The Key Relationship Between Academic and Clinical Medicine

Academic medicine providers are increasingly depending on their clinical practices to fund their education and research divisions. How do academic medical providers balance financial performance with clinician and community needs amidst competing missions that challenge their business models? In this episode of Value-Based Care Insights, Daniel Marino sits down with Dr. Joseph Bosco, Vice Chairman of Clinical Affairs at NYU Langone Health, Department of Orthopedic Surgery and President of the AAOS, and Jeff Peters, a national expert in growth and service line strategies, to explore how academic medicine is addressing conflicting missions across their enterprise. Gain insight into growth models in academic medicine that prioritize clinician and geographic accessibility to keep patients in-network, while maintaining a strong focus on research, education, and quality care. 

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Dan Marino. On our program we've had a number of guests who've talked about or shared with us their insights on academic medicine. And as we discuss time and time again, the world of academics, as we think about productivity and supporting the different priorities within the academic mission, it is definitely different than community-based care. Mostly due to just the goals and the objectives of a lot of the providers that are within academic medicine. I mean many of the academic institutions. they have the clinical mission, they'll have their research mission, they'll have their academic mission. And many of them have worked through all 3 of those missions, which really provides a lot of competing priorities. But in the end of the day what we are starting to see and have seen for the last number of years, is there's continued pressure on the academics to provide the right level of financial performance. The right level of ability to expand and really supporting, or, let's say, connecting with their community based provider partners.

Well, I'm really excited today to have 2 wonderful guests who have an incredible amount of knowledge in this area. 1st is Doctor Joseph Bosco. Doctor Bosco is professor and Vice chair of NYU Langone health orthopedics. In his role he's led his department's transformation from a single specialty orthopedic hospital to a clinically integrated musculoskeletal delivery system. And then we also have Jeff Peters, Jeff is a frequent guest on the program. He and I have worked together for many, many years, is a national expert in strategy, helping organizations anywhere from health systems to individual hospitals, to medical groups, helping them with their financial improvements, strategic growth, and a lot of service line development as well. Dr. Bosco, Jeff, welcome to the program.

 

Joseph Bosco:

Thank you, Dan. Great to be here. Hi, Jeff!

 

Jeffry Peters:

Thank you. Yeah. It's an honor, Dan. Thank you.

 

Daniel Marino:

So, Doctor Bosco, maybe we could start with you as you. You think about some of the challenges that academic medicine has, particularly the financial challenges and things are changing. We're not seeing the level of reimbursement that we used to. We're not seeing the funding that we used to. And there's continued pressure on the academics to change their model. What are you seeing as you, as you talk to your peers around the country?

 

Joseph Bosco:

Well, WI think we're all experienced the same thing, you know. Traditionally, as you mentioned, academics had a academic medicine had 3 goals: clinical care, education and research. And it really that really hasn't changed as much. It's just that, you know, frankly, you know, in order to do your research mission and your education mission, you need to be a have a very politically relevant and make money clinically, frankly. You know no margin, no mission. And traditionally, and that even now education and research doesn't reimburse enough to keep a hospital and Medical school afloat. Frankly, so. It's the clinical. It's the clinical mission that funds much of the research and the education, especially.

 

Daniel Marino:

I agree there's that focus has really been over the last couple of years on more of the on the clinical mission. Has it changed the perspective of how some of your colleagues in in academics, their perspective on, on how they need to be productive? I mean, many of them have gone into academic medicine for the mission right? for to really be able to support maybe other areas. A lot of them see themselves as scientists as opposed to just providers. Are you seeing that change?

 

Joseph Bosco:

Yes, as really the pressure. Financial pressure is ratcheted up, and especially in orthopedics, frankly. Orthopedics is a little different, because most orthopedic surgeons a like what we do a lot clinically, and also even now get it gets reimbursed at a very high level. So when you hire a person that's going to be a half clinician, half scientist. Right? That's what they do. They are. They are making a sacrifice with the income they make. And that's just the way it is. And so what we see happening invariably is, they wanna be half clinician, half scientists, and that usually it evolves into 3 quarter clinician one quarter science. It's not just greed or wanna make a lot of money. Frankly, we see it. It's cause they enjoy doing the clinical part. So again, we really have to make an effort to make sure that the clinical activities drive and pay for the educational activities. And you know frankly, with the amount of consolidation that's happened in the healthcare industry today, right? Huge hospital networks. You know, we went from a single specialty Orthopedics hospital Manhattan to now a clinically integrated network with 4 community hospitals, 6 surgery centers and increasing accessibility. So that's, you have to go where the patients are, and so your physicians, your academic physicians, have to be able to move out to where the patients are, and sort of, If you will, get away from the mothership a little bit. If you don't do that, you'll be surrounded by a bunch of by a bunch of very adept surgeons or physicians giving high quality, clinical care, and guess what patients are going to drive past 4 or 5 of these doctors to see the academic doctor in the middle of the city, right? Or in somewhere in Iowa, where they have to drive 3 hours to get to Iowa City to see the doctor. They're not going to do that anymore.

