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1O
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Michael M L Johns, M.D.
Dean ot llifi Mcdi<:.»l Facullv
Vice Prftsident (of Medicine
April
16,
1993
Ms. C h a r l o t t e Hayes
Domestic P o l i c y A s s i s t a n t
O f f i c e o f t h e Vice President
old Executive O f f i c e Building
Washington, DC 20501
Dear C h a r l o t t e :
Thank you f o r your h e l p i n a r r a n g i n g t h e A p r i l 14 m e e t i n g
between I r a Magaziner and my c o l l e a g u e s and me. We v e r y much
a p p r e c i a t e d your a s s i s t a n c e . Tt was a v e r y p r o d u c t i v e s e s s i o n .
I would l i k e t o ask one more f a v o r o f you. Would you k i n d l y
f o r w a r d t h e enclosed document t o Mr. Magaziner and t h e Task
Force? The document "Guaranteed Access t o T e r t i a r y Care Centers
i n a Reformed H e a l t h c a r e System", d e s c r i b e s t h e advantages o f
c e n t e r i n g t e r t i a r y care i n a r e l a t i v e l y few " N a t i o n a l Healthcaxe
Resource C e n t e r s , " w h i l e c o n t i n u i n g t o u t i l i z e a v a r i e t y o f
h e a l t h care s e t t i n g s f o r t h e education o f f u t u r e h e a l t h care
professionals.
I hope t h a t you w i l l c a l l upon me i f I can p r o v i d e
a d d i t i o n a l i n f o r m a t i o n t o t h e Task Force, o r i f I can be o f h e l p
t o you. Again, thank you f o r your generous a s s i s t a n c e .
Sincerely,
Michael E. Johns, M.D.
Dean o f t h e M e d i c a l F a c u l t y
slw
Enclosure
�S N B : H S H O M D ADMIN; 4-16-93 ;10:56AM ;
E T Y J U C. F E.
1
CLINICALPRACTICE-
912024566231;# 2/18
[HSH P IS
O N O KN
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Sh o o Mdcn
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720 Rutland Avenue / L^itimorft MD 21205-219S
(410) 955-3180/FAX (410) 955-0889
Michael M E. Johns. M D
Dean of tha Medical Fiioiiiy
Vice President for Mcdicme.
A p r i l 16, 1993
Mr. I r a Magaziner
Senior Advisor t o t h e President
f o r P o l i c y and Development
The White House
Old Executive O f f i c e B u i l d i n g
Room 216
W a s h i n g t o n , DC 20500
Dear Mr. Magaziner:
I am p l e a s e d t h a t I had an o p p o r t u n i t y t o j o i n w i t h
r e p r e s e n t a t i v e s o f t h e academic m e d i c a l community and meet w i t h
you and y o u r s t a f f on Wednesday. As I mentioned t o y o u , t h e
Johns H o p k i n s U n i v e r s i t y School o f M e d i c i n e t a k e s i t s l e a d e r s h i p
r e s p o n s i b i l i t i e s very s e r i o u s l y .
We p l a y a v i t a l r o l e i n
p r o v i d i n g p r i m a r y c a r e t o o u r East B a l t i m o r e community, and i n
p r o v i d i n g secondary and t e r t i a r y c a r e t o p a t i e n t s f r o m t h e
B a l t i m o r e / W a s h i n g t o n m e t r o p o l i t a n area, t h e S t a t e o f M a r y l a n d ,
t h e r e g i o n , and t h e n a t i o n . We a r e proud o f o u r a c c o m p l i s h m e n t s
and t h e s i l l s o f o u r f a c u l t y and s t a f f .
I have e n c l o s e d f o r your c o n s i d e r a t i o n a document e n t i t l e d
"Guaranteed Access t o T e r t i a r y Care C e n t e r s i n a Reformed H e a l t h
Care System." I t d e s c r i b e s t h e advantages o f c e n t e r i n g t e r t i a r y
c a r e i n a r e l a t i v e l y few " N a t i o n a l H e a l t h c a r e Resource C e n t e r s , "
w h i l e c o n t i n u i n g t o u t i l i z e a v a r i e t y of h e a l t h care s e t t i n g s f o r
the education of f u t u r e h e a l t h care p r o f e s s i o n a l s .
I b e l i e v e t h a t a r e f o r m e d h e a l t h c a r e system s h o u l d be
c r a f t e d t o t a k e advantage o f t h e e x t r a o r d i n a r y c a p a b i l i t i e s o f
academic m e d i c a l c e n t e r s l i k e o u r s . The Johns H o p k i n s M e d i c a l
I n s t i t u t i o n s , i n c l u d i n g t h e U n i v e r s i t y Schools o f M e d i c i n e ,
H y g i e n e and P u b l i c H e a l t h , and N u r s i n g , and t h e Johns Hopkins
H o s p i t a l , t r a i n and s u p p o r t an immensely t a l e n t e d c a d r e o f
p r o f e s s i o n a l s whose combined e f f o r t s i n r e s e a r c h , e d u c a t i o n and
c l i n i c a l p r a c t i c e a r e a proven n a t i o n a l resource.
Multi-faceted
N a t i o n a l H e a l t h c a r e Resource C e n t e r s l i k e o u r s have a u n i g u e
a b i l i t y t o draw from a wide range o f h e a l t h p r o f e s s i o n a l s and
b i o m e d i c a l t e c h n o l o g i e s t o c r e a t e new, more e f f i c i e n t , and more
e f f e c t i v e h e a l t h c a r e d e l i v e r y and management systems f o r t h e
nation.
We have v a s t e x p e r i e n c e i n c r a f t i n g and t e s t i n g such
systems, and a r e p r e p a r e d t o do even more. I hope t h a t y o u and
t h e Task Force w i l l g i v e c a r e f u l c o n s i d e r a t i o n t o t h i s n a s c e n t
proposal.
�1
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......
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—
"^u</*uuo^oi;ff a/10
Mr. I r a Magaziner
A p r i l 16, 1993
Page 2
At our meeting I a l s o mentioned t h e economic r e a l i t i e s of
the academic medical center and the m u l t i p l e sources o f f i n a n c i n g
of our mission. The Johns Hopkins U n i v e r s i t y School o f Medicine
i s t h e most successful research center i n t h e United States, y e t
we s u f f e r an unexpected consequence. We lose money from our
research a c t i v i t i e s . I t i s only from p h i l a n t h r o p y , endowment
income, and t h e s a c r i f i c e s of our f a c u l t y t h a t we m a i n t a i n t h e
m u l t i p l e missions t h a t are t h e core o f our success. Our f a c u l t y
accept s a l a r i e s t h a t are on average $50,000 - $70,000 l e s s than
the average U.S. p h y s i c i a n , so t h a t we may f u n n e l c l i n i c a l
p r a c t i c e earnings back i n t o t h e o r g a n i z a t i o n t o support t h e
school o f Medicine's i n f r a s t r u c t u r e and s h o r t f a l l s i n research
funding. I n t h e new h e a l t h care system, a new source o f funds
must be i d e n t i f i e d t o replace t h e e x i s t i n g c r o s s - s u b s i d i z a t i o n of
research and medical education. Otherwise we r i s k l o s i n g our
f i n e s t research and education centers.
Thank you again
r o l e of t h e academic
system. Please f e e l
f u r t h e r i n p u t t o you
f o r your h o s p i t a l i t y and i n t e r e s t i n t h e
medical center i n t h e e v o l v i n g h e a l t h care
f r e e t o c a l l upon me i f I can p r o v i d e
and the Task Force.
Sincerely,
Michael E. Johns, M.D.
Dean o f t h e Medical F a c u l t y
slw
Enclosure
�S N B : H SCH. O MED. ADMIN; 4-16-93 ;10:57AM ;
ET YJU
F
CLINICALPRACTICE-
912024566231;* 4/18
Guaranteed Access t o T e r t i a r y Care Centers
In A Reformed Health Care System
Executive Summary
T h i s n a t i o n r e q u i r e s a d i v e r s e network o f h e a l t h care resources t o
p r o v i d e m e d i c a l l y a p p r o p r i a t e and c o s t - e f f e c t i v e c a r e , r e s e a r c h and
training.
For t h e purposes o f maximum e f f i c i e n c y and a s s u r i n g t h e highest
q u a l i t y , t e r t i a r y care should be d i r e c t e d t o a group o f d e s i g n a t e d t e r t i a r
care c e n t e r s , " N a t i o n a l Health Care Resource Centers" (NHRCs). These
c e n t e r s should be designated from among academic medical c e n t e r s and
s e l e c t e d o t h e r major h o s p i t a l c e n t e r s t h r o u g h o u t t h e U n i t e d S t a t e s .
Designated NHRCs would complement t h e c r i t i c a l r o l e s o f o t h e r AHP are
h o s p i t a l s and o t h e r p r o v i d e r networks, and support t r a i n i n g and research i
p r e v e n t i v e and p r i m a r y care i n m u l t i p l e community s e t t i n g s , ( r u r a l , urban,
and t e a c h i n g ) w i t h s p e c i a l t y care t r a i n i n g p r i m a r i l y c o n c e n t r a t e d i n NHRCs
Any g l o b a l budget o r cost c o n t r o l s must be designed t o accommodate t h
a t y p i c a l s e r v i c e s and p a t i e n t s o f t h e NHRCs. The b a s i c b e n e f i t s package
must cover t r e a t m e n t o f t e r t i a r y s e r v i c e s i n q u a l i f i e d c l i n i c a l t r i a l s tha
o f f e r an a l t e r n a t i v e t o standard, p o s s i b l y l e s s e f f e c t i v e , t h e r a p i e s .
P a t i e n t s i n managed care programs must be guaranteed a p p r o p r i a t e access t c
t e r t i a r y c a r e . Otherwise, such t r e a t m e n t w i l l be r a t i o n e d o n l y t o a f f l u e n
oatients.
The m u l t i - f a c e t e d NHRCs would have a unique a b i l i t y t o draw from a w i
range o f medical p r o f e s s i o n a l s , b i o m e d i c a l t e c h n o l o g i e s and p u b l i c h e a l t h
p r o f e s s i o n a l s t o c r e a t e new, more e f f i c i e n t , and more e f f e c t i v e H e a l t h car
d e l i v e r y and management systems. They a l r e a d y have v a s t experience i n
c r a f t i n g and e v a l u a t i n g such systems.
The s e r v i c e s t h a t need e x c l u s i v e NHRC d e s i g n a t i o n are r e l a t i v e l y r a r e
and thus t h e i r requirements i n terms o f s p e c i a l i z e d y e t m u l t i - d i s c i p l i n a r y
care are e a s i l y underestimated.
The r e g i o n a l i z a t i o n o f the s i c k e s t p a t i e n
would a v o i d expensive d u p l i c a t i o n and assure t h e h i g h e s t q u a l i t y care f o r
a l l p a t i e n t s . The NHRCs, i n t u r n , w i l l c o n t i n u e t o f o s t e r t h e r e s e a r c h an
d i s c o v e r y t h a t i s needed t o assure t h e c o n t i n u i n g f l o w o f new d i s c o v e r i e s
p r e v e n t i o n , d i a g n o s i s and t r e a t m e n t t h a t are e s s e n t i a l t o t h e f u t u r e o f ou
h e a l t h care system. And, Americans w i l l c o n t i n u e t o have access t o t h e be
h e a l t h care i n the w o r l d .
�SENT BY:JHU SCH. Oh MtU. AUMIN; 4-16-93 ;1U:58AM ;
CLINICALPRACTICE-
912024566231;# 7/18
DISCUSSION DRAFT
GUARANTEED ACCESS TO TERTIARY CARE CENTERS
IN A REFORMED HEALTHCARE SYSTEM
BACKGROUND
For y e a r s , America's h e a l t h c a r e has been p r e e m i n e n t i n t h e
world, p r o v i d i n g the l a t e s t i n l i f e s a v i n g s o p h i s t i c a t e d medical
t r e a t m e n t f o r i t s c i t i z e n s and
c a p a b i l i t i e s a r e due,
those of o t h e r c o u n t r i e s .
These
i n l a r g e p a r t , t o the c o n t r i b u t i o n s of
g r o u p s o f h i g h l y s p e c i a l i z e d p h y s i c i a n s a t what m i g h t
be termed
o u r n a t i o n ' s " N a t i o n a l H e a l t h c a r e Resource C e n t e r s . "
However,
w i t h t h e changes a p p a r e n t l y b e i n g s u g g e s t e d by t h e n a t i o n a l
h e a l t h c a r e r e f o r m p l a n , i t can no l o n g e r be t a k e n f o r g r a n t e d
t h a t t h e s e r e l a t i v e l y few c e n t e r s o f m e d i c a l
excellence
will
c o n t i n u e t o e x i s t and t o p r o v i d e l e a d e r s h i p i n h e a l t h c a r e f o r t h e
c i t i z e n s o f t h e U n i t e d S t a t e s and
It
f o r the world.
i s i m p e r a t i v e t h a t America m a i n t a i n i t s l e a d e r s h i p r o l e
i n p r o v i d i n g advanced h e a l t h c a r e s e r v i c e s .
Our
Healthcare
Resource C e n t e r s d i s s e m i n a t e
techniques
National
t h a t maintain the high q u a l i t y of the
h e a l t h c a r e system.
t h e knowledge
and
country's
Consequently, i t i s c r i t i c a l t o recognize
n a t u r e o f t h e p r a c t i c e of t h e s e p h y s i c i a n - l e d c e n t e r s and
resource
requirements,
which a r e d i f f e r e n t from t h o s e
community p h y s i c i a n s and h o s p i t a l s .
the
of
Proposed f e d e r a l p o l i c y
w o u l d e q u a t e a l l h o s p i t a l s as s i m i l a r and
it
the
i m p o s s i b l e f o r such N a t i o n a l H e a l t h c a r e
equal —
and c o u l d make
Resource C e n t e r s i n
t h e U n i t e d S t a t e s t o s u p p o r t t h e i r s o c i e t a l mandate t o t r a i n
�SENT BY: JHU SCH. or MfcU.
providers
AUMIIM
^i-io-aj
-iu^oaAivi ;
L L I IN I LALrKAL
and seek s o l u t i o n s t o mankind's
an approach w i l l
create
r e s o u r c e s and s e r v i c e s
11 L L -
912U24566231 ;# 6/18
h e a l t h burdens.
