A Medical School For The Community
2018; Project HOPE; Volume: 37; Issue: 11 Linguagem: Inglês
10.1377/hlthaff.2018.1193
ISSN2694-233X
Autores Tópico(s)Primary Care and Health Outcomes
ResumoLeading To HealthHealth Professions Education Health AffairsVol. 37, No. 11: Patient Safety LEADING TO HEALTHA Medical School For The CommunityJessica Bylander AffiliationsThis article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. Jessica Bylander ([email protected]) is a senior editor at Health Affairs, in Bethesda, Maryland.PUBLISHED:November 2018Open Accesshttps://doi.org/10.1377/hlthaff.2018.1193AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractFunded in part by taxpayer dollars, Dell Medical School has a mandate to improve community health. It’s also identifying novel ways to reward value.TOPICSMedical educationClinicsPaymentTaxesPopulation healthPatient careMedicaid patientsLow incomeGrantsPrimary care providersAustin is a city of contrasts: Tex-Mex and tech, swimming holes and skyscrapers. But there’s a more poignant contrast evident in the Texas capital: the one between the increasingly wealthy residents of the fast-growing city and the marginalized communities that are left behind. Take the contrast between the University of Texas at Austin, an elite and well-endowed university, and the historically poor and minority area of the city that it abuts. Segregationist practices in the 1920s and 1930s deepened racial and ethnic divides in Austin, and even after these practices ended, Interstate 35 long served as a de facto dividing line between the haves and have-nots in the city.So when Austin at last gained its own medical school in 2014, some residents were concerned that the new Dell Medical School would become another “ivory tower,” disconnected from the marginalized communities it claimed to serve.“I didn’t think that they would be providing services to the communities in which we’re most vulnerable and who were directly impacted by health inequities,” says Priscilla Hale, a native of East Austin and executive director of allgo, an Austin-based organization for queer people of color in Texas. Hale now serves on a community strategy team that advises the medical school.There is certainly the risk that Dell Medical School could go the way of other health care “anchor” institutions that are located in underserved neighborhoods but don’t necessarily benefit the residents of those areas.1 But Dell Med, as it’s familiarly known, is not a traditional medical school. Its unique creation story confers a mandate to serve the community of Travis County, where Austin is located—particularly its poorest residents. The medical school’s staff and leaders were hired to execute the school’s vision of making Austin a “model healthy city,” which requires as a key first step improving the health of those most in need in the community.“People don’t want health care, they want health,” says Claiborne “Clay” Johnston, dean of Dell Med and vice president for medical affairs at UT Austin. “Can we take expenditures that generally are spent on providing health care…and can we convert that to much wiser expenditures in keeping people healthy?”The notion of having a medical school in Austin dates back to the 1880s, when UT Austin was founded. Voters at the time decided to locate the university’s medical branch elsewhere, in the Texas port city of Galveston, and in subsequent years medical schools were added in Dallas, San Antonio, and Houston. Yet for some, the goal of having a medical school on the University of Texas System’s flagship campus persisted.Funding was an issue, and the proposed solution was unique. In the early 2010s supporters of the medical school—including Kenneth Shine, a professor of medicine at Dell Med and the former executive vice chancellor for health affairs for the UT System, and Kirk Watson, a Democratic state senator—came up with the idea of levying a local tax to support the school. Watson listed the new medical school, a teaching hospital, and modern health clinics among his “10 Goals in 10 Years” to transform Austin’s health and economy.2In 2012 Travis County voters approved Proposition 1, which raised an existing property tax that supports Central Health—the public entity that funds health care for the county’s low-income and uninsured residents.3 The funds raised by the tax increase (an additional five cents per $100 valuation on top of the existing tax rate) went toward the new medical school to the tune of $35 million annually, and to other health-related ventures. (Additional funding came from the UT System’s Board of Regents and the Michael and Susan Dell Foundation.) In 2016 Dell Med’s first class of fifty students matriculated.Many of the forty-plus community groups that had campaigned for the tax increase represented Latino and black communities in Austin, Shine says, and the medical school in turn had to justify that the money was well spent on their health needs. Community members wanted more doctors and additional funds for health care, among other things. “We had both a moral and legal obligation,” Shine says.True community engagement, of course, is not easy. Even for a new medical school with a blank slate and a clear mandate to improve population health, the institution’s priorities and strategies—not to mention payment schemes—don’t always align with what the community wants or needs.