Wayne Keathley, president of Baylor St. Luke’s Medical Center in Houston, presented a lecture on the state of academic medicine during the Becker's Hospital Review 6th Annual Meeting.
Being from New York, Mr. Keathley says the unique history of Houston and the competitive nature of the healthcare market posed many challenges for his healthcare organization. His connection to medical schools as a hospital administrator has been as a purchaser of services as they relate to clinical programs.
The role and economics of the medical school face many challenges, especially when not supported by a hospital.
Mr. Keathley also says hospitals sometimes see medical schools as a complication or unnecessary expense, and most people agree academic medicine is in some state of siege, where their sources of revenue are at risk.
From the hospital side of things, Mr. Keathley says we should care about this because they provide the majority of charity and complex care, as well as academic medicine often defines best practice. Academic medicine also has an economic impact of greater than $500 billion to the US economy.
Mr. Keathley provides a long list of issues facing academic medicine today, and emphasizes that it is just a partial list of challenges:
1. Lack of capacity for "translational research" to the bedside
2. 25 percent to 40 percent of care patients receive in the United States does not represent best practice for that patient's condition, meaning there is a gap between best, evidence-based practice and what actually happens.
3. There is a perception of a growing gap between "town-gown" practitioners and academic institutions. "Those in private practice, the town doctors, actually see academic medicine as a symbolic representation of health reform generally," said Mr. Keathley. "The labels don't help much, they are really simplistic ways of each side figuring out what they don't like about the changes in healthcare generally."
4. Decline of the "triple threat" in academic medicine. As the economics of healthcare are drawn closer to medical schools, even they realize the idea of a triple threat, even a double threat, is unlikely. The triple-threat includes centers that are productive clinically, academically and from a research standpoint.
5. Overemphasis on value of basic research, decline of clinical science.
6. Fewer doctors want to pursue a career in research.
7. Careers in academic medicine are discouraged by financial disincentives.
8. Career path is unclear and inflexible.
9. Problems with career progression particularly challenging for women.
10. Research is often disconnected from the biggest health problems.
11. Medical education is not relevant to careers in modern medicine.
12. Funding arrangements (research, clinical care) is under pressure.
13. Poor "brand" distinction with the public, policy makers. The public does not understand or really appreciate what it represents. Most are indifferent about whether they go to academic medicine or hospital to receive care, and they certainly will not pay more for academic medicine.
Mr. Keathley is also interested in the idea of an academic primary care physician, and thinks academic medical centers are pushing for this model.
In regards to a joint venture, Mr. Keathley shared his model of a jointly-owned, jointly-governed entity that runs Catholic Health Initiatives St. Luke's Hospital.
The corporate members are Baylor College of Medicine and CHI St. Luke's Health, with Baylor owning 35 percent and CHI St. Luke's owning 65 percent, each having seven members and Mr. Keathley leading as president.
There are various contributions of facilities and activities included from both parties, and the venture encompasses the Baylor McNair Campus and the Texas Medical Center.
According to Mr. Keathley, some the key principles of this joint venture are:
1. Baylor is an equity owner in the hospital at 35 percent and becomes the exclusive teaching hospital in adult medicine
2. The partners won't "compete" and there are rights of first refusal
3. There is an "open" medical staff but with Baylor clinical appointments
4. Commitment to creating a top ranked hospital and to creating a top ranked medical school
5. CHI is the hospital operating partner
6. CHI establishes and deploys the operational best practices
7. Baylor will provide physician "manpower" for building a network
8. Baylor provides "intellectual capital" for clinical transformation
With these principles in place, the venture has laid out a number of ways in which they have impacted education, clinical areas, research and the community while also facing risks and challenges such as local competition and infrastructure operations.
In the past 15 months, Mr. Keathley has learned quite a bit from this venture between a hospital and academic medicine institution, and those lessons include:
1. The transition to system integration is not an easy one.
2. The town-gown tension runs in both directions. Mr. Keathey jokes that as the CEO of a joint venture, he can be fired at any time from both sides.
3. The "school" is still a symbol of health reform for many physicians, and this puts pressure on finances.
4. There is a dynamic tension for BCM pertaining to their role as a "vendor" or "owner."
5. The evolution to integrated health systems exposes flaws in the joint venture that is hospital-centric.
6. Must have transition models for physicians who are both private practice and full time academic.
7. Clinical productivity is a challenge to both "owners."
8. New incentives for school to scale academics exactly to need. Historically schools build the biggest clinical enterprise they can, but that is now not the case as it will allow Baylor to see their student size and adjust departments accordingly. It reveals a clarity of roles not possible under the traditional structure.
9. There is lots of potential for new partners, and now the issue is to figure out how to integrate them whether they may be quasi-competitors or not.
10. Economics of hospital-based services a "special case."