Does the Rise of the Private Sector Lead to the Demise of Academic Medicine in Canada?

1. Does the Rise of the Private Sector Lead to the Demise of Academic Medicine in Canada? Dr. Arthur T. Porter MD MBA FRCPC FACR Professor, Dept of Oncology, McGill University CEO, The McGill University Health Centre

2. Objectives • Does a change in the funding mechanisms in health care have an effect on academic output? • If yes, is the effect positive or negative? • Is it possible to introduce private sector funding and have a positive outcome on academia?

3. Definitions • What is academic medicine? • What do we mean by privatization?

4. Methodology • Explore the current challenges that affect academic medicine in a global context • Frame the impact of private funding against those issues

5. Subjectivity and Disclaimer • A personal view • Professor of Oncology in academic health centres (AHCs) in the US and Canada • CEO of an AHC in both the US and Canada

6. Academic Medicine • One definition • The capacity of the health care system to think, study, research, discover, evaluate, innovate, teach, learn, and improve. • International Campaign to Revitalize Academic Medicine 2005

7. The Climate Surrounding Privatization • Chaouli decision • Wait times

8. Public and Private Sector Involvement in Health Care • What are we discussing? • Hospitals & AHCs • Physicians • Research labs • Private • Public • Pharmaceutical industry • Why is this important? • Money & power remain two very compelling drivers of human behaviour!

9. Public and Private Sector Involvement in Health Care

10. Canadian Philosophy • The vast majority of health care in Canada is driven by a public sector philosophy • Yet the majority of Canadian physicians are in some form of ‘fee-for-service’ practice, albeit billing only one payer!

11. US Philosophy • The vast majority of health care in the US is funded by the private sector • Medicare/Medicaid& VA spending accounts for 6.6% of the GDP

12. Current Issues in Academic Medicine • Inadequate translational research • Gap between evidenced-based practice & reality • Difficulties in maintaining competencies in teaching, research & clinical care • Career progression • Prioritization in the face of limited funding • Big questions may not be answered • Changes in medical education • Leadership • Marketing

13. Translational Research Impediments • Poor capacity or what brings innovations directly to patients prompts the question: why is return on investment so poor? • High costs, slow results, lack of funding, regulatory burdens, fragmented infrastructure, incompatible databases, lack of qualified investigators & willing participants—Institute of Medicine (IOM) • Lack of clinical trials funding, inadequate facilities for patient-centric clinical research, fewer clinical academics, complex legal & ethical governance issues—Academy of Medical Sciences

14. Substantial Gap Between the Best Evidence-based Practice and Reality • Studies in the US, Canada & the Netherlands suggest that 30% to 40% of patients do not receive care commensurate with current scientific evidence & that 20% to 25% of the care that is provided is not needed or could be harmful. • This gap—the "know-do" gap between what we know about diseases & what we do to prevent & treat them—is expected to widen. Moreover, there is currently little regulatory demand for doctors to participate in continuing medical education.

15. Growing Gap Between Academics and Practitioners • The "town-gown" competition often found between academic & community-based practitioners has been destructive & contradicts the goals of providing high-quality health care. • It is contended that a closer link between research & service is needed to cultivate the culture of science required to improve clinical care & provide effective educational environments.

16. Jack of All Trades, Master of None • It is becoming impossible for a person to be competent simultaneously in practice, research & teaching. • Due to enormous time pressures & competing demands of research, teaching & clinical practice, many people believe that the traditional triad has become untenable.

17. Fewer Doctors Want to Pursue a Research Career • While the number of medical students is higher than ever, there are more vacancies in clinical academic posts. • In the US, 50% fewer of the current medical students have expressed interest in a research career. • In most countries, doctors who pursue a career in research are likely to earn much less than those who spend at least some time in private practice.

18. Disparity in the Focus of Research • Research is often unconcerned with the biggest health problems, particularly in a global context. • The 10:90 gap in which only 10% of global spending for health research is allocated to the health problems of 90% of the population appears unyielding. • Diseases for which there is little market value for drug development have been particularly neglected, yet these both disproportionately affect people in poor countries & represent a sizable proportion of the global health burden.

19. Medical Education Not Keeping Pace • Graduates aren’t prepared for careers in modern medicine. • Medical education doesn’t match patients' needs, public expectations, technological advances, changing organizational requirements & funding. (IOM) • It’s not in sync with the goal of bringing high-quality health care into the 21st century. • Students are rarely involved in decision-making or planning processes. • Thus far, it has failed to be adequately patient-centric, team-oriented & evidence-based.

20. The Big Squeeze • Huge pressures on the delivery of health care and reform often put the squeeze on academic medicine. • The fear of private-sector incursion into academic medicine. • Some fear that academic values will be lost; others, that medical education will be compromised by commercial interests.

21. The Big Squeeze • Huge pressures on the delivery of health care and reform often squeeze academic medicine. • Recent health care spending cuts have hurt the quality of clinical education, the recruitment & retention of clinical academics, & funding arrangements for academic departments—Canadian Institute for Academic Medicine. • Cuts have reduced the size & number of teaching hospitals & moved many previously inpatient services into ambulatory or outpatient settings.

22. Often Inadequate Leadership • The unclear role of AHCs has led to missed opportunities for innovation, early application & dissemination of new knowledge & leadership. • With a growing consumerist movement & the plethora of unregulated health information, the role of academic medicine to act as an honest independent broker with both patients & practitioners is crucial, yet largely unrealized.

23. Marketing 101 • Academic medicine relates poorly to its stakeholders • Insufficient time is spent interacting with key groups despite how important it is to ensure the academic medicine agenda addresses their concerns. • Patients, policymakers, practitioners, general public & the media • Does a poor job in positioning itself as part of global health human resources and as part of a health sciences profession that includes nursing, public health, social work, and other stakeholders.

24. Show and Tell • The value of academic medicine is not self evident. • Before resources will flow appropriately, it is important to re-establish the "story" that can convince policymakers—and the public they represent—of the critical contribution of academic medicine.

25. Impacts of Increasing Privatization • Competition • Customers and clients • Market forces • Winners and losers • Return on investment (ROI) • Increasing shareholder value • Knowing one’s product/service

26. Opportunities for AHCs • Funding sources tied to ROI concepts • CHIP program • Commercial funding • Development of a bench to bedside to business strategy • McGill Excellerator • The MUHC’s National Programme for Home Ventilatory Assistance

27. Rewarding Performance as a Success Driver • Pay for performance strategies

28. Building a Bridge with a Network of Alliances • In the US, the advent of managed care has required new funding arrangements and organizational structures, which in turn demand more effective "working alliances" between managed care organizations and AHCs • McGill RUIS Concept • Education • Clinical care • Research

29. The McGill RUIS • The McGill RUIS is a network of partners that assures a broad scope of specialized and ultra-specialized services to 1.7 million people spread across 63% of Quebec’s territory, namely 953,000 km2

30. Recognizing AHCs as a Patient Revenue Driver

31. The Big Health Picture • Gates Foundation • Drug company funding

32. Back to the Big Question • Does the Rise of the Private Sector Lead to the Demise of Academic Medicine in Canada? • No, but AHCs must be nimble and adapt continuously if they are to prove their value!

33. The New Rules of the Game • Building strong stakeholder relationships – know your business! • Embracing teamwork & collaboration • Adapting to increased competition • Increasing business & media savviness • Leveraging IT for medical education • Combining research with implementation & improvement • Focusing more on R&D and strategic planning to keep apace of increasing diversity & niche markets