Why academic medical centers need a stress test

A group of nine medical specialty societies recently announced the “Choose Wisely” campaign, targeting 45 commonly performed medical procedures and tests that offer little or no value in improving health. These interventions waste precious health care resources, lead to erroneous conclusions and/or false security, spur unwarranted additional interventions, and cause patient harm. Among the appropriately indicted procedures was cardiac stress testing of asymptomatic, low-risk patients. There is an old adage among savvy clinicians: “It is difficult to make an asymptomatic person feel better.” Attempting to do so can cause more harm than good.

Determining the utility and predictive value of a test must factor in sensitivity — the ability to rule out a disease; specificity — the ability to rule in disease; and the prevalence of the disease in the population being studied. Cardiac stress testing might be useful for evaluating exertional symptoms in moderate- to high-risk patients where prevalence of disease is high, but has very limited utility for screening the “worried well.

The Federal Reserve recently preformed a “stress test” on 19 of the largest U.S. commercial banks. This exercise was essentially a solvency gut check under assumptions that included 13 percent unemployment, a 50 percent nosedive in the stock market, and a 21 percent drop in the housing market. The seemingly good news is that most of them demonstrated adequate capital reserves and resiliency to pass the test. The seemingly bad news is that 7,400 other banks were not tested, and chances are it is one of those untested banks that holds your money.  I use the modifier “seemingly” because the true utility of such tests on banks is not actually known and making assumptions of what to do next when the test itself may be flawed is a recipe for potential disaster.

So, should we perform a “stress test” for academic medical centers? Are they a high-risk cohort? Are they symptomatic?

Bob Herman recently listed 12 revenue pitfalls for these complex organizations. Last month, PricewaterhouseCoopers released a brief on how AMCs might “avoid a margin meltdown.” Both highlight vulnerabilities in governmental and private revenue streams for clinical care, research, and education.

The AAMC Group on Faculty Practice joined the Council of Deans and Council of Teaching Hospitals in Miami last month for a spring meeting. Deans, CEOs, and others previewed UHC’s Project Endurance, themed on the Antarctic explorations of Ernest Shackleton and featuring a fictional “Endurance University Medical Center” (EUMC). In essence, what UHC performed was a stress test on a fictional but realistic AMC.  Faced with dramatic, yet plausible, cuts to clinical, research, and educational revenue, EUMC had to turn itself inside out to begin to rebalance the operation.

While pleased to learn that everyone on Shackleton’s voyage did eventually return alive, all learned in graphic detail how academic medical centers will have to navigate through frozen funding streams in the future. There will be no sacred cows: Everything from program outsourcing to compensation will be on the table.

As an aside, I was particularly attracted to Shackleton’s original recruiting poster. “MEN WANTED for hazardous journey, small wages, bitter cold, long months of complete darkness, constant danger, self-return doubtful, honor and recognition in case of success,” it read. Where do I sign up?

The available evidence from the reports mentioned above would support a high prevalence of risk factors for AMCs. But is our patient “symptomatic” or just “worried well?” I guess that depends on how you look at it or whom you ask.

The financial margins for most AMCs are still quite good. However, some have already postponed capital-intensive expansions, limited tenured faculty positions, raised tuition most years above CPI, and altered physician compensation models. Many are putting on the “training wheels” for becoming accountable care organizations by developing patient-centered medical homes, participating in episode-based bundled payment pilots, and working with commercial payers in a staged movement from volume-based to value-based contracts. Some have engaged health services research and engineering school talent to improve core processes and education.  Others are employing simulation and distance learning to teach more efficiently.

While we may not know the true predictive value of stress testing AMCs, I would offer that they are certainly not the worried well. Proactive engagement in alternative future scenario planning, vigorous cost containment across missions, and exploring new business models and partnerships would seem a prudent prescription based on the test results thus far.

Michael Weitekamp is a Robert G. Petersdorf Scholar at the Association of American Medical Colleges. He blogs at Wing of Zock.

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