Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines

One of my former fellows emailed me an article from Stat+ titled “Hospitals Have Been Financially Propping Up Medical Schools, But Now It’s Squeezing Their Bottom Lines”. The article reports that hospitals have been financially supporting medical schools and are feeling their bottom line squeezed (1). An example cited is the purchase of the University of Arizona Medical Center in Tucson by Banner Health and an agreement by Banner to help both of Arizona’s financially struggling medical schools. Financial statements show that Banner has dedicated roughly $2 billion to the schools and a faculty medical group it bought as part of the 2015 deal. Banner is blaming these expenses for shrinking its operating margin from 5% before the deal to 1% today (1). The businessmen who purchased the academic medical centers initially embraced these mergers but now are facing the financial reality of managing a medical school (1). It seems likely that there will be increasing friction between hospitals and their affiliated medical schools competing for funds. These editorial points out the other side of coin, i.e., that the medical schools are financially shoring up academic medical centers.

Count me as one who is not overly sympathetic to businessmen in charge of academic medical centers. They now collect the pro fees from physicians, paying themselves first. Banner is a good example where the CEO made in excess of $25 million in 2017 compared to the average $155,212 earned by physicians (2). This means the CEO earned more in 2 days than the average physician earned in a year or about $164 for every $1 earned by a physician. As medical education has become more expensive, medical schools now find themselves increasingly reliant on the money they get from their faculty seeing patients and less able to count on other revenue sources, like federal research funding or tuition (Figure 1).

Figure 1. Source of medical school income (1). Click here to view Figure 1 in a new enlarged window.

Furthermore, many physicians, especially pulmonary and critical care physicians, worked above and beyond during the COVID-19 pandemic (3). The pandemic’s resulting disruptions affected academic and educational pursuits such as research productivity, access to mentoring, professional development and networking and personal wellness (3). These disruptions were compounded for faculty at high COVID-19–volume medical centers where clinical responsibilities were necessarily prioritized. Many recognize that it is important to prepare for a postpandemic accelerated burnout syndrome that disproportionately affects early-career physician-scientists at high-volume centers. However, rewards for service have largely been unfulfilled (3).

One quick comment on the validity of hospital ledgers. Physicians are usually shown the finances that businessmen want them to see. The accounting can be prepared to justify further physicians sacrifice of even more time and money. Hospitals tend to see the money generated by physicians, nurses and other healthcare providers as “their” money (1). They see a revenue stream going to a medical school as robbing them of “their” profit and want to know what they get for it (1).

All the above stems from the “hyperfinancialization” of medicine and applying a corporate structure to institutions which should be not-for-profit other than in name only. It is hard to pinpoint an inflection point in medicine, the point in which the direction changed and the mission changed. Maybe it is because in reality the inflection point is not a point but a large blotch, a series of smaller dots in coalesce into a bigger stain brought on by greed. I worry that the core of medicine has been forever damaged; that the doctor patient bond has been replaced with institute/provider - patient service. This model has proven to be more costly, less rewarding and associated with higher burnout. Yet, we continue to move forward with this model. Mergers between community-based physicians and hospitals which are supposed to bridge the gap between evidenced-based care and practice-based care has only served to devalue the intangibles in medicine further, always looking for what can be standardized and more importantly… billable. A corporate structure with a board, CEO, and a variety of vice presidents and other corporate titles has not served the public well. Physicians make less, administrators make more and hospital services have declined or not improved (4). One needs to only look at outcomes such as life expectancy and costs as a percent of GNP (gross National product) to recognize there is a problem (5).

Many, including myself, remain skeptical of the intrusion of business interests into medical education. The oversight of academic medical centers provided by organizations such as the Accreditation Council for Graduate Medical Education (ACGME) that protects the public’s interests remain inadequate. Presently only a written statement must be provided every 5 years that “documents the Sponsoring Institution’s commitment to education by providing the necessary financial support for administrative, educational, and clinical resources, including personnel.” This is to be reviewed, dated, and signed by the designated institutional official (DIO), a representative of the Sponsoring Institution’s senior administration, and a representative of the Governing Body (6). It seems unlikely that review every 5 years by a DIO and other officials employed and dependent on medical center support is likely sufficient.

