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June 26, 2014

Revolution in health care = changes in medical education


The convergence of personalized medicine, better imaging technologies, big data and analytics and the Affordable Care Act are fomenting a revolution in medicine and health care, said Arthur S. Levine, senior vice chancellor for the Health Sciences and the John and Gertrude Petersen Dean of Medicine.

Arthur S. Levine

Arthur S. Levine

In his June 12 state of the medical school address, “The Second Revolution in Medicine and Its Impact on Our School of Medicine,” Levine equated today’s transformation with the effects of Abraham Flexner’s groundbreaking 1910 report, “Medical Education in the United States and Canada,” which, he said “effected a revolutionary change in how medicine was taught and practiced in this country.”

Noting that the mandate of the Affordable Care Act goes beyond increasing access to include raising the quality and reducing the cost of health care, Levine said, “The more productive our biomedical and behavioral research, the more likely it is we can practice preventative medicine or targeted therapy and thereby lower the cost of treatment for individuals.”

Personalized medicine “means deeply interrogating the entire genome of a human being,” Levine said, noting that the cost of genetic sequencing soon will drop to about $1,000 — the equivalent of the cost of an MRI. “That will allow us to have the knowledge we need to understand the molecular roots of a disease or disorder, to prevent it if we understand what it is and what’s causing it,” he said.

Aiding that understanding are advances in imaging technologies. “The imaging of tissues, bodies, cells, organs — all of that is accelerating at a phenomenal rate now,” Levine said.

In addition, UPMC is investing $100 million in accumulating patient data, including genomics, insurance claims, environmental exposures, history and family, social and economic data, Levine said. “The challenge will be not accumulating the data, but making sense of it once we do that, and that is a real intellectual challenge.”

With these changes occurring against the backdrop of the Affordable Care Act, “if you put all that together, I really do think that we are in the midst of a revolution in medicine and health care,” Levine said, adding that interprofessionalism — “to have others besides physicians offer primary care to the degree that their training, experience and ability permits” — also has the potential to reduce health care costs.

“I do think that this is a very good time. It’s a scary time. I think the next two years in particular will be volatile and there will be some unpredictable elements about it,” Levine said.

“Nonetheless I think we are exquisitely well positioned for the future but it has to be a future that is surrounded by the economic context in which we find ourselves. It goes without saying that we cannot let our expenses exceed our revenues. It’s no different than when you go to Giant Eagle … They’ll only let you take out of the store what you pay for.”


Despite the fact that “it’s a very rocky time for the NIH,” the University remains No. 5 in terms of National Institutes of Health funding — behind Harvard, Penn, Johns Hopkins and the University of California San Francisco, said Levine.

While the end of federal stimulus funding eliminated an upward blip in research funding, “we’re not going down, we’re staying level — and most of the country is not, so that leaves us in a good position,” Levine said.

Pilot grants, bridge funding and free scientific and editorial review of grant applications are all available to aid health sciences researchers, the dean said.

Core facilities that provide services to investigators also have been developed “to help people get grants,” but the cores are under review, he said.

“We are beginning an exercise in which we actually look at the use of each core: the number of faculty using it, who they are, whether their grants depend uniquely on access to that core, whether the core’s activities could be replicated in some other way,” the dean said, noting that some cores had been more successful than others at covering their expenses through user fees.

“We are studying the entire core enterprise because the subsidy has gotten very high. … I’m not sure that we can sustain it at the level that we’re at,” Levine said, adding, “One or two of these cores may have to be diminished in order for us to sustain what we are hoping to accomplish.”


Levine noted that NIH doubled its budget from $13 billion to $27 billion between 1998 and 2003, prompting research institutions to construct new buildings, add faculty and train new researchers, “assuming that this gravy train would continue forever.” Instead, “The train has stopped, and in fact it has gone backward. And so there is no way that we can sustain the level that we’re operating at now. We all recognize that.”

The dean referenced two recent commentaries that he labeled “extremely important, particularly taken together” in terms of the current climate.

In recognition that biomedical and behavioral research can’t be supported at their current levels amid the current funding climate, former National Academy of Sciences President Bruce Alberts, cell biologist Marc W. Kirschner, Princeton President Emeritus Shirley Tilghman and Nobel laureate and National Cancer Institute director Harold Varmus proposed solutions in their editorial, “Rescuing U.S. Biomedical Research From its Systemic Flaws,” published in the April 22 Proceedings of the National Academy of Sciences journal.

Levine commended the authors’ recommendation that the federal government provide a more stable and predictable funding stream by appropriating funds for NIH on a five-year (rather than the current annual) basis.

However, he decried as “damaging to academic medicine” the authors’ recommendations that institutions foot the bill for researchers’ salaries and pick up all overhead costs. “If either or both of those recommendations were to be implemented it would end biomedical research at the universities of this country virtually overnight,” Levine said. “It certainly would be devastating to research as we know it in the universities.”

Noting that “none of (the authors) have actually worked in an academic medical center for many years,” Levine said, “None of them are in the trenches and I don’t think they are reasoning this through.”

Levine said he has collaborated on a response, “basically applauding the authors for their insights and those remedies we think are appropriate but rebutting the remedies that we think would be damaging.”


Another article, “Academic Medical Centers Fear Squeeze From Affordable Care Act,” by Anna Azvolinsky, published in February in Nature Medicine, correctly points out that academic medical centers — “defined at a minimum as a hospital and medical school,” Levine said — are more expensive to operate than a community hospital.

“By definition an academic medical center has to support research, teaching, training, a specialized infrastructure, super-specialized physicians et al.,” Levine said. In short: “Community hospitals are cheaper than academic medical centers,” prompting major insurers to increasingly exclude academic medical centers from their networks.

While nearly half of the nation’s academic medical centers have been excluded by major insurers in their regions, Levine said, “In that regard, Pittsburgh is utterly different.

“Despite the current imbroglio with Highmark, UPMC enjoys a privileged position,” the dean said, noting that UPMC has 62 percent of the patients in the region — nearly 4 million people. In addition, UPMC has its own insurance plan and is not totally dependent on clinical revenue, but also has a large international and commercial services division; “it has products it can sell to other people.”

Levine said that while Pitt may be the most financially well positioned academic medical center in the country, “it doesn’t mean that UPMC is not threatened by the implications of the Affordable Care Act” because high copays and insurance deductibles are making consumers think carefully about their medical care, regardless of what insurance they have.

“I think that over the next two years in particular — fiscal ’15 and fiscal ’16 — we will have to work very closely with UPMC; we will have to be very vigilant about what the economic impact is.”

Levine labeled the Affordable Care Act “an inspired and inspirational piece of social legislation,” but cautioned that it is imperfect, as is “every other major social policy that ever has been developed in this country.” Noting that Social Security and Medicare rules continue to be changed, the Affordable Care Act likewise will continue to change, Levine predicted. “It will reach some sort of steady state years from now, not immediately.”

The downside to the legislation: “It will in fact squeeze clinical revenues,” the dean said. “The medical school is exquisitely dependent upon monies delivered from UPMC in support of our academic mission. That is our major source of discretionary revenue,” he said, adding that the medical school’s endowment is smaller than that of many of its competitors and that the school receives little in state funding.

“We do not have the wherewithal necessary to continue our quite remarkable momentum without adequate if not generous support from UPMC based on their clinical revenue,” he said, adding that over the next two years, “We will need to re-equilibrate ourselves with response to the re-equilibration that UPMC has to do to bring their expenses into line with their revenue.”


Levine’s address is posted at

—Kimberly K. Barlow