The changing health care landscape, accelerated by the Affordable Care Act, has signaled a move of the federal government, as well as private insurers, from fee-for-service to value-based reimbursements. To ramp up for this change, academic health centers are creating larger, integrated care delivery systems through mergers and acquisitions of hospitals, physician practices, and potentially of digital health companies.
The thinking is that scale will help academic health centers leverage their size and unique strengths to: 1) establish a large patient base and market share, which will allow them to endure and continue to provide the safety net care for the most complex and vulnerable patients; 2) mitigate the risks in transitioning from fee-for-service to more global reimbursement models; 3) position themselves to more effectively negotiate with payers for favorable reimbursement rates; and 4) preserve the academic missions of education and research.
Economists, regulators, policy makers, insurers, academic medicine leaders, patient groups, and consumer groups have voiced both support and cautions for the moves to integrate large health systems. However, there has been less attention on the impact on medical research; there are some extraordinary opportunities and some daunting risks.
The opportunities: First, the expansions will significantly increase the size and the diversity of the patient and population base for outcomes research. With the anticipated requirements for addressing the social determinants of health in quality improvement efforts and reimbursements, a more diverse patient base will present advantages for integrating research into care delivery and community-engaged research to target social determinants to help reduce health disparities.
Second, the integration will provide new opportunities for conducting health care delivery science across different sites with different cultures, practices, and attitudes. Implementation science, at its best, can serve to evaluate various interventions, then scale or spread those that work and stop those that do not. The recent growth of centers that focus on innovation, improvement, and implementation science, from 10 in 2006 to 48 in 20151, points to academic health centers' efforts to build an infrastructure for care delivery and population sciences.
Third, with the President's Precision Medicine Initiative, the expanded patient base will provide a superb venue for integrating demographic, diagnostic, EHR, and other data with genomic data. This comes at a time of concurrent efforts to accelerate EHR interoperability to enhance care, lowering the historical hurdle to clinical outcomes research across systems.
Fourth, care delivery science and patient outcomes research can have "local" benefits on the patients and communities the system directly serves. Such impacts are easily observed by local community members and policy makers, building trust and support for the institutional efforts and continued partnerships.
Finally, this area of research can establish evidence-based approaches to improve care and patient outcomes which can, in turn, help influence future federal and state policies that take into account the complexity of caring for patients served by safety net health systems.
The risks: Basic research is one area of academic medical research that may be at risk. Unlike outcomes and care delivery research, basic science may not directly benefit the patients and populations served by the health system in the short term.
Basic science builds on thousands of incremental but crucial advances in laboratories across the globe to create new knowledge. Take the well-known "statins," a drug class for treating high LDL cholesterol, and also the recent new treatment class, the PCSK9 inhibitors: both came from a nearly a century of basic science. Biochemical, molecular, cellular, and physiological studies were conducted in laboratories throughout the world that identified intricate details of pathways for the metabolism of LDL cholesterol, uncovering potential sites in the pathway for treatments. This is one example, and there are thousands more. While basic science may not provide the relatively more direct effects on the patients and populations served by the health systems, the results will ultimately have a tremendous impact on both patients' health and the costs to the health systems.
Under the intense pressure to reduce costs and preserve fragile margins, will the newly integrated, large health systems focus singularly on care delivery and population management and not see the importance of investing in basic research as a priority and part of the research mission? I hope not. Abandoning basic medical research is abandoning our future.
A note of optimism. Perhaps bigger and more integrated academic health systems can intentionally leverage the forces at play in their environment to continue to ensure on-going support for basic science. We know that academic health centers are committed to investing in medical research; as our recent study with Huron Consulting Group shows that, for every $1.00 of sponsored research received, the average academic health center spends an additional $0.53 out of their own pocket.
There is also an increased effort by academic research leaders to focus on research priorities that are consistent with the institutional and community missions, needs, values, and resources. Perhaps we can borrow from pharmaceutical companies' agreement on "precompetitive spaces," in which research across different integrated health systems is also integrated – where some centers work collaboratively to address vexing health problems like diabetes, heart disease, and cancer through integrating basic science, clinical research, outcomes research, and implementation science.
The voices of the academic research community have been relatively silent on the issue of mergers and acquisitions, and it's time to engage. There are some extraordinary opportunities for medical research, and some daunting risks. Ignoring either is short-sighted. If the academic medicine community works together to achieve the goals of consolidation, stabilizing fragile clinical margins, and calming the sustainability concerns, it can also sustain its historical commitment to investing in medical research to improve the health, wellness, and quality of patients' lives – sometimes even finding cures for them.
1AAMC data, 2015
Ann Bonham, PhD, was formerly chief scientific officer at the Association of American Medical Colleges.