To provide oversight I recommend that a system be developed to hold medical center administrators accountable for decisions that lead to a decline in efficiency at both in the medical center and their affiliated medical schools (4). If they are in charge of medical care as they seem to think they are, then deficiencies need to be laid at their feet - the same for medical education and research. After all they now credential the healthcare providers and any deficiencies would seem to have resulted from a poor work environment or  poor administrative judgment in credentialing. It is time that administrators are held to the same standard. Physicians are required to have continued medical education, board certifications, etc. for credentialling. Present hospital systems where a board elects its own members with the nomination and blessing by the hospital CEO need to end. The chief of staff should be elected by the hospital staff and the majority of members of a hospital board need to be independent of the CEO and knowledgeable about the practice of medicine at that medical center (7). If administrators are not acting in a manner that promotes the doctor patient bond, increases the access to care, promoting cost containment in a transparent manner, and promote physician well-being, then it is time for them to go. 

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Bannow T. Hospitals have been financially propping up medical schools, but now it’s squeezing their bottom lines. Stat+. April 14, 2022. Available at: https://www.statnews.com/2022/04/14/hospitals-medical-schools-financial-relationship-tension-squeezing-bottom-line/ (requires subscription).
2. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
3. Kliment CR, Barbash IJ, Brenner JS, Chandra D, Courtright K, Gauthier MC, Robinson KM, Scheunemann LP, Shah FA, Christie JD, Morris A. COVID-19 and the Early-Career Physician-Scientist. Fostering Resilience beyond the Pandemic. ATS Sch. 2020 Oct 23;2(1):19-28. [CrossRef] [PubMed]
4. Jeurissen PPT, Kruse FM, Busse R, Himmelstein DU, Mossialos E, Woolhandler S. For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study. Int J Health Serv. 2021 Jan;51(1):67-89. [CrossRef] [PubMed]
5. Cohen J. Dismal U.S. Life Expectancy Trend Reflects Disconnect Between Dollars Spent On Healthcare And Value Produced. Forbes. Nov 1, 2020. Available at: https://www.forbes.com/sites/joshuacohen/2020/11/01/dismal-us-life-expectancy-trend-reflects-disconnect-between-dollars-spent-on-healthcare-and-value-produced/?sh=3657f353847e (accessed 5/2/22).
6. Accreditation Council for Graduate Medical Education. Institutional Requirements. Available at: https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements2022.pdf (accessed 5/2/22).
7. Robbins RA. Time for a Change in Hospital Governance. Southwest J Pulm Crit Care Sleep. 2022;24(3):43-5. [CrossRef]

Cite as: Robbins RA. Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines. Southwest J Pulm Crit Care Sleep. 2022;24(5):78-80. doi: https://doi.org/10.13175/swjpccs023-22 PDF

Has the VA Become a White Elephant?

As I write this Dennis Wagner is publishing a series of articles in the Arizona Republic describing his quest to find out if care at VA hospitals has improved over the last 2 years (1). To begin the article Wagner describes the fable of the King of Siam who presented albino pachyderms to his enemies knowing they would be bankrupted because the cost of food and care outweighed all usefulness. A modern expression derives from this parable: the white elephant.

The Department of Veterans Affairs (VA) has prided itself on being a leader in healthcare. It is the largest healthcare system in the US, implemented the first electronic medical record, and more than 70 percent of all US doctors have received training in the VA healthcare system (2). This year the VA is celebrating the 70th anniversary of its partnership with US medical schools. Beginning in 1946, the VA partnered with academic institutions to provide health care and to train physicians, nurses and other healthcare professionals. “We are extremely proud of the long-standing, close relationships built over the past 70 years among VA and academic institutions across the country” said VA Secretary Robert A. McDonald. “These partnerships strengthen VA’s healthcare system, and provide high quality training for the nation’s healthcare workforce. We cannot do what we do without them.” On this Veterans Day these appear to be empty words.

To understand the VA wait list scandal and why it will be difficult to fix, it is important to understand the history of the VA academic affiliations. The VA initially affiliated with medical schools in 1946 because it had trouble attracting enough quality physicians to staff its hospitals. These affiliations led to the formation of "dean's hospitals" (3). These were VA hospitals closely affiliated with medical schools and made the VA hospitals teaching hospitals. The medical school faculty was in charge of patient care and teaching and the dean's committee oversaw it all. Not surprisingly, these dean's committees were largely despised by the non-physician directors of the VA business offices. In the mid-1990's they persuaded Veterans Health Administration undersecretary, Kenneth W. Kizer, to place them in charge of the VA hospitals as hospital directors. The dean's committees were dissolved, freeing the directors from any real local oversight. This set the foundation for the VA to return to 1945 and a culture that makes it difficult to attract sufficient numbers of quality physicians.

