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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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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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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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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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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.
Representative terms from entire chapter:
clinical education
