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chapter 7 EXPECTATIONS AHC FOR THE OF 21ST CENTURY THE Previous chapters of this report have reviewed how the external envi- ronment in which AHCs function will change in very fundamental ways in the future, affecting how AHCs carry out each of their roles both individu- ally and in combination. Nonetheless, the AHC roles in education, re- search, and patient care will remain important in the future. The public will continue to need a well-prepared workforce, to value the discoveries science can offer, and to seek innovations in the delivery of care. However, it is also true that each role will require modification and adaptation to meet the needs of the 21st century. Because the roles remain relevant does not imply that their execution and approach need not change. This chapter synthesizes the discussion and findings of preceding chap- ters to provide a set of recommendations for each role performed by AHCs, with emphasis on how each will need to be transformed to meet the needs of the public in the coming decades. The AHC of the 21st century will need to use its roles, resources, and leadership to improve the health of patients and populations. To this end, it will have to lead in the development, refinement, and application of the evidence base and education grounded in the evidence base as the foundation for both treating illness and improving health. In the committee's vision of the 21st century AHC, AHCs will effectively integrate their roles so that research develops the evidence base, patient care applies and refines the evidence base, and education teaches evidence-based care, and all are designed in an overall context of and commitment to improving health. 110

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 111 TRANSFORMING THE ROLES OF THE 21ST-CENTURY AHC The prior chapters in this report have identified a number of forces for change in the environment within which AHCs carry out their roles. Be- cause AHCs are major participants in each of these roles, the challenge of transforming the roles to respond to this changing environment falls par- ticularly to them, although all organizations performing any of the roles should also meet the expectations for each. The modifications required have been described in previous chapters and are summarized in Table 7-1. AHCs need to respond to the forces for change, and the nation has the right to look to them for such a response. AHCs need to respond for several reasons. The forces for change described in Chapter 2 are more likely to increase, not lessen in the coming years. The population will continue to age and diversify, and the pace of technological change will increase. The rising costs of care threaten AHCs in a number of ways. State budget crises have caused some states to question their support for graduate medical education and to consider its withdrawal or reduction. Rising costs can be expected in turn to increase the number of uninsured, many of whom rely on AHCs for their care. To the extent that higher costs of care affect hospital operating margins, access to capital will also be affected. The pressures on AHCs can be expected to intensify, rather than lessen, in the future. Although AHCs have successfully represented their concerns at the federal and state levels in the past, it will probably be more difficult to count on continued relief in the coming years. Emerging concerns are re- ordering priorities as concerns with deficits, bioterrorism and homeland security, Medicare reform, and malpractice are reordering priorities as they draw the attention of policy makers. Furthermore, if AHCs are unable to demonstrate sufficient progress in meeting society's changing and emerging needs (as described in previous chapters), future support is likely to come with increasing legislative or regulatory restrictions, which could poten- tially leave AHCs with fewer options to respond. The sooner AHCs act, the better chance they will have of controlling their future. The nation has a right to expect AHCs to respond because the way in which AHCs carry out their activities in education, research, and patient care influences the capabilities that reside throughout the health system generally. Although all health care organizations are affected by the trends described in this report, the choices made by AHCs will have an effect well beyond their own organizations, exerting a profound influence on what kind of health care the American people will enjoy. Decisions about how to train health professionals influence the clinical skills they use in practicing within the larger system. Decisions about what types of research to pursue and how to share the results influence future practice patterns and insur- ance policies.