Such
unnecessary c o s t l y d u p l i c a t i o n o f
and w i l l d i l u t e t h e average p r a c t i t i o n e r ' s
e x p e r i e n c e w i t h complex p a t i e n t c a r e .
I f Americans a r e t o c o n t i n u e r e c e i v i n g t h e b e n e f i t s o f
m e d i c a l advances and l e a d e r s h i p ,
National
b o t h t o d a y and tomorrow, o u r
H e a l t h c a r e Resource C e n t e r s must be r e c o g n i z e d as an
i n t e g r a l p a r t of t h e n a t i o n a l healthcare
r e f o r m p l a n and
s o l u t i o n s must be c r a f t e d w h i c h s u p p o r t , r a t h e r t h a n t h r e a t e n t h e
vital
i n t e r e s t s of society.
PAH
4/15/93
�S N B : H SCH. O M D ADMIN; 4-16-93 ; 0 5 A ;
ET YJU
F E.
1:9M
CL1N1CALPRACTICE-
912024566231;# 9/18
THE DEFINITION OF A NATIONAL HEALTHCARE RESOURCE CENTER
•
M u l t i - S p e c i a l t y Group P r a c t i c e i A m u l t i - s p e c i a l t y g r o u p
of physicians
who a r e s a l a r i e d and p r a c t i c e as p a r t o f
a not-for-profit institution.
The p h y s i c i a n s '
i s e n t i r e l y devoted t o t h e n o t - f o r - p r o f i t
•
Community S e r v i c e ;
The N a t i o n a l
practice
institution.
H e a l t h c a r e Resource
C e n t e r a c c e p t s assignment f o r l o w income p a t i e n t s .
•
Severity
Proxy:
The case mix i n d e x f o r t h e c e n t e r ' s
M e d i c a r e p a t i e n t s who r e q u i r e h o s p i t a l i z a t i o n i s
greater
t h a n 1.40.
The NHRCs must c o n d u c t m e d i c a l
r e s e a r c h programs and p a r t i c i p a t e s i n a c c r e d i t e d
g r a d u a t e m e d i c a l e d u c a t i o n programs.
•
National
and R e g i o n a l R e f e r r a l C e n t e r :
The NHRC has a
broad g e o g r a p h i c p r a c t i c e base, w i t h a t l e a s t 25% o f
i t s patients
[excluding "primary care
h o s p i t a l i z a t i o n s " ] r e f e r r e d f r o m beyond a 50 m i l e
radius.
•
Public Health:
effectiveness,
epidemiological
The NHRC must be c a p a b l e o f outcome,
healthcare
o r g a n i z a t i o n and
r e s e a r c h t o a c t as change a g e n t s f o r
t h e p u b l i c h e a l t h o f t h e c i t i z e n s and t o t r a i n
health
professionals.
3
public
�S N B : H S H O M D ADMIN; 4-16-93 ;10:59AM ;
E T Y J U C . F E.
CL1NICALPRACTICE-
912024566231;#10/18
NATIONAL HEALTHCARE RESOURCE CENTERS
The
National Healthcare Resource Centers (NHRC) a r e
i n v a l u a b l e n a t i o n a l resources: leaders i n discovery,
i n bringing
medical advances from t h e l a b o r a t o r y t o t h e bedside, i n
developing and p r o v i d i n g q u a l i t y healthcare,
i n evaluating the
medical e f f e c t i v e n e s s o f new t h e r a p i e s , and i n p r o v i d i n g
innovation
i n public health.
Past advances, such as t h e r o l e o f
v i t a m i n A i n v i s i o n care and t h e e r a d i c a t i o n o f smallpox portend
the f u t u r e s i g n i f i c a n t c o n t r i b u t i o n s from research-based
practice-focused
p u b l i c h e a l t h , such as AIDS,
TB and other scourges.
devoted b i l l i o n s
our n a t i o n ' s
medicine-resistant
Our N a t i o n a l and s t a t e governments have
of d o l l a r s t o develop these centers.
They serve
s i c k e s t people, together w i t h a broad n a t i o n a l and
i n t e r n a t i o n a l group o f r e f e r r e d p a t i e n t s , f o r whom t h e p h y s i c i a n s
at these Centers are o f t e n t h e p a t i e n t ' s l a s t hope.
The r o l e o f
these NHRCs -- and the concomitant continued success o f American
medical discovery
— w i l l be threatened by healthcare
reform
unless t h e unique missions o f NHRCs are recognized and
incorporated
The
i n t h e reform plan.
four issues t h a t c a l l f o r the d e s i g n a t i o n
of National
Healthcare Resource Centers are access, cost c o n t r o l s , c l i n i c a l
t r i a l s and medical research.
�SENT BY:JHU SCH. OF MED.
•
ADMIN; 4-16-93 ;11:00AM ;
Access:
CLINICALPRACTICE-
912024566231;#11/18
P a t i e n t s i n managed c a r e programs must be
guaranteed
a p p r o p r i a t e access t o a N a t i o n a l H e a l t h c a r e
Resource C e n t e r .
T e r t i a r y p a t i e n t s who
cannot r e c e i v e
s t a t e - o f - t h e - a r t treatment through the r e g u l a r
f a c i l i t i e s of t h e i r h e a l t h networks
t h e y meet t h e t r e a t m e n t and
o r AHPs (and, i f
referral criteria)
should,
t h r o u g h a p p r o p r i a t e l i n k a g e , be p e r m i t t e d t r e a t m e n t a t
a NHRC.
Otherwise,
only t o a f f l u e n t
such t r e a t m e n t w i l l be r a t i o n e d
patients.
To r e d u c e d u p l i c a t i o n o f s p e c i a l i z e d f a c i l i t i e s
and
s o p h i s t i c a t e d personnel, a l l t e r t i a r y care should
d i r e c t e d t o a group of d e s i g n a t e d
t e r t i a r y care
t h a t would i n c l u d e many academic m e d i c a l
be
centers
c e n t e r s , and.
s e l e c t e d o t h e r major h o s p i t a l s i n a r e a s where academic
medical c e n t e r s are not p r e s e n t , or are unable
expand t o meet t h e demand.
Academic m e d i c a l
to
centers:
should also take r e s p o n s i b i l i t y f o r the c o o r d i n a t i o n
of,
and
s e r v e as t h o change a g e n t f o r , t h e
s i z i n g " of the graduate medical
"right
e d u c a t i o n work f o r c e
pipeline.
•
Cost C o n t r o l s :
Any
g l o b a l budget or c o s t c o n t r o l s must
be designed to accommodate the a t y p i c a l s e r v i c e s and
p a t i e n t s of the National
H e a l t h c a r e Resource
Centers.
�5CNT BY:JHU SCH. Oh MtU. A M 1 ; 4-16-93 ;11:00AM ;
U1\
CL1N1CAL^KAC1 ILL-
912024566231;#12/18
NHRCs have been t h e major change agents f o r outcomes
r e s e a r c h and c o s t e f f i c i e n t c a r e d u r i n g t h e p a s t
years —
fifty
and t h e y c o n t i n u e t o e v o l v e t o be more
r e s p o n s i v e and more e f f i c i e n t .
But, cost
e f f o r t s must r e c o g n i z e t h e u n i q u e
control
resource
requirements
a p p r o p r i a t e t o p a t i e n t s o f v a r y i n g s e v e r i t y and
complexity.
Clinical Trials:
The b a s i c b e n e f i t s package must
treatment o f t e r t i a r y services i n q u a l i f i e d
trials
cover
clinical
that, o f f e r an a l t e r n a t i v e t o s t a n d a r d , p o s s i b l y
less e f f e c t i v e , therapies.
The c u s t o m a r y e x c l u s i o n o f
" i n v e s t i g a t i o n a l " s e r v i c e s must n o t e x t e n d t o q u a l i f i e d
clinical trials
a t NHRCs i n v o l v i n g c a n c e r t h e r a p i e s ,
m i n i m a l l y i n v a s i v e t r e a t m e n t s and d i a g n o s t i c
procedures,
etc.
at
organ t r a n s p l a n t a t i o n , and AIDS s e r v i c e s ,
Indeed,
NHRCs
many t e r t i a r y s e r v i c e s s h o u l d o c c u r
which
are able t o f i e l d
only
multi-specialty
teams o f p r o f e s s i o n a l s w i t h t h e e x p e r t i s e t o p e r f o r m
the
s e r v i c e r e p e t i t i v e l y , c o s t - e f f e c t i v e l y , and w i t h
b e t t e r c l i n i c a l and f i n a n c i a l outcomes.
For example, a t JHU, abdominal s u r g e r y f o r p a n c r e a t i c
cancer has a s i g n i f i c a n t l y h i g h e r success r a t e t h a n a t
other regional f a c i l i t i e s .
L i v e s and money would be
saved i f a l l p a t i e n t s from Maryland
and t h e s u r r o u n d i n g
s t a t e s were t r e a t e d by t h e most s u c c e s s f u l s u r g i c a l
team i n t h e r e g i o n .
�SENT BY:JHU SCH. OF MED. ADMIN; 4-16-93 ;ll:00AM ;
Research:
CLIN1CALPRACTICE-
H e a l t h c a r e r e f o r m must n o t undermine
b i o m e d i c a l r e s e a r c h programs sponsored
Institutes
912024566231;#13/18
o f H e a l t h and o t h e r s .
by t h e N a t i o n a l
C o m p e t i t i o n based on
p r i c e a l o n e w i l l s t e e r p a t i e n t s away f r o m t h e academic
m e d i c a l c e n t e r s where c l i n i c a l r e s e a r c h i s p e r f o r m e d .
Y e t , t h e b a s i c b i o m e d i c a l r e s e a r c h and c l i n i c a l
trials
conducted
a t these c e n t e r s are the f o u n d a t i o n of
medicine.
T h i s work i s e s s e n t i a l t o p r o g r e s s i n
b i o m e d i c a l s c i e n c e and h e a l t h , and t o d e v e l o p i n g
approaches t h a t w i l l r e p l a c e more e x p e n s i v e
effective therapies.
We
and
new
less
a r e on t h e v e r g e o f a new
era
of d e v e l o p i n g m o l e c u l a r t o o l s f o r p r e v e n t i o n and
t r e a t m e n t , as w e l l as p o w e r f u l new
and e f f e c t i v e n e s s e v o l u t i o n .
Our
methods f o r outcomes
reformed h e a l t h
system must a s s u r e t h e c o n t i n u e d v i t a l i t y
of
this
e s s e n t i a l work.
The
NHRC has been t h e f o c u s f o r outcomes r e s e a r c h .
America has a need f o r more c l i n i c a l
investigators
t r a i n e d t o use t h e t o o l s o f p u b l i c h e a l t h , o f
t e c h n o l o g y assessment, and s o p h i s t i c a t e d
statistical
methods t o d e t e r m i n e t h e t r u e e f f e c t i v e n e s s o f such
i n t e r v e n t i o n s as d r u g s , t e c h n o l o g y ,
m o d i f i c a t i o n and
behavior
i n n o v a t i v e d e l i v e r y systems.
s a v i n g s i n h e a l t h c a r e c o s t s can be r e a l i z e d
Real
from t h e
development of c o n t r o l l e d m e d i c a l e f f e c t i v e n e s s and
outcomes r e s e a r c h
initiatives.
new
�SENT BY:JHU SCH. O MED. ADMIN; 4-16-93 ;11:01AM ;
F
CLINICALPRACTICE-
912024566231;#14/18
ACCESS MUST BE PROTECTED
This n a t i o n r e q u i r e s a d i v e r s e network o f h o s p i t a l s t o
p r o v i d e m e d i c a l l y a p p r o p r i a t e and c o s t - e f f e c t i v e c a r e
efficient
l i n k a g e s and c r i t e r i a .
The d e s i g n a t i o n o f NHRCs w o u l d
complement t h e s e r v i c e s o f o t h e r r e g i o n a l r e f e r r a l
h o s p i t a l s and t h e i r p h y s i c i a n g r o u p p r a c t i c e s .
t h e i r h e a l t h care
teaching
This plan
would ensure t h a t these n a t i o n a l r e f e r r a l c e n t e r s
t h e i r services with the c r i t i c a l
through
also
coordinated
r o l e s o f t h e o t h e r p r o v i d e r s and
practitioners.
The n a t i o n ' s NHRCs cannot s u r v i v e as e q u a l members o f l o c a l
AHPs and p r o b a b l y
cannot s u r v i v e by f r e e - l a n c i n g o u t s i d e t h e AHP
system i n a f i n a n c i a l l y d r i v e n c o m p e t i t i v e scheme t h a t seeks t h e
cheapest care.
The s e r v i c e s t h a t r e q u i r e e x c l u s i v e NHRCs
d e s i g n a t i o n a r e r e l a t i v e l y r a r e and, t h u s , e a s i l y
during large population s t a t i s t i c a l
overlooked
analyses.
For p a t i e n t p r o t e c t i o n , i t i s i m p e r a t i v e t h a t AHPs be
r e q u i r e d t o a f f i l i a t e w i t h one o r more NHRCs t o p r e v e n t
a p p r o p r i a t e care o r performance o f substandard care.
develop c r i t e r i a
denial of
We must
f o r the appropriate r e f e r r a l of appropriate
p a t i e n t s , and f o r t h e a l l o c a t i o n o f r e s o u r c e s t o make NHRCs as
c o s t - e f f e c t i v e as p o s s i b l e .
S i m i l a r l y , we must p r o v i d e a
d e s c r i p t i o n o f t h e services t h a t should
be p r o v i d e d
a t community
h o s p i t a l s t o a v o i d unnecessary d u p l i c a t i o n o f s e r v i c e s .
�S N B : H SCH. O MED. ADMIN; 4-16-93 ;11:01AM ;
ET YJU
F
CLINICALPRACTiCE-^
912024566231;#15/18
The c r i t e r i a f o r d e s i g n a t i n g a r e a l i s t i c number o f NHRCs
would r e q u i r e some development.
I t would be reasonable t o begin
w i t h the l i s t o f the top twenty (20) r e s e a r c h - i n t e n s i v e medical
centers.
The top 20 research i n t e n s i v e i n s t i t u t i o n s , based upon
c o m p e t i t i v e , peer-reviewed NIH awards, p r o v i d e over one-half o f
the
f e d e r a l l y funded research and discovery i n the n a t i o n .
