The P&S Journal: Spring 1998, Vol.18, No.2
Academic Medicine: A Discussion with the Dean
Most of the newspaper headlines, broadcast sound bites, and talk show dialogue about the health care system is devoted to managed care, costs, and access. Where’s the discussion about academic medicine, which is integral to all of these issues but also vital to a part of the health care system that everyone takes for granted: medical research? Dr. Herbert Pardes, vice president for Health Sciences and dean of the Faculty of Medicine at Columbia, discusses the progress made in heightening awareness of academic medicine’s role, calling attention to the special financial needs of academic medical centers, and bringing medical school contributions out of the shadows of health care discussions.
P&S: Even though medical schools and teaching hospitals have not been at the top of the health care discussion priorities list, aren’t things getting better?
Herbert Pardes (HP): Yes, and that’s the good news. Thanks to some enormous support by the country’s leaders and key legislators, research funding through the NIH [National Institutes of Health] is looking up. We owe an enormous debt of gratitude to President Clinton, Vice President Gore, Columbia’s own Harold Varmus [a 1966 P&S graduate who directs the NIH], and Donna Shalala, Secretary of Health and Human Services.
P&S: How much has NIH funding increased?
HP: The current NIH budget is $13.6 billion, and President Clinton has proposed a research fund that would increase NIH funding by $1.15 billion in 1998-99 and by more than 50 percent over the next five years. The impact of this increased funding is what is most impressive: It means one in three grants will be funded, rather than the one in five grants that were funded under previous levels of NIH funding. It’s also important to note that many legislators, including Senator Connie Mack of Florida, Congressman John Porter of Illinois, and Congressman George Gekas of Pennsylvania, have been very vocal in calling for the NIH budget to be doubled.
P&S: Will this additional funding solve the problems?
HP: While we can’t be unappreciative of the growing support of medical research by the American public—and the policy-makers—increased funding of research is not the whole picture. Additional NIH grants will add pressure to medical schools and our teaching hospitals for institutional investments, because the money will require us to increase our capacity to conduct research. We will need to build new laboratories, renovate our existing laboratories, buy more equipment, and find more salary money for the portion of the cost the NIH expects us to pay researchers.
P&S: So, NIH funding doesn’t cover the entire cost of research?
HP: Institutional support is an important part of the overall cost of research. A research program for an investigator depends on grant money plus institutional funds. That has always been the case, but the financial demands on the institution have increased. The NIH has increasingly cost-shifted, meaning that the medical schools must make up the difference when salary caps, graduate student tuition limitations, and matching requirements reduce support for the direct costs of the research.
P&S: Where does the institutional money come from?
HP: That’s the challenging part of the good news: The sources of revenue for each institution’s share of research funding are drying up. Tuition from medical students goes to pay for their education. Clinical dollars—which used to pay for research—are receding. And most philanthropy is restricted, so I—and other medical school deans—don’t have flexibility to use private donations to pay for the research infrastructure.
P&S: What’s being done to solve the problem?
HP: We are suggesting NIH mechanisms that would support research infrastructure needs. We are also pursuing local and state support for infrastructure improvements so our institutions can take fullest advantage of the increased research funding, which has obvious benefits for local and state economies.
P&S: Why has academic medicine taken a back seat to other health care system changes?
HP: The changes in the health care system in this country have been so sweeping that focus naturally has been on the parts of the system that affect the overall population—direct medical care. Whether that care is received in a doctor’s office, an emergency room, a hospital’s surgical suite, or a neighborhood clinic, the interaction between physician and patient is of primary concern to the public. As a physician and as a patient myself, I understand that. The farther removed a cog in the system is from that interaction, the less attention it will get.
P&S: As the less-squeaky cog, then, how do medical schools, like P&S, and teaching hospitals get more attention?
HP: The responsibility rests with people in my position, with faculty at academic medical centers like ours, and with alumni who are conducting research or delivering care that is dependent on advances that academic medicine makes possible. We need to get the issue out front and center.
P&S: What kinds of advances make particularly strong arguments in the case for support of academic medicine?
HP: There are powerful messages that describe the historical accomplishments and continuing potential of medical schools and teaching hospitals. These organizations have long led the way to medical advances and life-saving treatments. Medical schools and teaching hospitals are places of innovation in health care, where new procedures and treatments have been pioneered for generations. Not only does academic medicine have an important part in helping Americans live healthier, longer lives through innovation, we educate the doctors who will carry on this tradition for families tomorrow. Lowering the cost of health care is important—we all want that—but we must keep in mind what the implications of those cuts are.
P&S: What could the implications be?