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112 ACADEMIC HEALTH CENTERS TABLE 7-1 Adapting the Roles of AHCs Role 20th Century 21st Century Education Education that emphasized: Education that emphasizes: Treatment of symptoms of Teaching of research-based best individual patients practices in a variety of clinical Activities of individual practitioners settings that model best practices Hospital-based training Understanding of the Undergraduate and graduate determinants of health and illness training Use of evidence-based educational methods Coordination of approaches across the continuum of education and across clinical and management education Patient Care Patient care that emphasized: Patient care that emphasizes: Treatment of the symptoms and Development of structures and illnesses of patients who arrive team approaches designed to at the institution improve health Relative emphasis on specialty Modeling, testing, and refinement care of research-based best practices Care that reflects predominantly for clinical care local patterns of practice Use of collaborative approaches to health, especially for vulnerable populations Research Research that emphasized: Research that emphasizes: Basic research advances Linking of basic, clinical, health Accomplishments of an services, and prevention research individual principal investigator Improved understanding of the Publication in professional journals clinical, organizational, and cost effectiveness of new treatments and established practices Teams of researchers that span the sciences Translation of knowledge into practice Additionally, AHCs receive a significant level of public support for their activities. Over the last decade, the federal and state governments have allocated approximately $100 billion to support activities in clinical educa- tion and research and to provide disproportionate-share funds to care for the poor and uninsured (Anderson, 2002).1 The majority of this funding 1 These are estimates for the AHC enterprise. It is recognized that Medicare funds for graduate medical education are provided to the hospital, whereas much of the National Institutes of Health (NIH) funding goes to individual investigators at the medical, nursing, or other professional school.

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 113 has gone to support the activities of AHCs, so the nation has the right to look to them for guidance and leadership in addressing the health needs of the American people. Finally, the current health care system is characterized by many prob- lems, such as the increasing costs of care, dissatisfaction on the part of both patients and those working in health care, and evidence of disparities in health, as well as clear opportunities to improve health status. Recent sur- veys revealed that 79 percent of the public and 83 percent of physicians believed the health care system needed fundamental change or a complete rebuilding (Blendon et al., 2001). Another study found that 41 percent of hospital nurses were dissatisfied with their jobs, and 23 percent planned to leave their jobs within the next year (Aiken et al., 2001). Because of the complexity of the problems facing the system, no single solution will suf- fice; in any case, however, AHCs need to be a part of the solution for improving the health care system. The prior six chapters have documented the need for change in how AHCs carry out their roles if they are to continue to serve the public interest in the coming decades. The aim of the committee's proposed overall strat- egy for accomplishing this transformation is to start a process of continuing and long-term change. The recommendations that follow offer a two-part plan. First, the external environment should create a set of incentives that will clearly signal the need for change in each of the AHC roles and serve as a spur for actions by the AHCs. In education, Congress should create a dedicated fund that can foster innovation in the educational approaches used to prepare health professionals. In research, federal funding agencies should work together to support collaborations among a mix of scientists that do different types of research, to answer the big questions of science and health. In patient care, public and private payers and foundations should support experimentation in working across settings of care to rede- sign and restructure care processes that are aimed at improving the health of both patients and populations. In response to the external changes described in this report, AHCs should examine how they carry out their roles and adapt them as necessary. In education, AHCs will need to examine fundamentally the methods and approaches used to prepare health professionals; adapting current curricula will not be sufficient. In research, AHCs will need to examine how their research programs link across the continuum of research; expanding the number of studies done will not be sufficient. In patient care, AHCs will need to restructure care processes to focus on health for patients and popu- lations; improving institutionally based care for their own patients will not be sufficient. The second part of the proposed strategy addresses the AHC itself, rather than any specific role, and asks AHCs to examine how they organize,

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114 ACADEMIC HEALTH CENTERS perform, assess, and internally support their varied roles. The recommenda- tions offered to this end call on AHCs to establish systems across the enterprise that will facilitate the flow of information throughout the AHC, foster accountability to measure and reward needed changes, and develop leaders who will take on the transformations required. It is not possible to assign any given recommendation to the medical or nursing school, to the AHC hospital, or to any other individual component of the overall AHC. Given the interdependence of the AHC roles, no indi- vidual component of the AHC can accomplish any given recommendation. For example, the medical school can reform its own curriculum but cannot unilaterally achieve more interdisciplinary approaches in education unless it works with the nursing, public health, allied health, and other schools. Educators can reform a curriculum but must work closely with clinical faculty in the hospital or other practice sites to affect the training experi- ence for students. Improving and accelerating the translation of research into clinical care will require close work between the professional schools and the hospitals and clinics. Furthermore, because AHCs are organized in different ways, the committee believes it is not possible to assign selected recommendations to specific components of the AHC in a way that would be meaningful for all AHCs. Implementing the committee's recommendations will require that AHCs function as a more coordinated and cohesive operating entity across their constellation of organizations and functions. AHCs have traditionally de- scribed themselves as having multiple roles--in research, in education, and in patient care. As long as AHCs view these roles as separate and distinct, the aim will be to maximize each, a perspective that creates a set of con- flicts. There is a trade-off, for example, between the AHCs' research and patient care roles. As research organizations, the AHCs are objective arbi- ters of what does and does not work in health care (Thier, 1994), but as competitors in the clinical services market, they want to use a new proce- dure or technology before others do so, sometimes in advance of full knowl- edge on its effectiveness. There is also a trade-off between the education and patient care roles. As educators, AHCs have as a primary goal provid- ing health professionals with a broad-based education that recognizes the whole patient and the factors that affect health and illness; patient care in the acute care setting is episodic, with a procedural and specialty focus. The more specialized an AHC's services become, the less representative are its patients, and this in turn compromises its effectiveness as a training site. Finally, there is a similar trade-off between the education and research roles in that research questions tend to be defined to test hypotheses, whereas the education of health professionals should provide a broad understanding of the processes of health and illness. In economic terms, each activity has a different production function (Samuelson and Nordhaus, 1989).

