those of the author(s) and do not necessarily
reflect the view of the organizations or agencies that provided support for this
project.
Library of Congress Cataloging-in-Publication Data
Academic health centers : leading change in the 21st century / Committee on the
Roles of Academic Health Centers in the 21st Century ; Linda T. Kohn, editor.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-08893-3 (hardcover)
1. Academic medical centers--United States.
[DNLM: 1. Academic Medical Centers--trends--United States. WX 27 AA1
A168 2004] I. Kohn, Linda T. II. Institute of Medicine (U.S.). Committee on the
Roles of Academic Health Centers in the 21st Century.
RA966.A23 2004
362.12--dc22
2004001871
Additional copies of this report are available from the National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or
(202) 334-3313 (in the Washington metropolitan area); Internet, http://
www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at:
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Copyright 2004 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent
adopted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
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"Knowing is not enough; we must apply.
Willing is not enough; we must do."
--Goethe
Adviser to the Nation to Improve Health
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated
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Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
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Sciences.
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National Research Council.
www.national-academies.org
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COMMITTEE ON THE ROLES OF ACADEMIC HEALTH CENTERS
IN THE 21ST CENTURY
The Honorable JOHN EDWARD PORTER (Chair), Partner, Hogan and
Hartson, L.L.P. Washington, DC, Member of Congress 1980-2001
LINDA AIKEN, Claire M. Fagin Professor of Nursing and Sociology and
Director, Center for Health Outcomes and Policy Research,
University of Pennsylvania, Philadelphia, Pennsylvania
J. CLAUDE BENNETT, President and Chief Operating Officer, BioCryst
Pharmaceuticals, Inc., Birmingham, Alabama
HENRY BIENEN, President, Northwestern University, Evanston and
Chicago, Illinois
NANCY-ANN MIN DEPARLE, Adjunct Professor of Health Care
Systems, Wharton School, University of Pennsylvania; Senior Adviser,
JP Morgan Partners, New York, New York
EDWARD W. HOLMES, Vice Chancellor for Health Sciences and Dean,
University of California San Diego School of Medicine, La Jolla,
California
LAWRENCE LEWIN, Executive Consultant, Washington, D.C.
NICOLE LURIE, Senior Scientist and Alcoa Professor of Policy Analysis,
The RAND Corporation, Arlington, Virginia
STEVEN M. PAUL, Group Vice President, Lilly Research Laboratories,
Eli Lilly Company, Indianapolis, Indiana
PAUL G. RAMSEY, Vice President Medical Affairs and Dean, University
of Washington School of Medicine, Seattle, Washington
ROBERT REISCHAUER, President, The Urban Institute, Washington, DC
JOHN W. ROWE, Chairman and CEO, Aetna Inc., Hartford,
Connecticut
MARLA SALMON, Dean and Professor, Nell Hodgson Woodruff School
of Nursing, Emory University, Atlanta, Georgia
CHRISTINE SEIDMAN, Howard Hughes Medical Institute and Brigham
and Women's Hospital, Professor of Medicine and Genetics, Harvard
Medical School, Boston, Massachusetts
M. ROY WILSON, President, Texas Tech University Health Sciences
Center, Lubbock, Texas. Until June 2003, Dean, School of Medicine
and Vice President for Health Sciences, Creighton University, Omaha,
Nebraska
LIAISON FROM THE BOARD ON HEALTH SCIENCES POLICY
JAMES CURRAN, Dean and Professor of Epidemiology, Rollins School
of Public Health, Emory University, Atlanta, Georgia
v
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STUDY STAFF
LINDA T. KOHN, Study Director
MARYANN BOLCAR, Program Officer
RANDA KHOURY, Project Assistant
RONNÉ D. WINGATE, Project Assistant
JANET M. CORRIGAN, Director, Board on Health Care Services
vi
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REVIEWERS
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with proce-
dures approved by the NRC's Report Review Committee. The purpose of
this independent review is to provide candid and critical comments that will
assist the institution in making its published report as sound as possible and
to ensure that the report meets institutional standards for objectivity, evi-
dence, and responsiveness to the study charge. The review comments and
draft manuscript remain confidential to protect the integrity of the delibera-
tive process. We wish to thank the following individuals for their review of