HP: Cutting health care costs could bring about unintended consequences in the long run. In the short run, we’ve already seen deep cuts in government support for research. Sacrificing life-saving research and the hospitals that train our doctors is too high a price to pay.
P&S: And the medical schools?
HP: We can’t ignore our core mission—to educate men and women who will be the physicians and medical researchers of the future. If the numbers of medical school applicants decline, we will have fewer people from whom to choose the best students. We cannot have the best health care system in the world without the best doctors, and we can’t have the best doctors without the best students and the best medical education system. If our faculty are forced to spend more time generating funds to offset the shortfalls in traditional funding, they will have less time for teaching.
P&S: People understand the importance of support for medical education and for medical research, but what about the patient base that sets teaching hospitals apart?
HP: The hospitals associated with medical schools—the teaching hospitals—are at front and center in treating the poor and the sickest patients in our neighborhoods, our towns, and our rural areas. There’s an interesting formula—6-50-25: The major teaching hospitals make up 6 percent of all hospitals but they provide nearly 50 percent of the nation’s charity care with only 25 percent of the cost covered by state and local government support. The other 75 percent of the cost must be borne by academic medical centers like Columbia-Presbyterian.
P&S: Where has the support gone?
HP: Both the sources and the balance of our support have shifted and shrunk. Government support has dropped, although recent activity we’ve already discussed suggests this may reverse itself, at least with regard to grants for scientists. Historically, the unique costs associated with medical education, research, and charity care have been offset by special payments from Medicare and Medicaid programs and from insurance companies. Medicare and Medicaid are containing costs, and managed care has resulted in less money in reimbursement to us for caring for patients. Although managed care plans are quick to seek the benefits of medical research, most plans do not have reimbursement formulas that help underwrite the costs of research and clinical advances that benefit their members and may keep them healthy.
P&S: Can’t we just make do with less?
HP: We’ve already taken steps to become as lean as we can be without sacrificing quality. As the art of medicine has become more the business of medicine, we’ve adapted to market forces. There has been downsizing and reductions in costs. We have found economies in forming collaborations with other like-minded institutions. We have used information technologies to become more efficient. We work together more in teams to economize and share resources. But we shouldn’t be content to settle, especially in light of the revolution in health care delivery of the past decade. We can prevent, treat, even cure diseases we once thought were hopeless. Patients spend less time in the hospital and get more care in outpatient centers—not just because of managed care but because clinicians have found efficient, effective ways to deliver care in that setting. And we’re moving steadily forward in developing treatments for the still-aggressive cancers, Alzheimer’s disease, and AIDS.
P&S: What will happen if we continue to lose resources?
HP: Caring for the underinsured and the uninsured will surely be compromised if we have to make do with less. Some medical schools and teaching hospitals will have to close if they cannot find some way to replace the dollars that the competitive marketplace is squeezing out of the health care system. That would be the worst-case scenario. In some ways, the alternative is as bad: Medical schools and teaching hospitals could end up staying open, but have their programs marginalized. Nobody wants to go to a medical school, a teaching hospital, or a physician labeled “borderline.” We should not lose sight of the margin of excellence that sets places like P&S and Columbia-Presbyterian apart.
P&S: Why can’t we be more competitive with hospitals that are not affiliated with medical schools?
HP: Care at a teaching hospital costs more because it builds in the training, education, and research costs that contribute to the higher standards of care offered by teaching hospitals.
P&S: Why hasn’t the public agenda included the issue of increased funding for medical schools and teaching hospitals?
HP: I am convinced that the public cares about this issue. The problem is that the public isn’t aware of the problem. Survey after survey has revealed that the public overwhelmingly supports medical research and our other core missions. Medical research, especially, is one area that relates to each and every individual. Everyone has a family member or friend who at one time has had a serious disease; people “get” the importance of medical research and clinical advances and they connect that importance with their own health or the health of people they love. What they don’t “get” is that medical research is done in medical schools and teaching hospitals. And they don’t realize the potential financial threats to the enterprise. Until they can connect all three—medical school institutional resources with medical advances with individual health—we have a problem that will not be solved because we don’t have the public awareness.
P&S: What can P&S Journal readers do?
HP: Alumni, faculty, and friends of the school and the medical center can help put this issue on the public agenda. We have joined with the Association of American Medical Colleges in a communications campaign, “Tomorrow’s Doctors, Tomorrow’s Cures,” to raise public awareness. We need to convince Americans of the importance of medical schools and teaching hospitals to the nation’s health care system and build a broad base of support for preserving our critical missions. The public support is vital to moving policy-makers from introducing legislation to passing and implementing it by financing it.