Beyond "health care reform".

The author discusses the need to make corrections in the U.S. health care system, describes the simplistic and money-oriented definition that many persons have of "health care reform," and discusses the issues he thinks will and will not be dealt with in the coming reforms of the health care system. He maintains that true reform would deal with matters such as restraining expansion of the health care industry, setting reasonable fees, and confronting the harmful social and environmental conditions that result in high "medical" care costs and poor health statistics. The medical profession--including academic medical centers--has a large role to play in true health care reform, which will involve facing the major barriers (which he outlines) that are now impeding important reforms (e.g., increasing the number of generalist physicians; finding better ways to pay for medical students' and residents' education). The profession cannot make progress in true reform without developing a vision of what the U.S. health care system should be and becoming active in moving toward that vision, acting in the interests of both the individual patient and the community as a whole. The author outlines some of the barriers to finding that vision (such as the influence of third-party payers on the doctor-patient relationship and the fragmentation of medicine and medical education by specialties and subspecialties) and proposes the characteristics and values of the kind of medical education and community involvement of academic medical centers that can help create the needed vision, regain the trust of the public, and thereby reform health care in the interests of both the community and the profession.

QMHC interview: Robert M. Heyssel, M.D.. Interview by Marie E. Sinioris.

In 1991, US News and World Report rated The Johns Hopkins Hospital as the best hospital in the country. Its survey of physicians revealed that Hopkins is perceived to be at or near the top in 13 of the 15 specialties studied. For the past three years, The Johns Hopkins Health System has been taking a hard look at the nonclinical aspects of health care delivery. Surveys of patients, physicians, nurses, and employees have revealed a litany of frustrations that can interfere with the delivery of excellent care. To focus on these issues, Hopkins launched a systemwide total quality management (TQM) process in 1989. Dr Robert M. Heyssel and other senior executives provided leadership that has been essential to the initiation and maintenance of the TQM process at The Johns Hopkins Health System. TQM has been associated with impressive results in several areas. In addition, more than 500 people have received intensive training in the use of statistical tools and teamwork. An additional 900 people are scheduled to attend this program in the future.

Changing environment and the academic medical center: the Johns Hopkins Hospital.

Academic medical centers need strong patient bases and strong financial bases to educate and to support research. After careful delineation of its mission with regard to patient care, research, and education, the Johns Hopkins Hospital expanded its health care delivery capabilities and strengthened its position in the health care marketplace by acquisitions of and mergers with other hospitals and a health maintenance organization in the Baltimore area. The resulting conglomerate, operating under the direction of a holding company, the Johns Hopkins Health System, has achieved its goals of expanding patient care capabilities, broadening the patient base, and enlarging the asset base and cash flow. Half the medical residents at the Johns Hopkins School of Medicine receive training at nontraditional sites, and further expansion of teaching activities is being explored. Potential roles of traditional and nontraditional teachers in these activities are discussed.

The challenge of governance: the relationship of the teaching hospital to the university.

In an academic medical center, patient care is primarily the business product of the hospital and its organized medical staff, while education and research belong primarily to the medical school dean and the faculty. Each unique business--patient care, education, or research--must be managed with regard for the others, but first it needs to be considered separately and operated for results related to its primary goal. It is essential that governing bodies understand the business they govern. Mutual understanding, trust, and integrity are keystones in executing primary responsibility for the different activities in pursuit of the overall shared missions. Ten principles seem reasonable for governance and management of academic medical centers. They recognize the businesses, define potential problems, set tasks, and, if every person fulfills his difficult work, provide the organizational means for resolving conflict. The principles are listed in this paper.

The Johns Hopkins experience in Columbia, Maryland.

A university-related prepaid group practice was established in Columbia, Maryland, in 1969, by the Johns Hopkins Medical Institutions with the cooperation of the Connecticut General Life Insurance Company. Objectives were based on the traditional triad of service, teaching and research. The effort continues. There has been visible success in the achievement of each of the objectives. It is evident, however, that the development of the Columbia Medical Plan would have been facilitated if there had been a larger population base in which to market membership in the Plan, if marketing had been under the direction of the health-care provider, and if the burden of the building and running of a hospital had not been assumed. Overall, the experience suggests that the Health Maintenance Organization movement has only modest ultimate potential as an option in health-care delivery in the current economic milieu of American medicine.