248  Pursuing Excellence in Healthcare One might argue that a single AMC should be able to survive in its own market if it can provide excellence in patient care in all areas. is is true; how- ever, only a relatively small group of AMCs can claim excellence in each area of clinical medicine. In most cases, these are long-standing institutions or newer institutions that have emerged through a unique structure that provides an exceptional level of financial support. Indeed, looking at the majority of hospi- tals, Porter and Teisberg note [2]: e current structure in which many local providers operate at mod- est scale in their home region is an artifact of history and has little logic in terms of patient value. Even if most services are provided locally, services in each practice unit can be managed or supported by premier integrated national organizations. Again, it is important to note that Porter and Teisberg based their assessment on the hospitals’ ability to provide outstanding patient care rather than on the financial aspects of the hospitals. Indeed, three “local mergers” that have suc- cessfully taken place include Massachusetts General Hospital and the Brigham and Women’s Hospital, Beth Israel Hospital and Deaconess Hospital, and New York Hospital and Columbia Presbyterian Hospital. However, each of these six hospitals had very similar cultures: Massachusetts General, the Brigham and Women’s, Beth Israel, and the Deaconess were all historic teaching hospitals of Harvard Medical School and most were among the “haves” of AMCs in terms of endowments, research support, and annual fundraising efforts. e hypothesis that local affiliations can work when they are based on the core principle of providing outstanding patient care is supported by the success of the partnership between Meharry Medical College and Vanderbilt University Medical Center [44]. e alliance encompassed three very different institu- tions—all of which had existed in Nashville since the late 1800s: Meharry Medical College was established for the distinct purpose of train- ing African American physicians in 1876 and remains the largest private, comprehensive, historically African American institution for educating health professionals and scientists in the United States. Meharry oper- ated Hubbard Hospital, which provided healthcare for the majority of Nashville’s African American population. Established in 1874, Vanderbilt University Medical Center is a research-inten- sive AMC whose hospital was ranked number 16 and whose medical school was ranked number 15 by U.S. News and World Report in 2008 [45]. Nashville General Hospital opened in 1890 to provide care for the city’s indi- gent population. Vanderbilt had maintained an exclusive contract with Developing Strategic Regional and Global Collaborations  249 Nashville General until 1985, when Meharry also gained a clinical affilia- tion with the hospital. In 1992, Hubbard Hospital and Nashville General Hospital faced major needs for renovation or replacement at a time when the introduction of TennCare and other managed care plans in Nashville had lessened the need for two hospitals that primarily served the poor and uninsured. As a result, the Metro Council of Nashville- Davidson County elected to merge Nashville General and Hubbard Hospital. As part of the agreement, Meharry would assume all responsibility for professional staff- ing at Nashville General, an ambulatory clinic would remain at Nashville General’s historic site, Meharry would assume the cost for renovating Hubbard Hospital, and the county would lease the Hubbard facility from Meharry for a period of 30 years. As a result of the agreement, Vanderbilt was not administratively responsible for the professional staffing of Nashville General for the first time since it opened. Both academic centers were stressed by the decision. Although Vanderbilt no longer had the obligation to staff Nashville General, it lost a valuable training site for its fellows, residents, and students. By contrast, Meharry gained a renovated and up-to-date clinical facility on its own campus, but it did not have enough staff to assume responsibility for full clinical coverage at Nashville General. As a result, the two institutions formed an alliance with the goal being to: improve the educational experience of students and house staff of both institutions; increase joint research and training grants; enhance the quality and quantity of services for the patients of Nashville General; and jointly provide new ways of maintaining the health of the community [46]. us, by taking advantage of the strengths of each institution, the alliance between Vanderbilt and Meharry would result in meeting the fundamental core mission of providing outstanding patient care for all of the patients served by Nashville General Hospital. Implementing the Meharry–Vanderbilt alliance was not easy. e creation of a successful alliance required real resources, a buy-in from all stakeholders, the creation of mechanisms to ensure good communication and trust, federal sup- port for collaborative research, sensitivity to the cultural aspects of each partner institution, and willingness