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Fixin' Healthcare

Tuesday, December 12, 2006

Academic Health Science Centers - The Same, Only More

Conflicts of interest are as old as sin itself. Most of the time and in most ways, people are aware of these conflicts and they are overlooked unless obvious harm results. "No blood, no foul". As the stakes grow higher, there is growing concern about situations involving large amounts of money and/or blatant disregard for rules and regulations. The most concern, however, is directed to whether conflicts of interest both small and large corrupt the system in which they lodge.

It is difficult to eliminate all conflicts of interest. Some are not discovered in a timely fashion or become known long after the fact. Others are considered acceptable due to the expertise of those involved. Whether or not disclosure of conflicts represents adequate response depends upon who is passing judgement.

Some conflicts of interest are so large they defy response. "Steal thousands of dollars and end up in jail; steal millions and become a king". The reasons for this are not always clear. Most often the explanations are that it is a necessary tradeoff to do business and to change things would destabilize the system.

Academic health science centers and teaching hospitals are heavily invested in the current health care system. Patient care is a necessary aspect of teaching and, initially, the income was incremental and supplemental. However, the academic health science centers learn over and over the painful lesson of the leverage exerted by supplemental income. Depending upon the environment, one dollar of supplemental income can command as much energy and attention as ten dollars of previously allocated budget.

The cash flow from clinical care has become a tsunami for academic medicine. It permeates every nook and corner of the academic health science center. The specialists generate the most income, so the specialists rise to the top of the totem pole. A sizeable amount of this money ends up in the pocket of those who generate it and it is allocated to other forms of support for their own departments. This is an environment that mimics broader society comprised of different socioeconomic strata with stars and ordinary citizens.

It is this environment that educates the health care practitioners of the future. Would health care be different, if this environment was different? What circumstances would be required to change this environment? How do Mandarins view the future when they are heavily invested in the present? Could it be the same, only more of it?

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