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Financial Troubles Threaten Medical Education
The growth of managed care is causing financial pressures that threaten the quality of care and teaching provided by academic health centers, a new report concludes. The report was issued by the Commonwealth Fund Task Force on Academic Health Centers, a group established in 1995 to study the effects of changes in health care financing on the traditional missions of academic health centers, including medical education and research, specialized health care services, and care for indigent and uninsured patients.
Academic health centers—which are made up of medical schools and the clinical facilities associated with them—offer more specialty services than other hospitals, treating a larger proportion of "medically vulnerable" patients who need rare, complex, or innovative services not readily available elsewhere. Providing these services is crucial, not only to individual patients but also to medical research and education, the report notes. But insurance reimbursement policies fail to take into account the greater expenditures necessary to treat these patients and are slow to recognize new procedures as standard and thus reimbursable. Adding to the financial pressure on academic health centers is the fact that they also treat more poor and uninsured patients than do other hospitals.
In the past, the centers have often subsidized specialty treatments with earnings from routine patient care. But increased competition in the health care market has reduced prices for routine care, the report says. If competition drives other hospitals to eliminate unprofitable services and concentrate on relatively simple and sought-after procedures such as coronary bypass surgery or pacemaker implants, academic health centers, obligated by their educational and research missions to provide care without regard for its profitability, are the losers.
That is already happening, according to University of Kansas Medical Center professor Dolores Furtado, and the results are not good for medical education. She notes, as does the report, that the next generation of physicians and physician educators cannot be adequately trained without exposure to the latest advances in care and technology. But Furtado also points out that students need exposure to routine, ambulatory cases to develop reliable medical skills. In her experience, treatment of these routine cases is decreasing in academic health centers, with the result that teaching hospitals are sending students out to other facilities to complete their training. In addition, says Furtado, the teacher-student relationship is damaged when physician educators are pressured to spend more time doing "productive"—and billable—clinical work.
"Ideally, attending physicians teach third- and fourth-year medical students through a combination of demonstrating procedures, lecturing, and discussing with students what they are doing. But the physicians have less time to spend with students, and increasingly they teach just by demonstrating, with residents taking over the other aspects of teaching," Furtado says.
The report concludes that specialty services and their concomitant benefits—innovations in care, standby capacity to treat burn or trauma cases, and education of physicians—are social goods that the government should support if the health care market fails to do so.
The AAUP has established a working group to address issues in medical education. The group has initiated an electronic discussion and encourages those interested to participate.
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