to use the strengths of each of the partners. Indeed, the success of the program was seen in the ability of the departments of sur- gery to form a joint department while at the same time preserving the integrity of each institution. Faculty appointments, including the appointment of a new chief of surgery at Meharry, were made jointly by both institutions; economies 250  Pursuing Excellence in Healthcare of scale were met by sharing resources, facilities, and faculty for medical educa- tion; and Meharry gained a surgical residency program. e alliance has led to expansion of all educational programs, growth in research and research funding, the awarding of a clinical and translational sci- ence award that incorporates investigators at both institutions, and an increase in surgical volume. As noted by the chairs of surgery at Meharry and Vanderbilt, “Nothing that has transpired would have occurred without the commitment to excellence and mission displayed by the individuals who have been recruited to work in this alliance” [47]. Other cities can learn important lessons from the experience in Nashville—in particular, that AMCs within the same geographic region but with historically different cultures can find important ways in which collaboration can make both institutions stronger and better able to fulfill their societal missions. e AMC demographics in Philadelphia provide an ideal case study for the potential development of intercity collaboration. Because the state reports volumes and out- comes for cardiovascular procedures, this discussion will focus on cardiovascular services, although the same logic could be applied to other services as well. Today, Philadelphia has four allopathic medical schools and their affiliated hospitals with cardiac programs: the University of Pennsylvania (Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital), Drexel University School of Medicine (Hahnemann University Hospital), omas Jefferson University (omas Jefferson University Hospital), and Temple University (Temple University Hospital). In 2007, the Hospital of the University of Pennsylvania accounted for 1,297 cardiovascular surgery dis- charges, Penn Presbyterian Medical Center had 569, omas Jefferson University Hospital had 360, Pennsylvania Hospital had 271, Hahnemann University Hospital had 260, and Temple University Hospital had 241 [48]. Although the relationship between patient outcome and volume is con- troversial [49–51], after careful review of the literature, the Leapfrog Group (a coalition of more than 150 large public and private healthcare purchasers that represents over 40 million people) recommended that individual hospitals performing more than 450 cardiac surgery cases per year be Leapfrog Group compliant (with the exception of New York, New Jersey, Pennsylvania, and California, which base their standards on being in the lowest quartile of mortal- ity rates in the state) [52]. Similarly, in Michigan, a hospital cannot initiate a new open heart surgery program without having a consulting agreement with a hospital that has an existing open heart surgery program that performs a minimum of 400 open heart surgical cases per year for 3 consecutive years. e new program must perform a minimum of 300 operations. Leapfrog Group standards also require a minimum of 400 percutaneous coronary interventions each year. is standard Developing Strategic Regional and Global Collaborations  251 is met at only a few of the Philadelphia AMCs, although it is met by a number of community hospitals. Not only do Jefferson’s, Hahnemann’s, and Temple’s cardiac surgery pro- grams not meet Leapfrog Group standards, but the low volumes preclude these programs’ participation in clinical trials of some of the most innovative new tech- nologies in the field of cardiovascular medicine. For example, because of its large patient volumes, Penn participates in the study of new technologies, including percutaneous mitral valve repair and aortic valve replacement—procedures that can replace or repair a cardiac valve without the need for open heart surgery. However, the other academic medical centers are precluded from participat- ing in these studies because they lack the requisite clinical volumes. Sponsors for the new devices require that participating centers have hybrid catheterization laboratories that can accommodate both cardiologists and surgeons, interven- tional cardiologists who perform large volumes of complex procedures, and a large volume of aortic valve surgery. e requisite large hospital volumes are not because of the need to enroll a large number of patients but rather because these complex procedures have a steep learning curve; therefore, physicians need to do cases on a regular basis in order to maintain their technical skills. A similar lack of appropriate volumes is seen when cardiac transplantation volumes among the Philadelphia academic hospitals are examined. Between January 1, 2008, and September 30, 2008, Penn performed 34 heart trans- plants, Jefferson performed 11, and Hahnemann and Temple both performed 6. Although the U.S. Centers for Medicare and Medicaid Services recently lowered the number