This post is by Edward Abraham, MD, a partner in the payer/provider sector of the health practice at Guidehouse, a corporate affiliate member of America’s Essential Hospitals, and Michelle Moratti, a partner at Guidehouse and a leader for the health segment’s strategic advisory services.
Academic medical centers (AMCs) play a unique role in the U.S. health care delivery system. According to the Association of American Medical Colleges, more than 400 major teaching hospitals and health systems, including nearly one-third of America’s Essential Hospitals members, are affiliated with the nation’s 154 accredited medical schools, which train next-generation providers, performing research and accelerating the development and adoption of new approaches to care.
With their unique position in the health care industry, AMCs are experiencing an increasing magnitude of challenges associated with multiple, competing goals and the need to maintain a tenuous balance of cross-subsidization across activities, including providing:
- Medical education to future physicians and other health care providers.
- Groundbreaking clinical and translational research.
- Tertiary and specialized acute care services to the most severely ill or injured patients.
At the same time, no two AMC models are alike. Each has its own balance of these three functions. Some emphasize education more than research, while others emphasize research more than clinical care, and still others prioritize clinical activity.
However, the balance of those functions at each AMC, along with the traditional AMC business model, face pressure from economic uncertainty and the effect of the COVID-19 pandemic. The time has come for AMCs to reconsider their strategy, operations, and traditional core practices to successfully manage future volatility and ensure long-term growth.
A new analysis from association corporate affiliate member Guidehouse provides insights into how the same market forces that affect all providers distinctly affect the nation’s AMCs.
AMCs Treat an Increasing Percentage of Patients
Guidehouse’s analysis shows that AMCs are treating more patients across the United States each year, which in turn drives up their case mix index (CMI), average length of stay (ALOS), and operating expenses. These increasing numbers of patients add up to dramatic — and more costly — changes in how AMCs function. Specifically:
- Patient days at AMCs rose by 17 percent between 2008 and 2020. By comparison, patient days at non-AMC hospitals dropped by 7 percent over the same 13-year period.
- Patient discharges at AMCs rose by 11 percent between 2008 and 2020, though they dropped by 4 percent from 2019 to 2020 in response to the pandemic. By comparison, patient discharges at non-AMCs dropped 10 percent between 2008 and 2020.
- The CMI at AMCs rose 17 percent between 2011 and 2020. Much of that increase over the nine-year period happened in 2020, when the pandemic reduced the volume of less severe, elective procedures.
Historically, AMCs have struggled with ALOS, often due to inefficiencies associated with their care models and teaching activities. In many AMCs, patients cannot leave the hospital until a resident, fellow, faculty member/attending, and/or hospitalist writes and signs a patient’s discharge note. Only then does the discharge team — nursing, discharge planning, and social work — mobilize to get the patient safely out the door. The patient-discharge wheels at AMCs can turn slowly, inflating ALOS. Greater patient volumes and more sicker patients only exacerbate this situation and, along with it, already high operating expenses.
Financial Stability is Unpredictable
AMC profit margins, which support all three components of their mission, are dropping fast. Guidehouse’s analysis shows:
- Operating expenses at AMCs rose 123 percent between 2008 and 2020. Operating revenue didn’t keep up, rising only 110 percent over that same 13-year period. When expenses rise faster than revenue, margins degrade.
- Both ends of that margin equation aren’t as bad and, in fact, are better at non-AMCs. Operating expenses at non-AMCs rose 58 percent between 2008 and 2020, compared with 123 percent at AMCs. Meanwhile, operating revenue at non-AMCs rose 60 percent between 2008 and 2020, compared with 110 percent at AMCs. Margins didn’t degrade as fast at non-AMCs because operating revenue rose faster than operating expenses, albeit not by much.
- AMCs incur a higher average adjusted cost-per-case than non-AMCs. In 2020, that cost was $9,037 for AMCs and $8,413 for non-AMCs.
Unpredictable is the best way to describe how the money flows in, among, and between the three parts of an AMC’s traditional business model. The once predictable flow of money into an AMC from medical school tuition, Medicare graduate medical education (GME) payments, grants, research program contracts, and philanthropy is today in a constant state of flux for reasons unrelated to patient care. That also puts a great deal of pressure on AMC profit margins.
The combination of expenses rising faster than revenue and unpredictable revenue from other sources makes AMCs ripe for new thinking.
Reconsidering Core Practices
As the numbers show, more patient volume isn’t the answer to financial stability because all volume isn’t created equal. Additionally, as value-based care and alternative payment models replace waning fee-for-service models, AMCs need to fundamentally reconsider the patients they seek to treat and how they treat them, while still maintaining their three-part mission. Establishing and achieving a target patient case and complexity mix is critical to financial sustainability.
In strategizing new approaches to operations and core practices to effectively manage today’s volatile environment, AMCs should consider their:
- Target mix of dedicated teaching floors and non-teaching floors and corresponding use of general and specialized hospitals.
- Surgical versus medical patient volume, particularly at the higher end of the complexity continuum.
- Strategies to develop a portfolio of programs that achieve the optimal patient mix.
- Provider-to-provider network development to achieve target portfolio patient composition including digital network development and second opinion services.
- Process for managing patients from a throughput perspective to optimize capacity utilization including aggressive use of pre- and post-discharge digital tools.
- New post–acute care, integrated care models with the goal of reducing ALOS and readmissions.
AMCs also should consider some rather significant and dramatic changes in their teaching practices, and particularly their effect on patient throughput, including:
- Examining how the designation of teaching and non-teaching patients can ensure teaching goals are met while optimizing utilization of scarce capacity via effective patient throughput.
- Critically looking at their medical education programs, particularly those focusing on GME, including size of the program, distribution of medical specialties, and deployment and use of medical specialties. All these variables, if not well thought out, can impact patient throughput.
- Considering and/or further developing hospital-at-home programs as well as having hospitalists involved in emergency department operations and emergency patient care decisions at an early point.
- Partnering with community hospitals in new ways to allocate inpatient demand across available capacity within a geography
Any change that affects patient volume and/or care delivery must be viewed in terms of its effect on the other two components of an AMC’s mission: clinical research and medical education. One change cannot be made without understanding how it will affect the other two parts of core AMC activities.
It’s Time for AMCs to Reset Their Business Models
The complex interdependency between AMCs’ three-pronged mission has contributed to slow change within their organizations. Any one move will affect dozens or even hundreds of other functions upon which people employed or affiliated with the AMC base their careers and livelihoods. That makes decision-making exponentially more complicated at AMCs than at non-AMCs.
Yet, the numbers show that the industry is changing in volatile and permanent ways, and these shifts affect AMCs more dramatically than non-AMCs. Inertia or even the lack of awareness for the need to change will put AMCs behind the rest of the industry. A new AMC strategy is key to driving financial stability and long-term growth.