These
same c e n t e r s , r e p r e s e n t i n g only 16% o f a l l medical schools,
account f o r almost 40% of a l l academic medical c e n t e r p a t i e n t
care.
The congruence o f r e s e a r c h - i n t e n s i v e and h e a l t h care-
i n t e n s i v e centers i s o f t e n strengthened by programs i n a f f i l i a t e d
schools o f p u b l i c h e a l t h t h a t provide the e x p e r t i s e and
i n f r a s t r u c t u r e t o improve healthcare d e l i v e r y .
The 20 research
i n t e n s i v e i n s t i t u t i o n s are t h e r e f o r e the t o p 20 research and
h e a l t h c a r e i n t e n s i v e centers.
R e g i o n a l i z a t i o n of the s i c k e s t p a t i e n t s w i l l assure the best
p o s s i b l e outcomes f o r p a t i e n t s .
And NHRCs w i l l be "kept whole."
The NHRCs, i n t u r n , w i l l f o s t e r the research and d i s c o v e r y t h a t
i s needed t o assure a c o s t - e f f e c t i v e h e a l t h c a r e system.
Expensive d u p l i c a t i o n w i l l be avoided.
And, Americans w i l l have
access t o the best healthcare i n the w o r l d .
�SENT BY:JHU SCH. O MED. ADMIN; 4-16-93 ;ll:01AM ;
F
CLINICALPRACTICE-
912024566231;#16/18
WHAT ARE THE I S S U E S S P E C I F I C TO NHRCS?
WHAT S P E C I A L RECOGNITION SHOULD BE PROVIDED TO NHRCs?
•
Guaranteed Linkage:
Each managed care program each
Accountable Healthcare P a r t n e r s h i p (AHP), and a l l other
h e a l t h c a r e networks, must develop f o r m a l
referral
r e l a t i o n s h i p s w i t h one (or more) o f t h e N a t i o n a l
Healthcare
Resource Centers.
n a t i o n ' s focus f o r t e r t i a r y
•
Payments:
The NHRCs w i l l be t h i s
care.
Any g l o b a l budget or cost c o n t r o l s must be
designed t o accommodate t h e a t y p i c a l s e r v i c e s and
p a t i e n t s of the NHRC, through incremental payments t o
recognize s e v e r i t y , complexity, a d d i t i o n a l
resources^
teaching and research.
•
Medical C r i t e r i a
and Standards:
The basic b e n e f i t
package must cover the a p p r o p r i a t e treatment o f very
ill
patients.
Medical c r i t e r i a must be developed t o
assure t h e a p p r o p r i a t e u t i l i z a t i o n o f t h e N a t i o n a l
Healthcare Resource Center by d e l i n e a t i n g
those
s e r v i c e s and p a t i e n t c h a r a c t e r i s t i c s which describe
p a t i e n t s who must be d i r e c t e d t o t h e NHRC.
�SENT BY:JHU SCH. O MED. ADMIN; 4-16-93 ;11:02AM ;
F
CLINICALPRACTICE-
912024566231;#17/18
RECAP OF SAVINGS
1.
Reduction o f m u l t i p l e s i t e s o f d u p l i c a t e d
f a c i l i t i e s and services
2.
high-cost
(economies-of-scale).
Improved e x p e r t i s e and q u a l i t y o f care w i t h r e s u l t a n t
lower t o t a l c o s t s , and improved outcomes, when compared
w i t h t e r t i a r y care d e l i v e r e d i n community h o s p i t a l s on
an ad hoc basis.
This country does n o t need hundreds
of small l i v e r t r a n s p l a n t programs, i n s t i t u t i o n s must
not be allowed t o dabble i n t e r t i a r y
3.
care.
Removes t e r t i a r y costs from community s e t t i n g s ,
l o w e r i n g t h e i r r a t e s t r u c t u r e and keeping them focuseid
on community h e a l t h care.
4.
Make community s i t e s b e t t e r and more a p p r o p r i a t e
primary care t r a i n i n g l o c a t i o n s f o r medical
students
and housestaff.
5.
Evaluate outcomes, e f f e c t i v e n e s s , and p u b l i c h e a l t h
s e r v i c e s t o assure t h a t the most a p p r o p r i a t e
services
are provided a t the most a p p r o p r i a t e s i t e s by t h e most
a p p r o p r i a t e p r o f e s s i o n a l c a r e - g i v e r s , and a t t h e most
a p p r o p r i a t e time i n the course o f the h e a l t h c o n d i t i o n .
PAH
4-15-93
11
�iKNl" BY:JHU SCH. Q\r MtU. AUMINI 4 - l b - a 3
;li:U2AM
CLIINlCALrKACI ICt-
ai2U24566231;#18/18
TYPES OF MEDICAL SCHOOLS
Ranearch I n t e n s i v e (*Top 20)
(NIH Data)
Lor
jmbia
Duka
Einstein
Harvard
Johns H o p k i n s
New York U .
North Carolina
Pittsburgh
Rochester
Stanford
U. o f Chicago
U. o f M i c h i g a n
U. o f P e n n s y l v a n i a
U. o f M a a h l n g t o n
UCSF
UCSD
UCLA
Washington U n i v e r s i t y
Yale
Community Based ( 2 3 )
( S e l f - d e f i n e d by Dean)
G e n a r a l i s t P f o d u c a r g (Top gO)
(AAMC Data)
U. o f Washington
UCSF
Alabama-Birmingham
East C a r o l i n a
East Tennessee S t a t e
Eastern V i r g i n i a
Hawaii
Illinois
M a r s h a l l U.
MC o f Ohio
Mercer
Michigan Stata
Minnaaota-Duluth
Morehouse
Nevada
N o r t h Dakota
N o r t h e a s t e r n Ohio
South Dakota
Southern I l l i n o i a
SUNY a t Syracuse
Texas A & M
Texas Tech
U. o f South C a r o l i n a
WSBC
East C a r o l i n a
M a r s h a l l U.
Mercer
Michigan State
Morehouao
Nevada
Southern
Illinois
Virginia
Wright State
Wright State
Arkansas
Iowa
MC o f P e n n s y l v a n i a
Minnesota
* I n r e a l i t y , t h e 20 r e s e a r c h i n t e n s i v e
s c h o o l s a r e a l s o some o f t h e moat
healthcare intensive i n s t i t u t i o n s
in the nation.
Nebraska
Oregon
South Alabama
Texas - Houston
uc D a v i s
UC I r v i n e
12
�A PROFILE OF THE
"We
FUNDING BASE OF THE
ACADEMIC MEDICAL CENTERS
must a f f i r m t h e c e n t r a l r o l e o f r e s e a r c h and i n n o v a t i o n
i n our n a t i o n ' s e d u c a t i o n a l and t e c h n i c a l a c t i v i t i e s . "
statement
'This
i s p a r t i c u l a r l y t r u e i n the biomedical sciences
medical care.
The
and
academic m e d i c a l c e n t e r i s t h e source
of
knowledge, l e a d e r s h i p , and t h e t o o l s t o p r o v i d e i n n o v a t i v e , c o s t e f f e c t i v e h e a l t h care.
MEDICAL SCHOOL FUNDING: A BRIEF HISTORY
Through t h e f i r s t t h r e e decades o f t h i s c e n t u r y , f u n d i n g f o r
m e d i c a l e d u c a t i o n i n t h e U n i t e d S t a t e s was
endowment revenue, g i f t s , and s t a t e and
A f t e r World War
primarily
from
l o c a l government s u p p o r t .
I I , t h e p a r t n e r s h i p o f t h e academic m e d i c a l
c e n t e r and t h e F e d e r a l Government's N a t i o n a l I n s t i t u t e s o f H e a l t h
r e s u l t e d i n t h e f l o w e r i n g of b i o m e d i c a l knowledge d u r i n g t h e
x
5 0 s , 'SOs,
and
x
70s.
By 1960,
approximately one-half
medical schools d e r i v e d
(49.9%) of t h e i r revenue from g r a n t s
c o n t r a c t s , o f which t h e l a r g e s t source was
f o r research
and, w i t h i n r e s e a r c h , t h e g r e a t e s t subset was
r e s e a r c h a t 27.2%.
government a t 15.8%.
school of medicine,
total
The
(37.3%)
F e d e r a l Government
next l a r g e s t source was
The
and
s t a t e and
local
c l i n i c a l p r a c t i c e of the f a c u l t y of the
however u n d e r s t a t e d , i s r e c o r d e d as 3% o f
revenue.
1
C l i n t o n Campaign Promise
Johns Hopkins U n i v e r s i t y
School o f M e d i c i n e
Rev. 2/18/93
Page 1
�By 1981 t h e g r o w t h i n g r a n t s and c o n t r a c t s had n o t k e p t pace
w i t h t h e g r o w t h o f c l i n i c a l p r a c t i c e revenues.
contracts f e l l
Grants
from o n e - h a l f t o j u s t over o n e - t h i r d
t o t a l revenue.
The
(37.3%)
of
l a r g e s t segment c o n t i n u e d t o be r e s e a r c h , but
i t t o o grew more s l o w l y , and dropped from 37.3%
school of medicines'
revenues.
Government accounted
f o r o n l y 16.9%
1981, s t a t e and
and
t o o n l y 20.7%
of
W i t h i n research the Federal
o f t h e s c h o o l ' s revenue.
By
l o c a l government s u p p o r t had i n c r e a s e d from
a p p r o x i m a t e l y 16% t o 20.8%
and c l i n i c a l p r a c t i c e revenue zoomed
from 3% t o 15.7%.
The
academic medical center of today, the locus f o r t r a i n i n g
and d i s c o v e r y ,
now
earns
l e s s than one-quarter (24.6%) of i t s
revenue from grants and c o n t r a c t s .
f a l l e n p r e c i p i t o u s l y to only 12.9%
income to support t h e i r own
State appropriation
for a l l s c h o o l s .
s a l a r i e s and
31.6%
of a l l medical school revenue.
Faculty
the mission
school of medicine and academic medical center now
of
the
account f o r
Together with h o s p i t a l
reimbursements to the medical school, p a t i e n t care
account f o r 42.1%
has
sources
of a l l revenue.
I n t h e 1960s, w i t h h a l f o f a l l revenue coming from r e s e a r c h
s o u r c e s , t h e u n d e r p i n n i n g s of t h e s c h o o l o f m e d i c i n e
depended
upon r e s e a r c h i n g e n e r a l and t h e F e d e r a l Government i n
particular.
medical
Today, t h e u n d e r p i n n i n g o f t h e m e d i c a l s c h o o l i s
service.
Johns Hopkins U n i v e r s i t y
School of Medicine
Rev. 2/18/93
Page 2
�The c o n t r o v e r s y o v e r t h e c a l c u l a t i o n of
indirect cost
for
research grants highlight
the r e a l i t y t h a t r e s e a r c h c a r r i e s a
structural deficit
is,
surpluses
- that
i n other endeavors.
p r a c t i c e and i n s t i t u t i o n a l
intensive
schools
i t must be s u b s i d i z e d from
Only s u r p l u s e s from c l i n i c a l
endowment
f u n d s a l l o w t h e 20 r e s e a r c h -
to r e m a i n i n t h e r e s e a r c h and e d u c a t i o n
game.
MEDICAL SCHOOLS - DISTINCTIONS THAT MAKE A DIFFERENCE
Most comparisons
of medical schools
highlight
d i f f e r e n c e s b e t w e e n p u b l i c and p r i v a t e s c h o o l s .
slowing,
or o f t e n absolute
increase
in clinical
medical
schools
reduction in state
practice
a p p e a r more s i m i l a r .
and i t s
the goals
the
funding,
and
the
private
B u t , as we d i s c u s s
the
i t may be more f r u i t f u l
and m i s s i o n s o f t h e a c a d e m i c
school of medicine,
With
i n c o m e , many p u b l i c and
r e f o r m o f the h e a l t h care system,
evaluate
the
medical
to
center
vis-a-vis:
1) R e s e a r c h - I n t e n s i v e
2)
Less
3)
Community P r a c t i c e
Schools
Research-Intensive
Base
Schools
2
2
O u r p r e l i m i n a r y r e s e a r c h on t h e s e t h r e e s u b s e t s o f s c h o o l s has b e e n
e x p a n d e d by P a u l J o l l y , e t . a l . a t , t h e AAMC.
The AAMC has d e v e l o p e d a
l i s t o f t h e t o p 20 s c h o o l s , a c c o r d i n g t o t h e amount o f r e s e a r c h g r a n t s .
A second group o f 20, which produced t h e h i g h e s t p r o p o r t i o n o f p r i m a r y
care physicians.
A n o t h e r g r o u p o f 23 s e l f - i d e n t i f i e d c o m m u n i t y - b a s e d
s c h o o l s and t w o o r t h r e e o t h e r .
We t o o k a s l i g h t l y d i f f e r e n t t a c k :
Our r e s e a r c h u t i l i z i n g t h e 1992 AAMC
I n s t i t u t i o n a l G o a l s R a n k i n g R e p o r t l i s t s r e s e a r c h - i n t e n s i v e as s c h o o l s
r a n k i n g 1 - 20.
We s u g g e s t t h a t a p r o x y f o r t h e " b a l a n c e d s c h o o l s " w e r e
t h e m i d p o i n t s c h o o l s r a n k i n g 51 - 70 and a p r o x y f o r t h e c o m m u n i t y - b a s e d
s c h o o l s a r e s c h o o l s numbered 101 - 1 2 0 , o u t o f a t o t a l o f 126 m e d i c a l
schools.
Johns H o p k i n s U n i v e r s i t y
School o f Medicine
Rev. 2 / 1 8 / 9 3
Page 3
�M e d i c a l s c h o o l s conceived a l o n g t h i s continuum
one a n o t h e r i n many ways.
differ
from
Since we used r e s e a r c h f u n d i n g as t h e
d i s c r i m i n a t o r , as one would expect, t h e most
significant
d i f f e r e n c e i s t h e i r performance
The
i n research.
research
i n t e n s i v e s c h o o l s average $130 m i l l i o n o f r e s e a r c h each.
Of t h e
20 l e s s r e s e a r c h - o r i e n t e d s c h o o l s i n t h e sample, each g a r n e r e d
average o f o n l y $20 m i l l i o n of r e s e a r c h .
