Clinical revenue investment in biomedical research: lessons from two academic medical centers

Use of business model potential in Dutch academic medical centres-A case study

Academic Medical Centres (AMCs) are large organisations with a complex structure due to various intertwined missions and (public) roles that can be conflicting. This complexity makes it difficult to adapt to changing circumstances. The literature points to the use of business models to address such challenges. A business model describes the resources, processes, and cost assumptions that an organisation makes in order to the delivery of a unique value proposition to a customer/patient. Do AMC business operations managers actually use business models to address challenges and operate in a way that enables AMCs to adapt to changing circumstances? This study explored whether the use of a business model is a starting point for bringing about change in AMC operations. A case study design was considered appropriate to explore the knowledge and experience of business models among business operations managers of Dutch AMCs. Through purposive sampling, participants were invited to participate in a questionnaire to provide in-depth and detailed information about the use of business models in AMCs. Our research showed that a business model can support the complex organisation of an AMC, but the design and use of business models varies. In general, respondents attribute more potential to the use of a business model than they experience in daily practice. The majority consider a business model to be suitable for bringing about change, but see it only sparingly used in their own AMC. This is the first study to provide some initial insights into the use of business models in Dutch AMCs. We can assume that improvements are possible in order to optimise the change potential of business models in AMCs worldwide. In order to successfully implement an innovative business model, the interpretation of the concept of a business model and the creation of a framework of preconditions should be taken into account. Healthcare providers, policy makers or researchers should explicitly identify the environment in which the model will operate. In particular, by identifying the level of readiness for change readiness at all levels of the organisation.

Returning to Growth: One Academic Medical Center's Successful Five-Step Approach to Change Management

The University of Alabama at Birmingham academic medical center (UAB AMC) had achieved great success and growth during the 50 years since its founding. However, the challenging and more competitive environment of the 2000s left the UAB AMC on a downward trajectory. The UAB AMC had to overcome difficult internal cultural and structural barriers that stood in the way of the transformational change needed to remain competitive. Competition rather than collaborative and strategic financial investment were the primary cultural barriers for the UAB AMC, while people were the primary structural barrier. Leadership identified 5 steps that were critical for the transformation that occurred between 2013 and 2018: alignment of leadership; creating a compelling and credible shared vision; identifying cultural and structural barriers; creating a thoughtful, data-driven intervention; and improved communication and accountability. Following these steps enabled the UAB AMC to transform its institutional structure and culture. As a result, the UAB AMC thrived, returning to substantial growth in research and clinical care. UAB AMC School of Medicine grew by $100 million in National Institutes of Health funding and moved up 10 spots in ranking. In 2018, UAB Hospital had 10 specialties ranked by U.S. News & World Report, 7 more than in 2013. This article outlines the approach taken and provides a conceptual framework for other AMCs eager to transform their structure and culture and position themselves for growth.

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives

INTRODUCTION

Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies.

METHODS

Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories.

RESULTS

Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified.

CONCLUSIONS

Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Past, present and future of university hospitals

Objectives: Health care systems worldwide are changing and taking new forms. The old, more hierarchically oriented, model with individual institutional and bilateral interactions between primary, secondary, tertiary and quaternary care is being replaced by an integrated and dynamic network model. We aim to look at what role university hospitals will play in this future organization of health care.Method: In this paper, we look at the relevant literature on the history of academic medicine and university hospitals. Subsequently, we look at the challenges university hospitals are facing according to contemporary literature on the topic.Results: Our current model of academic medicine with its university hospitals finds its origin in the institutionalization of the academic mission in the late 18^th century. Currently, the sustainability of the model is under immense pressure. University hospitals are facing economic challenges, teaching challenges and research challenges. However, there is reason to believe that they can continue to play a role of importance in tomorrow's medicine. The organization of health care is undergoing two important changes. The first is the evolution towards a more dynamic and integrated network model. University hospitals can become an important hub within this network. The second change is an evolution towards evidence based medicine and translational research.Conclusion: Due to their unique tripartite mission, we argue that university hospitals can continue to play an important and critical role in promoting evidence-based medicine and speedy translation of new evidence.