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 115 Furthermore, maximizing each role will not necessarily lead to im- provements in health. Maximizing the number of specialists trained may not produce better health, maximizing the number of research studies con- ducted may not translate into better care for people; and maximizing the number of physician visits or hospital admissions may not affect health status. AHCs should recognize the interdependent and complementary nature of their historically individual roles within an overall context that encom- passes a commitment to improving the health of patients and populations. Indeed, the unique contribution of AHCs in coming decades will lie in their ability to achieve such an integration of their roles within medicine and across all health sciences, including public health, nursing, dentistry, phar- macy, and others, to foster the health of all Americans. By effectively capi- talizing on opportunities for integration across roles, specialties, and pro- fessions, AHCs could potentially improve health outcomes, accelerate the translation of scientific discoveries into safe and effective practices, lead the way toward more efficient use of human capital and technology, improve public health, and promote healthy lifestyles. This integration involves more than the simultaneous provision of education, research, and patient care. It requires the purposeful linkage of these roles so that research develops the evidence base, patient care applies and refines the evidence base, and educa- tion teaches evidence-based approaches to care and prevention. The title of this report calls on AHCs to lead efforts for change. Lead- ing such efforts for the 21st century will require that AHCs initiate change within and across their roles, as well as throughout their own diverse organizations. RECOMMENDATIONS Before providing its recommendations, the committee wishes to em- phasize its serious concern regarding the problems facing people who are uninsured, recognizing the relationship among a lack of insurance, difficul- ties in accessing care, and an individual's health (Institute of Medicine, 2001a, 2002). AHCs that care for a disproportionate share of the poor and uninsured bear a financial burden that may affect their ability to continue to carry out their core activities in research and education. The committee has not made a specific recommendation regarding this problem because its impact is broader than AHCs. Furthermore, the committee recognizes that the consequences for AHCs of a program that offers universal coverage, such as national health insurance, are unclear, and depend on how cost containment efforts or support for research and education might be struc- tured. However, we strongly urge that the ranks of the uninsured be re-

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116 ACADEMIC HEALTH CENTERS duced, and that AHCs devote more of their attention to the future chal- lenges of improving the health and well-being of all people. The committee believes that among all the AHC roles, education will require the greatest changes in the coming decades, and our recommenda- tions in this area are quite specific. We regard education as one of the primary mechanisms for initiating a cultural shift toward an emphasis on the needs of patients and populations and a focus on improving health, using the best of science and the best of caring. Thus, our recommendations start with this role. Transforming the Roles of AHCs for the 21st Century Reforming the Education of Health Professionals AHCs have historically emphasized the education of physicians at the undergraduate and graduate levels, relying on the hospital's inpatient and outpatient settings as primary training sites. Guiding the education role so that it prepares health professionals not just to treat illnesses of patients but to have an impact on the health of populations will require much more than curricular change. Rather, a more fundamental review of the approaches, methods, and settings used in clinical education will be required. Recommendation 1: AHCs should take the lead in reforming the con- tent and methods of health professions education to include the inte- grated development of educational curricula and approaches that: a. Enable and encourage coordination among deans of various profes- sional schools and leaders across disciplines (such as medicine, den- tistry, nursing, public health, pharmacy, social work, and basic sci- ences) to remove internal barriers to interprofessional education. b. Ensure that all teaching environments--from the classroom to sites for clinical rotations and preceptorships and practice--are exem- plars for the future of health care delivery (e.g., by modeling team- based care and using information technology) and, in collaboration with local health care leaders, demonstrate how to improve health for populations and communities, as well as individual patients. c. Emphasize training in skills that will be needed to improve health, such as the theory and computational skills necessary to compre- hend the new biological sciences, as well as the social and behavioral sciences. d. Develop, recognize, and reward those who teach and conduct re- search on clinical education.