The
an
sample o f s c h o o l s
numbered 101 - 120, p r o x i e d as t h e community-based s c h o o l s ,
averaged o n l y $3 m i l l i o n
The m a j o r i t y
i n research.
(50.53%) of r e s e a r c h d o l l a r s was
twenty (20) r e s e a r c h - i n t e n s i v e schools.
s c a l e be e x p l o i t e d to sequester
h a l f ? , one-third?)
One
of medical
earned by
Should economies of
r e s e a r c h i n only a f r a c t i o n
(one-
schools?
m i g h t assume t h a t t h e c l i n i c a l p r a c t i c e r a t i o would
be
h e a v i l y w e i g h t e d towards t h e community-based s c h o o l s : That t h e
community p r a c t i c e and l e s s r e s e a r c h - i n t e n s i v e s c h o o l s p r o v i d e a
l a r g e amount o f c l i n i c a l p r a c t i c e , w h i l e t h e r e s e a r c h s c h o o l s ,
c o n t e n t w i t h r e s e a r c h , would p r o v i d e p r o p o r t i o n a t e l y l e s s .
d a t a shows o t h e r w i s e .
The
research schools, w h i l e generating
l e s s revenue from c l i n i c a l p r a c t i c e t h a n from t h e i r
sources
still
The
research
e n j o y a r e l a t i v e advantage o f 40% more c l i n i c a l
p r a c t i c e revenue t h a n t h e l e s s r e s e a r c h - i n t e n s i v e s c h o o l sample.
That i s , t h e r e s e a r c h - i n t e n s i v e c o l l e c t e d almost $89 m i l l i o n i n
c l i n i c a l p r a c t i c e revenue vs. t h e 20 l e s s r e s e a r c h - i n t e n s i v e
s c h o o l s which o n l y c o l l e c t e d $55 m i l l i o n .
The
community-based
s c h o o l s c o l l e c t e d f a r l e s s , o n l y $18 m i l l i o n a t each s c h o o l .
Johns Hopkins U n i v e r s i t y
School of Medicine
Rev. 2/18/93
Page 4
�I t m i g h t be f a i r t o h y p o t h e s i z e
school's
p r a c t i c e i s weighted
care.
research-oriented
tertiary
toward
the less r e s e a r c h - i n t e n s i v e schools
care b u t , s t i l l ,
t h a t the
and s p e c i a l t y c a r e ,
l i k e l y p r o v i d e more p r i m a r y
a l s o a f a i r amount o f t e r t i a r y
and s p e c i a l t y
F i n a l l y , t h e community-based s c h o o l s , a v e r a g i n g
m i l l i o n per s c h o o l , p r o b a b l y
only
$18
r e f l e c t s l i m i t e d access t o t e a c h i n g
h o s p i t a l f a c i l i t i e s and t h e p r o v i s i o n o f p r i m a r i l y s p e c i a l t y and
primary
care.
What k i n d s of p a t i e n t s are t r e a t e d a t academic
centers?
Medicaid
At Hopkins, a r e s e a r c h - i n t e n s i v e s c h o o l , 13%
are
( M e d i c a l A s s i s t a n c e ) , 26% are Medicare, 14% s e l f - p a y ,
36% Blue S h i e l d and o t h e r commercial i n s u r a n c e ,
and
which i n c l u d e s HMOs, worker's compensation, e t c .
third,
medical
39%,
are g o v e r n m e n t a l l y
funded.
I f we
11% o t h e r ,
More t h a n
i n c l u d e 11%
one-
bad
d e b t s f o r s e l f - p a y poor p a t i e n t s , we are l e f t w i t h o n l y 53%
r e l a t i v e l y f u l l paying,
i . e . , insured p a t i e n t s .
Net p h y s i c i a n income a t m e d i c a l
schools
uncompensated c a r e , c o n t r a c t u a l a d j u s t m e n t s
Medicaid
programs, f e e r e d u c t i o n s due
and bad d e b t s .
as
i s tempered by
f o r t h e Medicare
to accepting
assignment,
I t i s common f o r a s c h o o l t o c o l l e c t o n l y
h a l f o f t h e p r o f e s s i o n a l fees b i l l e d .
Thus, one
and
should
one-
mentally
double t h e c l i n i c a l p r a c t i c e revenue f i g u r e s t o observe t h e
amount o f m e d i c a l
medical
s e r v i c e s rendered
t o p a t i e n t s a t academic
centers.
Johns Hopkins U n i v e r s i t y
School of M e d i c i n e
Rev. 2/18/93
Page 5
�The c o l l e c t i o n r a t e f o r t h e t w e n t y
research-intensive
s c h o o l s i s n o t a v a i l a b l e , b u t i t i s l i k e l y t o be s i m i l a r t o Johns
Hopkins, t h a t i s l e s s t h a n 60% o f charges.
billed
by Johns Hopkins, o n l y 56 c e n t s
For e v e r y d o l l a r
i s collected.
The r e s t i s
written off.
EDUCATIONAL REVENUES
Although, r e s e a r c h - i n t e n s i v e
research
schools provide the m a j o r i t y of
and over one-quarter of the c l i n i c a l p r a c t i c e provided
by a l l schools of medicine, they s t i l l meet t h e i r s o c i e t a l
mission through t r a i n i n g a l a r g e r number of medical students,
graduate students, and h o u s e s t a f f .
Research i n t e n s i v e s c h o o l s a r e t w i c e (215%) t h e s i z e , by
t o t a l revenue, o f t h e average m e d i c a l s c h o o l .
T u i t i o n and fees
d i f f e r g r e a t l y : t h e r e s e a r c h - i n t e n s i v e s c h o o l on average
twice
receives
(218%) t h e t u i t i o n and fees o f t h e average s c h o o l .
Yearly
endowment income i s a l s o s i g n i f i c a n t l y d i f f e r e n t , w i t h a l l
s c h o o l s r e c e i v i n g l e s s than $1 m i l l i o n , b u t t h e r e s e a r c h i n t e n s i v e r e c e i v i n g over $7 m i l l i o n .
Reversing t h i s r a t i o , i s
s t a t e and l o c a l government a p p r o p r i a t i o n s , where a l l s c h o o l s
r e c e i v e over $15 m i l l i o n on average, w h i l e t h e r e s e a r c h - i n t e n s i v e
s c h o o l s o n l y r e c e i v e $1.6 m i l l i o n .
t u i t i o n and f e e s ,
I f one adds t o g e t h e r (a)
(b) endowment income, and ( c ) s t a t e and l o c a l
government a p p r o p r i a t i o n s , we dampen t h e d i s s i m i l a r i t i e s , and
heighten
the s i m i l a r i t i e s .
A l l s c h o o l s average a t o t a l o f $21.2
m i l l i o n and r e s e a r c h - i n t e n s i v e s c h o o l s average $19.8 m i l l i o n .
Johns Hopkins U n i v e r s i t y
School o f Medicine
Rev. 2/18/93
Page 6
�Thus,
[
of
while research-intensive
money f r o m t u i t i o n
schools
receive
schools
earn
and endowment i n c o m e , t h e g r o u p o f a l l
f a r greater
public
support.
Not s u r p r i s i n g l y , r e s e a r c h - i n t e n s i v e
larger
a s i g n i f i c a n t amount
i n t h e i r complement o f b a s i c
schools
science
faculty,
f a c u l t y on a v e r a g e v s .
a l l schools
faculty.
the research-intensive
twice
Furthermore,
(219%) t h e number o f c l i n i c a l
are
slightly
with
h a v i n g 80 b a s i c
117
science
schools
f a c u l t y as a l l
have
over
schools.
Even though t u i t i o n and f e e s a c c o u n t f o r o n l y about 3% of
research-intensive schools'
do not s l i g h t
revenues,
research-intensive
their educational mission.
506 m e d i c a l s t u d e n t s
on a v e r a g e ,
While a l l schools
the r e s e a r c h - i n t e n s i v e
have s l i g h t l y more
(118%)
o r 599 s t u d e n t s .
schools
(246%)
t h e number of g r a d u a t e
have t w i c e
s l i g h t l y more
It
not t h e
is
(141%)
amount
but,
(26.87%)
also,
of
schools
Research-intensive
research schools
(1)
students,
a l l medical schools
(15.87% of
a r e not m e r e l y t h e backbone of our b i o t e c h n o l o g y
over h a l f )
have
housestaff.
c l e a r from t h e s e d a t a t h a t
same and (2)
schools
the
126
research
are
schools)
(i.e.,
the s o u r c e of an e x t r a o r d i n a r i l y l a r g e
clinical
practice'.
'Among t h e t w e n t y r e s e a r c h - i n t e n s i v e s c h o o l s t h e amount o f p r a c t i c e i s
i d e n t i c a l b e t w e e n p u b l i c and p r i v a t e .
The s i x p u b l i c s c h o o l s a v e r a g e d
$ 8 8 . 5 6 m i l l i o n o f c l i n i c a l p r a c t i c e c o l l e c t i o n s and t h e p r i v a t e s c h o o l s
averaged $88.67 m i l l i o n i n c o l l e c t i o n s .
The s a m p l e o f p r i v a t e s c h o o l s
w i t h i n t h e " l e s s r e s e a r c h - i n t e n s i v e s c h o o l " s a m p l e showed more c l i n i c a l
income per s c h o o l a t t h e p r i v a t e l y f u n d e d s c h o o l s .
Johns Hopkins U n i v e r s i t y
School of Medicine
Rev. 2 / 1 8 / 9 3
Page 7
�A NOTE ON THE CRITICAL ROLE OF TEACHING HOSPITALS
The
287 AAMC C o u n c i l o f Teaching
H o s p i t a l (COTH) members,
representing the large teaching h o s p i t a l s i n the United States,
c o n s t i t u t e 6% o f a l l h o s p i t a l s but 26% o f g r o s s p a t i e n t
revenue.
At t h e same t i m e , t h e COTH members absorb 28% o f a l l m e d i c a l bad
debt expense and 50% o f a l l c h a r i t y c a r e .
Academic m e d i c a l
c e n t e r s , t h r o u g h t h e 287 COTH h o s p i t a l s , have p r o v i d e d a c r u c i a l
s e r v i c e t o s o c i e t y i n c a r i n g f o r t h e poor, t h e u n i n s u r e d , and t h e
underinsured.
A subset of the 287 COTH h o s p i t a l s , the 120 major
teaching
h o s p i t a l s located w i t h i n academic medical c e n t e r s w r i t e - o f f , a s
c h a r i t y c a r e , an average of $17.5 m i l l i o n / y e a r and have an
average bad debt expense of an a d d i t i o n a l $12.7 m i l l i o n .
Through the medical school curriculum
and
and h o s p i t a l
residency
f e l l o w s h i p programs, the academic medical center t r a i n s the
p h y s i c i a n s of tomorrow.
The medical school and the teaching
h o s p i t a l , along with other h e a l t h p r o f e s s i o n a l t r a i n i n g programs,
make the academic medical center the locus f o r progress i n
medicine and h e a l t h .
The r e s u l t i s the t r a n s f e r of q u a l i t y
medicine from the laboratory
bench to the bedside.
The
preeminence of American medicine i s based on s u s t a i n i n g
extraordinary
c e n t e r s of l e a r n i n g and c a r e .
these
However, without the
I n d i r e c t Medical Education (IME) or D i r e c t Medical Education
(DME)
adjustment f a c t o r s or some other support f o r the s o c i e t a l
Johns Hopkins U n i v e r s i t y
School o f Medicine
Rev. 2/18/93
Page 8
�s e r v i c e s o f Academic M e d i c a l C e n t e r s , t h e t e a c h i n g h o s p i t a l ' s
survival i s i nquestion.
(See Tabs 2 & 3 f o r d i s c u s s i o n o f
i m p l i c a t i o n s f o r graduate medical education.)
THE ACADEMIC MEDICAL CENTER AND HEALTH SERVICES RESEARCH
P r o p o s a l s f o r r e f o r m o f t h e h e a l t h c a r e system a r e o f t e n
framed i n terms o f c o s t c o n t a i n m e n t .
However, t o e n j o y an
e f f e c t i v e h e a l t h care system we must i n c r e a s e c o s t e f f e c t i v e n e s s ,
n o t m e r e l y decrease e x p e n d i t u r e s .
The academic m e d i c a l c e n t e r
has been t h e source o f an e x t r a o r d i n a r y a r r a y o f advances i n t h e
t e c h n o l o g y and b i o l o g y o f m e d i c i n e .
We can r e a d i l y a p p r e c i a t e
t h e m e d i c a l b e n e f i t s d e r i v e d from t h e s e advances, b u t we must
a l s o n o t e t h e i r c o n t r i b u t i o n t o h e a l t h care c o s t s .
Through h e a l t h s e r v i c e s r e s e a r c h , t h e academic m e d i c a l
c e n t e r has t h e c a p a c i t y t o f i n d c o s t e f f e c t i v e s o l u t i o n s t o
technologically driven health costs.
Reformers
and r e s e a r c h e r s
t o g e t h e r must develop t h e t o o l s f o r b e t t e r m e d i c a l d e c i s i o n
making, a p p r o p r i a t e n e s s r e v i e w , outcome r e s e a r c h , q u a l i t y
assurance, and t h e o r g a n i z a t i o n o r r e o r g a n i z a t i o n o f m e d i c a l
care.
Johns Hopkins U n i v e r s i t y
School o f M e d i c i n e
Rev. 2/18/93
Page 9
�table 1
aamc data 1990-91, types of schools
Note 1
research intensive
sample #
1-20
Public
research
clinical practice
ratio, research:practice
average research/school
average practice/school
Private
research
clinical practice
ratio, research:practice
average research/school
average practice/school
Note 2
Note 3
community-based
sample #
101-120
SAMPLE TOTALS
sample #
51-70
6
$594,975,471
$531,878,416
1.12
$99,162,579
$88,646,403
15
$294,525,154
$744,286,463
0.40
$19,635,010
$49,619,098
13
$40,984,422
$166,319,504
0.25
$3,152,648
$12,793,808
34 ... the 34 public schools account for
$930,485,047
22.78% of all research
$1,442,484,383
21.86% of all clinical practice.
14
5
$107,347,134
$355,830,816
0.30
$21,469,427
$71,166,163
7
$23,112,773
$196,615,733
0.12
$3,301,825
$28,087,962
26 ... the 26 private schools account for
39.16% of all research
$1,599,302,658
27.18% of all clinical practice.