“This is a trickier part of what we’re trying to do,” Johnston says. “If you rely on grants to do it, then you’ll just do projects while you have grant funding, and the projects will go away when the grant funding goes away. That happens over and over again, and all you do then is lose the trust of your community. They think you’re just in there to get your paper written and then you’re going to leave.”Instead, Dell Med leaders set out to build a new, comprehensive approach to providing and paying for care that they hope will be more sustainable in the long run.Team CareIn the Health Transformation Building, one of the medical school’s three new buildings at the south end of UT Austin’s campus, a patient is leaving an appointment at UT Health Austin, the clinical practice of Dell Med. Two bilingual undergraduate students from UT Austin who staff the concierge desk wish her well in Spanish. The clinic has bright, polished facades; high-end amenities such as flat-screen TV monitors in every patient room; a dreamy cloudscape wallpaper that lines the long hallway, created from photos of actual Texas skies; and no waiting rooms.When the patient arrived for her appointment, she would have been ushered to her room, where she’d remain for the entire appointment. Every provider she needed to see for her care—say, a primary care physician, mental health care provider, social worker, nurse practitioner, and physical therapist—would come to her. On average, these visits last about 105 minutes, and a patient sees about five providers, explains Nicholas Arledge, executive director of clinical operations at Dell Med.At present, these team-based visits are designed for specialty care in a few areas, including musculoskeletal health, women’s health, neuroscience, and work-related injuries, for which a patient typically would have had to travel to multiple providers for care.“All of that is all over the map,” Arledge says, noting that a patient could have many different visits with many different medical records. “We’ve tried to change that.”The clinic plans to provide general and episodic care, as well.It took about three years to develop the new team care model and the new clinics, says Stacey Chang, executive director of the Design Institute for Health, a collaboration between Dell Med and UT Austin’s College of Fine Arts, which helmed this redesign.“We had to understand the needs of everyone involved—clinicians, staff, administrators,” Chang says. “Then also patients as well.”Patients have described the new care model and clinic as “disorienting,” he says, which he considers both a positive and a negative.“They’re not used to owning their care room,” he says. “We had to reorient them.”Dell Med’s curriculum is also rooted in team-based care. From day one, medical students work frequently with students in social work, nursing, pharmacy, and other fields.“In many places, physicians and other health care clinicians are lone gunmen,” says William Tierney, chair of the Department of Population Health at Dell Med. “In reality, health care is a team sport. If one can’t work side by side and collegially with people who have different types of training and bring different types of value to a health care encounter, we’re never going to get over the hump of providing high-quality care.”Condition-Specific Bundled PaymentsFor two specialties—musculoskeletal health and women’s health—care is not only delivered differently but also paid for differently, with a bundled payment tied to a condition rather than to a specific procedure or surgery. This incentivizes providers to deliver care that aligns with patients’ goals and facilitates payment of the variety of providers that Dell Med employs on its care teams, from surgeons to dieticians.When Kevin Bozic, the inaugural chair of the Department of Surgery and Perioperative Care, joined Dell Med in 2015, there was a 1,400-person wait list among Central Health patients to see a specialist for musculoskeletal care. The average wait to see an orthopedic surgeon was 400 days.“Imagine if someone told you you’ve got a problem, and you can take care of it in 400 days,” Bozic says.So Bozic and his team began implementing team-based care for these patients and worked their way through the wait list within six months. The longer, more comprehensive visits have led to fewer follow-up appointments because patients get the care they need in one stop.4 According to early results, patient-reported hip function had improved among treated patients by 43 percent and patient-reported knee function by 29 percent at the patients’ first follow-up visit.5“It wasn’t magic, it was just actually having someone who would focus their efforts on the problem,” Bozic says.Currently, payment for musculoskeletal care at Dell Med comes from a bundled payment contract with Central Health that covers patients from Central Health’s Medical Access Program (for low-income people who don’t have Medicaid, Medicare, or private insurance), patients from Community Care Collaborative (a partnership between Central Health and Seton, a health care system that is part of Ascension), and patients who pay on a sliding scale. Under the novel condition-specific bundle, payment is triggered when a patient with hip or knee arthritis comes to the clinic to initiate treatment, rather than when they undergo surgery.