 

Daniel Marino:

Yeah, it's going to, really. And it limits the growth right limits the opportunities. So, Jeff, you know, I know you've worked with numerous academic institutions across the country, academic medical centers. This is really a paradigm shift within their strategy, and you know you wrote a great article that came out in HFMA. I don't know 3 or 4 months ago on how you you've captured working with one academic Medical Center, and how you were able to help support their growth within the community, very similar to what Dr. Bosco just described. How difficult is it to have the leaders kind of make that paradigm shift dealing with either the pressures within our industry, or maybe even the culture that exists within the academic institution?

 

Jeffry Peters:

Yeah. So let me put the context. I think what Dan is referencing is the work that I've done over 45 years with the University of Chicago Medicine, which is a major academic medical center. Historically based in Hyde Park. And through an affiliation with what was once a community hospital, we built a network of family care centers in markets that they had less than 1% market share and put in free standing emergency rooms, primary care practices, specialty practices, supporting ancillaries, surgery center and treatment centers for cancer. And it's been very successful in growing their market share from 1% to 20% in the targeted areas. And it typically, it's been adding a hundred 1 million dollars incrementally to the enterprise. But what we're seeing is in academic medical centers. The physicians are very focused on their department. And just like bot Dr. Bosco references, how do we make orthopedics more accessible? How do we push it out? Unfortunately, as academic medical centers have built these integrated delivery systems, there's leakage. There's primary careers who are there, but don't necessarily refer to the specialist. A lot of the reason why is, you see a patient in in the emergency room, you wanna refer them to an orthopedic surgeon and the orthopedic surgeon only has hours one day a week at the Ambulatory Care Center. That patient wants to access that specialist right away, because in the market, there's other orthopedic centers that have instant access. So increasingly, what we're seeing academic medicals look at is a new model that is like the traditional multi specialty physician group practice. Where there's primary care, there's specialist. They have ancillaries, they have a surgery center, and they're not just linked on their productivity individually, or their contribution to the department. There are incentives so that they take good care of the patient, and if they prevent leakage and keep the patient within their multi-specialty group that's based there, and use the ancillaries and all of that, there's financial rewards.

 

Daniel Marino:

That are kind of tied into that that help to kind of drive where they wanna go and reward the physicians. I think, for that for that new model. So let me turn to you, Dr. Bosco, kind of building on what Jeff had mentioned, as you start to think about driving that care into the community, or even setting up different types of structures, you know, I've always said form follows function. You need to have the right incentives in place in order to drive the right level of behavior. What are you seeing on the on, on the types of compensation, modeling or the types of incentives that help some of the academic providers, the academic physicians kind of think about delivering care differently?

 

Joseph Bosco:

Sure. So I think you know, basically, there's no reason why you can't see patients and perform as like a community-based surgeon and ha be available, or have people that you work be available that does not necessarily have to impinge or impede your academic mission. You could be a researcher, you could teach and still have availability to see patients right? So what we try and align people's incentives, because we know that if we're not available, if we're not provide service right away to folks, they'll go somewhere else. They'll go to one of the residents that we've trained. That does a great job right? So we don't wanna lose those patience. No, you know we can't rely on this academic arrogance, I call it. That's been built over 30 years, saying, well, they'll wait to see Professor Bosco 3 weeks. No, they won't. They'll go somewhere else, probably just as qualified as me and do a good job. So in in many ways, we're in competition on a clinical basis for these patients, and we have to be available and affable.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino. You're listening to value based care insights. I'm talking with Dr. Joseph Bosco and Jeff Peters. Discussing the changes in academic medicine and some of the pressures and challenges that are associated with delivering care. Sorry, Jeff, you're gonna make a comment.

 

Jeffry Peters:

Yeah, thank you. Dan. I agree with Dr. Bosco that you've gotta be accessible. You've gotta you've gotta take care of that patient, and you've gotta take care of that patient where they live. That's still an evolving concept, Joe. I think in academics, because there are, the majority of academic physicians want the patient to come to them to come to the Mecca. And you know, for really rare problems, it makes sense. But for the majority of problems that an academic organization is taking care of, it can be taken care of just as well and more conveniently in a community setting. And I think organizations that evolve like Doctor Bosco has talked about and I know his big messages how do we improve our accessibility? Those are the ones that are really going to survive and thrive because they're responding to the needs of their patients.