$1,793,801,023
$1,468,842,751
$1,241,354,474
1.18
$104,917,339
$88,668,177
ALL SCHOOLS
Total
research
clinical practice
proportion of schools in each sample
proportion of research in each sample
proportion of practice in each sample
average research/school
average practice/school
ratio, research:practice
Notes
20
$2,063,818,222
$1,773,232,890
15.87%
50.53%
26.87%
$103,190,911
100%
$88,661,645
100%
116%
20
$401,872,288
$1,100,117,279
15.87%
9.84%
16.67%
$20,093,614
19%
100%
$55,005,864
62%
100%
20
$64,097,195
$362,935,237
15.87%
1.57%
5.50%
$3,204,860
37%
18%
16%
$18,146,762
Note 4:
60
$2,529,787,705
$3,236,285,406
126
$4,084,000,000
$6,600,000,000
47.62%
61.94%
49.03%
$42,163,128
$32,412,698
$53,938,090
$52,380,952
33%
78%
62%
PAH
18-Feb-93
�notes to table 1
note #7:
On a list of medical schools ranked by funded research,
schools numbered 1 -20 are research oriented — and the 20 average $103 million of research each.
Practice income is almost $89 million each. Practice, we suggest is weighted toward tertiary & specialty.
note #2:
Less research-intensive schools are proxied as numbers 51-70. These 20 schools have $55 million of practice income
vs. only $20 million of research. Practice is more balanced, but in dollars is likely to be primarily tertiary & specialty.
note #3:
The community schools — numbers 100-120 — [I omitted the last 6 to avoid
incomplete data] — do little practice and even less research. And, their practice is almost entirely primary with a little specialty.
These schools attract very little NIH money ($3 million each) and relatively little clinical income, i.e. averaging $18 million each.
note #4:
The three percentages describe the sample, vs. the entire 126 schools. The 60 schools represent 47.62% of the schools and 61.94% of the research.
note #5:
This ratio, research:practice shows the relative strength of research. For research-intensive schools research is 116% of practice;
The data in the upper portion of the table shows 112% for public and 118% for private schools.
PH
A
is-F.b-M
�table 2
aamc Golly et. al.) paper data
Median total revenue
Tuition & Fees
Endowments Income
State & Local Gov't Appropriations
TOTAL, 3 above
All schools
$143,023,000
100%
$5,092,000
$833,000
$15,295,000
$21,220,000
4%
1%
11%
15%
Research Intensive
$308,123,000
$11,120,000
$7,096,000
$1,601,000
$19,817,000
100%
ratio
2.15
4%
2%
1%
6%
2.18
8.52
0.10
0.93
Faculty
- basic science
- clinical science
80
426
117
934
1.46
2.19
Medical Students
Graduate Strudents
Housestaff
506
114
420
599
281
592
1.18
2.46
1.41
PAH
18-F9b-93
�table 3a
research-intensive schools, i.e. #1 thru #20 on top research funding list
public
private
michigan
n Carolina
u of Washington
ucla
uc san diego
uc san francisco
small town
small town
baylor
Columbia
duke
small town
einstein
harvard
jhu
new york university
u of penn
Pittsburgh
rochester
Stanford
small town
u of Chicago
Washington u
yale
large city
very large city
large city
large city
large city
very large city
very large city
large city
large city
very large city
very large city
large city
large city
very large city
large city
large city
PAH
18-F«b-93
�iXfJSS OF MEDICAL SCHOOLS
Pesearch I n t e n s i v e (*Top 20)
(NIH Data)
Baylor
Columbia
Duke
Einstein
Harvard
}hns Hopkins
.ew York U.
North Carolina
Pittsburgh
Rochester
Stanford
U. o f Chicago
U. o f M i c h i g a n
U. o f P e n n s y l v a n i a
U. o f Washington
UCSF
UCSD
UCLA
Washington U n i v e r s i t y
Yale
Community Based ( 2 3 )
( S e l f - d e f i n e d by Dean)
G e n e r a l i s t P r o d u c e r s (Top 20)
(AAMC Data)
U. o f Washington
UCSF
Alabama-Birmingham
East C a r o l i n a
East Tennessee S t a t e
Eastern V i r g i n i a
Hawaii
Illinois
M a r s h a l l U.
MC o f Ohio
Mercer
Michigan State
Minnesota-Duluth
Morehouse
Nevada
N o r t h Dakota
N o r t h e a s t e r n Ohio
South Dakota
Southern I l l i n o i s
SUNY a t Syracuse
Texas A S M
Texas Tech
U. o f South C a r o l i n a
West V i r g i n i a
Wright State
* I n r e a l i t y , t h e 20 r e s e a r c h i n t e n s i v e
s c h o o l s a r e a l s o some o f t h e most
health care intensive i n s t i t u t i o n s
in the nation.
East C a r o l i n a
M a r s h a l l U.
Mercer
Michigan State
Morehouse
Nevada
Southern
Illinois
Wright State
Arkansas
Iowa
MC o f P e n n s y l v a n i a
Minnesota
Nebraska
Oregon
South Alabama
Texas - Houston
UC D a v i s
UC I r v i n e
�T E M P L E UNIVERSITY
A Commonwealth University
Health Sciences Center
Philadelphia, Pennsylvania 19140
Office of the Vice President
for the Health Sciences Center
April 16, 1 9 9 3
Elizabeth M. Short, M.D.
Associate Chief of Medicine
Director for Veteran Affairs
8 1 0 Vermont Avenue, N.W.
4 6 6 Tech
Washington, D.C. 2 0 4 2 0
Dear Dr. Short:
On behalf of Temple University allow me to take this opportunity to express my
gratitude for the privilege of presenting Temple's views on healthcare reform. I found this
most recent meeting to be quite informative and reassuring. The forum permitted us to
reach a mutual understanding of our common interest in the concept of equal access to
our healthcare system, and the need to maintain strong academic health centers for their
clinical roles as tertiary care institutions and for some, as safety net hospitals, while
assuring their continued viability as center of clinical investigation and education. A t the
request of Mr. Magaziner I have summarized my discussion points on the needs of the
academic medical center and graduate medical education funding.
Academic medical centers as a group provide the best tertiary and quaternary care
available in the United States. In many areas these same centers are located in the inner
city and form a critical safety net for those people that are not able to access mainstream
healthcare. The continuation of the additional supports for disproportionate share and
indirect medical education are necessary to preserve the financial viability of the academic
The cost of treating indigent patients is, and will continue to be, more expensive
than the cost of treating more affluent patients. Universal access does not address the
problems associated with the need to educate the population about primary and
preventive care. Moreover, significant outreach efforts will be necessary to encourage
people to seek timely and preventive care. For example, 6 0 % of the children in Temple's
immediate service areas are born to high risk mothers, despite the fact that Temple
provides free pre and post-natal care including transportation. In our immediate service
area the infant mortality rate is 19.6 per thousand and 9 3 % of the free care patients are
admitted as emergency admissions. A t Temple fully 8 0 % o f the indigent patients require
nutritional intervention along w i t h their clinical treatments. Reducing the cost of treating
the indigent will only be accomplished through the availability of employment, adequate
housing, a lessening of urban violence, and substance abuse, and education regarding the
importance of preventive care and prompt care for illness or injury.
�Even under the proposed universal access system, free care will continue to exist at the inner
city academic medical centers. In many impoverished urban areas there exists a segment of the
population who simply will not cooperate with the process necessary to obtain medical assistance
coverage. Disproportionate Share and Indirect Medical Education provide a funding source for this
free care and address the inequities faced by the institutions which treat the more complicated
illnesses of the poor, and bear the burden of the extraordinary costs of effective tertiary care.
Academic medical centers through their clinical investigation provide new advances in the
treatment of illnesses. Innovations that reduce both patient risk and treatment cost, such as
laproscopic surgery, must be pursued. This will only occur if research is supported by the Federal
Government, as Medicaid, HMO's, HIO's and alternate care systems do not address these costs in
the competitive marketplace.
Medical Education must be supported if we are to train tomorrow's doctors and not destroy
the delicate safety net of care in the inner city. Urban violence and the sometimes poor health
condition of the community require the presence of highly trained specialists in such areas as
neurosurgery, orthopedics, and cardiology. This is particularly true in the case of violent trauma. If
Medical Education funding is lessened as proposed under the President's budget, the inner city will
experience a flight of resident physicians seeking specialist training to the suburbs, where the cost
of the training can be funded through development efforts and profits from private patients. Such
a policy shift will have, as an unintended consequence, an adverse impact on the access to care in
the inner city. Equally important, it will not appreciably increase the number of primary care
physicians.
To increase the number of medical students selecting careers in primary care, we must
improve their earning potential compared with specialties and we must lessen their debt burden
from Medical School. At Temple, students graduate medical school with an average of $70,000 in
debt, with minority students accumulating an average of $94,000. A possible alternative would be
to forgive the principal amount of their debt at the end of their fifth year of practice as a primary
care physician. During the five years the physician would be required to pay the interest on the
debt. For minority or financially disadvantaged students, scholarships could be offered contingent
upon their agreement to practice as primary care physicians for the same five year period. Were
the student not to fulfill the practice portion of the contract, then the "scholarship" would convert
to a debt.
In closing, I would again extend my appreciation for the privilege of sharing my concerns in
regard to the future of the academic medical center. I can be reached at 215-221-4638.
Sincerely,
_eon S. Malmud, M.D^
Herbert M. Stauffer Professor of Diagnostic Imaging
Vice President, Health Sciences Center
Chief Executive Officer, Temple University Hospital
LSM:dc
cc:
Charlotte Hayes
�The University of Kansas Medical Center
Office of the Executive Vice Chancellor
April 16. 1993
Ira Magaziner
Old Executive Office Building
Room 216
Washington, DC 20500
Dear Ira:
Thank you for asking for my draft recommendations regarding the key problems we
discussed in our April 14th meeting. Once again, let me say how much I appreciate your
time and that of your staff in looking into the specific problems facing academic health
centers. I for one, and I am certain the majority of my colleagues, will be very supportive
of the directions the program is headed and anxious to be active players in improving the
accessibility and effectiveness of the health care delivery system in this country.
Most sincerely,
D. Kay Clawson, M.D.
Executive Vice Chancellor
DKCrmm
3901 Rainbow Blvd.. Kansas City, Knnsas 66160-7100 • (913) 588-1400
�Apr- 16,1993
02:00PM
FROM
TO
p_
ISSUES:
The continuedfiscalviability of medical schools and academic health centers under
managed care proposals.
The need to produce more primary care physicians (and other primary health
providers) and fewer tertiary specialists.
PROBLEM:
Medical schools and academic health centers fund many educational endeavors with
cost shifting mechanisms, most recently in the utilization of physician practice plans.
Academic medical center faculty are traditionally in the high income producing
specialties, which results in a disproportionate number of specialists in these fields.
While this trend is, indeed, contradictory to educational needs, it is an effective
mechanism of providing funding for academic programs.
PROPOSAL:
To provide incentives for medical schools to hire more primary care physicians, to
put more emphasis on primary care curriculum and to produce a higher proportion
of primary care physicians, I would recommend:
A.
Target all schools for 50% of their graduates entering primary care training
programs, excluding M.D./Ph.D. students from the calculation. Those schools
who achieve that level would receive program funding support, which would
allow them to experiment with different primary care education models. JL
would recommend that the formula be:
No. of students
enrolled
B.
X
% entering primary
care residency programs
X
$
(This figure should
be between $3,000$5,000 la order
to be meaningful)
For those schools not meeting the 50% threshold, they could be eligible for
participation if in each successive year, they increase their output by 5% from
the base year and each succeeding year until they reach 50%. Their formula
should then be:
No. of students
enrolled
X
% entering primary
care residency programs
the previous year
$
X
This would serve as an incentive for all schools to strive to meet the 50%
goal. Although some of the traditional research schools might have difficulty,
they would have an opportunity to participate in addressing a national need,
as well as having an advantage of access to more research funds with which
to cross-subsidLze their programs.
Q 4
�Hpr 16,1993 02:01PM
C.
FO
RM
TO
P.05
We are now recognizing the serious dearth of clinical investigators and
medical school faculty who have had research training and are capable of
conducting their research and producing the physicians and physical scientists
of the future. To protect this small group and hopefully increase its numbers,
the following is recommended:
1.
Individuals pursuing the academic tract and a combined M.D/Ph.D.
degree would not be counted in the school's percentage of students
entering primary care.
2.
Individuals could enter the National Health Service Corp with an
understanding of service as a full-time faculty member in a medical
school. They would be expected to divert 50% or more of their efforts
to clinical research and research training after graduation. An average
of one full day per week would be devoted to indigent care at the
university or in the inner-city, to migrant health care or some other
service provided to the underprivileged.
SOLUnON:
•
While academic health centers must become more cost effective, proficient providers
of care, it must be recognized that their existence is a national resource. They have
to have patients for teaching and research, as well as thefinancialsupport to operate.
Any legislation must acknowledge this need. It should be specifically stated that the
State Health Alliances must take into consideration the need to maintain the medical
school and the teaching environment within that Alliance's jurisdiction. There should
be a specific charge to work with the medical schools to ensure their viability while
meeting the requirements of managed care.
April 16, 1993
D. Kay Clawson, M.D.
University of Kansas Medical Center
�UNIVERSITY OF
PENNSYLVANIA
MEDICAL CENTER
University of Pennsylvania School of Medicine
Hospital of the University of Pennsylvania
21 Penn Tower
Philadelphia. PA 19104^055
Tel: (215) 898-5181
Fax: (215) 89&-5607
William N. Kelley, M.D.
Chief Executive Officer
Executive Vice President, University of Pennsylvania
Dean, School of Medicine
Roben G. Dunlop Professor of
Medidne and Biochemistry and Biophysics
April 16, 1993
Mr. Ira Magaziner
Senior Advisor for Policy Development
Executive Office of the President
Room 216 Old Executive Office Building
Washington, DC 20500
Dear Ira:
In follow-up to Wednesday's meeting, I wantedtoprovide my thoughts on several key
questionsrelatedto academic health centers (AHCs) that must be addressed in a reformed health
system.
Simply defined, an academic health center is a complex composed of a school of
medicine and a teaching hospital with fiilly developed programs in quaternary and tertiary care.