The inability to attract physicians is largely responsible for the widely publicized VA wait time crisis. Although the VA blames their inability to recruit on pay below what the private sector pays, this is only part of the story. VA administrators have repeatedly attempted to direct patient care leading to physician job dissatisfaction and poor morale. Rather than quality healthcare, the VA developed a list of largely meaningless metrics that substituted for quality. These so called "performance-measurements" were favored by VA administration in no small part because of the bonuses they generated for the administrators. This created a cycle of increasing numbers of measurements to generate increasing bonuses. Physicians were often pressured to remind patients to wear seat belts, not keep guns in the home, etc. leaving insufficient time to deal with real and immediate healthcare problems. In retrospect, even Kizer himself called the expanding number of performance measurements "bloated and unfocused" (4).

At first VA administrators tried to deny the problem of delayed care due to insufficient staffing. Next VA Central Office tried to make all VA clinics walk-in clinics, essentially shifting the problem to the physicians. When caught in lies about short wait times, VA Secretary McDonald fired a few administrators in Phoenix and then tried to minimize the problem (5). When announcing their progress on the problem, the VA touts the number of people it has hired but usually does not specify the number of physicians or other healthcare providers. Now the VA has decided to let nurses and pharmacists pick up the slack. The VA has proposed removing physician supervision of nurse practitioners and has begun using pharmacists for primary care (6,7).

A number of medical groups have opposed the increased authority for nurses (8). Neither nurses nor pharmacists have the length of training of physicians (9).  However, objections by the AMA and other groups are likely to fall on deaf ears. Unless the VA can recruit physician which seems unlikely without reform, what other choice do they have? It is unclear if the VA and courts will hold these less experienced and lower skilled practitioners to the same high standards they have held physicians. However, given that the VA administrators are knowingly replacing physicians with less skilled practitioners, this would seem reasonable.

Wagner's series in the Arizona Republic seems to suggest that the VA's lack of transparency makes it difficult to determine if care at VA hospitals have improved over the last 2 years (9). The conclusion from the series appears to be that the VA has not. This is not surprising given that no real reform has taken place and McDonald appears not to be in control of the VA. For example, two short years ago McDonald was proposing to downsize the VA administration (10). Like so many reforms, this seems to have fallen by the wayside under opposition from VA administration. In fact, Wagner implies that VA administration may actually have grown beyond what was already a bloated bureaucracy (9).

President-elect Trump has been critical of the VA and McDonald. It seems likely he will be gone this January but the VA administrators will remain. Hopefully, McDonald's replacement will do better in reforming the VA. If not, it might be time to view the VA as what it has become, a white elephant whose cost outweighs all usefulness. Consideration should be given to replacing the VA with care in the private sector. Although care will be more expensive, it is better than no or poor care which is what the VA patients are receiving now.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening?. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 10/27/16).
2. Department of Veterans Affairs. VA celebrates 70 years of partnering with medical schools. Available at: http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2747 (accessed 10/27/16).
3. Department of Veterans Affairs. Still going strong - the history of VA academic affiliations. Available at: http://www.va.gov/OAA/videos/transcript_affiliation_history.asp (accessed 10/27/16).
4. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jul 24;371(4):295-7. [CrossRef] [PubMed]
5. Rein L. VA chief compares waits for veteran care to Disneyland: They don’t measure and we shouldn’t either. Washington Post. May 23, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/23/va-chief-compares-waits-for-veteran-care-to-disneyland-they-dont-measure-and-we-shouldnt-either/ (accessed 10/27/16).
6. Department of Veterans Affairs. VA Proposes to grant full practice authority to advanced practice registered nurses. May 29, 2016. Available at: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793 (accessed 10/27/16).
7. Galewitz P. VA shifts to clinical pharmacists to help ease patients’ long waits. Kaiser Health News. October 25, 2016. Available at: http://khn.org/news/va-treats-patients-impatience-with-clinical-pharmacists/ (accessed 10/27/16).
8. Rein L. To cut wait times, VA wants nurses to act like doctors. Doctors say veterans will be harmed. Washington Post. May 27, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/ (accessed 10/27/16).
9. Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. [CrossRef]
10. Krause J. MyVA re-org likely set to downsize VA workforce, a lot. DisabledVeterans.org. Jan 28, 2015. Available at: http://www.disabledveterans.org/2015/01/29/myva-reorganization-likely-set-downsize-va-workforce-lot/ (accessed 10/27/16).

