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A Brutally Honest Exchange at a Faculty Committee Meeting

and few seem to be interested.


Trust me, I'm a doctor...

"Why is the current system not serving the academic mission? This is like trusting the people whose last rocket didn't reach the moon when they say this next one will -- why trust the rocket scientists who failed? Will this arrangement just be in place for the next dozen years and then will there be something new?"


Senate Committee on Finance and Planning

Tuesday, October 20, 2009

Professor Luepker next reported on the last Board of Regents' meeting, where Senior Vice President Cerra made presentation on "Evaluating Integration of the Clinical Enterprise." Copies of the slides that Dr. Cerra used with the Regents were distributed to Committee members. This is a massive reorganization in a major portion of the University, Professor Luepker commented, and it caught his attention not only because it is a new direction for health-care settings but also because this is a billion-dollar-per-year enterprise (or more). The reorganization proposes the integration of the Fairview hospital management corporation with the University of Minnesota Physicians (UMP) and the University of Minnesota.

It struck him, Professor Luepker related, that apart from the financial magnitude of the proposal, there are a number of other questions that should be addressed.

-- Where does research and education fit in with this new, integrated organization? The presentation was mainly about the reorganization of clinical practice.

-- Who runs the organization? It appears that the proposed Board of Directors will be composed of non-University people, and it appears that the organization will be run like a business.

-- The intent is to pay clinicians salaries competitive with the community. Clinicians at the University are now paid less than the market; clinicians in private practice work hard, but they do not usually have teaching or research responsibilities.

-- There are no dollars figures included in the presentation, but the amounts involved must be very large. Where will the dollars come from and what is the University getting involved in? One motivating factor is to gain market share and compete better with other health-care systems--but those systems now take University students and train them for free.

There are a number of elements to this plan that go beyond the Academic Health Center, he concluded, and the AHC is such a big part of the University that this issue clearly falls into this Committee's bailiwick.

What leapt out at her, Ms. Kersteter said, is that there is little about the teaching mission in the presentation, and that is more expensive in a teaching hospital. She said she was also concerned about the residency program; if that is done badly, there would be a big impact on the community.

If the new Board of Directors is primarily external, Mr. Erikson said, it is not likely it would focus on the educational mission of the Medical School. One could look at this proposal from a very different perspective and not understand that it more expensive to have a teaching hospital.

Professor Konstan said that if one looks at this from the 50,000-foot level, one can understand that the health-care industry is in a storm and people want to lash the rafts together, but one needs to be concerned that the University doesn't lash itself to a rock, which this could be.

Second, he said he would like to see a statement about the mission that the Board of Directors would be sworn to uphold, because it does not appear the mission would be the same as the University's mission.

Finally, he recalled the time when the University sold its hospital to Fairview; that was supposed to solve the problems.

Now this document shows a whole bunch of problems that weren't solved.

Why is the current system not serving the academic mission? This is like trusting the people whose last rocket didn't reach the moon when they say this next one will -- why trust the rocket scientists who failed? Will this arrangement just be in place for the next dozen years and then will there be something new?

This feels a lot like "trust me," he said.

Professor Luepker said he agreed with Professor Konstan: the mission of the new organization is not clearly stated (and perhaps it is simply economic survival), other than "advance excellence and innovation in integrated patient care, medical education and research."

Professor Olin said this proposal would set up a role conflict for individuals who will work for two organizations: the Clinical Scholar work versus the profit-driven organization. The mission is thus important. There have been two structures in place, one devoted primarily to education and one primarily profit-based. How would this proposal affect AHC finances? How would it address the Medical School deficit?

Professor Morrison said there is a big push in health care to develop integrated systems, and this proposal is oriented in that direction. The federal government may prefer integrated systems in the health plans it supports, and thus require them, and they may save some money. The Mayo Clinic is a model for this kind of integration. Most years it does well. That is the good side. The bad side, he said, that the Mayo Clinic has a good little medical school, but could not run a large medical school in its environment--and they know it. The idea of the plan for the University hospital and clinics seems to be to solve financial problems of the Medical School and the hospital by putting them in a box and separating them financially from the University. The University will provide the research and education infrastructure and the credibility of an academic connection. The financial infrastructure required to run the Medical School and its research operation will be carried by the University.

What chunk is falling away from the University, Professor Konstan asked? As he reads the proposal, he said, AHC faculty who are not completely clinical will be University faculty, but a larger percentage of their time will go to the new health system than they would spend on UMP. He said he agreed with Professor Morrison that this proposal would carve off the viable part of the AHC and leave the rest hanging around the University's neck. He said he worries that the University will go down this path without articulating well what will happen--because that would generate opposition. The role of this Committee is to ask where things are going so "we can shed light on it."

Professor Olin reported, in response to a question from Professor Martin, that the AHC Faculty Consultative Committee has asked for the report from the consulting firm but has been told they are not finished. They have had no in-depth discussion of this proposal, he said. Professor Martin said she hoped the AHC FCC would demand consultation for themselves and their colleagues to ensure a positive academic outcome.

There are two pieces involved, Professor Morrison said: the financial, and the one he is more concerned about, the educational. How is this still part of the University? Do they just need the cover of the University? "Affiliation" with the University does not equal a real relationship with the academic operations of University. He said he was also concerned about how the other colleges of the AHC, Dentistry, Public Health, Veterinary Medicine and perhaps Nursing would fit into this enterprise, and about whether the Medical School could become simply a trade school within the new hospital entity.

Ms. Stahre said that this proposal has an ominous tone and may have much broader implications than just the clinical enterprise.