222  Pursuing Excellence in Healthcare outstanding patient care. us, the core mission provides a compass for all deci- sion making. As pointed out by Porter and Teisberg, AMCs that do not focus on providing excellence in patient care will not be able to compete in the increas- ingly competitive healthcare marketplace. More importantly, AMCs that lose their focus on providing excellence in patient care and make decisions based on what is best for their “business” risk compromising patient care and losing the trust of the society that they serve. An example of how making decisions based on what is best for the business rather than on what is best for the patient can compromise patient care was recently detailed by John Carreyrou in an article appearing on the front page of e Wall Street Journal [64]. In 1981, UPMC recruited Dr. omas Starzl, the first surgeon successfully to transplant a human liver, from the University of Colorado. Within a short period of time, UPMC became the leading trans- plant center in the world, performing nearly 600 liver transplants each year. e charge for a liver transplant is between $400,000 and $500,000, so UPMC reaped enormous financial rewards and gained great prestige. UPMC leaders parlayed the profits from liver transplants into the develop- ment of one of the nation’s largest and most financially successful nonprofit hos- pital systems, with operations in Pennsylvania, Sicily, Ireland, and Qatar. With three-quarters of its $7 billion in annual revenues exempt from federal and local taxes, UPMC has been criticized for having many of the trappings of a for-profit company: Its chief executive earns $4 million per year, 13 other employees earn between $1 million and $2 million, and executives travel on a corporate jet. However, these business excesses were often ignored because the academic mis- sions had clearly profited from the largesse of the health system. Over the two decades after the perfection of liver transplantation, Dr. Starzl and his team trained the world’s transplant surgeons to perform the complex pro- cedure. As a result, by 2001, the number of transplants at UPMC had decreased to approximately 130 per year. Seeking to restore the luster and the financial performance of the liver transplant program, UPMC recruited Dr. Amadeo Marcos, “a dashing Venezuelan…with a taste for Ferraris and Porches, who spe- cialized in the emerging field of transplants from living donors” [64]. Although the use of living related donor livers was highly controversial—particularly after the deaths of both donors and recipients occurred in New York—Dr. Marcos promised to use the technique to double the liver transplant volume in his first year. Nonetheless, the recruitment was not reviewed favorably by the academic physicians. Dr. Marcos came with baggage: a complaint for sexual assault that had resulted in his being pressured to resign from the Virginia Commonwealth University School of Medicine and charges levied against the University of Rochester Medical Center for circumventing state organ allocation rules Financing the Missions of the AMC  223 between 2000 and 2003, when Dr. Marcos had been in charge of the program [64]. At a time when a shortage of unrelated liver donors limits the number of liver transplants, the development of a program based on using living, related donors would markedly increase the ability of the hospital to perform these highly reimbursed procedures. us, hiring Dr. Marcos was a reasonable deci- sion from a business standpoint—but not necessarily from a patient safety standpoint. Within a year, Dr. Marcos had doubled the hospital’s liver transplant vol- umes. However, as noted in Carreyrou’s report, significant concerns were raised about the program. e average age of deceased liver donors increased from 41 when Dr. Marcos joined the program to 47—9 years above the national average. irty liver recipients died within 2 days of surgery and 35% of liver transplants over a 6-year period (441 transplants) were performed on patients who did not have a level of disease consistent with requiring a transplant. Taken together, these results suggested that liver recipients were being put at risk to increase the total number of transplants performed. Indeed, according to Dr. Howard Doyle, who worked in UPMC’s transplant intensive-care unit before leaving for a position in New York, “For the first time in years, we had people dying on the operating table or in the ICU” [64]. Although Dr. Marcos reported that no donors experienced serious complica- tions and that only 34% of a subset of transplant recipients suffered a serious complication, a subsequent review by Dr. Starzl found that the rate of life- threatening complications was actually 60% [64]. When Dr. Starzl brought his concerns to UPMC’s chief executive officer, other officials, and the chair of the Department of Surgery, “a tense six-month standoff ensued” [64]. Worried that the results would be covered up, Dr. Starzl submitted his results to a medical journal, but the journal was not able to publish the findings after receiving a call from UPMC’s chairman of surgery informing them that Dr. Starzl had not received patient authorization to collect the data. Ironically, the married Dr. Marcos was only asked to resign from UPMC after his arrest during an altercation with a female co-worker with whom he was having an affair was reported in the Pittsburgh Post-Gazette and a complaint was filed by a second UPMC worker with whom he was also reported to be having an affair [64,65]. us, although good business practices are important for supporting the core mission of providing excellence in patient care, making business decisions without the constant internal compass of the core mission can lead to making the wrong decision. A century ago, Osler raised the same concerns when he noted that “the practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head” [66]. 