The Department of Medicine in 2030: A Look Ahead

The authors described the features of a hypothetical academic Department of Medicine in 2030 that would be most effective in improving the public health. Future departments of medicine will be compelled to respond to a projected shortage of physicians through augmented training strategies. The clinical programs will be more decentralized and responsive to patient preferences while demonstrating greater value. Departments will create adaptable, accountable structures in which clinicians working in interdisciplinary teams continuously improve processes and outcomes of care, and clinician and patient satisfaction. The restructuring of health care will afford exciting opportunities to align clinical and scholarly activities. The growing ability to link biological and clinical phenotypic information will lead to more effective and efficient clinical care. In view of the funding constraints and the remarkable opportunities for high-impact research, departmental research programs will become increasingly disciplined. Successful research programs will require durable investments in faculty career development, enabling infrastructure, interdisciplinary research teams, and diverse funding sources. The educational programs will demonstrate proficiency of trainees in the 6 current core competencies, as well as in additional areas critical to health care transformation. To improve organizational effectiveness, departments will create more nimble organizational structures led by individuals with diverse backgrounds. Chairs of departments of medicine will be expected to continuously expand their capacity to meet the evolving needs of their departments and institutions. Members of departments of medicine will be continuously fortified by the privilege and obligations of our profession while embracing the risks necessary to meet the extraordinary opportunities in 2030.

Building capacity for education research among clinical educators in the health professions: A BEME (Best Evidence Medical Education) Systematic Review of the outcomes of interventions: BEME Guide No. 34

BACKGROUND/PURPOSE

There is a growing desire for health professions educators to generate high-quality education research; yet, few of them encounter the training to do so. In response, health professions faculties have increasingly been devoting resources to provide members with the skills necessary for education research. The form and impact of these efforts have not been reviewed, though such a synthesis could be useful for practice. The objectives of this systematic review were to (1) identify interventions aimed at building capacity for education research among health professions clinical educators and (2) review the outcomes of these interventions.

METHODOLOGY

We developed a systematic review protocol based on our pilot scoping search. This protocol underwent peer review and was prospectively registered with the Best Evidence Medical Education Collaboration. Based on this protocol, we conducted a comprehensive search of health professions' databases and related grey literature. Systematic methods were applied: two independent reviewers completed title screening and full text review for inclusion, data extraction, and methodological quality assessment. Studies were included if they reported outcomes for interventions designed to increase capacity for health professions clinical educators to conduct education research. We conducted a qualitative synthesis of the evidence which included detailed reporting of intervention characteristics and outcomes.

RESULTS

Our search returned 14, 149 results, 241 of which were retained after title and abstract screening, and 30 of which met inclusion criteria after full text review. Seven groups of interventions were identified, the most frequent being teaching scholars programs (n = 10), health professions education fellowships (n = 3) or master's programs (n = 4). The most commonly measured outcome was change related to enhanced scholarly outputs (grants, papers, abstracts, and presentations) post-intervention. Unfortunately, most of the included studies lacked detailed description of the intervention and were of low to moderate quality with post-test only design.

DISCUSSION/CONCLUSIONS

This review demonstrates that various interventions can have a positive impact on the ability of health professions clinical educators to conduct education research. We note several key elements of the interventions including: (1) protected time, (2) mentorship and/or collaboration, (3) departmental and institutional commitment and leadership, and (4) financial support. Through our analysis we describe the complexities around evaluating clinical educators' health professions research activities and the interventions used to promote education research. While improved study quality would allow more detailed understanding and evaluation of these key features, we are able to provide recommendations for potential strategies for improving participation in and quality of health professions education research based on this analysis.

Gender distribution of U.S. medical school faculty by academic track type

PURPOSE

Over the past 30 years, the number and type of academic faculty tracks have increased, and researchers have found differences in promotion rates between track types. The authors studied the gender distribution of medical school faculty on the traditional tenure track (TTT) and clinician-educator track (CET) types.