They are theflagshipsof the American health care system, serving as the nexus of medical
education, biomedical, behavioral, and health services research, as well as patient care. In
addition to their role as educators of our nation's physicians, AHCs are at the core of this
nation's biomedical and behavioral research enterprise. They are at the cutting edge in terms
of the understanding and treatment of disease, and the translation of this knowledgefromthe
bench to the bedside. They also serve as providers of care to the most seriously ill patients,
and, because they are typically located in urban areas, are the major providers of care to the
nation's indigent.
As we discussed, the pure managed competition model couldrepresenta serious threat
to the continuedfinancialviability of these institutions as well as their ability to attract patients
critical to both their education andresearchmissions. Owing to their unique and multi-faceted
missions, it will be difficult for them to compete with institutions whose sole or principal
mission is patient care. Certain protections must be built into thereformedhealth system if we
are to preserve and strengthen these critical components of our health care system.
Our meeting on Wednesday touched on many of the issues critical to the future of AHCs
and I would liketoaddress each of these in turn.
�fiPR-16-1993
21=38
FROM UPMC/CPUP E JOHN BLACK
TO
912024567739
P.03
Mr. Ira Magaziner
April 16, 1993
Page 2
n
Support for CT' 'f?I Tnyestigators
A number of variables in the current health care environment make the pursuit of clinical
investigation relatively unattractive for today's medical student. They include, but are not
limited to, the prolonged period of clinical training required by our medical graduates and the
impact of accumulating debt burden on career choice. While there has been debate regarding
the adequacy of the current supply of clinical researchers, there is little doubt that the need for
these health care professionals will be particularly acute in the years ahead. Major advances
in molecular biology, medicine, and medical informatics will create a substantial need for more
expertise, particularly fully-trained physicians and other health professionals, in academia,
industry, and government service, to transform these discoveries into cost-effective treatments
for human disease.
Implementation of the managed competition framework will make it difficult for AHCs
to meet this critical human resources need. The need to be cost-competitive with providers that
do not serve a medical education and research mission, will limit the ability of AHCstoprovide
the necessary support for this career track. Moreover, as the number of specialists decline, so
too will the pool of individuals pursuing clinicalresearch.Alternative mechanisms will be
required, therefore, if we are to meet the need for clinical investigators and be positioned to
take full advantage of the opportunities which recent advances in biomedical research present.
One option for addressing this problem is development of a loan forgiveness program,
along the lines of the National Health Service Corps, for individuals who choose clinical
research as a career choice. Like the current situation for the primary care physician, the
physician scientist typically faces huge medical education debts and a modest level of
compensationrelativetoother potential career options. Unlike the primary care physician,
however, there is little reasontobelieve this will improve. One way to change this disincentive
is through a loan forgiveness, or tuition payment program, whereby students agree to serve as
clinicalresearchersfor a specified period of time. A loan forgiveness program has recently
been put in place for intramural AIDSresearchersat the National Institute of Allergy and
Infectious Diseases. Similar programs for clinical investigators in the extramural research
community should likewise be supported.
Given limitedresourcesat the national level, the Federal government may needtolook
beyond the Congressional appropriations processtofund this and other potential initiatives in
this area. There are many sectors, in addition to the Federal government and academic
medicine, that have a substantial stake in the supply of well-trained, clinical investigators. They
include the health and life insurance industries as well as health-related foundations with a
disease-specific interest. A partnership of these groups, led by the Federal government, may
serve as a catalyst for additional support for initiatives in dinical research.
�Mr. Ira Magaziner
April 16, 1993
Page 3
Sustaining AHCs as Centers For Quaternary and Tertiary Care
AHCs serve as referral centers for the most seriously ill patients and the locus for state
of the ait clinical care. There are several reasons for sustaining the role of an AHC as a center
for quaternary/tertiary care and other specialized health services. AHCs serve as the incubators
for new health care technologies andrepresenta natural environment for monitoring and
refining new methods of treatment. Such referrals also are key to a medical school's ability to
fulfill its educational mission of training the next generation of physicians in the most up-to-date
methods of clinical care. However, given theresourcesdevoted to medical education and the
research infrastmcture, AHCs will be hard-pressed to compete on the basis of price alone for
these quaternary/tertiary services unless certain adjustments are made in the managed
competition framework.
I strongly support your position that there is a need to carve out those costs unique to
AHCs and providereimbursementfor these expenses through a separate income stream funded
by all payers. This, in effect, would "level the playing field" so that AHCs could fairly
compete on the basis of quality and price. There are several proposals on the table that would
institute such a system to reimburse AHCs for the cost of graduate medical education. If such
a mechanism is adopted, I would urge that the level of payments for GME recognize all the
costs involved in graduate training, includingresidents'stipends and benefits, salaries and
benefitsrelatedto faculty and supervision, and overhead costs related to the graduate education
process.
GME, however, is not the only factor which accounts for higher costs at AHCs. AHCs
treat more seriously ill and indigent patients, provide the infrastructure for biomedical and
behavioral research, and offer clinical training experiences for undergraduate medical students
and other health professions students, characteristics which add to an institution's cost base.
In recognition of these additional costs, the Medicare program has historically paid teaching
hospitals an indirect medical education (IME) adjustment. Likewise, some modified version
of an adjustment to account for those costs unique to AHCs, above and beyond the direct costs
of graduate medical education, will be required in a managed competition environment. The
adjustment should be formula driven, rather than based on year to year appropriations, and
should be funded by all payers.
I would also suggest that all accountable health plans, where feasible, include in their
network an academic health center. Such a requirement would guarantee all of our citizens
access to the latest in state of the art care when medically necessary. At the same time, it
would help guarantee a certain flow of patients to academic health centers on which their
educational and research programs rely.
Another approach, which could be implemented in concert with the mechanisms noted
above, would be the establishment of certainregional"centers of excellence" for the use of
emerging technologies and specialized methods of treatment. AHCs would be a natural place
�Mr. Ira Magaziner
April 16, 1993
Page 4
for designation as such centers given their strong emphasis on biomedical research, particularly
if they have a health services research component. This regionalization of certain emerging
technologies would help to control the widespread diffusion of new technologies absent
sufficient outcomes research to judge their cost-effectiveness.
Undergraduate Medical Education
According to the Assodation of American Medical Colleges, medical school revenues
from patient care have expanded significantly over the past few decades and currendy constitute
the largest single source of funding for medical schools. The faculty practice plans at AHCs
represent the major source of these dollars. A managed competition environment potentially
will limit the ability of practicerevenuesto subsidize the cost of undergraduate medical
education as well as graduate medical education andresearch.New mechanisms will be
required to fund these costs.
As mentioned above, there are a number of proposals being discussed that would
establish a national pool to pay for graduate medical education, funded by all payers, that would
reimburse providers for the costs of their graduate training programs. Recognizing that
undergraduate and graduate training are all part of the same medical education continuum,
perhaps it makes sense to set up a parallel funding mechanism for undergraduate medical
education. Like the GME fund, all payers would be required to make payments into this fund
which would then be allocated to schools of medicine on a per capita basis. Of course, to the
extent that the costs of undergraduate medical education were directly reimbursed, the add-on
for the additional costs associated with academic medical centers, discussed above, could be
discounted.
I hope my initial thoughts on these questions which are so critical to AHCs are helpful.
Your strong and active interest in these issues is very much appreciated. Please feelfreeto call
me if you have any questions or ideas you would like to explore further.
Sincerely,
6William N. Kelley, M.D.
WNK:lp
cc:
Ms. Charlotte Hayes
Ms. Libby Short
�STATEMENT OF THE MOREHOUSE SCHOOL OF MEDICINE
submitted t o :
The O f f i c e o f P u b l i c L i a i s o n and
The White House H e a l t h Task Force
A p r i l 14, 1993
�INTRODUCTION
One o f the most important issues our Nation faces today i s how t o
improve the d e l i v e r y and f i n a n c i n g of our health care system.
Two
f a c t s helped place h e a l t h care a t t h e center o f the American
domestic agenda: 37 m i l l i o n of our c i t i z e n s do not enjoy access t o
the very system lauded as the best i n the world, and, as a nation
we spend, by every measure, more than other leading i n d u s t r i a l
c o u n t r i e s w i t h l i t t l e r e a l i s t i c expectation o f slowing the r a t e of
expenditure. I n s h o r t , we have t h e most expensive system i n the
world, by a wide margin, and some of the i n d u s t r i a l world's poorest
h e a l t h data.
We welcome the focus of the A d m i n i s t r a t i o n and the Nation on these
important
issues.
Additionally,
we applaud
t h e p o s i t i o n the
A d m i n i s t r a t i o n i s t a k i n g i n emphasizing the r o l e of primary care as
a means of r a i s i n g the health status of Americans and i n ensuring
access f o r a l l i n d i v i d u a l s .
The medical schools a t Morehouse, Howard, Meharry, and Drew are
dedicated t o t r a i n i n g physicians t o provide care t o a l l Americans,
and e s p e c i a l l y t o those t r a d i t i o n a l l y underserved i n d i v i d u a l s who
t y p i c a l l y reside i n poor and m i n o r i t y , r u r a l and urban communities.
These i n d i v i d u a l s account
f o r a s i g n i f i c a n t p o r t i o n of the 37
m i l l i o n Americans w i t h o u t access.
�In order t o achieve our mission, we have always been s e n s i t i v e t o
the changing environment of medical education and the h e a l t h care
i n d u s t r y as a whole.
Thus, our academic programs place a high
p r i o r i t y on an understanding of t h e value o f prevention, managed
care, e t h i c a l r e s p o n s i b i l i t y , and t h e medical-social approach t o
the p r a c t i c e of medicine.
The
Nation's m i n o r i t y medical schools and the Health Care Task
Force share a c e n t r a l o b j e c t i v e of improving access and r a i s i n g the
h e a l t h s t a t u s f o r a l l Americans, e s p e c i a l l y poor and underserved
individuals.
This statement b r i e f l y describes the s t a t e o f m i n o r i t y h e a l t h , the
r o l e t h a t the Morehouse School of Medicine i s p l a y i n g i n addressing
the d i s p a r i t i e s i n health s t a t u s , and i d e n t i f i e s and recommends
those p o l i c i e s and programs t o support the m i n o r i t y medical schools
in
our ongoing
effort
t o improve
the h e a l t h
of underserved
individuals.
MINORITY HEALTH
I n the United States, there e x i s t s a s u b s t a n t i a l d i s p a r i t y between
the
health
individuals.
of the general
By every
population and t h a t
meaningful
of m i n o r i t y
measure, m i n o r i t i e s
are a t
greater r i s k of being s i c k e r , dying sooner, seeing a physician less
�o f t e n or l a t e r i n an i l l n e s s , having fewer i n t e r a c t i o n s w i t h the
h e a l t h care system, and generally have a less healthy outlook than
the m a j o r i t y population.
e l i m i n a t e the gap
Americans.
Our goal i s t o narrow and u l t i m a t e l y t o
i n h e a l t h status between m i n o r i t y and
Today, u n f o r t u n a t e l y , the gap
i s appreciable
white
and
is
widening.
By now,
we are a l l too f a m i l i a r w i t h the long and t e r r i b l e l i t a n y
of h e a l t h s t a t i s t i c s describing the d i s p a r i t y i n h e a l t h s t a t u s .
This d i s p a r i t y begins w i t h the very onset of l i f e .
Black i n f a n t s
die at twice the r a t e of white i n f a n t s (19.9% vs. 8.6%,
per
1000
l i v e b i r t h s ) , are twice as l i k e l y t o have low b i r t h w e i g h t (12.7%
vs. 5.7%), and are twice as l i k e l y t o be born prematurely
(18% vs.
8.5%). These outcomes are consistent w i t h research t h a t shows t h a t
black women are less l i k e l y t o receive prenatal care during t h e i r
f i r s t t r i m e s t e r of pregnancy than t h e i r white counterparts (62% vs.
80%) .
The d i s p a r i t y continues through e a r l y developmental years and i n t o
adolescence, teenage and e a r l y a d u l t years.
pre-school
children
c h i l d r e n are less l i k e l y t o be
(75%
vs.
89%).
Blacks die
For example, black
immunized than
from homicide
and
white
legal
i n t e r v e n t i o n a t a r a t e s i x times t h a t of whites.
Disease also o f t e n exacts a d i s p r o p o r t i o n a t e t o l l i n the m i n o r i t y
community.
One
of the most t r a g i c and f r i g h t e n i n g examples i s i n
�the area of AIDS. I n 1989, 51% of a l l female AIDS cases were among
Black women, and 52% of a l l p e d i a t r i c AIDS cases were among Black
infants.
Overall,
according t o the U.S.
Department of Health and Human
Services, the incidence of death f o r the 15 leading causes of death
among Blacks i s 52% higher than f o r whites.
We also know t h a t socio-economic f a c t o r s play an important r o l e i n
the h e a l t h s t a t u s of i n d i v i d u a l s .
Generally, groups w i t h higher
incomes and higher l e v e l s of educational attainment enjoy h e a l t h i e r
outcomes.
correlate
Similarly,
lower
positively with
incomes
poor
Hispanics are d i s p r o p o r t i o n a t e l y
among the l e a s t educated.
and l e v e l s
h e a l t h outcomes.
of education
Blacks
represented among the poor and
A graph best i l l u s t r a t e s t h i s p o i n t .
Blacks
Hispanics
Whites
3 3%
28%
11%
unemployment rate
13%
9%
5%
High School Dropout Rate
37%
49%
23%
% completing college
11%
9%
21%
% l i v i n g below the
poverty l i n e
and
�P r e d i c t a b l y , educational attainment r e l a t e s d i r e c t l y t o income. I n
1987, median income f o r a couple where n e i t h e r the husband nor the
w i f e completed high school was $17,000.
When both had 13-15 years
of education, median income rose t o $40,000.
When both f i n i s h e d
high school and beyond, median income rose t o $57,000.
THE MOREHOUSE SCHOOL OF MEDICINE
The Morehouse School o f Medicine t r a i n s students f o r careers as
primary care physicians i n r u r a l and urban underserved
communities.
