Clinical revenue
For many AMCs, clinical revenue has become the single largest source of funding for the School of Medicine. GI revenues are generated by professional billings from office and hospital-based consultations, management of established patients, and endoscopic procedures performed in a variety of practice settings (inpatient endoscopy units, hospital outpatient departments, and ambulatory endoscopy centers [AECs]). Technical revenues (monies paid to facilities as opposed to the professional fees paid to providers) associated with procedures (usually much larger than professional fees on a per service unit basis) almost always track to hospitals because many of the procedures are hospital-based or performed in hospital-funded (and owned) AECs.
Progressive GI divisions often have developed their own AECs and are able to model a financial partnership with their AMCs that combines professional and technical reimbursement in a collaborative manner. Gastroenterology benefits also from "niche" areas of health care delivery in AMCs, namely transplant hepatology, interventional endoscopy, inflammatory bowel disease, oncology, and esophagology.
Some of the ability to augment GI programs has evolved from new models of revenue sharing between hospital systems and GI divisions that are based on income from AECs plus other "technical fees" such as revenue from biologic medication infusion. Technical fees (also called facility fees) are the monies paid to endoscopy labs, clinics, or hospitals in distinction to the "professional fee," which is reimbursement to providers for their medical services. Downstream revenue attributable to transplant hepatology has helped to redefine the close relationship between GI divisions and hospitals, where applicable. Practice ownership in AECs has helped transform GI health care economics not only in community-based gastroenterology but also in academic gastroenterology. Where AMCs adopt practice models that parallel community practice, such as the development of AECs, there is convergence of financial and clinical goals between AMCs and community gastroenterology. This comes during a time when community practices are increasingly concerned about long-term security as independent practices especially as health care reform progresses. This combination of factors has led some AMCs to develop closer alliances with community GI practices in their region.
There are several models of cooperation between academic GI faculty and community practices. The "loosest" affiliation occurs when the AMC creates a facilitated referral process targeted to key community practices in return for lending the AMC "brand" to the practice. Closer partnerships might include a shared inpatient service, professional service agreement, co-management of clinical service lines, or joint-venture arrangements to build and manage AECs.
A number of practices have realized advantages of full merger and have negotiated a pathway to becoming clinical faculty members. The AMC typically provides the shared electronic medical record (EMR) and assumes full responsibility for practice operations and office staff. With this arrangement, practices typically enjoy higher managed care rates, immediate buyout of hard assets (such as an AEC and infusion services), and the professional fulfillment attendant to becoming an academic clinician and educator.6
Emerging economic pressures
Training and education for GI fellows continue to be of paramount importance to GI divisions. There are more than 100 Accreditation Council for Graduate Medical Education accredited GI fellowships across the United States, but the number of fellows emerging from 3-year fellowship training has remained relatively constant during the last 10-15 years. Fellowship has been modified by the integration of advanced (fourth year) fellowships that align with the niche areas of gastroenterology: transplant hepatology (Accreditation Council for Graduate Medical Education accredited), interventional endoscopy, inflammatory bowel diseases, esophagology/motility, and potentially oncology. Typically, the mix of financial support for GI fellowship training, a not insignificant cost for academic gastroenterology, involves National Institutes of Health T32 training grants (for the research component of GI fellowship), Graduate Medical Education support, and clinical revenue (directly from the GI budget and indirectly from the hospital budget). Occasionally, unrestricted industry support may help, especially in the advanced GI fellowships.
Traditionally, AMCs have been able to command higher managed care rates compared with nonacademic hospital systems to account for time related to clinical care delivered by an attending physician as he or she teaches medical students, residents, and fellows in the art and science of medicine or technical skills related to endoscopic procedures or surgery. This situation is changing rapidly as cost pressures force both state and commercial payers to bring increasing scrutiny to total cost of care negotiations.
Currently, an overriding concern for purchasers of health care is cost. Purchasers of health care are increasingly carving out narrowed provider networks that are based largely on cost, a situation that may leave some AMCs excluded from large groups of patients.7
