The three missions of academic radiology compete with one another for time and funding. Revenue for the clinical mission often subsidizes education and research. Given the internal and external drivers/pressures on health care and, more particularly, on academic health centers, the current model is unsustainable. Trends seen in other industries are entering academic health care. The radiology department of the future will need to be more efficient with increasingly fewer resources while meeting its missions at higher levels of expectation.
In this report, we examine the evolving ability of academic health centers (AHCs) to meet the demands of their multiple missions and project trends on academic radiology departments. Since the Flexner report , AHCs have faced many challenges. One element of this evolution has been the development of medical schools and their hospital partners into complex medical businesses . Initially, AHC clinical volumes were sized to meet basic educational and research needs. Clinical volumes exceeded the volumes needed solely to meet these needs. The increased revenues were used to fuel growth in academic enterprises, not just in clinical arenas. Although there was concern that increased clinical business would destroy the academic mission, clinical revenue has become the engine that today subsidizes much of the AHC academic mission. One study showed the clinical mission has provided >70% of faculty salary .
Despite representing only 6% of U.S. hospitals , AHCs provide a disproportionate share of complex care ( Table 1 ). They provide 22% of services to Medicare beneficiaries and 28% of all Medicaid care. AHCs also provide 41% of all hospital-based charity care. Data analysis by the Association of American Medical Colleges (AAMC) and the Council of Teaching Hospitals and Health Systems has demonstrated that a much higher level of complex care by Case Mix Index (CMI) is found in the AHCs.
Table 1
Percentage of Intensive Care Units (ICUs), Transplant Services, and Trauma/Burn Centers in Academic Health Centers
Center Percent Neonatal ICUs 40% Surgical transplant services 50% Pediatric ICUs 62% All Level I trauma centers 61% All burn care centers 75%
Data from (4).
AHCs also have a disproportionate economic impact due to the type of care provided and the cross-subsidization of the education and research mission. An AAMC study showed AAMC-member medical schools and hospitals account for 1 of every 43 wage earners and had a combined economic impact of $512 billion in 2008 . A recent analysis suggests that the national investment in medical research has been a good return on investment. Approximately 40% of medical research in the United States is federally funded . Preliminary results demonstrate that $1.00 of National Institutes of Health (NIH) funding initially generates $1.70 of output of bioscience industry, but the long-term return may be as high as $3.40. The life expectancy improvement since 1970 has a social value estimated at $61 trillion. AHC have become big business, and radiology is a key component.
The 100 years after Roentgen’s discovery of x-ray saw an explosion of imaging technology, which has become an essential part of patient care. On a recent survey, computed tomography (CT)/magnetic resonance imaging (MRI), balloon angiography, mammography, and ultrasound were in the top dozen of medical innovations ranked by physicians . Investments were made in radiology research, with radiology leaders taking active roles on the national stage. In 2000, President Clinton signed the National Institute of Biomedical Imaging and Bioengineering Establishment Act into law. Dr. Elias A. Zerhouni, former chair of radiology at Johns Hopkins, served as director of the NIH from May 2, 2002, to October 31, 2008. During this period of investment and technology growth, radiologists’ salaries grew, with the specialty becoming one of the highest paid specialties . However, growth in health care resulted in health care becoming a $2.2 trillion business, accounting for nearly 20% of the gross domestic product (GDP); this makes the current model unsustainable. As the national deficit and federal spending are reexamined over the coming years, this continued financial support is not ensured. Changes in funding for health care and, in particular, for AHCs could have unintentioned consequences on population health, employment, research, education, and access to complex medical care.
Current state
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In just 6 categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20% of total health care expenditures .
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Table 2
Estimated Sources of Excess Costs in Health Care (2009)
Source of Excess Costs Cost Unnecessary services $210 Billion Inefficiently delivered services $130 Billion Excess administrative costs $190 Billion Prices that are too high $105 Billion Missed prevention opportunities $55 Billion Fraud $75 Billion
Data from (3).
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Table 3
Advantages and Liabilities of University Physician Practices
University Physician Practices: Advantages University Physician Practices: Liabilities
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Changing reimbursement models
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Multidisciplinary and multicommunity partnership
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Institutional funds flow models
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Outside influences
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Conclusion
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