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Committee on the Roles of Academic Health Centers in the 21st Century Linda T. Kohn, Editor

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. 01-267 and 20010609 between the National Academy of Sciences and The Rockefeller Brothers Fund, with additional support from The Commonwealth Fund, the Institute of Medicine, and the Na- tional Research Foundation. Any opinions, findings, conclusions, or recommenda- tions expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Academic health centers : leading change in the 21st century / Committee on the Roles of Academic Health Centers in the 21st Century ; Linda T. Kohn, editor. p. ; cm. Includes bibliographical references and index. ISBN 0-309-08893-3 (hardcover) 1. Academic medical centers--United States. [DNLM: 1. Academic Medical Centers--trends--United States. WX 27 AA1 A168 2004] I. Kohn, Linda T. II. Institute of Medicine (U.S.). Committee on the Roles of Academic Health Centers in the 21st Century. RA966.A23 2004 362.12--dc22 2004001871 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http:// www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"Knowing is not enough; we must apply. Willing is not enough; we must do." --Goethe Adviser to the Nation to Improve Health

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engi- neers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE ROLES OF ACADEMIC HEALTH CENTERS IN THE 21ST CENTURY The Honorable JOHN EDWARD PORTER (Chair), Partner, Hogan and Hartson, L.L.P. Washington, DC, Member of Congress 1980-2001 LINDA AIKEN, Claire M. Fagin Professor of Nursing and Sociology and Director, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania J. CLAUDE BENNETT, President and Chief Operating Officer, BioCryst Pharmaceuticals, Inc., Birmingham, Alabama HENRY BIENEN, President, Northwestern University, Evanston and Chicago, Illinois NANCY-ANN MIN DEPARLE, Adjunct Professor of Health Care Systems, Wharton School, University of Pennsylvania; Senior Adviser, JP Morgan Partners, New York, New York EDWARD W. HOLMES, Vice Chancellor for Health Sciences and Dean, University of California San Diego School of Medicine, La Jolla, California LAWRENCE LEWIN, Executive Consultant, Washington, D.C. NICOLE LURIE, Senior Scientist and Alcoa Professor of Policy Analysis, The RAND Corporation, Arlington, Virginia STEVEN M. PAUL, Group Vice President, Lilly Research Laboratories, Eli Lilly Company, Indianapolis, Indiana PAUL G. RAMSEY, Vice President Medical Affairs and Dean, University of Washington School of Medicine, Seattle, Washington ROBERT REISCHAUER, President, The Urban Institute, Washington, DC JOHN W. ROWE, Chairman and CEO, Aetna Inc., Hartford, Connecticut MARLA SALMON, Dean and Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia CHRISTINE SEIDMAN, Howard Hughes Medical Institute and Brigham and Women's Hospital, Professor of Medicine and Genetics, Harvard Medical School, Boston, Massachusetts M. ROY WILSON, President, Texas Tech University Health Sciences Center, Lubbock, Texas. Until June 2003, Dean, School of Medicine and Vice President for Health Sciences, Creighton University, Omaha, Nebraska LIAISON FROM THE BOARD ON HEALTH SCIENCES POLICY JAMES CURRAN, Dean and Professor of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia v

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STUDY STAFF LINDA T. KOHN, Study Director MARYANN BOLCAR, Program Officer RANDA KHOURY, Project Assistant RONN D. WINGATE, Project Assistant JANET M. CORRIGAN, Director, Board on Health Care Services vi

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REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evi- dence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the delibera- tive process. We wish to thank the following individuals for their review of this report: Henry Aaron, Brookings Institution, Washington, DC David Blumenthal, Massachusetts General Hospital, Partners Healthcare, Boston, Massachusetts David R. Challoner, University of Florida, Gainesville, Florida Don E. Detmer, Cambridge University Health, Judge Institute of Management, Cambridge, UK Robert Galvin, General Electric Company, Fairfield, Connecticut Harry R. Jacobson, Vanderbilt University, Nashville, Tennessee Peter O. Kohler, Oregon Health & Sciences University, Portland, Oregon Ronda Kotelchuck, Primary Care Development Corporation, New York, New York vii

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viii REVIEWERS Joel Kupersmith, Texas Tech University, Lubbock, Texas Mary O. Mundinger, Columbia University, New York, New York Cecil B. Pickett, Schering-Plough Research Institute, Kenilworth, New Jersey Mitchell T. Rabkin, Harvard University, Cambridge, Massachusetts Leon E. Rosenberg, Princeton University, Princeton, New Jersey Linda Rosenstock, University of California, Los Angeles Bruce Vladeck, Mt. Sinai School of Medicine, New York, New York Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Robert Johnson, Profes- sor, New Jersey Medical School, appointed by the Institute of Medicine, and Enriqueta Bond, President, Burroughs Wellcome Fund, appointed by the National Research Council. They were responsible for making certain that an independent examination of this report was carried out in accor- dance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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PREFACE The last few decades have been heady times for science and health. Our knowledge of how to improve health has grown significantly and new technologies have successfully supported those endeavors. The coming de- cades are likely to bring even more progress. As we gain a better under- standing on how to use the discoveries of genetics, proteomics, and other biologies, we will have the potential to fundamentally alter care in ways that we can only begin to imagine. Combined with a public that is armed with more information and better able to make healthy choices and be more involved in its own care, the potential is great for making large strides in improving human health. In the fall of 2001, the Institute of Medicine convened a committee to examine the roles of academic health centers (AHCs) in the coming decades in fostering and supporting these advances in health care. The challenge to this committee was to look into the future and consider how AHCs can be prepared to fulfill their promise by carrying out their roles in education, research, and patient care to improve health for all people. AHCs demon- strated great vision and accomplishment during the 20th century. They will need these qualities in the coming decades if they are to adapt and respond to the changing needs of people and the expanding capabilities that health care will offer. This committee was intentionally designed to include a diverse group of individuals from varied backgrounds so as to bring contrasting views to the subject at hand. The members did not always agree, and on occasion a ix

