They Say That It’s All Happening At the U. - An Editorial

Richard M. Pauli, M.D., Ph.D.

The following is a personal reflection on some of the changes that are occurring in health care in general and, more specifically, within the Medical School of the University of Wisconsin. It is admittedly one person’s assessment and most certainly does not represent the views of the University administration.

Change, even beneficial change, can create anxiety. I have been told often and by many individuals within the hierarchy of the University administration that my concerns, my anxieties, are simply the consequence of having to face the tumult of beneficial changes within health care and within our Medical School. I have become convinced that they are wrong. Rather, that anxiety is well grounded in legitimate concerns about the future of academic medicine and the future of programs that I think are important. We - academically committed physicians - are, indeed being buffeted by change — decreasing support from the State, dramatic alterations in the organization of clinicians and of all academic personnel within the University Medical School, increasing impact of managed care, and so forth. What has actually changed, what will change and what will be the consequences in the future for programs such as the Wisconsin Stillbirth Service Program?

State support for the Medical School continues to decrease, both in real dollars and, more dramatically, in the proportion of total expenditures. This has, among other consequences, resulted in continually increasing dependency on clinical revenues to maintain not only clinical programs but academic activities as well.

Partly in response to this increasing subsidizing of academic activities through clinical revenue (and partly because of less selfish motives including the recognition of the need for a more coherent approach to patient care issues), the clinical faculty of the Medical School recently joined together in the University of Wisconsin Medical Foundation. The Foundation may, indeed, be a positive force in some ways. However, through its efforts, certain risky and, in my opinion, ultimately harmful changes are afoot. First, the Foundation has tied individual income (of physicians within the Medical School) far more closely to clinical revenue generation. Intended or not, this has placed relatively greater merit on highly remunerative clinical activities while implicitly devaluing both non-patient care activities and patient care programs that, by their nature, are not highly remunerative. Secondly, in order to counteract the inroads made by competing managed care programs and to create an adequate referral base, emphasis has been placed on buttressing primary care activities (i.e. those most in direct competition with community physicians). In contrast, there has been remarkably little attention directed at insuring the continuation of referrals from outside the University system for super-subspecialty care that otherwise would be unavailable to patients in need of it (with the notable exception, again, of certain highly remunerative activities such as organ transplantation). Likewise, no attention has been paid to those areas of clinical practice that can survive only through referrals from large geographic areas well beyond the area usually viewed as within the University catchment region.

Concomitant with these internal changes, of course, have been the well recognized changes arising because of increasing penetration of managed care organizations within virtually every medical market in the State. As with the UW Medical Foundation, managed care in general has some merit. On the other hand, three features of most managed care models are inimicable to activities such as WiSSP. Managed care programs emphasize demonstrable cost saving. They place barriers between the providers within their organization and those outside of it, even if expertise outside of the organization is unique. They have little or no commitment, in general, to public health issues and rather are organized to insure cost-effective treatment of individuals. Those three features, together, make it hard for me to imagine that stillbirth assessment as a University-community collaborative activity will survive within a managed care setting (unless, of course, it can be done for free).

Virtually simultaneous with these, the Medical School (i.e. both the basic science and clinical departments) has begun to develop what has been termed an Accountability Model for determination of base salary (that is, monies generated to a large extent through State support of the School). Once again, there are some virtues to such an accountability model. Unfortunately, at least in the early drafts of this model that are currently circulating there is no recognition or reward for outreach education, continuing medical education or community service. Ignoring the special nature of the ‘Wisconsin Idea’ is, to me, a betrayal of a mission entrusted to all of us. Certainly it appears to devalue activities such as WiSSP.

What do these changes mean for genetics services in general and for activities such as WiSSP in particular? Currently the activities of the Clinical Genetics Center (of which WiSSP is a part) receive funding from 14 different sources - many insecure and uncertain in the future. Currently WiSSP’s part includes a small amount through Maternal and Child Health funds (which themselves may well be in jeopardy in the not too distant future). That supports a portion of one genetics counselor (Catherine Reiser who is Associate Director of WiSSP) and subsidizes activities such as mailing of summary letters, travel for outreach educational activities and this newsletter. Other sources have been used for special activities such as development and dissemination of the educational videotapes that (I hope!) are familiar to most of you. Finally, the physician time committed to the project is viewed as part of my academic mission (i.e. service, outreach) and is then indirectly sustained by State base salary support.

Within the context of what I have thus far discussed, what is WiSSP? It is fundamentally a University-community outreach effort. It requires involvement of an out-of-program physician with special expertise. It is essentially a public health approach to a generally underappreciated problem. It is not easily supportable through usual medical reimbursement models. It is dependent on maintaining collaborative ties with primary care physicians and other health care providers throughout the State. It is, if nothing else, a non-remunerative patient care activity. It is all of those things which seem to be experiencing devaluing — by the University of Wisconsin Medical Foundation, by the Accountability Model of the University of Wisconsin Medical School and by society as a whole. Will it then survive?

I continue to have a fierce, personal commitment to what WiSSP does. That does not, however, assure its survival. The forces now in motion will make it more and more difficult to provide such a service (and, for that matter, will make it more and more difficult to continue many of the traditional activities of an academic physician). I can not envisage a solution to these dilemmas. WiSSP may cease to exist.

"I do believe it’s true," but hope that somehow it isn’t.