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 117 Health professions training is a major factor in creating the culture and attitudes that will guide a lifetime of practice; however, health care practi- tioners will not be prepared for practice in the 21st century without funda- mental changes in the approaches, methods, and settings used for all levels of clinical education. Current training of health professionals emphasizes primarily the biological basis of disease and treatment of symptoms, with insufficient attention to the social, behavioral, and other factors that con- tribute to healing and are part of creating healthy populations. The training of disciplines in separate "silos" creates boundaries where coordination and collaboration are needed to improve health. Furthermore, there is little coordination among undergraduate, graduate, and continuing education; the result is duplication in some areas and gaps in others. If care is to be more patient-centered, focus on improving the health of people, and meet the needs of an aging, chronically ill, and increasingly diverse population, educational programs will require major redesign and reorientation to integrate training across the disciplines, adequately prepare and reward educators, and conduct research to expand the evidence base on health professions education. Furthermore, the clinical setting in which students are taught must be able to demonstrate care that is patient-cen- tered and health-improving, and model practices that are evidence-based, continuously improving, and cost-efficient. For example, it is meaningless to teach the importance of interdisciplinary teams or the use of clinical information systems if such approaches are not exemplified in the practice settings in which students are taught. Although curricular changes will be required, adding one more course to an already overcrowded curriculum is not the answer. New approaches to clinical education will be required, especially to reflect practice in inter- disciplinary teams and greater use of information and communications systems. Although educational reform is being undertaken in most disci- plines, more such efforts are needed, not only within but also across disci- plines, since changes by one group of practitioners will affect the work of others. AHCs should take a leadership role in reforming clinical education. In addition, education oversight organizations (accrediting, licensing, and cer- tifying bodies) should work together and revise their standards to require demonstration of competencies in patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics, as called for in a recent Institute of Medicine report (Institute of Medicine, 2003). Finally, funders must send a clear signal that these types of changes in health professions education are important and must happen more quickly, as urged in the next recommendation.

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118 ACADEMIC HEALTH CENTERS Recommendation 2: Congress should support innovation in clinical education through changes in the financing of clinical education. a. Congress should create an ongoing fund that provides competitive grants to support educational innovation. Funds should support educational innovations such as use of clini- cal information systems, testing of new educational approaches in hospital and nonhospital settings, and evaluation of curricular and other needed reforms in clinical education. Priority for such funds should be given to those organizations that integrate the training of multiple health disciplines (e.g., medicine, nursing, pharmacy, therapy, public health, administration) and that use information technology in their clinical education programs. To create this education innovation fund, Congress should redi- rect the portion of the funding provided for indirect medical edu- cation that exceeds the additional costs of caring for Medicare patients that are attributable to teaching activities (commonly referred to as the "empirical amount"). Availability of these funds should be contingent upon implementing innovations in clinical education and training environments. b. In addition, Congress and the administration should promptly revise the current statutory framework of Medicare support for graduate medical education to support more interdisciplinary, team-based, nonhospital training that aims to improve the health of patients and populations. Revisions should include consideration of whether other payers should provide specific support for the education of health professionals; examine the relationship between support for the training of physician and nonphysician clinicians; assess the appro- priate recipient of support; and identify mechanisms for account- ability for both the disbursement and the use of public funds. The committee recommends a two-pronged approach to address both short- and long-term issues in the financing of clinical education. First, the recommended innovation fund should be created using a portion of the public resources currently devoted to existing programs to initiate immedi- ate change in individual training programs. AHCs need to make changes in the content, methods, and approaches for clinical education, and support should be provided for those efforts through the innovation fund. Second, a set of more broad-based, long-lasting changes is also needed. The committee does not question continued support for health professions education but believes that the current methods are insufficient to meet future needs and must be fundamentally revised to encourage the training