We are p a r t i c u l a r l y proud t o provide o p p o r t u n i t i e s f o r academically
talented
and economically
medical education.
disadvantaged
students
t o pursue a
Because many o f our students themselves come
from underserved communities, neighborhoods where r e s i d e n t s a t r i s k
of excess m o r b i d i t y and m o r t a l i t y , they not only are more l i k e l y t o
r e t u r n and remain
i n those communities,
but they also have t h e
advantage of understanding the i n t e r p l a y between h e a l t h s t a t u s and
socio-economic
f a c t o r s such as income, employment and education.
We b e l i e v e t h a t the t r a i n i n g of physicians s p e c i a l i z i n g i n primary
care
i s an e f f e c t i v e
method
of providing
high
quality,
comprehensive care t o a l l Americans, and an e s p e c i a l l y e f f e c t i v e
means of responding t o the c r i s e s i n m i n o r i t y h e a l t h .
Primary care
emphasizes the need and appropriateness o f i n d i v i d u a l s t o assume
r e s p o n s i b i l i t y f o r t h e i r own h e a l t h .
Following a proper
diet,
g e t t i n g an adequate amount of r e s t and exercise, avoiding smoking
�and drugs, r e c e i v i n g e a r l y and p e r i o d i c prenatal care,
securing
immunizations f o r c h i l d r e n ages 1-4, r e c e i v i n g p e r i o d i c h e a l t h
screenings and conducting s e l f examinations are a l l a c t i v i t i e s f o r
which i n d i v i d u a l r e s p o n s i b i l i t y can and should be assumed. Primary
care physicians
serve as general
managers of an i n d i v i d u a l ' s
h e a l t h , by t r e a t i n g most h e a l t h problems, encouraging i n d i v i d u a l
responsibility,
and r e f e r r i n g
p a t i e n t s , when appropriate,
for
s p e c i a l t y care.
SUPPORTING PRIMARY CARE
We applaud the emphasis the A d m i n i s t r a t i o n i s p l a c i n g on primary
care.
The Administration's FY'94 budget proposes an increase o f
$232 m i l l i o n (out of $3.1 b i l l i o n ) t o expand access t o primary and
preventive h e a l t h care services f o r underserved populations.
These
include a d d i t i o n a l funding i n the amount o f :
$20 m i l l i o n f o r the NATIONAL HEALTH SERVICE CORPS t o fund
a t o t a l o f 416 scholarships, 600 Federal loan repayment
agreements, 325 State loan repayment agreements and 150
Federal s a l a r i e d providers.
$51 m i l l i o n f o r THE HEALTH PROFESSIONS PROGRAMS which
focus on d i r e c t primary care, nursing, and disadvantaged
assistance.
Within t h i s amount, $5 m i l l i o n i s requested
�for
a new Primary Care Loan Program and $3 m i l l i o n f o r
analysis of h e a l t h s t a f f i n g issues.
The
p r o v i s i o n of adequate scholarship assistance i s
c r i t i c a l i n attempting t o increase m a t e r i a l l y the number
of
medical students choosing
medicine.
t o p r a c t i c e primary
care
Students o f t e n leave medical school w i t h a
sizeable debt burden.
Because s p e c i a l t y p r a c t i c e o f t e n
o f f e r s a greater earning o p p o r t u n i t y , students o f t e n f e e l
t h a t they have l i t t l e choice i n deciding t o t r a i n i n a
s p e c i a l t y area.
$65 m i l l i o n f o r COMMUNITY AND MIGRANT HEALTH CENTERS t o
fund 90 new s i t e s f o r a t o t a l 1,637 s i t e s .
An estimated
7.1 m i l l i o n people w i l l be served through these centers,
and increase o f 585,000.
$40 m i l l i o n f o r t h e MATERNAL AND CHILD HEALTH BLOCK GRANT
to provide primary h e a l t h care t o c h i l d r e n and services
to c h i l d r e n w i t h s p e c i a l h e a l t h needs.
$21 m i l l i o n f o r the 15 HEALTHY START COMMUNITIES t o step
up the f i g h t against i n f a n t m o r t a l i t y .
$3 5 m i l l i o n f o r FAMILY PLANNING CLINICS which w i l l serve
over 5 m i l l i o n i n d i v i d u a l s , and increase of approximately
�1 m i l l i o n people, o f whom t w o - t h i r d s a r e under age 25.
I n a d d i t i o n t o these e f f o r t s i n s u p p o r t o f p r i m a r y c a r e , we commend
t h e A d m i n i s t r a t i o n f o r p r o p o s i n g an i n c r e a s e i n reimbursements
for
p r i m a r y care p h y s i c i a n s i n d i r e c t m e d i c a l e d u c a t i o n under Medicare.
We b e l i e v e t h a t any s e r i o u s e f f o r t t o c o n t a i n c o s t s must i n c l u d e
actions
t o make t h e p r a c t i c e
of primary
care
more
attractive
i n direct
support o f
financially.
PROPOSED ACTIONS
We endorse t h e A d m i n i s t r a t i o n ' s p r o p o s a l s
p r i m a r y care i n i t i a t i v e s and urge your s u p p o r t i n t h r e e a d d i t i o n a l
areas t o s t r e n g t h e n t h e c a p a c i t y o f m i n o r i t y m e d i c a l s c h o o l s .
1.
DISPROPORTIONATE SHARE HOSPITALS (DSH)
We a r e aware t h a t t h e e n t i r e M e d i c a i d program i s under r e v i e w by
t h e Task Force, i n c l u d i n g t h e DSH p r o v i s i o n t o p r o v i d e a d d i t i o n a l
s u p p o r t f o r t h o s e h o s p i t a l s which s e r v e a d i s p r o p o r t i o n a t e number
o f poor and u n i n s u r e d i n d i v i d u a l s .
which
have
residency
programs
As you know, m e d i c a l
which
provide
care
p a t i e n t s i n these i n s t i t u t i o n s a r e a b l e t o r e c e i v e
schools
t o indigent
reimbursement
f o r the care provided.
In
o u r view,
mechanism
i t i s important t h a t
t o c o n t i n u e a stream
the Administration
of indirect
financial
retain a
support.
�particularly
program be
to minority
medical
schools, should
the
fundamentally changed or e l i m i n a t e d .
Because most
m i n o r i t y medical schools do not enjoy the f i n a n c i a l
support and
s t a b i l i t y a v a i l a b l e t o other educational i n s t i t u t i o n s ,
assistance provided through the DSH
Medicaid
financial
program i s e s s e n t i a l f o r the
c o n t i n u a t i o n of operations and general f i n a n c i a l s t a b i l i t y .
2.
We
urge
LEGISLATIVE INITIATIVES
your
strengthening
support of two
the
capacity
legislative
of
i n i t i a t i v e s aimed a t
historically
black
medical
institutions.
a.
T i t l e I I I Of the Higher Education Act. Section 326.
Strengthening H i s t o r i c a l l y Black Graduate I n s t i t u t i o n s
This s e c t i o n helps graduate HBCUs t o e s t a b l i s h and strengthen t h e i r
physical
plants,
development
offices,
endowments,
academic
resources and student services. Schools r e c e i v i n g assistance under
t h i s s e c t i o n do not e n r o l l undergraduates, are t h e r e f o r e i n e l i g i b l e
t o receive P e l l g r a n t s , and thus cannot receive r e g u l a r T i t l e I I I ,
Part
B funding.
provides
critical
institutions.
We
This p r o v i s i o n
financial
urge
your
expansion of t h i s program.
of the Higher
support
support
for
Education
minority
Act
graduate
f o r the c o n t i n u a t i o n and
�b.
Biomedical F a c i l i t y Construction
at M i n o r i t y I n s t i t u t i o n s
L e g i s l a t i o n t o reauthorize the National I n s t i t u t e s of Health ( S . l
and
H.R.4) would
establish
an extramural
grants
program f o r
biomedical and behavioral research f a c i l i t i e s c o n s t r u c t i o n t o be
located i n the National Center f o r Research Resources (NCRR). The
l e g i s l a t i o n would authorize the NCRR D i r e c t o r t o make a v a i l a b l e up
t o 25% of the funds appropriated f o r biomedical research
facility
c o n s t r u c t i o n t o "INSTITUTIONS OF EMERGING EXCELLENCE", described as
research centers a t m i n o r i t y i n s t i t u t i o n r e c i p i e n t s o r m i n o r i t y
centers of excellence.
P a r t i c i p a t i o n of m i n o r i t y i n s t i t u t i o n s i n
biomedical research i s modest.
This l e g i s l a t i o n i s an important
step i n p r o v i d i n g funds needed t o permit m i n o r i t y i n s t i t u t i o n s t o
develop
t h e capacity
research funding.
t o compete r e a l i s t i c a l l y
f o r biomedical
We urge your support of t h i s l e g i s l a t i o n .
SUMMARY
I n summary, we commend the A d m i n i s t r a t i o n f o r the d i r e c t i o n i t has
taken t o b r i n g balance back t o the h e a l t h care system.
The l a s t
two decades have been an e x c i t i n g time i n American h e a l t h care.
The t e c h n o l o g i c a l advances we have witnessed i n these l a s t
years
have, again, set the standard f o r h e a l t h care i n t h e world.
With
these
advances, however, have come t h e o v e r - s p e c i a l i z a t i o n o f
medicine, and the de-emphasis of primary care.
10
Unfortunately, we
�d r i f t e d away from the p r a c t i c e of family and
which had
served f a m i l i e s and
i n d i v i d u a l s so
community medicine
w e l l during
this
century.
The
Administration,
through
i t s emphasis on
primary
care,
is
demonstrating t h a t i t i s not only possible and but optimal t o have
both world leading technology and a world class system of
care d e l i v e r y .
Now
health
t h a t we have achieved the former, we must work
t o b r i n g about the l a t t e r .
We
agree w i t h the Task Force t h a t a
r e t u r n t o the p r i n c i p l e s of f a m i l y and community medical p r a c t i c e
i s the most e f f e c t i v e way
t o ensure access f o r a l l Americans, t o
c o n t r o l costs and preserve q u a l i t y .
We welcome your work i n b r i n g i n g needed reform t o our health care
system.
We o f f e r our support and assistance as you continue w i t h
t h i s important work.
11
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�CONSIDERATIONS F R THE S P O T O FEDERALLY
O
UPR F
S O S R D MEDICAL CLINICAL INVESTIGATION
PNOE
Michael A. Friedman, M D
..
Currently, for nearly every disease, standard therapies are insufficiently
effective, too toxic or too expensive. Additionally, the excellence of the health
research of academic institutions and the vigor of the biotech industries mean that
there will be an increasing need for high quality clinical research in order to
identify better prevention, treatment, and rehabilitation technologies and products.
Financially, there are two components of this clinical investigation - the research
costs (special tests, data collection, statistical analysis, etc.) and the clinical
care costs (routine care appropriate for that condition). The former costs should
be borne by the research sponsor (such as the National Institutes of Health), the
latter costs have traditionally been reimbursed by third party payers. (The
situations of pharmaceutical industry or private charity, sponsored research will
not be examined here). But, since Federally sponsored clinical research utilizes
tax dollars and aims to benefit the health of all citizens, i t is essential that
consideration be given to h w payment for the clinical care costs of such research
o
can be incorporated into a new, comprehensive, health care plan.
It is assumed that in the future only legitimate clinical services would be covered,
ineffective approaches would not be funded, and unproven interventions would be
carefully scrutinized rather than not automatically excluded. Also, i t is assumed
that Federally sponsored research would continue to be scrupulously peer reviewed
and quality assured so that optimal care would be provided, the best scientific
questions pursued and ethical standards upheld. Although such research addresses
broad biologic, medical outcomes and cost-effectiveness issues, the overall scope of
this effort would remain small (predictably less than 5% of all patients).
Possible options for covering these clinical care costs include:
1)
N reimbursement whatever would be permitted. Only wealthy, motivated
o
patients could participate in such research - very l i t t l e research
would occur and access to the benefits of participation would be
inequitable. Research progress would be slow.
2)
The sponsor could begin paying for all clinical costs as well as
research costs; these costs would be enormous and could not be
accommodated in the present appropriations. Specifically, a vast
increase in the D H research budget would be required for Federally
HS
sponsored clinical research projects (from NIH, C C etc.).
D,
3)
Permit reimbursement (consistent with coverage guidelines) for clinical
care costs for patients participating in appropriately defined clinical
trials.
While clinical investigation is a relatively small component of the health care
package, i t is crucial. It would be most in accord with the national scientific and
societal goals to exercise either the second or third option (or s m variant).
oe
Otherwise, advances in relieving the suffering and premature disability and death of
citizens will not continue to be realized.
Mthough Michael A. Friedman, M D is the Associate Director, Cancer Therapy
..
valuation Program of the National Cancer Institute, the opinion expressed is a
personal one only.
�Council of Medical Genetics Organizations
Genetics and Health Care Reform
FACT SHEET
Access to appropriate and affordable health care is a critical problem for American children and
families with genetic conditions and birth defects. More than 13 million Americans have genetic
disorders. Each year over 100,000 infants are found to have birth defects, which are the leading
cause of infant mortality and a major factor in childhood morbidity.
These conditions dramatically emphasize the difficulties of the current American health care
system in dealing with chronic disease and providing family-centered, community-based,
multidisciplinary, and coordinated services for children and adults. With rare exceptions, present
managed care systems routinely fail in important primary care functions for these patients.
We support the need for Health Care Reform in order to:
•
•
Ensure equal access to services regardless of medical condition.
Obviate the former practice of denying coverage to people with complex conditions.
Genetic health care services play an important and growing role in primary care for millions of
Americans. New genetic technologies offer extraordinary promise for cost-effective preventive
strategies for common diseases such as breast and colon cancer. Newborn screening programs
and birth defects registries provide successful models for population-based health data
surveillance, outcomes research and coordination of care.
For these and other important reasons, the Council of Medical Genetics Organizations
urges that any future health care reform:
•
Ensure quality services to patients with the more than 6,000 recognized genetic
disorders. These conditions are rare and unfamiliar to most health care providers and
require methods of diagnosis and management which are not currently part of primary
care. Regionalizing such services - including genetic services- is economical and
would insure needed access to quality specialized diagnosis and treatment.
•
Provide coverage in the basic benefits package for specialized or long-term care. If
this is not possible, then such individuals should be covered by supplemental benefits.
•
Recognize that genetic testing to identify mdividuais at-risk for common diseases will
make possible a cost-effective, targeted approach to disease prevention - providing
specific intervention for those at-risk and saving millions in the costs of surveillance
for those found not to be at increased risk.
