The Three Pillars of the Medical-Industrial Complex – and the Physician. Part 5. Decoupling Research.

Posted on | July 15, 2016 | 4 Comments

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Mike Magee

Historically, for a century since the Flexner report, some 40 premier academic health systems have been the masters and the model for American health delivery, constantly reinforcing the three-prong definition of the ideal senior level “thought leader” and successful academic physician – researcher, teacher, clinician. But in 2009, AHA president, Rich Umberstock, predicted more change and more competition for the elite coming from every angle of his 5700 hospital institutions. As he saw it, the sources of this pressure would be electronically linked, seamless, risk-bearing integration, with and without an added graduate medical education apparatus.

As he said, “Our vision actually steps ahead of the traditional payment incentives that hospitals have been operating under.  And it also envisions a more integrated approach with physicians and other community interests because hospitals can’t improve the health of a population on our own – we need partners.  But, if the question is, should we be trying to diminish the reliance on treatment, then the answer is absolutely yes. Is there any other way to show that we’re on the side of the patient and the community?  No.”

That said, what should be done, if anything, about the 40 or so Academic Medical Centers whose academic physicians are the chief cogs in the wheels of commerce in the Medical-Industrial Complex, as they travel back and forth along the profitable roads that lead from bedside to research lab to government panels and Congressional testimonials? And how much money is at stake? Is it enough to make conflicts of interest unavoidable? And are these top flight institutions increasingly dependent and beholding to federal and industry dollars?

The answer to the final question is a definitive yes. As the government and insurers have moved to managed care, and payment restrictions and penalties have increased, occupancy rates have continued to fall. The losses on the in-patient side have continued to grow, though expansion of insurance coverage, especially for the poor and urban communities, and ramping up of faculty ambulatory practice plans have buffered the losses. Still, the reliance on federal and industry research dollars is now well-entrenched and expanding daily.

The grand-daddy of the Academic Medical Center is Columbia-Presbyterian Medical Center, founded in 1928. This is where New York Times columnist, Steven Brill, turned for emergency surgery for his aortic aneurysm. It lays claim to being “the world’s first medical center to combine complete patient care, medical education and research facilities in a single complex.” Its medical school, the College of Physicians & Surgeons, is revered. In 1997, it merged with the New York Hospital and its’ Cornell School of Medicine to form New York-Presbyterian Hospital. In the following two decades, the corporation has expanded its care network folding in dozens of ambulatory sites and smaller hospitals. In the first decade of the new century, it also launched the Irving Cancer Research Building, the Audubon IV center for biotechnology research, and a new research building on 165th street. Those investments paid off richly. In 2007 alone, the organization was awarded 742 million in NIH grants. Were one to fold in state grants, Foundation grants, research directed personal philanthropy, and non-transparent financial support and research partnerships with pharmaceutical and medical device companies, this figure could be safely doubled.

As recounted by Brill, the institution now houses some 22,000 employees servicing roughly 125,000 patients a year who partially occupy 2500 hospital beds. Total revenue is in the range of $4 billion a year, with operating profits of around $500 million. Their are 11 skilled executives within the organization that earn over $1 million in compensation a year. At the top of the ladder is their physician CEO, with a salary well in excess of $3 million a year. He would willing tell you that the future viability of his organization is increasingly dependent on research dollars. But is that good for the physicians, patients, or society overall?

These select hospitals find themselves in the same quandary as the AMA, whose dependency on industry income though journal advertising, sponsorship of CME, or underwriting of specialty organizations and the fully bought consumer organizations they spawn, have left AMA leadership irreparably entangled and ethically compromised. One need only look at the current opioid epidemic for evidence. The prescription for hospitals is the same as for the AMA. Balance of power must be re-established through rules and regulations that manage these oligopolies.

For the Academic Medical Center, this means splitting off one of the three historic arms of the academic physician’s mission. In short, education and clinical care must create legal and ethical firewalls that separate it from research. Only by doing this can the public be confident that their interests, and not those of various corporate entities are being served. Research enterprises must stand on their own, in the full glare, and under the close examination of  “comparative effectiveness” research, with appropriate independent governmental agencies assuring safety, quality, and transparency.

Steven Corwin, MD, CEO of New York-Presbyterian likely well deserves his compensation. It is an enormous enterprise he is managing. But he need not be the czar of an entrepreneurial research effort as well, while attempting to serve New York City’s daily health and wellness needs. Segregating health and professional education and training, from profit driven biomedical research is long overdue. As AHA’s Rich Umbdenstock suggests, hospitals have their hands full already these days. CEO’s need to be judged primarily based on their provision of efficient, seamless, and integrated care of patients and community. He says, “Integration is a fancy word, I think, for everybody playing a role in a larger system, in a way that coordinates both resource deployment and service delivery… ideally the medical and nursing schools and clinical practicums will promote that, but also you’ll see it organizationally and rewarded within organizations because of the potential for both greater coordination and greater resource efficiency…there’s now a track record of greater integration across the country that President Obama has touted and others are looking to—the Cleveland Clinic Foundation, Geisinger Health System, Intermountain Healthsystem, Kaiser Foundation Hospitals, Mayo Clinic, and others.”

If we wish to substantially reform American health care, we must go where the money and bodies are hidden – that’s research. The AMA, its Federation and peer review journals, the AAMC, the premier Academic Health Centers, the NIH and FDA, and the public’s understanding of “scientific progress” and what’s best for our health, all tract back to a non-transparent and conflicted medical research apparatus. By segregating and exposing it’s finances and, in some cases, unhealthy relationships to critical examination, we may finally understand why the vastly expensive American health care system, at least on some scales, has so remarkably  under-performed.

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