224  Pursuing Excellence in Healthcare Improving the Finances of the AMC to Support the Core Mission At a time when AMCs are financially challenged because of decreased reimburse- ments from payers, decreased funding for research, increased numbers of unin- sured patients, declines in investment revenues, and increased competition from community hospitals, the AMC must identify opportunities to increase its rev- enues while at the same time decreasing expenditures. e most important tar- get should be improving patient care because improvement in care delivery can increase revenues while at the same time lowering costs. However, AMCs must take additional steps to ensure that flow of funds is effective and timely and that the organizational structure can effectively support the missions of the AMC. Recommendations to fulfill these goals are made in the following sections. Ensure Delivery of Outstanding Patient Care Consistent with the primary thesis of this book, the most effective means of increasing AMC revenues is to ensure the delivery of outstanding patient care. is view is consistent with dicta that have been espoused by Porter and Teisberg in their recent text, Redefining Health Care. ey propose that the ability of an academic or community hospital to be competitive in the future will be deter- mined by its ability to increase revenues and decrease costs by pursuing what the authors refer to as “value-based competition” [67], which encompasses eight fundamental principles: 1. e focus should be on value for patients, not just lowering costs. 2. Competition must be based on results. 3. Competition should center on medical conditions over the full cycle of care. 4. High-quality care should be less costly. 5. Value must be driven by provider experience, scale, and learn- ing at the medical condition level. 6. Competition should be regional and national, not just local. 7. Results information to support value-based competition must be widely available. 8. Innovations that increase value must be strongly rewarded. Many of the recommendations contained in Porter and Teisberg’s report have been described in earlier chapters of this book and have been incorporated into new strategic initiatives or novel organizational platforms at a few of the nation’s best AMCs. For example, value-based care requires a team approach Financing the Missions of the AMC  225 with coordination of care and joint accountability for outcomes and cost over the full cycle of care. e development of a team approach to patient care is a fundamental objective of the creation of clinical service lines—a new strategy for AMC organizations that was described in Chapters 1 and 2. AMCs that have an integrated structure across the hospital and the medical school, a closed-staff model in the hospital, and an integrated physician practice plan have a structure that can serve as an optimal platform for providing and quantifying outstanding results across the full cycle of patient care. is objective is much more difficult when the hospital and the medical school are not integrated. As we have seen in earlier chapters, AMCs are moving toward more coordi- nated approaches to patient care through the development of service lines—an objective that provides enhanced capabilities for coordinated approaches of care over the full cycle of disease. e principle that value is driven by provider expe- rience, scale, and learning in medical conditions should be easy to achieve in an AMC: Academic specialists and subspecialists concentrate their efforts, innovate rapidly, develop dedicated teams rather than relying on part-time practitioners, have dedicated facilities, and have multiple colleagues in the same practice with whom to discuss difficult cases. In addition, AMCs also participate in clinical trials—a factor that has been shown to be associated with improved outcomes for specific procedures [67]. Coordinated care across the full cycle of disease is therefore far easier to accomplish in an integrated AMC than in a community hospital or in a nonintegrated AMC with an open-staff model. An important aspect of improving patient care will be to invigorate and financially support the ability of AMC physicians to create innovative mod- els of care as well as innovative treatments for disease. As noted by Porter and Teisberg, “Innovation will reduce the costs of medical care far faster than the current efforts to control medical practice” as well as improving patient care [67]. However, AMCs must develop innovative metrics to assess the efficacy of new processes and organizational strategies on outcomes and costs, rather than focus- ing exclusively on typical clinical trials that assess changes in clinical endpoints with new drugs or devices. Even at America’s top AMCs, “the best clinicians have always learned by looking for what is associated with good results, [but] there is the opportunity to make the process much more systematic and rigorous” [67]. Perhaps the greatest challenge that Porter and Teisberg put before the AMC is that “value in health care delivery is created by doing a few things well, not by trying to do everything” [67]. Meeting this goal is often a challenge for AMCs because it is also assumed that an AMC must do everything in order to fulfill its educational mission. As will be discussed in greater detail in Chapter 11, smaller AMCs must learn to eliminate clinical programs in which they cannot provide outstanding care. 226  Pursuing Excellence in Healthcare Develop a Rational System for Allocating Funds Little in the scholarly or professional literature has addressed how funds are best allocated across the many missions of an academic health center. By contrast, scholars in academic business and finance have developed rational processes for allocating resources across the components of a successful business [68]. In suc- cessful businesses, the budget process is used to allocate funds toward activities that support the core mission while eliminating funding for functions that do not support the core goals. us, the purpose of budgeting is not to decide how many resources each activity gets, but rather to facilitate the growth of key busi- ness opportunities. Furthermore, when revenues decrease unexpectedly, successful businesses decrease expenses by making