Population Health is Precision Medicine for Neighborhoods

Michener: I think the greatest challenge academic health centers face right now is the rapidity of change and the fact we can't let go of the old model without dying, but we can't avoid grasping the new model without failing in the future. I'm Lloyd Michener, Chair of the Department of Community and Family Medicine at Duke.

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Magill: I'm Mike Magill. I'm the chair of the Department of Family and Preventive Medicine at the University of Utah. Lloyd, do you think there will be academic health centers that close within the next five years?

Michener: I'd like to think that doesn't happen, Mike, but I have to say that's certainly a possibility. The changes we see coming that are already underway are so sweeping that it's hard to imagine that some folks won't fall asunder as they try to figure out what to do.

Magill: So what kind of change is going to be coming down the pipe?

Michener: It's a change from fee for service reimbursement, which we've been under, actually, since World War II, but it's larger than that. It's a change from episodic, silo-based care to actually trying to take care of people in the form of their lives and their communities. It's about value and providing care that people need and want in the places and ways they find useful.

Magill: Is it really the role of an academic health center to care about the health of a community? Aren't we in the business of doing heart transplants?

Michener: Certainly many of the people in our communities need heart transplants and I hope we always have academic health centers not just doing them, but figuring out how to do them better. That said, not too many people, happily, need heart transplants. I think if you go back to the reason we have academic health centers, as opposed to just health centers, it's really to figure out how to do that better. It's not just to do the high end, it's to figure out how to keep people healthy in communities that are healthy. Figuring out how to do that is probably actually one of the greater intellectual challenges we face in America these days, in fact, around the world. I can't think of anything better for an academic health center to do.

Magill: So Duke represents an example of many academic health centers that have built huge stacks of intensive care units and operating rooms. They've done that on an expectation that they would generate high fee for service revenue, high margin, in order to cover the debt service and to stay in business. Aren't they going to have trouble making a transition to a different model?

Michener: I think the only way it can be pulled off, and I think it can be pulled off, is if you broaden the base. If you think actually are going to need MRIs? How many benefit from that? The number may go up on an overall basis as our population ages. As we get more precise and better prevention, it may actually fall, balance those out. I think we probably aren't going to need a whole lot more than we have now, maybe fewer. It'll be those surviving academic health centers that people need to come to, want to come to, but perhaps under different reimbursement models than we have now.

Magill: So as we reduce the utilization for an existing population, one way academic medical centers can continue to thrive is if they do not increase capacity, but rather they build their care for larger populations of older folks.

Michener: Yes. Sometimes that will require additional capacity because if you're taking care of, let's say, a million people, two million people, it would be a rare academic medical center, health center that actually is perfectly aligned with the needs of that population. Some areas may need to shrink, but I think also some will need to grow.

Magill: What is the strategy that you're taking at Duke? You're not the only academic medical center in North Carolina. The capacity is in excess of the demand for the shifting denominator-based care that they'll be moving toward.

Michener: Well that depends how quickly we can get some of those cities healthy. Actually, we may need many of them if we keep at the ever-growing rates of chronic disease in some of those big cities. That said, folks are going to have to figure out what they're really good at. Either they'll figure it out voluntarily or the increasing competition for cost and value will help them discover that not everybody agrees with their assessment. I think we're going to see a focusing on expertise and value and a shift in business to those places that can provide it.

Magill: What's the role of primary care in this brave new world?

Michener: One is clear, it's that we'll continue to see large numbers of people as their primary care provider. The person who's with them from birth to death, but I don't know that we're going to need to do everything we've traditionally done. A lot of the care we've tended to do has tended to be around routine prevention that PAs and NPs and actually nurses and sometimes home health aides can do at least as well as we can. I think we're going to be letting go of some things that frankly have given us great joy. Some things we're going to let go of, others I think we're going to be adding.

Magill: How do we deal with the dilemma of needing to train people for a future that isn't here yet?

Michener: Isn't that what academic health centers are always supposed to be doing? In the issue of dealing with teams, actually there are a number of highly effective, efficient teams in most academic health centers, they're called ORs, intensive care units, intensive care pediatric units that actually do very well. I would argue many family medicine centers are like that. It's really an issue of making sure that we learn from those that are working well and that we spread that knowledge to others and that we all continue to improve.

Magill: As we move into the new constrained payment environment, what we see is academic health centers not being responsible just for patients that come through the doors of our ERs and our ORs and intensive care units. Can we really reach out beyond the walls?

Michener: Academic health centers, if you really go way back into their beginning and founding, actually come from the need to serve. It's the community we always have served, we're just rediscovering how to do it. I think the greatest challenge academic health centers face right now is the rapidity of change and the fact that we can't let go of the old model without dying, but we can't avoid grasping the new model without failing in the future. It's the ability to balance the old and the new at the same time and it requires visionary leadership and the ability to manage in complex times. Some academic health centers have that. I think Utah would be a good example. I think Duke is another. It's that challenge of leadership and of embracing the complexity of change that is perhaps our greatest challenge after such a long period of success.