WASHINGTON, DC-Health care reform legislation-i.e., the Affordable Care Act (ACA) of 2010-holds the promise of expanding access to underserved Americans, but it also could place unprecedented demands on academic medical centers (AMCs). So said Herbert Pardes, MD, President and CEO of New York-Presbyterian Medical Center-the largest US nonprofit, non-sectarian hospital. Dr. Pardes is a former dean of Columbia University's medical school, former director of the National Institute of Mental Health, and served as Assistant US Surgeon General from 1978 to 1984.
Speaking here at a news briefing at the National Press Club, Dr. Pardes outlined a number of challenges that specifically face AMCs under health reform, including workforce shortages; funding issues; and the increasing pressures of providing care for the sickest, poorest, uninsured Americans and undocumented immigrants.
He warned that if AMCs are squeezed too much, their important role in scientific and medical innovation may be compromised. On a personal note, Dr. Pardes said that in the 1980s a colleague of his at an academic medical center where he was on the faculty was working on the difficult problem of liver transplantation, which was then such a new technique that it was not even clear how well it would work. Just a few years later, Dr. Pardes' own son experienced liver failure, and his life was saved by the innovative transplantation techniques developed by AMC medical research.
Dr. Pardes shared several case studies to illustrate how academic medical centers care for severely ill patients-often referrals from other hospitals-for whom there is no other hope. One case involved a seven-year-old girl with cancer. "A young girl came to New York-Presbyterian with a cancerous tumor so embedded in her abdomen that surgeons had to remove all her abdominal organs to excise the tumor and save her," he said.
"AMCs reach profoundly into the lives of millions of people, with lifesaving treatments. They take on the toughest and most formidable problems[horizontal ellipsis]. Even though they constitute only 6% of all hospitals, they provide 41% of the charity care, 28% of Medicaid, and 22% of Medicare."
For AMCs, ensuring access will be a particular challenge under health reform, Dr. Pardes continued, nothing that in 2014, some 32 million more Americans will have health insurance and will need to enter the health care system. But this expansion will occur just as large numbers of baby boomers are reaching retirement age and facing the increased medical needs that often accompany old age-72 million of them by 2020.
"This growth will place unprecedented demands on the health care workforce," said Dr. Pardes. "The Association of American Medical Colleges projects a shortage of 130,000 physicians by 2025. Since it takes up to 10 years to train a new doctor, we are already behind." (The American Society of Clinical Oncology has been predicting shortages of medical oncologists, radiation oncologists, and nurses, which must be addressed to ensure access to quality cancer care for all Americans.)
Repeal Caps on Residencies Supporting by Medicare through GME
To remedy these looming medical workforce shortages, Dr. Pardes put in a strong plea for repealing Congressional caps on the number of residencies supported by Medicare through Graduate Medical Education (GME).
"In 1997, when the physician pipeline seemed full, Congress capped the number of residencies supported by Medicare," noted Dr. Pardes. "Despite the efforts of political leaders such as Senator [Charles] Schumer and Congressman [Charles] Rangel, the ACA did not include financing to expand GME. Last November, the Deficit Reduction Commission recommended cutting Medicare funding for GME by $60 billion over 10 years, which would dramatically exacerbate the problem if adopted."
While Dr. Pardes said that he certainly believes that more primary care practitioners are needed to provide increased access under health care reform, he cautioned that simply increasing the number of primary care practitioners is not a magic bullet. "There's an illusion that some people have that having more primary care professionals will reduce the need for specialists," he said. "This view is simplistic and myopic. We need to look at the whole spectrum of medicine."
Controlling Costs
Dr. Pardes warned that of the multiple demands of the health reform legislation, controlling costs may put the greatest squeeze on AMCs. Health reform mandates $155 billion in Medicare cuts for hospitals over the next 10 years, $50 billion of which will be in reduced "dish" payments for uncompensated and charity care.
Hospitals agreed to these cuts, through the American Hospital Association, to help fund the ACA. "The expectation was that the expansion of coverage will offset that reduction," he explained. "In some places that will be true. But it won't happen in states like New York, New Jersey, and Pennsylvania that had extensive Medicaid programs in place before the ACA was passed[horizontal ellipsis]. Academic medical centers already take care of a disproportionate share of Medicaid patients, so they will suffer the reductions without the benefit of the offsets."
Dr. Pardes said that the Secretary of the US Department of Health and Human Services should "undertake measures to guarantee that the financial equation actually works before imposing large 'dish' reductions." He said risk adjustments need to be made for patients treated at AMCs in terms of poverty, cultural diversity, and the economic circumstances of their community.
AMCs may seem more expensive than other hospitals, but that is because they do more, Dr. Pardes said. He cited physician training, which is costly; specialized space, such as emergency rooms, burn units, trauma units and neonatal units; specialized equipment and technical support personnel; and even translation services for non-English speaking patients-For example, he said that at his hospital, translation services cost $3 million a year.
"There is a danger that in the desire to reduce costs across the board, academic medical centers could be disproportionately impacted because of their higher cost base." He pointed out that the US economic contribution of AMCs could also be adversely affected by the health reform squeeze, noting that AMCs throughout the country contribute more than $512 billion annually and account for 3.3 million full-time jobs.
"As other industries have gone overseas, and thousands of jobs have been exported, the innovation of academic medical centers is one of the bright spots of American competitiveness," said Dr. Pardes.
Proposed Congressional Cuts to NIH
Asked by OT if he is concerned about proposed Congressional cuts to the National Institutes of Health-which could adversely affect innovative research at AMCs-Dr. Pardes said, "I think any cut to NIH is very unwise." And he added that he would be "very disturbed" by cuts in NIH funding, which would be "bad public policy" because it makes no sense to cut the very enterprise which allows the United States to make potentially money-saving strides in scientific and medical innovation. President Obama, to his credit, Dr. Pardes said, has emphasized scientific innovation-"Yes, let's be efficient, but let's be wise in making the cuts."
Uncompensated Care to Undocumented Immigrants
Asked about the amount of uncompensated care AMCs give to undocumented immigrants, Dr. Pardes said that hospitals such as his have a moral obligation to provide medical care to undocumented immigrants. "It's easy to say that we shouldn't cover undocumented people, but they're still human beings," he said. He referred to medical coverage of undocumented immigrants as a "national problem" that needs a national remedy.
And asked to comment on the Republican-dominated Congressional efforts to repeal or chip away at health reform legislation, Dr. Pardes said, "I think we have to have health reform-let's forget about the legislation. We should be working on the very issues [members of Congress] are talking about."