Internal Medicine at the Inflection Point

A New Role for Departments of Internal Medicine in the Age of Chronic Disease

Departments of Medicine at academic health systems are at a strategic inflection point. Academic centers—tertiary facilities once confined to a single campus—have evolved into regional, multihospital academic health systems. The expanded clinical enterprises have altered the role and responsibilities of traditional academic departments, in some circumstances increasing their influence and in others diminishing it. In perhaps no case is this shift in responsibilities more apparent than in departments of medicine, given their sheer size and their clinical breadth covering historically a dozen or more clinical divisions.

The clinical and economic functions that have long defined the role of Departments of Medicine—generating referrals, providing subspecialty access and producing bench research—continue to be necessary but are no longer sufficient. A larger opportunity, and a more urgent imperative, has emerged—chronic disease and its effective management.

The United States is entering the full force of a chronic disease crisis. By 2030, the Baby Boomer generation will comprise 21 percent of the U.S. population. Nearly all of them—93 percent of Americans aged 65 and older—have at least one chronic condition. Roughly 80 percent carry two or more. These patients consume hospital capacity at extraordinary rates, cycle through emergency departments (EDs), generate avoidable admissions and require substantial specialist time without receiving the coordinated, longitudinal care their conditions require.

Health systems were designed for acute, not chronic conditions. Traditional service lines that emerged in many institutions with the intent of providing more complete care in specific clinical domains were aligned with organ systems or clinical specialties. They were well-suited for short-term events and acute interventions. They are not particularly effective in dealing with longitudinal episodes involving multiple chronic diagnoses and requiring interdisciplinary care coordination.

The misalignment between conventional organ system service lines and multidisciplinary chronic care management creates both a need and an opportunity. Departments of Medicine are uniquely positioned to claim a new and strategically influential role: as the clinical anchor for complex chronic patients with multidisciplinary needs and the incubator of applied clinical innovation in chronic disease management.

Basic research remains a core competence of the academic health system, and discoveries arising from basic research have always needed a translational complement. As basic research moves increasingly toward precision medicine, there will be an even higher premium on translational capabilities. Departments of Medicine have the multispecialty breadth, the research infrastructure, and the training mission to do what no other part of the health system can do as well: design, test, and scale new models of care for patients with advanced, complex chronic conditions. In doing so, they can unleash system capacity, improve patient wellbeing, reduce avoidable cost and position themselves at the nexus of clinical innovation and unmet need.

Framed correctly, this is not a proposal to spend more on sicker patients. In a health system operating at or near capacity, every avoidable medical admission occupies a bed that a surgical or procedural case could otherwise fill at materially higher contribution margin. Reducing avoidable utilization among the most complex patients is therefore a capacity-creation strategy—and capacity, not demand, is the binding constraint on growth for most academic health systems.

Others are moving into this space. Payer-owned and private complex-care organizations are building capitated models for the same population, with more capital and fewer institutional constraints. But they can only operate a care model. They cannot generate the evidence base, train the future workforce or manage the highest-complexity tail of the population. That is the advantage of the academic Department of Medicine, and it is the basis on which this strategy should be pursued.