of yearly transplants needed to qualify for federal reimbursement from 12 to 10, a recent study from Johns Hopkins suggested that the standards to designate hospitals that are best at performing heart transplants needed to be increased to at least 14 procedures per year [53]. e study showed that death rates at 1 month and 1 year after transplant increased steadily at hospitals that performed fewer than 14 heart transplants per year. At least two of Philadelphia’s four transplant programs are unlikely to meet the federal requirements and cer- tainly did not meet the Hopkins requirements in 2008. With the cardiac surgery programs at Hahnemann, Temple, and Jefferson not meeting optimal volume standards, some experts, including Porter and Teisberg, would suggest that these programs will not survive in a quality-guided market. Although extremely radical, the current situation facing the cardiotho- racic surgery program at these three long-standing institutions could be solved by development of a collaborative program in cardiothoracic surgery. By com- bining the three programs, their total case volume would be nearly 800 cardiac procedures per year; they would perform 23 heart transplants per year; 252  Pursuing Excellence in Healthcare the program would have access to exciting new investigational tools and techniques; opportunities for residency training in cardiothoracic surgery would be re- invigorated; and most importantly, patient care would be improved. As a result, the combined program would become a leading referral site for regional cardiac care. e structure of a collaborative program would have to overcome the many cultural differences among the three competing AMCs, would have to supersede the egos of the staffs of various institutions, and would not be easily accomplished. However, the focus on improving care would be innovative and exciting. A merger or alliance with other local programs may not be politically, legally, or economically expedient, other “global” strategies might be useful. For exam- ple, any or all of these programs might also benefit by “partnering” in some way with a nationally recognized cardiovascular program that is outside of their mar- ket area. is would allow them to bring world-class credentials in cardiovas- cular disease to the local marketplace and take advantage of the spin-offs from national name recognition while at the same time providing their cardiologists and cardiovascular surgeons with ready access to new and innovative technol- ogy (recognizing that some select disease states would travel to the “home base” for care). By folding their statistics into the overall statistics of the “partnering” program, they would also provide both payers and patients with a significant level of confidence in the quality of the program while at the same time meeting all Leapfrog-type benchmarks. is type of arrangement would not be substan- tially different than the efforts described earlier between Columbia-Presbyterian and Mt. Sinai Hospital of Florida but would represent one of the first alliances in a single product line between two academic medical centers. Finally, it must be recognized that any of these three hospitals could take a more traditional approach to increasing their procedural volumes in cardiovas- cular disease—investing heavily in the recruitment of individuals who could bring with them the latest new technology by virtue of their positions as the national leaders in these new areas. e ability to attract these types of indi- viduals would in all likelihood also require the recruitment of the basic sci- ence programs that may underpin these new clinical arenas. For example, the recruitment of an interventional cardiologist or cardiothoracic surgeon who is implanting autologous stem cells in the hearts of patients who are days or weeks status-post a myocardial infarction would likely require the establishment of a sophisticated stem cell research laboratory to complement their clinical needs. 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Mortality in Medicare beneficiaries following coronary artery bypass graft surgery in states with and without certificate of need regulation. Journal of the American Medical Association 288 (15): 1859–1866. 52. Birkmeyer, J. D., and Dimick, J. B. 2004. Potential benefits of the new Leapfrog standards: Effect of process and outcomes measures. Surgery 135 (6): 569–575. 53. Heart transplants: Do more or do none, Johns Hopkins study suggests. 2008. Press release, Jan. 29 (http://www.hopkinsmedicine.org/Press_releases/2008/01_29_08. html). 257 12Chapter Ensuring Governmental Support and Oversight of the AMC In the future the medical profession will also become closely associ- ated with the government, and with a far more important function— that which deals with the life and health of the people. It appears to me that the laity will soon appreciate the necessity of this work, possibly before the medical profession is ready to undertake it. William Mayo, 1910 [1] Introduction Although Dr. William Mayo had the foresight nearly a century ago to recog- nize the importance of government in supporting and regulating the practice of medicine, federal agencies have rarely exerted oversight of AMCs despite the fact that they should be viewed as a public trust. AMCs are entrusted with the tripartite mission of providing outstanding patient care, teaching the next generation of clinicians, and discovering the next generation of therapies. Most organizations in the United States whose activities have significant effects on the safety, health, or financial well-being of the American populace are carefully [...]