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 119 of a workforce that will be prepared to work in the interdisciplinary, health- oriented, information-driven models of care of the 21st century. Current funding methods for clinical education do not adequately support training in nonhospital settings, foster interdisciplinary approaches to training, or consider the relationship between the training of physician and nonphysician clinicians. The methods have encouraged growth in the number, size, and duration of medical residency programs and the training of specialists in inpatient tertiary settings (Henderson, 2000; Young and Coffman, 1998). For nurses and allied health professionals (including, for example, physi- cian assistants), current payment methods have favored programs in set- tings that do not train physicians and are not linked to universities. Current policies do not give either AHCs or Medicare the flexibility or encourage- ment to make adjustments as workforce needs change, even when clear needs are identified, such as clinicians to care for an aging, chronically ill population. State and federal policy makers continue to struggle with per- sistent problems regarding the mix and distribution of health professionals. The changes needed are large enough to require a fuller examination of the approaches used and incentives created by current funding mechanisms. As noted in Chapter 6, a number of prior proposals for revising pay- ment for clinical education have been advanced. The committee believes a broad view is needed, one that considers the development of the workforce required for the future. This analysis should move forward promptly while the innovation fund supports immediate changes that AHCs can and clearly should be developing. The committee identified three options for creating an education inno- vation fund. One was to create a new funding program. The education of health professionals is of sufficient value to society to justify the allocation of new funds to such an endeavor. Another option was to freeze current payments for graduate medical education and channel the amount due to inflation that would occur under the existing program into the innovation fund. Using this mechanism, about $40 million would have been made available to such a fund in 2001.2 The third option was to redirect a portion of the current funding for indirect medical education (IME) to reforms in clinical education. IME payments to teaching hospitals are intended to support the additional costs of caring for Medicare patients that are attributable to teaching activities. Analyses by the Medicare Payment Advisory Commission (MedPAC) re- vealed that Medicare's IME adjustment formula for 2002 is about twice the 2This figure assumes that $2 billion was provided to hospitals for direct medical education costs and that the Consumer Price Index was 2 percent.

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120 ACADEMIC HEALTH CENTERS calculated estimate of these higher costs (Medicare Payment Advisory Com- mission, 2002). For 2003, MedPAC estimates that about 2.5 percentage points of the 5.5 percent IME add-on (about $2.6 billion) is in excess of the current cost relationship (Medicare Payment Advisory Commission, 2003). These funds go into a hospital's general revenues, with no requirements placed on their use. AHCs use these funds to support other mission-related activities, so their use varies across AHCs. In its March 2003 report to Congress, MedPAC expressed its dissatisfaction with current payment policy because there is no accountability for the use of funds beyond the amount associated with the higher patient care costs attributable to teach- ing activities (Medicare Payment Advisory Commission, 2003). The committee does not deem it likely that an entirely new funding source could be created and does not believe that redirecting the increment provided by inflation would provide sufficient funds to support the en- deavor. Using a portion of the IME add-on would produce a larger pool of funds to support educational innovation. The committee believes that as the primary funder of graduate medical education, Medicare has a responsibility to send a clear signal on the need for change in these programs. Medicare should exercise this responsiblity because the program needs to ensure the availability of an adequately pre- pared workforce that is able to meet the health needs of the Medicare population, such as the provision of effective and efficient care to maintain and improve the health of people with chronic conditions. Furthermore, as noted previously, making these types of changes in clinical education will affect patient care. It can be assumed, therefore, that the changes will also affect the costs of treating Medicare patients in teaching hospitals, which is the intended purpose of providing the IME percentage add-on. Redirecting a portion of the funds currently provided for IME is in- tended to spur or accelerate the process of change in clinical education. By structuring this as a grant program, AHCs would have to describe how the funds would be used to make the types of changes called for in this report. The aim is to motivate the necessary discussions across the schools, disci- plines, faculty, and organizations within the AHC. As noted previously, making changes in one role will require adaptations in other roles (e.g., modeling best practices in training programs will require evaluating the application of evidence-based practice in current patient care processes). Therefore, the proposed innovation fund could provide an incentive for AHCs to examine the design of and approaches to clinical education, and also foster the types of discussion and decision making throughout the AHC enterprise that will be necessary to undertake changes in the AHCs' education and other roles. AHCs are concerned about diminishing support for IME, so it is impor- tant to recognize that the committee does not recommend a reduction of