this report:
Henry Aaron, Brookings Institution, Washington, DC
David Blumenthal, Massachusetts General Hospital, Partners
Healthcare, Boston, Massachusetts
David R. Challoner, University of Florida, Gainesville, Florida
Don E. Detmer, Cambridge University Health, Judge Institute of
Management, Cambridge, UK
Robert Galvin, General Electric Company, Fairfield, Connecticut
Harry R. Jacobson, Vanderbilt University, Nashville, Tennessee
Peter O. Kohler, Oregon Health & Sciences University, Portland,
Oregon
Ronda Kotelchuck, Primary Care Development Corporation, New
York, New York
vii
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viii REVIEWERS
Joel Kupersmith, Texas Tech University, Lubbock, Texas
Mary O. Mundinger, Columbia University, New York, New York
Cecil B. Pickett, Schering-Plough Research Institute, Kenilworth,
New Jersey
Mitchell T. Rabkin, Harvard University, Cambridge, Massachusetts
Leon E. Rosenberg, Princeton University, Princeton, New Jersey
Linda Rosenstock, University of California, Los Angeles
Bruce Vladeck, Mt. Sinai School of Medicine, New York, New York
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations nor did they see the final draft of the report before its
release. The review of this report was overseen by Robert Johnson, Profes-
sor, New Jersey Medical School, appointed by the Institute of Medicine,
and Enriqueta Bond, President, Burroughs Wellcome Fund, appointed by
the National Research Council. They were responsible for making certain
that an independent examination of this report was carried out in accor-
dance with institutional procedures and that all review comments were
carefully considered. Responsibility for the final content of this report rests
entirely with the authoring committee and the institution.
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PREFACE
The last few decades have been heady times for science and health. Our
knowledge of how to improve health has grown significantly and new
technologies have successfully supported those endeavors. The coming de-
cades are likely to bring even more progress. As we gain a better under-
standing on how to use the discoveries of genetics, proteomics, and other
biologies, we will have the potential to fundamentally alter care in ways
that we can only begin to imagine. Combined with a public that is armed
with more information and better able to make healthy choices and be
more involved in its own care, the potential is great for making large strides
in improving human health.
In the fall of 2001, the Institute of Medicine convened a committee to
examine the roles of academic health centers (AHCs) in the coming decades
in fostering and supporting these advances in health care. The challenge to
this committee was to look into the future and consider how AHCs can be
prepared to fulfill their promise by carrying out their roles in education,
research, and patient care to improve health for all people. AHCs demon-
strated great vision and accomplishment during the 20th century. They will
need these qualities in the coming decades if they are to adapt and respond
to the changing needs of people and the expanding capabilities that health
care will offer.
This committee was intentionally designed to include a diverse group of
individuals from varied backgrounds so as to bring contrasting views to the
subject at hand. The members did not always agree, and on occasion a
ix
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x PREFACE
dissenting voice even rose, reflecting the seriousness with which the mem-
bers viewed their charge. By the end of the deliberations, a mutual respect
had grown for the always thoughtful views expressed by each committee
member. I am thankful for the opportunity to work with such an experi-
enced, visionary, and talented group. Excellent staff support was also pro-
vided by Maryann Bolcar, Ronne Wingate, and Randa Khoury, under the
able and patient direction of Linda Kohn.
The challenges facing AHCs in the future will be significant. Change is
never easy and rarely smooth. But the opportunities are too great to for-
sake. I speak for the entire committee in believing that strong AHC leader-
ship and sound policy support will indeed make it possible to achieve better
health for all.
John Edward Porter
Chair
June 2003
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ACKNOWLEDGMENTS
The Committee on the Roles of Academic Health Centers in the 21st
Century gratefully acknowledges the contributions of the many individuals
and organizations through the course of the study that participated and
gave generously of their time and knowledge.