... cancer patients, survivors, and caregivers went to Capitol Hill to urge Congress to pass laws to help fight cancer, including facilitating drug evaluations at the FDA, passing the Family Smoking Prevention Act, creating a national cancer fund to support cancer research by increasing the federal tobacco tax, and increasing funding to the National Institutes of Health and the National Cancer Institute... nowhere in the American Cancer Society’s advocacy program is there a recognition that many of the new agents for treating human disease come out of translational science laboratories at AMCs that are part of collaborative efforts of scientists focused on the treatment of many different diseases; that the early phase I evaluations of new anticancer therapies, as well as many of the phase II and phase III... chapter, there is no common reporting mechanism regarding the financial health of an individual AMC Although AMCs provide some financial information in self-disclosures to the AAMC, these data can only be queried in the aggregate and investigators cannot gain access to data from individual institutions This lack of public reporting is in marked contrast to publicly traded institutions Thus, scholars who... scholars in the fields of finance, business, and education to identify the financial structures, organizational structures, and strategic initiatives that have led good AMCs to attain greatness will only take place if there is public access to and consistency in AMC financial reports Finally, it is imperative that the National Commission on Academic Medical Centers also have access to AMC financial reports:... contrast, the state of New York has successfully maintained a certificate of need program Thus, all of the hospitals in the state that perform interventional cardiac procedures, coronary artery bypass surgery, or heart transplantation have high volumes and outstanding results New York City has also instituted novel policies that improve care of patients having a heart attack Rather than taking the patient... AMC faculty and staff work Perhaps one of the reasons that AMCs have found it so difficult to convince state and local governments, as well as philanthropic foundations and individuals, of their needs is a complete lack of knowledge on the part of the public regarding the financial plight of many AMCs This could be rectified by transparency, national guidelines for reporting, and by making data available... programs per capita than virtually any other state in the United States, and the vast majority of the programs did not meet the volume standards mandated by many healthcare organizations, including the Leapfrog Group The bill was allowed to sundown because legislators who represented rural communities believed that an open-heart surgery program in their community would enhance the prestige of the community... obligation to oversee the banking and investment community led in large part to the ouster of many Republican candidates in the 2008 elections and to the election of Barack Obama as the 44th president of the United States However, despite the fact that AMCs are a public trust,” no federal agency oversees or regulates their activities other than licensing groups that ensure the adequacy of medical education... more than half of that at the Mayo Clinic To manage similar patients, the Mayo Clinic used fewer beds and half the number of physicians as did UCLA [27]: [For instance], the Mayo Clinic and the Cleveland Clinic allocate relatively fewer resources per capita and spend less per capita than their peers, while simultaneously receiving high marks on established quality measures Other academic medical centers... the business of healthcare know far more about the financial health of publicly traded companies, such as IBM, Pfizer, or General Motors, than they do about the AMC where they work or where they receive their healthcare Indeed, better public disclosure of AMCs may have allowed local officials to learn about the business practices at Allegheny Health System prior to its bankruptcy The ability of academic . increasing the federal tobacco tax, and increasing funding to the National Institutes of Health and the National Cancer Institute. However, nowhere in the American Cancer Society’s advocacy program. research funding, the awarding of a clinical and translational sci- ence award that incorporates investigators at both institutions, and an increase in surgical volume. As noted by the chairs of surgery. on the treatment of many different diseases; that the early phase I evaluations of new anticancer therapies, as well as many of the phase II and phase III studies of new anticancer agents, take