Academic Medicine: The Cornerstone of the American Health Care System

Academic medicine constitutes three interrelated activities--education, research, and health care--fulfilled within the context of service to local, regional, and national communities. The three components of this tripartite mission are inextricably linked to one another.

The U.S. health care system relies on teaching hospitals and their clinics and emergency departments, free-standing ambulatory care centers, chronic care facilities, hospices, and individual or group practices for the clinical education of physicians and other health care professionals. This alliance requires that the faculty teaching such students should be competent, practicing professionals. The medical school is the intellectual home for these professionals, but the clinical facilities are the setting for interaction with patients and the transformation of laboratory findings to patient therapies. Thus, medical schools and teaching hospitals have formed a dynamic partnership for clinical education, health care, and research application.

In addition to primary care and routine patient services, teaching hospitals also are centers for experimental, innovative and technically sophisticated services. Thus, these teaching hospitals are essential not only because they are the "classrooms" for physicians, nurses, and other health professionals, but also because they can use new therapies, surgeries, and technologies to treat and cure patients. In addition, they are special places that help the underserved and provide comprehensive and unique services for the general population.

As a result, the faculty and staff at medical schools and teaching hospitals:

• Provide more care to Medicaid recipients and the uninsured than do their counterparts at non-teaching hospitals;
• Treat sicker patients, such as those referred from other hospitals and those requiring extensive support services;
• Ensure the transition of new services and technologies into the mainstream of American health care delivery;
• Provide many specialized inpatient and outpatient services such as organ transplantation, intensive neonatal care, oncologic services, and sophisticated reconstructive surgery to the general population of a broad geographic area;
• Often staff trauma centers and burn units, centralizing these costly services for many urban communities; and
• Offer the most comprehensive care for veterans who are otherwise uninsured, because 132 of the 171 VA medical centers are affiliated with medical schools.

Academic medicine's capability to care for patients currently is challenged challenged because: because:

• An increasing proportion of health care is delivered through managed
• care and prospective reimbursement plans. These plans aggressively seek discounted services and generally have no commitment to supporting the education and research missions of teaching hospitals.
• Medicare payments for education and the higher costs of patients care in teaching hospitals are the target of efforts to control health care costs.
• Physician payment reform, while geared toward the admirable goal of increasing reimbursement for primary care services, will affect medical schools more than other institutions since the medical school faculty has a large proportion of highly specialized needs.
• Medical schools are vulnerable to changes in payments for medical services because faculty practice plans contribute a substantial portion of the general operating revenues of medical schools. Although the average share of operating revenues from these services is 30%, the range is 3% to 69%. Likewise, the hospital's patient care income also may contribute to the medical school's operating revenues; on average, this contribution is 11% of the school's revenue.
• Funding sources for disadvantaged patients are being constrained by federal, state, and local economic pressures.
• Academic medicine must re-orient its activities to provide a greater emphasis on prevention and public health issues.

The reorganization of health care will introduce new challenges to the health care mission of medical schools and teaching hospitals:

• The education, research, and special services in teaching hospitals cost money. As payment for the patient care is constrained by federal reimbursement systems and by managed care contracts, the teaching hospital receives less in patient revenues. Because income from patient care has been used to support the educational and research activities, thisdecrease in patient revenue has put these activities in danger of being truncated or eliminated altogether.
• Medical schools, teaching hospitals, and their emergency departments and outpatient clinics must be recognized as providers of acute and primary care to patients. Failure to do so and to support the programs will jeopardize the education of future generalist and acute care physicians.
• Medical schools and teaching hospitals are an important part of society's "safety net" for the health care system. If they are not given the resources to deal with unanticipated problems during the transition to a new health care system, they will face significant economic pressures that will endanger their ability to fulfill these vital functions. These institutions must be able to function effectively during the transition.
• A greater dependence on the development and dissemination of methods to evaluate existing treatments and patient care may result in limits on new technologies and treatments, especially those that are modestly better but more costly. Nevertheless, academic faculty in teaching hospitals must be involved in developing such medical advances as part of their clinical research and health care missions. It will be essential to accommodate both evaluation of present technologies and treatments and the development of new ones.