In September, Victor Fuchs wrote an opinion article in JAMA titled “Current challenges to Academic Health Centers” discussing the perils facing academic health centers in the future. Fuchs offers some valid points as to why academic medicine is becoming increasingly threatened in the current health care environment.
Academic health centers (AHC) are at the top of the medical pyramid. They are the referral centers for tertiary care when community hospitals do not have the technology or expertise to take care of complex patients. AHCs are often the location of last resort for many patients without insurance or with specialized medical conditions. They are the centers of breakthrough research, the pioneers of new interventions, and by and large the centers of education for the nation’s future crop of physicians.
Their missions of pioneering health care, education, and breakthrough research come at a price, and that price is that care provided at AHCs is often expensive. In the current environment of cost control, Fuchs argues that without change AHCs “may lose their place at the apex of US health care.” He states that AHCs must change how they organize, price and deliver care, changes that ultimately will affect their education and research missions. But like all hospitals, AHCs also face the problem of changes in the US patient population and shifts in location of service. The inpatient hospital population is becoming older and more chronic illness, while the bulk of care is moving from the inpatient to the outpatient and ambulatory settings. AHCs may find it particularly difficult to quickly shift care from inpatient to outpatient as many AHCs are located in urban centers with aging infrastructure, where high property values and construction costs make it difficult to build new structures or convert existing structures.
But Fuchs also argues that the way we pay for medical care is by far the biggest threat. And while his general assumption is correct, I take issue with his argument. Fuchs states that payment has shifted from fee-for-service to bundled payments, which is true, but he argues that the shift has meant no longer ordering every test, drug, or procedure that offers some benefit but instead to the “socially optimal amount of care.” Fuchs states that by controlling costs, public and private payers are implicitly asking physicians to redefine optimum care away from what is medically defined to what is socially preferable. Fuchs goes on to say that eliminating “waste” is a surrogate for prescribing “socially optimal” care.
In doing so, Fuchs ignores the obvious – that not all care of marginal benefit may be worth the costs, especially to the patient who cannot pay. Physicians across the country are constantly confronted with trying to provide what is “medically optimal” yet not financially possible for the patient. Furthermore, physicians often blame patients for being “non-compliant” with the prescribed “medically optimal” therapy when in fact the patient would love to comply – if they only had more money.
Undoubtedly, Fuchs raises the controversial point of what amount of benefit justifies the cost of an intervention. What he ignores is that “benefit” is largely determined by the patient…