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The
Health of the Future by
Bruce Fellman By any measure, the medical sciences at Yale as taught and practiced at the School of Medicine and its department of Epidemiology and Public Health, along with the School of Nursing, play a critical role in the health of the New Haven community, the state of Connecticut, the nation, and, increasingly, the world. Perhaps underappreciated, however, is the importance of Yale's medical enterprise to the well-being of the University. There is, of course, the matter of prestige. Whether the rankings are compiled by U.S. News & World Report or the National Research Council, many of Yale's health sciences programs are top-rated. Medicine also generates a significant amount of money: In the fiscal year 1995-96 the Medical School-through tuition, research grants, patient care, and other sources-brought in $434 million, or 43.6 percent of the year's $996-million University budget. That figure has been growing, steadily and dependably, since the advent of Medicare in the 1960s. But recent developments on the health-care front-particularly the advent of managed care-have created a host of uncertainties about the future. "There's a revolution out there," says Stephanie Spangler, Yale's deputy provost for biomedical and health affairs, herself an obstetrician and gynecologist. "It's a revolution in which each of us is an active player, often with multiple roles-as provider, as educator, as payer, as insurer, as policy maker, and as patient." In the three years since the Clinton Administration's plan to control skyrocketing medical costs collapsed, a concept called managed care has taken hold and changed every facet of American medicine. As a result, everyone involved in the University's enormous health professions endeavor has had to adjust to the rise of the health maintenance organization and a radically new way of doing business. Those efforts formed the core of the discussions from October 23 to 25 at the Association of Yale Alumni's semiannual Assembly, at which more than 250 delegates and their guests considered the past, present, and future of medicine at Yale, in the nation, and abroad. At "Yale and the Revolution in American Health Care," which was organized by David Gibson '78, an assistant clinical professor of orthopedics and rehabilitation at the Medical School, participants heard deans, doctors, nurses, and public health experts assess the state of health care. There were demonstration sessions that enabled delegates to bear witness to a number of technological breakthroughs. (Gibson and a colleague, Kevin Lynch, also a clinical professor at the Medical School, took their audience through the procedures they use to replace a worn-out knee with a metal-and-plastic prosthesis.) There was also extensive discussion of medical ethics. But the recurrent theme was the impact of managed care. At the Assembly's Friday banquet, keynote speaker Benjamin Carson '73, a pediatric neurosurgeon at the University of Pennsylvania and the newest member of the Yale Corporation, declared that a considerable amount of good has come from the managed care concept. "By making us focus on keeping down costs, managed care organizations have done us a favor," he explained. "But that useful role is finished, and we now have to move on." Precisely where remains uncertain, but as far as Yale is concerned the direction will be determined by David A. Kessler, the controversial former commissioner of the U.S. Food and Drug Administration who left Washington last summer to assume the deanship of the Yale School of Medicine. Kessler, a 46-year-old pediatrician with a bachelor's degree from Amherst, a law degree from the University of Chicago, a medical degree from Harvard, and additional training at New York University and Johns Hopkins, is perhaps best known for his attacks on the tobacco industry. During his six-year-tenure at the FDA, he also attracted considerable public attention for his efforts to create better food labels and to decrease the time it takes to evaluate and approve new drugs. Since becoming the Medical School's 15th dean on July 1, Kessler has been studying his new domain and formulating plans for helping the health sciences deal with what he admits is a harsh medical climate. Still, as he told the Assembly audience, there are "great opportunities" in the managed-care-and-beyond environment. If nothing else, its very harshness tends to bring into the fold only those students who see medicine as a calling. "Young people are now entering medicine for all the right reasons," he said. "They know about the cutbacks and the uncertainties of the system-they have their eyes open. But they're here because they know that being a doctor is a privilege." As Kessler and his colleagues on the Assembly panels made clear, figuring out what sort of doctors, nurses, public health practitioners, and researchers to train-indeed, determining the shape of the health-care industry in the 21st century-poses some monumental challenges. Perhaps the biggest is financial. Managed care originated as a response to health-care costs that in the 1980s and early 1990s were climbing at double-digit percentages, numbers that greatly exceeded the rate of inflation. The strategy has proven largely successful, and with more than three-quarters of all Americans who have health insurance currently enrolled in health maintenance organizations, or HMOs, the rate of growth has, in fact, been held in check. In general, this is welcome news for both the insured and for the companies that provide insurance. But for the Medical School, its professors, and Yale-New Haven Hospital (YNHH), with which the School is affiliated, there is a dark side to this phenomenon. YNHH is well known for its advanced treatment facilities and for its "superspecialists," all of whom are members of the Yale faculty. In the past, these doctors have been able to charge a premium for their services, but any profits did not go into the physicians' pockets, however. Rather, the surplus was used to fund such activities as research in the clinical and basic sciences, as well as the training of interns and resident physicians. The clinical income, which now accounts for 43.1 percent of the Medical School's revenues (up from 3 percent in 1960) has also been used to help reimburse area hospitals and doctors who are frequently called upon to provide care for those without medical insurance. However, in a relentless attack against costs, managed care organizations, propelled in part by cutbacks in federal Medicare payment allowances, are threatening to eliminate what is, after all, a kind of institutional benevolence. Orthopedic surgeon Kevin Lynch, for example, explains that his fees have been reduced by 30 percent. "The economics are fairly depressing," he says. "We're becoming the only true nonprofits in America." That is clearly an exaggeration, but it points to trouble in the future. "I used to be able to devote 20 percent of my time to clinical research and training, and that's down to 4 percent," Lynch explained. "The difference is the time spent fighting with insurers." Despite such difficulties, however, pediatrician Joseph Warshaw, the deputy dean for clinical affairs at the Medical School, noted that the sky hasn't fallen-yet. "Our clinical revenues are down 5 percent," said Warshaw, "and it's