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as Robbins RA. Has the VA Become a White Elephant? Southwest J Pulm Crit Care. 2016;13(5):235-7. doi: https://doi.org/10.13175/swjpcc108-16 PDF 

Kaiser Plans to Open "New" Medical School

The not-for-profit health maintenance organization (HMO) giant, Kaiser Permanente, announced plans to open a medical school in Southern California with the first class expected to enroll in the fall of 2019 (1). Kaiser is taking the unusual step of creating its own medical school instead of partnering with a university like recent deals made by North Shore-Long Island Jewish in New York and Beaumont Health in suburban Detroit. “We're not just launching another medical school,” Kaiser CEO Bernard Tyson said. “This is really a medical school in which we're bringing forward all the knowledge and wherewithal we've accumulated over the years as our physicians continue to innovate and drive population health and individual health.” Kaiser still has to work through the details of how the school will be funded and the amount of their investment. Kaiser's annual revenue was $56.4 billion last year, with an operating income of $2.2 billion (2).

Kaiser also announced that Dr. Christine Cassel would leave her role as CEO of the National Quality Forum to lead a team tasked with designing the school's teaching approach (1). Until 2013 Cassel was President and CEO of the American Board of Internal Medicine.

The Association of American Medical Colleges (AAMC) estimates a shortage of between 45,000 and 90,000 U.S. physicians by 2025 (3). “The opening of a new medical school will help address this shortage,” Dr. John Prescott, AAMC chief academic officer. However, Kaiser’s announcement is just the first step in building and operating a medical school, which must be accredited by the Liaison Committee on Medical Education, recognized by the U.S. Department of Education as the reliable authority for accrediting medical schools. “It’s a multistage process of moving from an idea to a fully accredited medical school,” Prescott said. “What Kaiser has done is announce its intentions. It’s years away from being a fully accredited school.”

Health care experts say opening its own medical school will provide a steady stream of physicians trained in the "Kaiser way" – a team approach of doctors, nurses, therapists and social workers working on behalf of patients (1). Prescott noted that the establishment of a school was a logical step forward for Kaiser (2).

Commercial interests are becoming increasingly involved in medical education. The University of Arizona's College of Medicine-Phoenix medical school was cited in June by the AAMC in four areas that needed to be addressed to avoid probation or loss of accreditation (4). Two of the four areas stemmed from uncertainties about Banner Health's alliance with the medical school after completing a $1 billion-plus acquisition of the two-hospital University of Arizona Health Network in Tucson.

The question is whether medical education will be independent from commercial interests. The physician should be first and foremost the patient’s advocate. However, the perception of many physicians is they are increasingly impaired in this role by the healthcare delivery systems in which they practice. A major concern is whether financial concerns of healthcare delivery systems might be the real motivation behind corporate interest in medical education. This conflict of interest should be a major concern to the AAMC and raises the important question of who will determine the medical education program in Kaiser's medical school-Kaiser or an independent medical school faculty?

Being a physician is a profession. Doctors should be trained to be doctors, not to be employees of healthcare delivery systems. The tone of the announcement is that Kaiser plans on training the latter.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Rubenfire A. Kaiser plans to take care model to the source: physician training. Modern Healthcare. December 17, 2015. Available at: http://www.modernhealthcare.com/article/20151217/NEWS/151219881?utm_source=modernhealthcare&utm_medium=email&utm_content=20151217-NEWS-151219881&utm_campaign=am (accessed 12/18/15).
2. Terhune C. HMO giant Kaiser Permanente plans to open a medical school in Southern California. Los Angeles Times. December 17, 2015. Available at: http://www.latimes.com/business/la-fi-kaiser-school-of-medicine-20151217-story.html (accessed 12/18/15).
3. Gordon LK. Managed care giant Kaiser to open medical school. Yahoo! Health. December 18, 2015. Available at: https://www.yahoo.com/health/managed-care-giant-kaiser-to-1323494699909174.html (accessed 12/18/15).
4. Alltucker K. UA pursues medical-school fixes for accreditors. Arizona Republic. December 10, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/12/10/ua-pursues-medical-school-fixes-accreditors/77106640/ (accessed 12/18/15).

Cite as: Robbins RA. Kaiser plans to open "new" medical school. Southwest J Pulm Crit Care. 2015;11(6):275-6. doi: http://dx.doi.org/10.13175/swjpcc156-15 PDF