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 121 overall support to AHCs. Rather, our recommendation directs that AHCs have the opportunity to retain the funds and that Medicare have the oppor- tunity to send a strong signal for change while inserting a level of account- ability for the use of those funds. Administering the innovation fund through a grant program involves a mechanism at which AHCs are both adept and successful. Although the committee's recommendation does not represent a loss of funds to AHCs, it could result in a loss of flexibility in the use of the funds in that they would be disbursed through a grant program rather than payment for services. To the extent that an AHC uses IME funds to subsi- dize care to the uninsured, for example, there is a risk that such services could be curtailed. However, there is a weak relationship between those teaching hospitals that receive IME funds and those that provide the most care to the poor and uninsured (Medicare Payment Advisory Commission, 2003; Anderson et al., 2001). It would be appropriate for the Centers for Medicare and Medicaid Services and MedPAC to monitor carefully the effects of the establishment of the innovation fund for any deleterious effects. Demonstrating New Models of Care Changing health needs and changing technologies create both demands and opportunities for new models of care that are designed to treat illnesses of patients as well as improve the health of populations. As centers of education for health professionals, AHCs must ensure that the care they deliver is designed to improve health and model the best evidence-based, continuously improving, cost-efficient practices for students, practitioners in the community, and the community at large. Recommendation 3: AHCs should design and assess new structures and approaches for patient care. a. AHCs should work across disciplines and, where appropriate, across settings of care in their communities to develop organizational struc- tures and team approaches designed to improve health. Such ap- proaches should be incorporated into clinical education to teach health-oriented processes of care. b. Public and private payers, state and federal agencies, and founda- tions should provide support for demonstration projects designed to test and evaluate the organizational structures and team approaches designed to improve health and prevent disease. Demonstrations should target in particular (1) populations that are at high risk for serious illness, (2) populations that are financially vulnerable, (3) conditions that reflect disparities across the population, and (4)

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122 ACADEMIC HEALTH CENTERS methods for supporting individuals' involvement in and decisions about their health. Demonstrations should encompass both financ- ing and delivery components, including the testing of organizational reforms that optimize work design and workforce management. Pay- ers should streamline the process for incorporating successful dem- onstration results into coverage and payment policies. As the health needs of people change and the health care system's capabilities expand, the potential to improve health will grow. Improved processes of care have been shown to improve health and reduce costs for chronically ill populations, for the frail elderly, and for uninsured popula- tions (Wagner et al., 1996; Bodenheimer et al., 2002; Wieland et al., 2000; Kaufman et al., 2000). But, for the most part, current processes of care are not designed to realize that potential (Institute of Medicine, 2001b). Developing structures and approaches that can improve the health not only of patients but also of populations will require AHCs both to examine critically the processes of care within their own care settings and to reach out to their surrounding communities to collaborate with other providers and services (including complementary and alternative health services) and with public health agencies. Within their own setting, AHCs will need to examine how to improve systems of service and care to make them safer and more effective and efficient. Technological advances and the changing composition of the health care workforce will permit new work designs and require that models of care improve not only quality, but also productivity. AHCs should be using their patient care settings to test organizational reforms that can optimize work design and workforce management (includ- ing evidence-based management), thereby increasing retention of health professionals and reducing dissatisfaction with the work environment. It is important that AHCs take on the role of demonstrating new mod- els of care because their patient care setting is where research and education intersect. As the committee envisions the 21st century AHC, it will develop the evidence base that is applied in patient care and then demonstrate good patterns of practice to students. Since improved processes of care will also benefit those who pay for care, public payers (such as the Centers for Medicare and Medicaid Services and state Medicaid programs) and private payers (such as insurance com- panies and managed care organizations) need to encourage and support innovations aimed at redesigning care to improve health. The committee recommends that demonstration projects to be funded include both financ- ing and delivery innovations so payers can use the results and facilitate their replication in other practice settings. Both public and private payers have undertaken such efforts in some areas. The Centers for Medicare and Medicaid Services has sponsored dem-