•
Expand and standardize the current public health system to ensure equity of access to
crucial screening, preventive and treatment services for persons with genetic diseases.
•
Provide a mechanism to rapidly translate the benefits of the national investment in
biomedical research into improved health care. We cannot afford to wait a generation
for Americans to benefit from these research findings.
Alliance of Genetic Support Groups • American Board of Genetic Counseling •
American Board of Medical Genetics • American College of Medical Genetics •
American Society of Human Genetics • Association of Cytogenetic Technologists •
Association of Professors of Medical and Human Genetics • Council of Regional Genetics Networks •
International Society of Nurses of Genetics • National Society of Genetic Counselors •
Society of Craniofacial Genetics
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Farah M. Walters
April 8, 1993
Group 40
Academic Health Centers
VahiM rrpnted for society:
Medical and health professional education "where they arc trained"
undergraduate medical students
graduate specialization: residents
post graduate subspecialization: fellows
continuing medical education: practitioners
other health professionals
Research in health sciences "where new knowledge is developed and tested"
basic and clinical sciences: site of most extramural supponed research
"new" sciences: outcome research, clinical effectiveness
evaluation of new technologies, therapies and health policies
Preventive and therapeutic care of the urban poor
Provider of resource intensive (often under-reimbursed) special services such as: trauma
centers, neonatal Intensive care, AIDS units, bum centers
Economic: major employer in musi inner city urban USA
What
Mt risk:
Price-driven competition will hurt multiple missions of Academic Health Centers (AHC),
their ability to offer postgraduate training and to support research (a significant
percentage is currently supported by Academic Health Centers).
The future of investigations in the clinical sciences that are concerned with new
technologies and their impact on health care.
Absence of AHCs in uthan America will have m^jor negative impacts on the health care
services and economic development of these communities.
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Academic Health Centers
(continued)
Proposed models!
Develop a separaie fuiancing status for AHC under a global budget/managed competition
plans taking into account the societal values created by these centers, which the country
wantstopreserve.
Establish separate funding mechanisms for graduate and postgraduate medical education
and for education of other allied health professionals. Funding for training programs
should be based on a sliding scalerelativeto national needs.
Establish AHC as "flagship" status in local or state health plans. Given each a
differentiating feature as a "center of excellence" in dealing with certain clinical
conditions.
Establish AHC as government supported centers for health servicesresearchparticularly
as it applies to outcome and effectiveness methodologies.
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RuahMWafas
Academic Health Centers at Cross Roads
Tntrnriiirtiftn
The status of Academic Health Centers in the United Slates is in serious jeopardy. The dilemma
these centers are facing is multifaceied. but two reasonsfigureprominently: the nation's
economic difficulties and the escalating cost of medical care. Neither reason, however, takes
into consideration the full role and mission of these institutions. Academic Health Centers are
a unique feature of the profession of Medicine world-wide. Uteir historicrolehas been to
preserve and secure a special dimension of excellence in the pursuit of new medical knowledge
and its application to health, as well as training of future generations of professionals.
The purpose of this paper is to define Academic Health Centers and their mission in the context
of health care for the twenty-first century. This definition should help shape their mission
statement and agenda, and provide aframeworkfor their role within the context of the National
Health Care Reform Proposal currently under development.
Definition and Role
Academic Health Centers are a loose or sometimes more integrated confederation of a medical
school, a major teaching hospital and a group of full-time faculty. The interaction between these
three components resulted in positioning Academic Health Centers as being the largest and most
advanced biomedical research institutions. As a matter of fact, the biggest share of the Federal
R&D programs goes to Academic Health Centers. It's no exaggeration to state that the current
molecular and cellular biomedical revolution is a direct result of Federal support for extramural
research conducted mainly in Academic Health Centers. The dramatic developments in the
medical sciences have led to the discovery of both preventive and curative measures for a variety
of conditions induding vaccines for infectious diseases and the genedc basis of Inherited
disorders such as cystic fibrosis. Simultaneously with being at the cutting edge of medical
science, these centers developed into tertiary caic instilulions offering our people the most
advanced therapeutic modalities and slate of tlie art diagnostic technology. Examples of recent
application of modem biomedical sciences to the well being of our population include several
recombinant products used for treatment of anemia, for hormonal replacement products such as
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human insulin, and the recombinant hepatitis B vaccine now a recommended component of wdl
child care. An additional major feature of Academic Health Centers is provision of core for the
urban poor. With all the economic difficulties of the past decades, these centers found
themselves in the midst of our country's social and economic ills. There was no choice but to
provide care for the indigent and to use multiple strategies torecoverthe cost. In spite of this
socially committed role, Academic Health Centers have not been successful in articulating or
significantly influencing a health care agenda for our country.
Probably the single most distinguishing role of Academic Health Centers is their involvement
in all aspects of medical education. The major revolution In medical education in this cuimiry
started in 1910. The Abraham Flexner's repon proposed that teaching the scientific bases of
medicine be accomplished In thefirsttwo years of medical education. This is to be followed
by another two years of essentially hospital-based clinical education. The outcome of this
strategy is a major educational role for the full-time faculty of Academic Health Centers. This
group of physicians and other professionals is now shouldering most of the responsibilities for
medical undergraduate education. As a matter of fact, in most medical schools in the U.S.,
undergraduate medical education is in large part conducted by clinical faculty who derive very
little or no compensation for thisrole.Furthermore, Academic Health Centers' faculty provide
most of the continuing medical education and post graduate training. The total effect of all these
activities is that Academic Health Centers have, therefore, taken on the major responsibilities
of medical education. Their role has surpassed that of Medical Schools or their parent
Universities. The continuum of medical education, startingfromthe four years of medical
school through residency and fellowship training, spans approximately 10. years. Added to that,
the necessary efforts of continuing medical education, the national responsibility of Academic
Health Centers in developing and maintaining the profession of Medidne may be fully
appreciated.
The full-time faculty of Academic Health Centersfindthemselves facing a similar challenge and
disadvantage. They are expected to pursue new knowledge and participate in its generation and
application to health of the public. In the meantime, they are committed to training of new
generations of health professionals and to translate their societal commitments hy providing
largely undercompensated or uncompensated care. At the same time, they are expected to
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compete In a price-driven market with other physicians who dedicate their full-time to the
pracdee of medicine and therefore are able to offer lower rates to managed care plans.
F ac
m ue
Over the past several decades, Academic Health Centers have developed afinancialstructure
that is now showing tremendous strains. Thefirstcomponentrelatesto the cost of research in
the extramural federal programs. Indirect cost recovery which many administrators of Academic
Health Centersfindinadequate is on the firing line because of several well publicized excesses.
Research is an expensive undertaking; the Federal Government caps the total income
investigators may draw from their grants while the associated costs of performing research are
escalating. Consequently, most Academic Health Centersfindit necessary to subsidize their
research programs to maintain their position at the forefront of medical science. The second
source of strain on Academic Health Centers' budget is care for the underserved populations of
urban America. Wliile litis item m y soon beresolved,its cumulative effect has had a
a
considerable negative impact and resulted in a cost structure for care delivery that is being
labeled as excessive. The end result is an assumption that Academic Health Centers are costing
the nation and its people an inordinatefinancialburden, The multifaceted role of Academic
Health Centers is crucial to the future of our nation. The truth is that we can no longer afford
tofinancethe future of medicine and its lead organizations (Academic Health Centers) by the
present system. Without a major change infinancing,the multiple missions of these Centers
(which necessitate cost shifting and higher charges) may be severely undermined in a pure pricedriven market.
Perspective
Academic Health Centers play a crucial role in the social, educational and research fabric of our
nation. Their survivability and enhanced effectiveness is a national imperative and sharpening
their role is urgently needed. Academic Health Centers must take the initiative as the national
debate on Health of the Public matures. A renewed commitment to the national agenda is
necessary. This may take the form of the following mission statement and set of objectives.
"The mission of Academic Health Centers is to lead the national effort pursuing the development
of new medical knowledge and iu adoption in a broad construct of health of the public. They
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are a key component in developing and applying new medical technologies and therapies and in
training a cadre of medical professionals capable of implementing this vision."
Five immediate objectives need to be considered:
1)
Establish a broad vision for basic science and clinical research needs and foster an
environment which allows Academic Health Centers to realize this vision.
2)
Establish a communityrolefor Academic Health Centers by developing model systems
for delivery of optimal prevendve and therapeutic care.
3)
Create an environineni for faculty, trainees and students to adapt to optimal utilization
of limited resources.
4)
Become an advocate for the health of the public at the national as well as regional levels.
5)
Implement policies for training students and post-graduate candidates that will adequately
meet the national needs.
Finally,financingthese multiple objectives should not berelegatedto compensation for one
activity (e.g. patient care). The cost of performingresearchand education of new generations
of health professionals should be factored in as well.
�fiPR 15
'93
M:36
FROM LYNN MORRISON
PAGE.002
(gg) American federation for Clinical Rese
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RECOMMENDED HEALTH CARE COVERAGE FOR
CLINICAL RESEARCH
^ ^ J ^ ^
Appropriate and necessary pattent can costs should be covered by fh« health care
plan for both patleats recdving standard treatment and patknts involTtd in an
approved InveittigaUonal protocol.
Instituie of Medidne, 1988 Report, page 7: "It is wholly inappropriateforthird
party payers to deny refmburecmentforall appropriate and necessary patient
care costs-.that would have been Incurred In an.y case simply because a
patient is on an investigational protocol. Such denial would be tantamount to
an abrogation of a contractual obligation."
NEJM Sounding Board Article, page 46: The recent refusal of some thirdparty payere to support the costs of patient care as part ofresearchtrials
threaten to compromise clinical investigations that might lead to progress in
the treatment of cancer."
2.
Health can plans should corer Investigational therapies when they are provided as
the best available medical care for a lethal condition.
Institute of Medicine, 1988 Report, page 8: There arc diseases for which
appropriate andrequiredcare involves investigational protocols...Third party
payers should seek to participate In funding of dinical trials above and beyond
reimbursing for standard patient care costs. This approach provides the
potential to increase the efficacy and cost effectiveness of diagnosis and
treatment, thereby allowing fbr the possibility of significantfinandalgain in
the long run."
NEJM Sounding Board Article, page 47: "Most patients assume that they arc
covered by health insurance for the costs of an Investigational therapy if no
effective standard thorapy exists for a lethal disease. Tbey are surprised and
frequently angry to discover that tho insurer will tax cover these costs."
n ^ e t o , lor PuWte P r f * , - L y n n Morriaon • »11 M t » » » o h u » e W ^ • ^ ^ ^ ^ ^ ^ ^ T ^ ^ ^ ^ ^ "
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• « X H W * - 7 0 7 2 • FAX 6 0 » 4 S » « M 1
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Health can plans should cover purely Investigational therapies In exchanfie for
outcome data.
Institute of Medidne, 1988 Report, page 16: The Committee recommends
acceleration in the growth in the nation's commitment to an organized agenda
for treatment outcomes research. Thefailureof the current investigatorinitiated grant mechanism to meet the challenge of outcome assessment
suggests, however, that a new approach is needed.
**
TOTAL P A G E . 0 2 3
**
�NEW YORK UNIVERSITY
A private university in lhe public
service
DAVID B. KRISER DENTAL CENTER
COLLEGE OF DENTISTRY
Office of the Dean
Arnold and Marie Schwartz Hall of Dental Sciences
345 East 24th Street, New York, NY 10010-4086
Telephone: (212)998-9898
FAX:
(212)995-4080
April 20, 1993
Dr. Elizabeth M. Short
Associate Chief Medical Director for Academic Affairs
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20420
Dear Dr. Short:
I was extremely pleased and honored to attend the meeting of the AAU, NASULGC, and
Pew Charitable Trusts held April 17 and 18 in Washington. In anticipating the meeting, one
of my chief expectations was that it would offer a chance to hear directly from members of
President Clinton's Task Force on National Health Care Reform. I am gratified that your
participation fulfilled that pivotal need for me.
Let me add that your wealth of information, your delivery and your marvelous sense of
humor all contributed significantly to the program, and were much appreciated by everyone.
From my particular vantage point, I found your positive response to my question regarding
national dental coverage most helpful in directing our future thoughts and decisions.
However, in light of a remark I overheard at the meeting about national fluoridation as the
solution to our country's dental service problem, I would like to bring to your attention some
particularly large additional gaps in needs for oral health care.
I know you are aware that, in the face of limited fluoridation nationally, we still face the
need to treat fully 84 percent of our children for caries. But certainly another, equally
troubling indicator of need is periodontal disease, one of the most prevalent human diseases,
which, at the last review, accounted for the loss of eight times as many teeth as those lost
through caries.
Nor can we forget the 40,000 cases of oral cancer diagnosed annually and the more than
9,000 persons who die from the disease each year, or the annually increasing numbers of
cases of malocclusion, traumatic injury and severe congenital oral-facial deformities. Perhaps
most importantly, the oral cavity is often a mirror of the rest of the body, exhibiting signs
and symptoms of more serious and widespread health problems. These include diabetes,
a host of chronic medical conditions, and autoimmune diseases, among many others.
�Dr. Elizabeth M. Short
-2-
April 20, 1993
Accordingly, one can conclude that our nation's oral health problem is much broader than
caries. It is my hope that the members of the President's Task Force will take this
information into consideration as they work to formulate a program to guarantee
comprehensive health care for everyone.
Please accept my deep gratitude for your efforts on behalf of all Americans. I know how
difficult your task is, and assure you that I stand ready to assist you and your committee in
any way I can to provide you a better understanding of the necessity for oral health care
throughout life to be a part of the health care reform issue.
I look forward to the recommendations of the Task Force and your committee, and offer
you my very best wishes for success in this most important policy-making enterprise.
Sincerely,
Edward G. Kaufman, D.D.S.
Dean
EGK/me
�
Dublin Core
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Title
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Health Care Reform
Identifier
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2006-0810-F
Description
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<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
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Clinton Presidential Records
Publisher
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William J. Clinton Presidential Library & Museum
Text
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Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Briefing Book on Academic Health Centers [3]
Creator
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Health Care Task Force
General Files
Identifier
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2006-0810-F Segment 1
Is Part Of
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Box 47
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
Date Created
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5/5/2015
Source
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42-t-2194630-20060810F-Seg1-047-011-2015
12090749