Support for this study was provided by the Institute of Medicine, the
National Research Council, the Rockefeller Brothers Foundation, and The
Commonwealth Fund. The Committee especially recognizes Melinda
Abrams of The Commonwealth Fund, and Linda Jacobs and William
McCalpin of the Rockefeller Brothers Foundation, for their special atten-
tion to this project.
A workshop was sponsored by the committee in January 2002 during
which the following people offered their views on the future roles for
AHCs: Gerard Anderson, Johns Hopkins University; Brian Biles, George
Washington University; Joseph D. Bloom, Oregon Health and Science Uni-
versity; David Blumenthal, Partners HealthCare System; Samuel Broder,
Celera Genomics; Jordan Cohen, Association of American Medical Col-
leges; Colleen Conway-Welch, Vanderbilt University; Charles Cutler,
American Association of Health Plans; Ezra Davidson, Charles R. Drew
University; Robert Dickler, Association of American Medical Colleges;
Gerald Fischbach, Columbia University; Jeff Goldsmith, Health Futures
Inc.; Ralph Horwitz, Yale University; Edward Hundert, Case Western Re-
serve University; Darrell Kirch, Pennsylvania State University; Uwe E.
Reinhardt, Princeton University; Sara Rosenbaum, George Washington
xi
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xii ACKNOWLEDGMENTS
University; Elaine Rubin, Association of Academic Health Centers; Ralph
Snyderman, Duke University; and Bruce C. Vladeck, Mount Sinai School of
Medicine.
Several university presidents made presentations about their own AHCs.
The committee is grateful to Lee C. Bollinger of Columbia University,
Judith Rodin of the University of Pennsylvania, Leonard W. Sandridge of
the University of Virginia, and Stephen J. Trachtenberg of the George Wash-
ington University for sharing their knowledge. In addition, Catherine Dower
of the University of California, San Francisco, and Robert Galvin of Gen-
eral Electric provided valuable testimony to the Committee during a July
2002 meeting.
The Committee acknowledges with gratitude a number of others for
providing their time and expertise to this work: Helene Bednash, American
Association of Colleges of Nursing; Linda Berlin, American Association of
Colleges of Nursing; Roger Bulger, Association of Academic Health Cen-
ters; Molly Cooke, University of California San Francisco; Alain Enthoven,
Stanford University; The Honorable Bill Gradison, Patton Boggs; David
Helms, AcademyHealth; George Kaludis, Kaludis Consulting; Brian Kimes,
National Cancer Institute; Peter Kohler, Oregon Health and Science Uni-
versity; Jay Levine, ECG Management Consultants; Craig Lisk, Medicare
Payment Advisory Commission; Alexander Omaya, Institute of Medicine;
Marian Osterweis, Association of Academic Health Centers; Julian
Pettingill, Medicare Payment Advisory Commission; James Reuter,
Georgetown University; Edward Salsberg, University of Albany SUNY;
Ellen Stovall, National Coalition for Cancer Survivorship; and Linda Weiss,
National Cancer Institute.
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CONTENTS
EXECUTIVE SUMMARY 1
1 INTRODUCTION 19
2 FORCES FOR CHANGE 30
TRANSFORMING THE ROLES OF AHCS
3 THE ACADEMIC HEALTH CENTER AS A REFORMER:
THE EDUCATION ROLE 45
4 THE ACADEMIC HEALTH CENTER AS A MODELER:
THE PATIENT CARE ROLE 65
5 THE ACADEMIC HEALTH CENTER AS A TRANSLATOR
OF SCIENCE: THE RESEARCH ROLE 77
CREATING AN ENVIRONMENT FOR INNOVATION
6 THE CONSEQUENCES OF CURRENT FINANCING
METHODS FOR THE FUTURE ROLES OF AHCs 92
xiii
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xiv CONTENTS
7 EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 110
8 CREATING SYSTEMS FOR CHANGE IN AHCs 127
REFERENCES 144
APPENDIXES
A ACADEMIC HEALTH CENTERS: ALL THE SAME,
ALL DIFFERENT, OR ... 161
B COMMITTEE ON THE ROLES OF ACADEMIC HEALTH
CENTERS IN THE 21ST CENTURY 198
