Correspondence
The Effect of Managed Care on Medical Education
N Engl J Med 2000; 342:1140-1141April 13, 2000
- Article
To the Editor:
Much as I admire Robert Kuttner's work, his history of medical education and academic health centers (Sept. 30 issue)1 is misleading in ways that take them off the hook for their current plight. After World War II, the American Medical Association blocked proposed legislation that would have provided aid to medical students and national health insurance, as well as several other proposals, and allowed federal support only for the construction of hospitals and medical research.2 The number of full-time faculty positions at medical schools had increased by 51 percent by 1950 and had doubled by 1960, largely because of research grants from the National Institutes of Health. Medical schools gradually turned away from undergraduate teaching and from the health care needs of the communities around them. Competition for research faculty and “clinical material” led to aggressive co-opting of local institutions, creating resentment among community physicians that is not new but 35 years old.3
General practice lost status, and subspecialties grew rapidly, resulting in many more specialists than were needed. Health insurers, including Medicare, strongly favored specialized practice. The medical-education lobby built generous funding into Medicare for residents. The rush for residents — young, talented, but cheap labor — started a 20-year expansion. Medicare also subsidized capital costs, resulting in metropolitan and regional medical complexes “oriented primarily toward research and training. Gleaming palaces of modern science . . . now stood next to neighborhoods that had . . . no doctor for everyday needs.”2 Academic medicine, unprofitable since the Flexner reforms, now generated large internal surpluses.
“Academic medicine became increasingly dependent on Medicare funds,” as Kuttner states, because when federal research funds flattened out, academic chairs and deans did not downsize but instead pressed faculty members to increase clinical revenues. No dean wanted to be known as having done a great job of downsizing. This put faculty members in an increasingly untenable bind, so they maximized services and charges as they were stretched to exhaustion.
Department chairs and deans also started leveraging their full-time budgeted faculty positions into half-time positions, then later into quarter-time positions. The resulting expansion was viewed not as poor management but as brilliant management, leading to further leveraging of clinical revenues, Medicare, and commercial research contracts. Thus, by the late 1980s, medical schools and their clinical empires had become a monstrous distortion of the program of scientific medical education developed by Osler and Welch at Johns Hopkins University. It is these complexes that Congress, employers, and insurers are trying to rein in. Nothing like them exists anywhere else in the world of advanced medicine. It is time to rethink academic medicine from the ground up.
3 ReferencesDonald W. Light, Ph.D.
University of Medicine and Dentistry of New Jersey, Stratford, NJ 080841
Kuttner R . Managed care and medical education. N Engl J Med 1999;341:1092-1096
Full Text | Web of Science | Medline2
Starr P. The social transformation of American medicine. New York: Basic Books, 1982:335-78.
3
Kendall PL. The relationship between medical educators and medical practitioners. Evanston, Ill.: Association of American Medical Colleges, 1965.
To the Editor:
The problem is not between managed-care organizations and medical schools but between managed-care organizations and hospitals. It is the continuing reliance of medical schools on hospitals, rather than on outpatient facilities, in training future physicians that makes trouble for medical education. Although Kuttner does refer to the experience of the Harvard Pilgrim Health Care ambulatory program, even that program relied heavily on hospital-based education in its early years. When medical schools begin to rid themselves of the overhead costs of hospital facilities, they will find that managed-care organizations are willing partners in medical education.
Daniel S. Harrop, M.D., M.B.A.
Brown University School of Medicine, Providence, RI 02912To the Editor:
Kuttner identifies many of the issues confronting academic medical centers as they attempt to sustain their educational programs in the face of unprecedented financial pressures. However, we disagree with one example he gives — specifically, his statement that teaching programs at Beth Israel Deaconess Medical Center, a major teaching hospital of Harvard Medical School, “are suffering along with the bottom line.” This statement is neither explained nor supported by any data. In reality, the unfailing commitment of the institution, its leadership, and its faculty to the training of physicians has allowed us to continue providing outstanding teaching programs, which have not experienced any decrement in quality.
Steven E. Weinberger, M.D.
Michael Rosenblatt, M.D.
Herbert Y. Kressel, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215To the Editor:
Kuttner erred in his description of the relation between Emory University and Columbia/HCA. In November 1998, Emory did announce a partnership with Columbia/HCA to manage 13 area hospitals and ambulatory surgery centers. According to Emory's press release on November 15, 1998, “The goals of both organizations are to forge an even stronger alliance between the private practice physicians on the medical staff of these hospitals and Emory's physicians; create unique efficiencies in delivering care to patients; and enhance opportunities for managed care contracting, marketing, and strategic planning.”1
The partnership is described as substantially different from the arrangement considered in 1994, in which Columbia would have exerted significantly more control over the Emory institutions. Nevertheless, it remains a fact that Emory Healthcare has aligned itself with a for-profit organization that has been under a legal cloud for several years.
From my perspective as an alumnus, the evolution of Emory University's well-respected clinic and hospitals into first Emory Healthcare and now “Emory Healthcare–Columbia/HCA, L.L.C.” illustrates the inexorable decline of centers of health care and learning into mere corporations specializing in health care.
1 ReferencesJeffrey S. Sartin, M.D.
Internal Medicine Specialists, Hutchinson, KS 675021
Agreement between Emory Healthcare and Columbia/HCA creates Atlanta's most comprehensive healthcare delivery system, November 15, 1999. (See: http://www.emory.edu/WHSC/HSNEWS/NEWS/announcement.html.)
To the Editor:
Kuttner is right that in a market-driven health care system, “no one is volunteering to pay the cost” of graduate medical education, and that graduate medical education is a “social cost . . . that must be borne collectively.” In New York State, we have recognized that it is difficult or impossible for teaching hospitals to charge more to cover the costs of graduate medical education when large purchasers of care (managed-care companies) can threaten to move blocks of patients elsewhere. We have a system similar to his concept of “an `all-payers' pool of support, which would tax health insurance premiums to finance a portion of medical education.”
For many years, New York's system of regulating hospital prices provided an add-on to teaching-hospital prices for the costs of graduate medical education.1 In 1996, the price-regulation system was ended, and hospitals now negotiate prices with third-party payers. All third-party payers (except Medicare and Medicaid) are assessed an amount per “covered life” in a region on the basis of the total costs of graduate medical education in that region.2 The resulting revenue is then distributed by the state to the teaching hospitals. (Medicaid contributes to graduate medical education through a different mechanism, but the result is the same.)
The Business Council of New York State, which primarily represents large employers, regularly attacks the system, but otherwise it has broad political support. The system was reauthorized by the state legislature in December 1999 with little controversy.3
Under New York's system, employers that do not provide health coverage for their workers do not contribute to graduate medical education. A more equitable approach would be a universal health plan funded by all employers and employees.4
4 ReferencesRichard N. Gottfried, J.D.
New York State Assembly, Albany, NY 12248