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x PREFACE dissenting voice even rose, reflecting the seriousness with which the mem- bers viewed their charge. By the end of the deliberations, a mutual respect had grown for the always thoughtful views expressed by each committee member. I am thankful for the opportunity to work with such an experi- enced, visionary, and talented group. Excellent staff support was also pro- vided by Maryann Bolcar, Ronne Wingate, and Randa Khoury, under the able and patient direction of Linda Kohn. The challenges facing AHCs in the future will be significant. Change is never easy and rarely smooth. But the opportunities are too great to for- sake. I speak for the entire committee in believing that strong AHC leader- ship and sound policy support will indeed make it possible to achieve better health for all. John Edward Porter Chair June 2003

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ACKNOWLEDGMENTS The Committee on the Roles of Academic Health Centers in the 21st Century gratefully acknowledges the contributions of the many individuals and organizations through the course of the study that participated and gave generously of their time and knowledge. Support for this study was provided by the Institute of Medicine, the National Research Council, the Rockefeller Brothers Foundation, and The Commonwealth Fund. The Committee especially recognizes Melinda Abrams of The Commonwealth Fund, and Linda Jacobs and William McCalpin of the Rockefeller Brothers Foundation, for their special atten- tion to this project. A workshop was sponsored by the committee in January 2002 during which the following people offered their views on the future roles for AHCs: Gerard Anderson, Johns Hopkins University; Brian Biles, George Washington University; Joseph D. Bloom, Oregon Health and Science Uni- versity; David Blumenthal, Partners HealthCare System; Samuel Broder, Celera Genomics; Jordan Cohen, Association of American Medical Col- leges; Colleen Conway-Welch, Vanderbilt University; Charles Cutler, American Association of Health Plans; Ezra Davidson, Charles R. Drew University; Robert Dickler, Association of American Medical Colleges; Gerald Fischbach, Columbia University; Jeff Goldsmith, Health Futures Inc.; Ralph Horwitz, Yale University; Edward Hundert, Case Western Re- serve University; Darrell Kirch, Pennsylvania State University; Uwe E. Reinhardt, Princeton University; Sara Rosenbaum, George Washington xi

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xii ACKNOWLEDGMENTS University; Elaine Rubin, Association of Academic Health Centers; Ralph Snyderman, Duke University; and Bruce C. Vladeck, Mount Sinai School of Medicine. Several university presidents made presentations about their own AHCs. The committee is grateful to Lee C. Bollinger of Columbia University, Judith Rodin of the University of Pennsylvania, Leonard W. Sandridge of the University of Virginia, and Stephen J. Trachtenberg of the George Wash- ington University for sharing their knowledge. In addition, Catherine Dower of the University of California, San Francisco, and Robert Galvin of Gen- eral Electric provided valuable testimony to the Committee during a July 2002 meeting. The Committee acknowledges with gratitude a number of others for providing their time and expertise to this work: Helene Bednash, American Association of Colleges of Nursing; Linda Berlin, American Association of Colleges of Nursing; Roger Bulger, Association of Academic Health Cen- ters; Molly Cooke, University of California San Francisco; Alain Enthoven, Stanford University; The Honorable Bill Gradison, Patton Boggs; David Helms, AcademyHealth; George Kaludis, Kaludis Consulting; Brian Kimes, National Cancer Institute; Peter Kohler, Oregon Health and Science Uni- versity; Jay Levine, ECG Management Consultants; Craig Lisk, Medicare Payment Advisory Commission; Alexander Omaya, Institute of Medicine; Marian Osterweis, Association of Academic Health Centers; Julian Pettingill, Medicare Payment Advisory Commission; James Reuter, Georgetown University; Edward Salsberg, University of Albany SUNY; Ellen Stovall, National Coalition for Cancer Survivorship; and Linda Weiss, National Cancer Institute.

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CONTENTS EXECUTIVE SUMMARY 1 1 INTRODUCTION 19 2 FORCES FOR CHANGE 30 TRANSFORMING THE ROLES OF AHCS 3 THE ACADEMIC HEALTH CENTER AS A REFORMER: THE EDUCATION ROLE 45 4 THE ACADEMIC HEALTH CENTER AS A MODELER: THE PATIENT CARE ROLE 65 5 THE ACADEMIC HEALTH CENTER AS A TRANSLATOR OF SCIENCE: THE RESEARCH ROLE 77 CREATING AN ENVIRONMENT FOR INNOVATION 6 THE CONSEQUENCES OF CURRENT FINANCING METHODS FOR THE FUTURE ROLES OF AHCs 92 xiii

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xiv CONTENTS 7 EXPECTATIONS FOR THE AHC OF THE 21ST CENTURY 110 8 CREATING SYSTEMS FOR CHANGE IN AHCs 127 REFERENCES 144 APPENDIXES A ACADEMIC HEALTH CENTERS: ALL THE SAME, ALL DIFFERENT, OR ... 161 B COMMITTEE ON THE ROLES OF ACADEMIC HEALTH CENTERS IN THE 21ST CENTURY 198