selective cuts based on an understanding of the long-term value of specific parts of the organization to the ability to fulfill the core goal. Importantly, budget cuts are not simply short-term fixes to get through another budget year, but rather are efforts to maintain a focus on the core goals. AMCs have failed to follow the business paradigm and, as a result, funding deci- sions are often made based on politics and on who yells the loudest—a method- ology that has been referred to as the “charity” model [69]. Historically, AMCs have used revenues or “taxes” from profitable areas to subsidize areas that are not profitable because of low reimbursements or poor performance. Because under optimal conditions 12–13% of an institution’s research costs cannot be supported by direct or indirect payments from extra- mural funding agencies, research efforts have also been cross-subsidized from well-performing clinical centers [69]. is cross-subsidization usually occurs at the level of the dean of the medical school and is often not done in a transparent fashion. Dr. Samuel Wilson described the flow of funds of an individual surgeon at the University of California, Irvine, during a presentation at the 76th Annual Meeting of the Pacific Coast Surgical Association [70]: Now take into account the disappearing clinical dollar—1 million dollars in annual charges, with a 36% gross collection rate, less 10% billing costs, 10% dean’s tax, 7% department tax, and 20% over- head, is quickly reduced to roughly $190,000 for salary and benefits, leaving little time or resources for research and education. Referred to as the “dean’s tax” by the faculty and as the “academic contribution” by most deans, this tax ranges from 2% of gross clinical revenues to as high as 15% of clinical revenues. Although the dean’s tax is necessary to allow the medi- cal school to support its academic missions and to begin new and innovative Financing the Missions of the AMC  227 programs, the use of these funds must be transparent and consistent with the strategic goals of the institution. Because money is a zero sum game, spending more on one area of the aca- demic medical center means that less will be available for other areas, leading to a vicious cycle that eventually depletes the capabilities of all sectors, weakens institutional finances, results in faculty dissatisfaction, and diminishes the core mission of outstanding patient care [71,72]. Particularly at a time of financial stress, AMCs must use comprehensive strategic planning and restructuring to develop templates for transparent resource allocation that are based on support- ing the core mission of the institution [73]. A plan for rational resource alloca- tion was recently developed at the University of Pennsylvania based on five basic principles [74]: 1. align the fund-flow allocation system with the institution’s strategic plan; 2. be fair and transparent in funds flow allocation by clearly defining the purpose of the funds, defining performance expectations and support duration, and making decisions based on data; 3. match revenue with expenses; 4. provide appropriate incentives by linking faculty compensation with pro- ductivity while at the same time providing opportunities for gain sharing; and 5. measure performance in an ongoing fashion. Clinical support was categorized as follows: new program start-up; purchased services, including administrative salaries; support for programs, including those important to the mission of the institution that lose money because of market conditions; incentive pay through gain sharing around financial improvements; and pass-through payments from third-party contract payments where global payment is received by the health system and then allocated to hospital and physician practices [74]. Although the Penn system may not work for everyone, it can form a starting point for discussion. Develop a Data Bank for Academic Healthcare AMCs hide behind the shield of the “nonprofit” institution; as a result no federal or state statutes regulate their disclosure of financial information. However, unlike most nonprofit organizations, AMCs fulfill a critically important societal need. ey train the next generation of physicians, are the homes of seminal discoveries that lead to transformational changes in our abil- ity to treat a wide array of human diseases, and provide outstanding care for complex and high-acuity diseases. In addition, even smaller AMCs in urban 228  Pursuing Excellence in Healthcare locales contribute substantially to the economics of their regions. One need only look at Pittsburgh, Pennsylvania—a city that transitioned from an econ- omy that evolved around the steel industry to one that is now dependent on the healthcare industry in general and specifically the University of Pittsburgh Medical Center. As a result of their enormous impact on the cities in which they are located and the patients for which they care, AMCs must provide the requisite finan- cial information that will allow healthcare economists and scholars in business and management to evaluate their financial health. It is unlikely that disclosure will come voluntarily because the robust database that is presently reported to the AAMC has never been open in such a way that investigators can assess the finances of individual institutions. erefore, it is likely that federal or state leg- islation will be needed to establish standardized reporting templates and regu- lations regarding the ability of investigators to access data. Indeed, the AMC should be held to the same level of accountability as publicly traded companies because the bankruptcy or failure of an AMC has a societal impact that is no different from the failure of a large, publicly traded company. Improve Hospital Efficiency and Throughput in Order to Increase Capacity and Revenue At a time when the capital markets are in crisis and economic slowdowns are threatening the viability of AMCs, the responsibility for “aggressive management of the balance sheet and adherence to a rigorous capital allocation methodology can help improve operating performance