 

Daniel Marino:

Yeah. And you have to. You have to think about it, you know. That's what I was kind of saying. It's a paradigm shift, right. You have to think about delivering that care differently which I think in in the academic setting, I mean, culturally, that could be really tough to overcome. You're used to doing it the same way within academic medicine. And really, that that has to change. So, as one example we've seen across the country over the last number of years certain specialties. That are, you know, these community-based physicians will partner with hospitals, with health systems to form these joint ventures either around surgery centers or some type of specialty hospitals, or what have you. And it's a way to really align those incentives, and to really be able to take it out to the community. What are you seeing Dr. Basco? How are you seeing that playing out in the academic world are you? Are you seeing some of the academic leaders, including that within their strategy where you're forming some of those joint ventures with either maybe the departments, if they will, if they can? or certainly with the community partners?

 

Joseph Bosco:

Well, so I think we have to take it back a step, you know, in order to be relevant clinically, you have to grow as an academic medical centers. Anyone. There's.

 

Daniel Marino:

Great Point.

 

Joseph Bosco:

You have to grow clinical basis right now. Traditionally, academics, you know, you have residents, so you have residents provide care well, resident work hours are decreasing, and it's very difficult to get additional residents. So you have a finite amount of resident work hours, right? And which is sort of decreasing. Then you have, you're increasing your clinical volume. So then, a higher percentage of your clinical care is gonna be provided by non resident physicians. So when we hire, you know, we bring a group in. They may not have any contact with our residents, with our teaching. They work, they work only with PAs. Some are full time academic faculty work with PAs in the office. or in the in the, or used to be. You had a resident in your office, and then, when you went to the or that resident went with you. Well, that worked, you know, 30, 40 years ago. It doesn't work.

 

Daniel Marino:

Yeah, it doesn't work now.

 

Joseph Bosco:

So you know, you have to get away from that resident thing. The other thing is I just wanted, you know, we talk about, you know, get increasing accessibility for financial reasons. We're forgetting the other thing is that when you add the Mecca, right, and you ask patients to access you. You're increasing socioeconomic disparities. We've done a lot of work on this. If you're poor and you don't have a car or and you live far away. You could have a hard time driving, you know, 2 hours to see someone. In New York we publish an article where we, the driving distance didn't make any difference. But if you live in queens you want to come to Manhattan and maybe 3 miles away. But you don't have a car. You can't take public transportation.

 

Daniel Marino:

Yeah, that's a great point. Great.

 

Joseph Bosco: You did. Your children. Who maybe work at an hourly wage at a Mcdonald's, or something like that. They can't afford to take off time, because they don't have permanent, you know, time off to take their parents the hospital. So they're hourly wage people, they're gonna lose money. So if when you do the whole thing where you have to drive to the Mecca, you're increasing socioeconomic disparities. So you get out in the communities and you see that.

 

Daniel Marino:

And I'd love that. And I and I think I mean, that makes so much sense. And I do a lot of research, and I work with a lot of organizations on improving kind of the or addressing some of the socioeconomic disparities. Do you think a lot of the academics take that into consideration with their strategies?

 

Joseph Bosco:

Well, listen. A couple of years ago I looked at the Bank of America. You know they had a 200 page state of the art of medicine. Right? And they said, Well, you know you have to look at, you know, high income zip codes and put your satellites in there, right?

 

Daniel Marino:

Yeah.

 

Joseph Bosco:

But what we've done at NYU we've gone to the poorest neighborhoods, and what we did was we elevated the quality care that the port that the lower socioeconomic groups get a lot of dual eligibles. That's been part of our mission. So when we look at our US News and we report rankings, we use one systems rankings, not just our hospital, but these, these safety net inner city hospitals that we've taken over as well. And we're proud of that fact. Now again, no margin, no mission. So you know we still keep our eye on the bottom line, but that doesn't prevent you from going out and putting satellites in low socioeconomic areas. So you could take good care of folks, because that's what we're supposed to do.

 

Daniel Marino:

Yeah, sure. Well, I know, Jeff, this has been a big area of focus for you as well, and you've incorporated this into a lot of the work that you've done with the academic institutions.