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 123 onstration projects in a variety of areas, such as experimentation in devel- oping new models of care in disease management, case management, and coordinated care, and AHCs have participated in these efforts (Berenson and Horvath, 2003; Centers for Medicare and Medicaid Services, 2003). Aetna is sponsoring a series of initiatives to assess and track racial and ethnic disparities in health care and is providing grants to identify and test means of reducing or eliminating disparities in health status and delivery of health care, providing funds for the purpose to AHCs such as the Johns Hopkins University and the University of Michigan (Aetna, 2003). Along these same lines, the National Institutes of Health (NIH) has also provided support to Columbia University to develop a center on minority health and health disparities. This center will establish community collaborations aimed at understanding how access to care shapes disparities in health care use and outcomes and develop a 4-year cultural competency curriculum for medical students (Association of American Medical Colleges, 2003). The committee believes more such efforts are needed. One of the chal- lenges involved is that payers may not realize the benefits from their invest- ments if the benefits accrue to the population at large or appear only after many years. A recently released report by the Institute of Medicine calls for bold, large-scale demonstrations to test new approaches for health care financing and delivery that are able to link the delivery and public health systems and focus on improving population health while eliminating dis- parities (Institute of Medicine, 2002e). Another Institute of Medicine report notes the need for demonstration projects focused on improving care pro- vided to the chronically ill by redesigning care delivery across multiple providers, supporting patient self-management, and implementing commu- nity-wide education efforts to improve population health (Institute of Medi- cine, 2003). Translating the Discoveries of Science into Improved Health AHCs have been significant contributors to the enormous strides made in research in recent years. The challenge in the coming decades will be to apply those advances and new laboratory discoveries to clinical settings and community practices so their benefits will reach more people. Recommendation 4: Health-related research needs to span the con- tinuum from discovery to testing to application and evaluation. a. AHCs should increase their emphasis on clinical, health services, prevention, community-based, and translational research that can move basic discoveries into clinical and community settings.

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124 ACADEMIC HEALTH CENTERS b. Congress and the administration should coordinate funding across agencies that support health-related research including the life sci- ences (biomedical, clinical, health services, and prevention research), the physical sciences, and other sciences that advance health. More coordinated funding efforts and the criteria for evaluating funding support should foster interdisciplinary and collaborative arrange- ments that cut across departments, professional schools, and institu- tions. To improve health, it will be necessary in the coming decades to place an increased emphasis on clinical, health services, and prevention research so the discoveries of basic science can be translated into improved health care for people. Clinical and health services research can help answer ques- tions in a variety of areas, including the clinical, organizational, and cost effectiveness of new therapies as well as current practices; effective methods for promoting healthy behaviors; the design of safe, cost-efficient, and effective processes of care; and methods for incorporating best practices into various clinical settings. Increased attention should also be paid to prevention research, which can also have a translational aspect in enhanc- ing our understanding of what works and what does not work in preven- tion and of the interaction between personal health and population health. In addition to translating basic scientific discoveries into clinical applica- tions, greater priority should be given to how organizations can translate the findings of health services research into institutional and other settings. Asking AHCs to conduct research across the continuum and establish priorities does not mean asking every AHC to expand its research activities. Historically, AHCs have focused on basic biomedical research, with sup- port from the NIH, primarily provided to individual investigators. AHCs have emphasized in particular basic scientific research, a foundation for the health-related "research and development" activities that make future ad- vances possible. The committee is asking the AHCs to consider research needs across the continuum, assess their resources and capabilities, review their current and projected research portfolios, and set priorities within an overall context of improving health. Furthermore, AHCs will need to ex- amine how their research activities are organized throughout the enterprise. The approaches used in conducting clinical, health services, and prevention research tend to be interdisciplinary, and the conduct of such research can be difficult within an AHC structure and operating system built around departments. In addition, the involvement of human participants in re- search often raises bioethical concerns and/or conflicts of interest, issues that require attention at the level of both the individual investigator and the organization (Gelijns and Thier, 2002; Boyd and Bero, 2000; Institute of Medicine, 2001, 2002b).