METHOD

The authors analyzed gender and academic track type distribution data from the March 31, 2011, snapshot of the Association of American Medical Colleges' Faculty Roster. Their final analysis included data from the 123 medical schools offering the TTT type and the 106 offering the CET type, which excluded any schools with 10 or fewer faculty on each track type.

RESULTS

The original dataset included 134 medical schools representing 138,508 full-time faculty members, 50,376 (36%) of whom were women. Of the 134 medical schools, 128 reported at least one of four track types: TTT, CET, research track, and other. Of the 83 medical schools offering the CET type, 64 (77%) had a higher proportion of female than male faculty on that track type. Of the 102 medical schools offering the TTT type, only 20 (20%) had a higher proportion of female than male faculty on that track type.

CONCLUSIONS

Medical schools offering the CET type reported higher proportions of female faculty on that track type. Given that faculty on the CET type lag behind their TTT colleagues in academic promotion, these findings may contribute to continued challenges in gaining academic and leadership parity for women in academic medicine.

Geographic mobility advances careers: study of the Executive Leadership in Academic Medicine (ELAM) program for women

PURPOSE

To explore whether geographic mobility is associated with career advancement of women in U.S. medical schools who are entering mid- to executive-level positions.

METHOD

Using an existing dataset of 351 participants in academic medicine who attended the Executive Leadership in Academic Medicine (ELAM) Program for Women (1996-2005) (adjusted to 345 participants in some analyses because data on initial faculty rank were missing), the authors conducted a quantitative study in 2009 to determine whether geographic mobility was associated with administrative promotion for those who relocated geographically (from employer while attending ELAM to employer at last job of record).

RESULTS

Twenty-four percent of women (83/345) relocated geographically (movers) after attending ELAM. Moving had a positive association with career advancement (P = .001); odds for promotion were 168% higher for movers than for stayers [odds ratio Exp(β) = 2.684]. Movers attained higher administrative positions (P = .003), and more movers (60%) were promoted at the most recent job compared with stayers (40%) (P = .0001). Few movers changed city size; 70% already resided in large or urban cities where most medical schools are located. Age was not a barrier to mobility. Career advancement was not related to research reputation (National Institutes of Health grant award ranking) of participants' schools (either at time of attending ELAM or post-ELAM).

CONCLUSIONS

Similar to findings outside academic medicine, 24% of women classified as geographic "movers" among midcareer faculty in medical schools attained career advantages. Psychosocial and socioeconomic factors underlying women's relocation decisions require additional study.

An adaptive approach to facilitating research productivity in a primary care clinical department

Efforts to foster the growth of a department's or school's research mission can be informed by known correlates of research productivity, but the specific strategies to be adopted will be highly context-dependent, influenced by local, national, and discipline-specific needs and resources. The authors describe a multifaceted approach-informed by a working model of organizational research productivity-by which the University of Minnesota Department of Family Medicine and Community Health (Twin Cities campus) successfully increased its collective research productivity during a 10-year period (1997-2007) and maintained these increases over time.Facing barriers to recruitment of faculty investigators, the department focused instead on nurturing high-potential investigators among their current faculty via a new, centrally coordinated research program, with provision of training, protected time, technical resources, mentoring, and a scholarly culture to support faculty research productivity. Success of these initiatives is documented by the following: substantial increases in the department's external research funding, rise to a sustained top-five ranking based on National Institutes of Health funding to U.S. family medicine departments, later-stage growth in the faculty's publishing record, increased research capacity among the faculty, and a definitive maturation of the department's research mission. The authors offer their perspectives on three apparent drivers of success with broad applicability-namely, effective leadership, systemic culture change, and the self-awareness to adapt to changes in the local, institutional, and national research environment.