“In the fee-for-service model, the incentive is overutilization, and the way to make money in fee-for-service is to do more stuff to people,” Bozic says. “In the capitation model, the incentive is underutilization, and the way to make money is to withhold care. In our model, the way to make money is to provide the right care to the right patient at the right time and optimize their health within the resources that we have to treat that condition.”Dell Med is working with a national collaborative as well as local and regional payers and employers, including the Teacher Retirement System of Texas and Employees Retirement System of Texas, to expand this new payment scheme more widely, Bozic says.“We’re not asking them to do routine care on a tight budget, we’re asking them to do superb care on a new kind of budget,” Johnston says. “They can think differently about the resources: not whether you can bill for it or not, but whether it’s the right thing for the patient.”Community InnovationSeveral employees at Dell Med likened the school to a start-up company, and the comparison bears out in a few ways. It shows in the medical school’s refrain that it’s OK to fail—and in its goal to ultimately profit from innovations that are incubated there.When Johnston came on board as dean in 2014, he assembled a staff of innovators and disrupters (including a few former colleagues of his from the University of California San Francisco) who embraced Dell Med’s mission of improving community health; creating new models of person-centered, team-based care that reward value; and accelerating innovation and research.“One of the wonderful things about this focus is it resonates with clinicians,” Johnston says. “Thoughtful clinicians want to achieve better outcomes for patients, and thoughtful clinicians have already thought about how wasteful our system is.”This team includes Karen DeSalvo, a professor in the Departments of Internal Medicine and Population Health at Dell Med who served as acting assistant secretary for health at the US Department of Health and Human Services during the administration of President Barack Obama and as national coordinator for health information technology in 2014–16.For DeSalvo, who grew up in a poor neighborhood in Austin, the school’s mission dovetails well with her interest in drawing more attention to the social determinants of health—something she says that all health entities will eventually have to grapple with. She wants to show that addressing all determinants of health in a systematic and meaningful way can reap benefits.“Everyone is beginning to understand that this is just essential to success in value-based payment and care models, but more importantly success for community vitality,” DeSalvo says.Dell Med’s team also includes Maninder “Mini” Kahlon, vice dean of the health ecosystem at Dell Med, who oversees what she calls a “house of innovation.”Through UT Austin’s Texas Health Catalyst, a collaborative for translating innovations into health products, Dell Med has supported promising products that address clinical needs, such as a sensor for at-home monitoring of patients with heart failure. Kahlon wants to do the same with innovations that address community and population health needs.“The goal eventually being that it becomes a business line at the same weight as what a clinical enterprise would normally be,” Kahlon says.For instance, Dell Med is helping scale up Streetcred, a project that originated in Boston and helps low-income families build assets and access government antipoverty programs within the doctor’s office.Kahlon expects ideas for community innovations to come from the community, not just the medical school. One source of ideas will be Dell Med’s community strategy team: nine grassroots leaders from marginalized groups such as black and Latino communities, people with mental illness, and queer communities. In addition, community members can identify high-priority health barriers and propose interventions to Dell Med’s Neighborhood Health Initiative, a community-based approach to improving the health of an entire neighborhood and its residents by addressing medical and social barriers to health.“We do some demonstrations ourselves,” Kahlon says. “But to create large-scale community impact and to source innovations from places where people know things that we might not know, we have to go out of our boundaries.”Transparency StrugglesPriscilla Hale, the member of Dell Med’s community strategy team, very much wants the school to fulfill its mission and mandate to the community, but there have been some indications that it’s struggling to do that, she says.Chief among them is an October 2017 lawsuit against Central Health brought by community members who say taxpayers’ money should go exclusively to health care for the impoverished, rather than such things as faculty members’ salaries.6 Dell Med says it has spent the funds in accordance with its affiliation agreement with Central Health and with state law.In a November 2017 community impact update, Dell Med noted that the number of medical residents providing care in Central Texas had increased from 218 in 2012 to 287 in 2017—a step toward fulfilling the community’s desire for more doctors.7As the school grows, Dell Med says that eventually the $35 million it receives each year from taxpayers through Central Health will become a smaller part of its revenue picture, and taxpayer dollars can be focused on care transformation and delivery.8Hale, who voted against the tax increase to fund the medical school, says that a challenge is a lack of transparency from Dell Med, including about where the taxpayer money is going.