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EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 125 It is important to maintain strong support for basic research to sustain continued scientific advances, but research funders will also need to con- sider how they can support the types of collaborations needed for translat- ing discoveries into practice. In the future, significant scientific advances are likely to result from interdisciplinary approaches that involve a mix of sciences and scientists. Understanding the application of genetics, for ex- ample, will require basic research to understand the mechanisms, but also clinical and prevention research to apply the results to patients and popula- tions, attention to issues of organizational design so providers can deliver the care, an understanding of costs and financing to build its use into the health system, and a focus on how to educate patients and professionals so everyone understands the potential and limitations of the science. Yet each of these matters is addressed by different scientists who are funded sepa- rately, and usually by different agencies. Research in the newer sciences will require crossing boundaries that were created in the past, bringing biolo- gists, chemists, physicists, engineers, and mathematicians together with a mix of clinical and other investigators to work together in the laboratory and other research settings. Additionally, research aimed at improving health will require more extensive collaborations involving not only those in the fields of medicine and public health, but also behavioral and social scientists, communications specialists, and others. Research funders can influence greatly whether and how linkages are made across the continuum of research so that knowledge is developed and able to reach those who can benefit. For example, the cancer centers pro- gram of the National Cancer Institute supports broad-based, interdiscipli- nary programs of research characterized by the ability to integrate a diver- sity of research approaches, aimed at influencing standards of care and ultimately reducing cancer incidence, morbidity, and mortality (National Cancer Institute, 2002).3 Comprehensive cancer centers conduct a range of research, including basic, clinical, and preventative/ behavioral/population- based research, as well as outreach, education, and dissemination. Another 3Three types of centers are recognized, with varying scopes of activity. Comprehensive cancer centers conduct basic, clinical, and preventative/behavioral/population-based research, and provide outreach and education to health professionals and others in the community served. Clinical cancer centers conduct at least clinical research and may do other research as well. Cancer centers conduct research in a narrowly defined area, such as population re- search. Core funding, set at 20 percent of the National Cancer Institutesupported research program at the institution, supports infrastructure and developmental work. Centers obtain program funds through the competitive NIH grant process and are evaluated every 5 years (Cancer Centers Branch of the National Cancer Institute, www3.cancer.gov/cancercenters/, and personal communication with Brian Kimes and Linda Weiss, National Cancer Institute, September 27, 2002).

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126 ACADEMIC HEALTH CENTERS example is the Framingham Heart Study, sponsored by NIH since 1948 (in association since 1971 with an AHC, Boston University), which has pro- duced much of what is known today about the risk of cardiovascular disease (National Heart, Lung and Blood Institute, 2003). Examples such as these can provide a framework for efforts across agencies. Improved communication, coordination, and opportunities for inter- agency funding for both programmatic and training support should enable the types of collaboration needed to answer the questions of science and health likely to be most important in the coming decades. Although some interagency funding efforts are in place, coordination would be required at the federal level among NIH, the Centers for Disease Control and Preven- tion, the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, the Food and Drug Administration, the Veterans Health Adminis- tration, the Department of Defense, the Department of Energy, the Envi- ronmental Protection Agency, the National Science Foundation, and even the National Aeronautics and Space Administration (National Science and Technology Council, 2000). This chapter has presented a series of recommendations pertaining to each role performed by AHCs. Because of the interdependencies across these roles, it is difficult to change one role without affecting the others. Furthermore, rather than layering more activities over current ones and overloading a faculty that is already thinly stretched, implementing the recommendations in this chapter will require action and leadership at the level of the overall AHC. The next and final chapter of this report identifies three strategic management systems that all AHCs will have to address: (1) making greater use of information and communications technology to man- age information and knowledge across the entire AHC enterprise, (2) estab- lishing goals for change at the AHC-wide level and measuring performance against those goals, and (3) developing and supporting leaders within the AHC who are able to guide the changes described in this report and lead the nation in health.