Fully aligned academic health centers: a model for 21st-century job creation and sustainable economic growth

Alignment is the degree to which component parts of academic health centers (AHCs) work cohesively. Full alignment allows AHCs to act quickly and cohesively toward common goals and to take advantage of opportunities that present themselves, particularly where collaboration is essential. Maryland's two major AHCs-University of Maryland Medicine (UMM) and Johns Hopkins Medicine (JHM)-have experienced periods of significant misalignment during each of their histories. Their most recent periods of misalignment caused significant negative economic and academic impacts. However, the process of realigning their clinical and research missions has not only given them a renewed economic vigor but has also paid significant dividends for the state of Maryland, helping it weather the current recession much better than other regions of the country. The two AHCs' continued economic success during the recession has led Maryland lawmakers to increasingly seek out their expertise in attempts to stimulate economic development. Indeed, UMM, JHM, and other fully aligned AHCs have shown that they can be powerful economic engines and offer a model of job growth and economic development in the 21st century.

The economics of new faculty hires in basic science

PURPOSE

To compare the streams of expenses and revenues associated with investment in a cohort of basic science investigators at the University of Rochester School of Medicine & Dentistry for seven years.

METHOD

The authors evaluated a medical school's financial investment in 25 basic science faculty who were hired between 1999 and 2004 to expand basic science research. The authors compared direct and indirect costs with the extramural grant support generated by these investigators through 2006. To facilitate a comparison of investments made and grants generated, the authors calculated present value (in 2006 dollars) of revenues and expenses using the school's approximate cost of capital.

RESULTS

Of the 25 faculty members hired, 24 (96%) remained at the school through 2006. From 1999 to 2006, the school invested a total of $69.0 million ($33.1 million in start-up costs and $35.9 million in indirect costs) to support the faculty members. Through 2006, these faculty members generated $99.7 million in extramural grant revenue ($70.7 million in direct grant revenue and $29.1 million in indirect grant revenue). Whereas the faculty generated $1.45 in total grant revenue per dollar invested, start-up expenses and incomplete recovery of indirect costs required the school to add 40 cents to every grant dollar generated to achieve financial equilibrium.

CONCLUSIONS

Investments in basic science research, even when successful, may require significant financial subsidies from academic health centers.

The relationship between the University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center--a profile in synergy

In the synergistic evolution of their research, educational, and clinical programs, the University of Pittsburgh (Pitt) School of Medicine (SOM) and the University of Pittsburgh Medical Center (UPMC) have followed one core principle: What is good for one is good for both. The collaboration is underpinned by UPMC's commitment to its community mission, including support for the academic and research objectives of the SOM. UPMC's conceptual origin was fostered by its experience with Western Psychiatric Institute and Clinic in the 1970s. Over time, UPMC acquired other hospitals through merger and negotiation and, by 2008, had grown into a $7 billion global health enterprise. From the outset, the senior leaders of both UPMC and Pitt committed to collaborative decision making on all key issues. Under this coordinated decision-making model, UPMC oversees all clinical activity, including that from a consolidated physicians' practice plan. Pitt remains the guardian of all academic priorities, particularly faculty-based research. UPMC's steady financial success underpins the model. A series of interrelated agreements formally defines the relationship between Pitt and UPMC, including shared board seats and UPMC's committed ongoing financial support of the SOM. In addition, the two institutions have jointly made research growth a priority. The payoff from this dynamic has been a steadily growing Pitt research portfolio; enhanced growth, visibility, and stature for UPMC, the SOM, and Pitt as a whole; and the sustained success of UPMC's clinical enterprise, which now has an international scope. Given the current stagnation in the National Institutes of Health budget, the Pitt-UPMC experience may be instructive to other academic health centers.

Linking academic and clinical missions: UC Davis' integrated AHC

Academic health centers (AHCs) rely on cross-subsidization of education and research programs by the clinical enterprise, but this is becoming more challenging as clinical reimbursements decline. These new realities provide an important opportunity to reevaluate the relationships between medical schools and academic medical centers. The authors examine the benefits of their ongoing commitment to create a fully integrated AHC at the University of California (UC) Davis, discussing strategies that serve as catalysts for continued growth. They explore how investments of proceeds from the clinical enterprise directly enhance educational and research initiatives, which, in turn, increase the success of patient-care programs. This has created a cycle of excellence that leads to an enhanced reputation for the entire health system. One strategy involves using clinical margins to "prime the pump" in anticipation of major research initiatives, resulting in rapid increases in external research funding and academic recognition. In turn, this facilitates recruitment of high-quality faculty and staff, improving the ability to deliver expert clinical care. The overall enhanced institutional reputation positions both the clinical and academic programs for further success. The authors posit that such approaches require executive-level commitment to a single strategic vision, unified leadership, and collaborative financial and operational decision making. Adopting such changes is not without challenges, which are discussed, but the authors suggest that an integrated AHC fosters optimized operations, enhanced reputation, and stronger performance across all mission areas. They also provide examples of how the UC Davis Health System has thus attracted philanthropists and investments from the private sector.