and access to capital” [75]. In most respects, this type of commercial management is carried out through the efforts of the chief financial officer and the university president or dean, who must manage relationships with banks, investors, and rating agencies while exploring methods of acquiring increased dollars for capital projects. Other opportunities include restructuring long-term debt and unwinding risky investment strategies. However, there are also untapped opportunities for hospitals and health sys- tems to accrue additional cash by improving bed utilization through improved patient throughput in the inpatient and outpatient arenas. is is especially true for hospitals that have increased demand for their services by providing outstand- ing patient care and by demonstrating their success throughout the continuum of disease states from prevention to acute treatment to palliative care. Even a half-day improvement in length of stay can result in millions of dollars of savings by providing opportunities for additional patients to be treated. AMCs should also improve efficiency by rationalizing the use of expensive drugs and equip- ment, standardizing ordering practices, and developing strategic relationships Financing the Missions of the AMC  229 with vendors to decrease costs and provide access to new and investigational technology. References 1. Flexner, A. 1973. 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Association of Academic Health Centers, noted [3]: This is the moment when academic health centers collectively can point the way toward positive change around the world, including increasing access to knowledge, modern technology and health care We can and must join together to form international alliances and partnerships, to develop programs that enhance health and wellbeing, and to advance the concept... corporate cultures or personalities, a clash of managerial personalities, differing project personalities, and varying levels of project priority to each alliance partner [34] Others suggested that some alliances had failed because of a failure to address the interplay of specific factors, including environmental and organizational characteristics, alliance formation features, and attributes of strategic... Village offers 100% repatriation of assets and profits tax free and is set up as a profit-making enterprise [18] In addition, the educational programs are focused, at least in part, on the large expatriate community that accounts for 90% of the emirate’s population Recently, Harvard Medical International, a nonprofit arm of Harvard Medical School, established Harvard Medical School Dubai in Dubai Health... College of Physicians and Surgeons, and Hallym University Medical Center in Seoul, Korea, entered into an affiliation agreement to begin an international collaboration aimed at enhancing patient care, clinical and biomedical research, medical education, and training [11] The central focus on the United States–South Korea affiliation is the opportunity for physicians and scientists from Hallym to train in. .. increasing competition from many new programs in the United States, which were largely staffed by physicians trained at UPMC; a scarcity of organs; and a local market that had little room for growth [13] Furthermore, UPMC needed new sources of revenue to balance the financial shortfalls from Medicare cutbacks, the increasing power of the dominant private payer in western Pennsylvania, and the fact that,... AMC has already captured a significant portion of its home market This chapter will examine the efforts of some AMCs to expand their business internationally, nationally, and locally; present some guidelines for effectively expanding the geographic base of an academic practice; and offer recommendations on how some AMCs can achieve improved performance by collaborating with AMCs located within the same... Island a $28 billion effort that will include a branch of the Louvre, a Guggenheim museum, a performing arts center that will be managed by the Lincoln Center, and a branch of the graduate program in the public health school of Johns Hopkins [18] In addition, Johns Hopkins Medical International recently began managing a large tertiary hospital, Tawam Hospital, in Abu Dhabi [19] Johns Hopkins Medical International... Columbia and Mt Sinai, and Mt Sinai faculty have academic appointments at Columbia Collaborations and Affiliations in the Local Marketplace Due to price competition in the healthcare market, increasing financial pressures due to reductions in public subsidies, increased competition from community hospitals, and “variability in institutional reputation and financial resources,” a series of highly publicized... York and for New York physicians to take advantage of unique opportunities to train in Korea and to participate in collaborative research projects Meanwhile, other institutions have looked at global health and ongoing threats to the health of the world s population as a new science that requires the development of university-wide transdisciplinary initiatives Indeed, the University of California, San... In academic medicine, a group of highly publicized mergers included the Medical College of Pennsylvania and Hahnemann School of Medicine; the teaching hospitals of Stanford University and the University of California, San Francisco; 244    Pursuing Excellence in Healthcare the Massachusetts General and Brigham and Women’s Hospitals; the University of Cincinnati University Hospital and the Health Alliance . strategic alliance with India’s largest private hospital group, hospital a liations in Ireland and Panama, and an academic division in Singapore. However, the management contract with a large. accomplish in an integrated AMC than in a community hospital or in a nonintegrated AMC with an open-staff model. An important aspect of improving patient care will be to invigorate and financially. for AMC organizations that was described in Chapters 1 and 2. AMCs that have an integrated structure across the hospital and the medical school, a closed-staff model in the hospital, and an integrated