clear that in the future, there'll be even less money to support our academic mission." Another concern is the availability of funds to support basic research. In the competition for dollars from the National Institutes of Health, the National Science Foundation, and other federal agencies, as well as from private foundations and companies, the various health sciences schools "have done extremely well," says Carolyn Slayman, deputy dean for academic and scientific affairs. Currently ranked fourth among major research universities in federal support, the Medical School in fiscal 1995-96 brought in nearly $200 million, which is about 45 percent of its operating budget. Despite the budget-cutting climate in Washington, biomedical research has come through relatively unscathed. "But we don't feel secure," says Slayman, and with competition increasing for a pool of federal funds that will not grow much-and may even decline-"we're going to have to be as resourceful as possible." One revenue stream that cannot be called upon to make up any shortfall is tuition, which only generates 3.8 percent of operating revenues. In fact, Robert Gifford, associate dean for education and student affairs, worries that even as managed care puts a squeeze on income, a considerable amount of additional money is going to have to be found for financial aid and infrastructure improvements. "It costs around $40,000 a year to go to medical school here, and we've always been able to attract the very best students in the world," says Gifford, who explains he was "so energized" by Kessler's arrival that the associate dean put off retirement. "But if we don't increase our financial aid package-something that schools like Penn, Harvard, Johns Hopkins, and Duke have already done-we'll be losing students. That threatens the very soul of the school." To remain competitive, Gifford argues that Yale will also have to put more money into facilities. "We could use a new student center, and the dorms and teaching laboratories are in serious need of renovation," he says. There are also the internal challenges that have come from the health-care profession's need to re-examine, and even reinvent, its role. "Never in the 50 years since I graduated from medical school have I seen such turmoil," says Howard Spiro, a professor of internal medicine who chaired an Assembly panel discussion on the ethics of managed health care. "Doctors have become double agents, and the therapeutic alliance between doctor and patient has been disrupted." In the past, says Spiro, a physician determined what treatment was in a patient's best interests and proceeded accordingly. But now, with many doctors dependent on HMOs, a physician may have to weigh the financial health of the managed care organization alongside the well-being of the patient. "Care is being allocated by algorithm and protocol, and there's no time to listen to the people we treat," notes Spiro disapprovingly. "Old doctors like me feel that medical care is not just another commodity." Out of this turmoil must come a new, and as yet undefined, kind of alliance, and Yale appears to be especially well placed to play a leadership role in developing the health-care system of the future. For example, to increase efficiency in the delivery of care, and to free doctors from the business side of medicine, the School is launching a not-for-profit, group practice corporation to deal with HMOs. A more aggressive technology transfer program, coordinated through the University's Office of Cooperative Research, is under way to translate discoveries in basic science into useful drugs, medical devices, and therapies. (The effort bore fruit recently when the Scirex Corporation, a Pennsylvania-based drug development services company, established a laboratory at the Medical School to work with investigators in the psychiatry department.) In addition, there are plans to create a new clinical sciences building, renovate existing facilities, and increase the endowment, which, according to recent figures, generates 2.8 percent of the Medical School's income. (The extra money, say officials, could be used for student financial aid.) Ironically, however, the medicine of the future need not look far afield for a new identity. "One of the best things to come out of managed care is its emphasis on wellness," says Gerard N. Burrow '58MD, who was Kessler's predecessor as dean and is now a special adviser to President Levin on health affairs. Burrow notes that Yale's schools of public health and of nursing are two places where the emphasis has long been on wellness, as well as on the team concept of medical care and on interdisciplinary education. "We're entering a glory period," Michael Merson, dean of the Department of Epidemiology and Public Health, told an Assembly panel discussion. "Our focus is on populations, on the health of all of the people all of the time. Managed-care organizations are grabbing our graduates." A good part of why Merson's discipline is on the rise in the managed care era lies in the simple fact that it is far cheaper to prevent diseases than to cure them. And yet, despite a record number of applicants, a rosy jobs picture, and a $10.8-million federal grant to establish the Center for Interdisciplinary Research on AIDS, the dean is not about to become complacent. "Prevention is invisible-there are no candlelight marches for diseases we no longer have," says Merson. "As a nation, we can get into trouble if we neglect our public health infrastructure." Nurses also can play a critical role in the prevention wars, says Judith B. Krauss '70MSN, the outgoing dean of the School of Nursing. (Krauss will return to teaching on July 1; her replacement is Catherine Lynch Gillis, who chairs the family health-care nursing department at the University of California at San Francisco.) "Nurses are extraordinary health educators," says Krauss, "and the current switch from hospital-based care to community-based care has provided us with an enormous opportunity." Yale specializes in training the "advanced practice nurse," a graduate school-educated practitioner capable of both delivering care, often in lieu of a doctor, and coordinating treatment that may involve many different specialists working over long periods of time. Employment opportunities for registered nurses are, in this market, shrinking, but advanced practice nurses are in demand as, says Krauss, "we turn our attention to care reform, not just cost reform. Our graduates have learned to manage the care environment, and they're skilled in such things as the safe and wise use of technology and in dealing with chronic diseases. So we can be a different kind of quarterback-but not a physician substitute-and we can serve as a bridge between public health and medicine." While the health-care system of the future will certainly involve more teamwork among the various disciplines represented at Yale than has been evident in the past, predicting the precise shape of this alliance remains a challenge. "We're working hard to define what good care is," says Dean Kessler. "Clearly, we can't continue to practice medicine the old way, so it's our job to train students to tackle change-and to change the world."
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Yale
Alumni Magazine, PO Box 1905, New Haven, CT 06509-1905. USA.
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