The evolving organizational structure of academic health centers: the case of the University of Florida

The organizational structures of academic health centers (AHCs) vary widely, but they all exist along a continuum of integration--that is, the degree to which the academic and clinical missions operate under a single administrative and governance structure. This author provides a brief overview of the topic of AHC integration, including the pros and cons of more integrated or less integrated models. He then traces the evolution of the University of Florida (UF) Health Science Center, which was created in the 1950s as a fully integrated AHC and which now operates under a more distributed management and governance model. Starting as a completely integrated AHC, UF's Health Science Center reached a time of maximal nonintegration (or dys-integration) in the late 1990s and at the beginning of this decade. Circumstances are now pushing the expanding clinical and academic enterprises to be more together as they face the challenges of market competition, federal research budget constraints, and reengineering clinical operations to reduce costs, enhance access, and improve quality and patient safety. Although formal organizational integration may not be possible or appropriate for any number of legal or political reasons, the author suggests that AHCs should strive for "functional integration" to be successful in the current turbulent environment.

The changing relationships between academic health centers and their universities: a look at the University of Pennsylvania

After a period of financial losses in the University of Pennsylvania Health System stemming from a combination of internal decision making and negative external market forces, the university set out to make substantial changes in the governance and administrative organization overseeing its health system and medical school. The changes were designed to assure the university and its trustees that financial controls were strengthened and that the missions of research, education, and patient care were balanced. The governance changes included creating a structure whereby a single administrative leader was responsible for all three missions--education, research, and clinical care--and reported directly to the president of the university. Further, existing governing boards responsible for various entities within the school of medicine and health system were disbanded, and a new single board was created to oversee PENN Medicine, the overarching organization established in 2001 and now responsible for oversight of the University of Pennsylvania School of Medicine and the University of Pennsylvania Health System. The realignment initiated by these major changes spawned additional refinements in leadership responsibilities and process controls that, together with the new governance model, are credited with financial recovery and stronger performance in all aspects of the enterprise. These structural changes led to greater emphasis on integrating and coordinating programs to take advantage of PENN Medicine's home in a leading university.

The challenge for excellence at the University of Louisville: implementation and outcomes of research resource investments between 1996 and 2006

In the decade beginning in 1996, the National Institutes of Health (NIH) budget doubled, whereas NIH funding at the University of Louisville School of Medicine increased nearly sevenfold. The schools of nursing and dentistry, the other Health Science Center schools at Louisville, experienced comparable growth. The University of Louisville was thus one of the fastest growing research enterprises in the country during this period. While there was an infusion of state funds, the authors believe that the magnitude of the research growth depended more critically on development of an effective strategic plan with closely monitored outcomes. This process included first the identification of programs of distinction deserving of investment and then the reallocation of resources from units that were not research-intensive to those that were. The strategy focused on (1) the recruitment of endowed chairs and their teams (thus the popular name for the program "Bucks for Brains"), (2) the implementation of new promotion and tenure standards, (3) the creation of research-productivity linked salary incentives, (4) the implementation of posttenure review, and (5) an effort to improve research infrastructure, including core facilities, and physical plant. The authors describe how the investment by the Commonwealth of Kentucky was structured and how accountability to the state facilitated this growth. This description of how postsecondary education reform and the infusion of modest resources through the Research Challenge Trust Fund were leveraged into a substantial return-on-investment at Louisville could serve as a guide to schools during this time of NIH budgetary constraint.