“A lot of corporations don’t want to put out information until it’s shiny and pretty,” Hale says. “That doesn’t work for communities who are dying.”Still, she says, she chose to serve on the community strategy team—work for which she’s paid as a contractor—to hold Dell Med accountable.“It’s a great opportunity for folks who are in the community who are most directly impacted to have impact and give a voice,” she says.To date, the group, which meets at least monthly, has been consulted about hiring decisions, health projects that faculty members want to implement in the community, and marketing, among other things. Dell Med and Central Health have issued annual reports detailing spending information.But there is still a ways to go in getting Dell Med to release information as quickly as the team would like, Hale says.Paying The BillsDell Med has so much on its plate that it can be hard to keep track of everything. Chalk that up to the start-up mentality, as well.“The silver lining is, health has a lot of challenges, so there are many places we can add value,” says Kahlon. “An entrepreneurial mind-set helps us scan the environment, and as opportunities come up, we can leverage them really quickly.”The chair of the women’s health department, Amy Young, is working to improve obstetric care for underserved women in Travis County. By changing the way pain is screened for in mothers, and what pain medications are prescribed by default, Young and her team, working with Seton, have seen a dramatic decrease in opioid use among new mothers.At the Design Institute for Health, Chang and his colleagues, including Dell Med’s chair of psychiatry, Steve Strakowski, are working with the state to redesign how mental health care is provided at Austin State Hospital.The Value Institute for Health and Care, a collaboration between the McCombs School of Business at UT Austin and Dell Med, is launching a master’s degree in health care transformation in the fall of 2019.It’s clear that everyone at Dell Med is excited about what’s possible. But as the school’s newness factor wears off, they also will need to demonstrate that innovation can pay the bills.“We’ve moved beyond the first two years of a start-up, and we’re actually getting into the financial crunch,” Kahlon says.For Johnston, success for his enterprise will involve not demonstrating just that some of these new payment and care models can be profitable, but also that other institutions can implement these programs with similar success.“I want us, in more than one area, to prove that we can provide better care at a lower cost, and I want to be paid for that,” he says. “That’s a trickier one because that requires somebody out there to change the way they pay. We do a lot of stuff that isn’t covered by traditional fee-for-service.”“And then I want us to show what scaling these things looks like,” he adds. “That last piece is years away. I hope not too many.”NOTES1 Diamond D. How the Cleveland Clinic grows healthier while its neighbors stay sick. 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Available from: http://www.kut.org/post/how-clinic-design-cut-orthopedic-wait-times-year-three-weeks-travis-county Google Scholar 5 O’Donnell J, Saunders R, Japinga M, Higgins A, Mather C, Jiranek Bet al. Expanding payment reforms to better incentivize chronic care for degenerative joint disease. Health Affairs Blog [blog on the Internet]. 2018 Apr 23 [cited 2018 Oct 15]. Available from: https://www.healthaffairs.org/do/10.1377/hblog20180416.346268/full/ Google Scholar 6 Goldenstein T. Residents sue Central Health over funding of UT Dell Medical School. Austin American-Statesman [serial on the Internet]. [Updated 2018 Sep 25; cited 2018 Oct 15]. Available from: https://www.mystatesman.com/news/local/residents-sue-central-health-over-funding-dell-medical-school/thYlN3RUF7JcCCDFieP73O/ Google Scholar 7 Dell Medical School. What we’re doing now: a community impact update [Internet]. Austin (TX): University of Texas at Austin; 2017 Nov [cited 2018 Oct 15]. Available from: https://utexas.app.box.com/s/ro4loqf89f8y5nzh8n83zlvyjvcg38ei Google Scholar 8 Dell Medical School. Progress report: how the Dell Medical School at UT Austin is leveraging the public’s investment and delivering a return to the community [Internet]. Austin (TX): University of Texas at Austin; 2017 Jan [cited 2018 Oct 15]. Available from: https://utexas.app.box.com/s/igxqra8vmipegyx629xsm06mlgsjl9w6 Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 2 History Published online 5 November 2018 InformationThis open access article is distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license.PDF downloadCited byDesigning an interprofessional dementia specialty clinic: Conceptualization and evaluation of a patient-centered model24 April 2022 | Journal of Interprofessional Care, Vol. 37, No. 2Importance of Community Impact as the Fourth Academic Mission: A Qualitative StudyPopulation Health Management, Vol. 24, No. 5
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