 

Jeffry Peters:

Yeah, I mean, I think Joe sort of represents how academic medicine needs to think about providing care. They've pushed their services out into the community, and they've provided access. So you have an ambulatory facility with an ER and somebody has a broken leg, they don't want the ER to stabilize it, and then go see the orthopedic surgeon at the Mecca, and it's gonna take you 2 weeks to get an appointment. You're gonna have to drive an hour. They want the ability to walk down the hall from the er that same day that at the very same hour, and have somebody who can take care of that broken leg or evaluate them to see if they need surgery. And the successful organizations are going to improve this access. It's the same thing when a primary care sees Mrs.Williams, who's a 95 year old, and says, you know, we've been dealing with this painting your hip long enough. I think you need to go see somebody, see if you need to have a hip replacement. We want to be able to go into our epic system and say, Mrs. Williams, when do you want to see the joint specialist who's in this building 5 days a week, and prevent that leakage.

 

Daniel Marino:

Them into that domestic network. I think that's really the key. But you have to. The only way that that's gonna happen is you need to make sure you have the access models and the community based facilities that would support it. So let me let me kind of address this or refocus our conversation. If any of our listeners right now, and there's a number of them that are within the academic setting, if they're thinking about changing their strategic focus, or some of them are really thinking about advancing their strategies right now to obviously enhance their financial performance, increase access, all of those things. You know. Let's start with you, Jeff. Anywhere that they would start, or what would you recommend as a starting point?

 

Jeffry Peters:

I think what they need to do is they need to really have a discussion as to sort of what is the goal. How can they take better care of the community that they wanna serve? And to look at that community in a broad geographical area, and then evaluate at the present time, are their services convenient to the populations they want to see? Is there immediate access to both primary care and specialist? Is there an integration between the specialist and the primary care? They need to look at it from the patient standpoint as opposed from being sort of institutionally focused.

 

Daniel Marino:

Yeah, that's a great, that's a great point. And I think a lot of times. you see, the focus being more inward facing as opposed to the outward facing. And then Dr. Bosco, is there any advice that you would give to some of the academic physician leaders? You know, if they're if you, if we have a medical director, or say a department chair or a section chief listening, that is thinking about expanding their service line. How do they create that right alignment to kind of change that focus? Maybe either in terms of balancing the different missions or improving the financial performance of their of their section or department.

 

Joseph Bosco:

Well, that's a great idea. And the way we look at it is, you know, a academic, medical, integrated musculoskeletal care delivery. It's a big tent right? And so you can, they have to think in terms, rethink about how they look at their providers, their physicians and surgeons. You need to welcome a clinically competent physician or surgeon that may have no interest in teaching, and has no interest in publishing, but they are, they are. They are contributing to the enterprise, as we say, by their clinical performance. They're providing excellent clinical care. And frankly, you know, if they see a lot of patients that those patients now can be research subjects of some of the research.

 

Daniel Marino:

Right.

 

Joseph Bosco:

They don't have the right answers this idea that if you don't.

 

Daniel Marino:

Right.

 

Joseph Bosco:

And 3, and you know, if you don't write 50 papers in 5 years, you're not gonna make 10 here. We're gonna let you go as long as they are contributing to the enterprise in in a meaningful way and performing within the standard that we set, then they're welcome. They can actually choose not to work with the residents if they want. And so but that's the only way that you can expand so you can have, I don't wanna say different tiers, but different. many of your physicians have different ways they wanna work, you know. Some people wanna work half time. Some people you know, wanna work 80 hours a week.

 

Daniel Marino:

Yeah.

 

Joseph Bosco:

You know, doesn't make any difference as long as they're as long as.

 

Daniel Marino:

That's a great point. I think if you can change that compliment and, like you said not having one physician that comes in with the pressures of being able to provide a certain level of research. Maybe they just wanna focus on that clinical support. You know. Then you build a strong complement of the faculty within that department. I think that's a great way of being able to ensure that the Department is supporting their strategy as well as the strategy of the organization.

Well, gentlemen, this was a great conversation. I really appreciate it. If if any of our listeners want to contact you, or maybe have some follow-up questions, Dr. Bosco, maybe we could start with you. Any information you can give on on how they can possibly contact you.

 

Joseph Bosco:

Sure they can. Email. Me is probably the best way at joseph.bosco@nyulangone.org

 

Daniel Marino:

Great. And how about you too.

 

Jeffry Peters:

Yeah, and feel free to email me. Jpeters@luminahp.com.

 

Daniel Marino:

Well, thank you, gentlemen, this is obviously a very important subject. I'd like to continue the conversation at some point down the road. Certainly, as we think about some specific initiatives as academics continue to align with their community based partners. But until then thank you again for joining me today, and a special thanks to our listeners for tuning in until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners