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OCR for page 142
~ 0licadons for Eclucadon md Rich
Investor-owned hospitals have not been
known for their participation in the educa-
tion of health professionals or in research.
The growth of investor-owned hospital chains
has come primarily through the acquisition
of independent proprietary hospitals, which
tended to be small and to have no relation-
ships with educational institutions. Until re-
cently, investor-owned companies showed
little interest in acquiring teaching hospi-
tals, and not-for-profit and public teaching
hospitals had lithe reason to consider a change
of ownership. American Hospital Associa-
tion data show that as recently as 1983 (see
Table 7.1) only 2 percent of the hospitals in
investor-owned chains and 2 percent of the
independent investor-owned hospitals had
medical residency programs,2 and none had
a nursing school. The average number of
medical residents per bed was much Tower
in for-profit hospitals, irrespective of size,
than in not-for-profit and governmental hos-
pitals (Table 7.21. Also, because oftheir size,
orientation, and lack of medical school af-
filiations, for-profit hospitals have not been
sites for research, nor have they had phy-
sician-researchers on their medical staffs.
Only since December 1981 have U.S. Pub-
lic lIealth Service regulations included pro-
visions that make for-profit organizations
eligible to receive research grants from the
National Institutes of Health, the nation's
TABLE 7.1 Percentage of Short-Term General Hospitals with Educational Affiliations, by
Ownership, 1983
Investor- Not-for- Not-for- State
Owned profit profit and Local
Chain ProprietaryChain Independent Government
Bed Size (%) (%)(%) (%) (%)
Residency program 2 226 22 10
Medical school
affiliated 2 225 21 9
Professional nursing
school 0 07 ~1
Council of Teaching
Hospitals 0 06 9 5
SOURCE: Hospital Data Center, American Hospital Association, 1985.
142
OCR for page 143
IMPLICATIONS FOR EDUCATION AND RESEARCH
TABLE 7.2 Average Number* of Residents and Trainees per Community Hospital, by
Ownership and Size, 1983
143
Investor- Not-for- Not-for- State
Owned profit profit and Local
Chain Proprietary Chain Independent Government
Bed Size (%) (%) (~O) (%) i%'
~ 24 0.33 0 0 0.02 0
25- 49 0 0.16 0.14 0.2S 0.01
50- 99 0.15 0.10 0.38 0.43 0.16
100-199 0.18 0.15 1.88 2.63 1.51
200-299 0.89 1.33 3.66 6.75 10.15
300-399 2.60 0.50 8.85 16.53 48.14
400~99 1.50 0.67 29.37 36.62 92.56
500-599 14.00 0 64.86 122.44 195.80
All hospitals 0.44 0.23 9.97 15.48 12.19
*Full-time equivalents.
SOURCE: Hospital Data Center, American Hospital Association, 1985.
largest supporter of biomedical research-
although, of course, there are many other
sources of research support.
Investor-owned hospitals and their parent
companies have been criticized for their lack
of involvement in education and research
on two grounds: for avoiding those costly
but important activities on which the future
of health care depends (and which activities
have never been fully self-supporting), and
for aDege~y attracting away patients on which
some teaching hospitals depended to be able
to cross-subsidize educational activities and
unsponsored research. These charges raise
many of the same issues examined in Chap-
ter 5 (on access to care, particularly of un-
insured patients), but satisfactory docu-
mentation is lacking about most key points,
other than the for-profits' lack of involve-
ment in education and research.
However, these issues and the premises
and assumptions Mat Hey reflect are to some
extent being replaced by new concerns. Since
the outset of this study, investor-owned hos-
pita] companies have greatly increased their
involvement in education and research by
acquiring, leasing, or entering into manage-
ment contracts with hospitals that have long-
starlding affiliations with medical schools and
traditions of significant involvement in ed-
ucation and research. Less visibly, investor-
owned chains have begun to support re-
search within their own institutions and also
by outside investigators.
Little information is available yet with
which to assess the impact ofthese changes.
At this juncture it is possible only to de-
scribe how investor-owned firms are becom-
ing involved in education and research and
to suggest some reasons for this involve-
ment, to speculate about fixture develop-
ments, and to raise potential areas of discuss
that should be monitored.
TEACHING HOSPITALS AND
INVESTOR-OWNED HOSPITAL
COMPANIES
Because of their size, multiple Unctions,
diverse sources of Finding, and relationships
with other institutions, major teaching hos-
pitals are exceedingly complex institutions.
Ibe fimc~ons of teaching hospitals have been
clescribed in capsule form by the Association
of American Medical Colleges (1984b) as fol
Tows:
In addition to the basic hospital services of pri
OCR for page 144
144
mary and secondary inpatient care, teaching hos-
pitals provide Me bulk of the nation's ternary
care for the most seriously ill; regionalized spe-
cial care and stand-by services; clinical training
of physicians arid other health care personnel;
access to medical services for disproportionate
numbers of the poor and medically indigent; arid
the development and testing of new diagnostic
and treatment services.
Teaching hospitals are, of course, the sites
for Graduate medico education (residency)
programs and for the clinical component of
undergraduate education in medicine, nurs-
ing, pharmacy, and the aLied health profes-
sions. Although most support for health
professional education comes through health
professional schools, hospital fiends have been
an important source of support for graduate
medical education by providing space for
instruction, by paying the salaries of resi-
dents and directors of graduate medical ed-
ucation programs, and, in some cases, by
paying medical faculty to supervise and teach
residents.
The funds for this support come from hos-
pital general revenues, most of which are
derived Tom patient care. Third-party pay-
ers for health care traditionally have gone
along with this practice on the grounds that
the presence of educational programs in-
creases the quality of care and that patients,
employers, and payers have a stale in the
continued adequate supply of health man
power.
In addition to transmitting knowledge to
the health professionals being trained therein,
these institutions do much to shape the val-
ues and attitudes of these health profession-
als regarding the place of science in medical
practice, the value of clinical experience,
and the nature of professional responsibility.
A major concern that has been voiced about
the ownership or operation of teaching hos-
pitals by investor-owned firms is that the
ethos of these unique institutions will be
changed.
Since the decline and disappearance of
proprietary medical schools in the late nine
FOR-PROFIT ENTERPRISE IN HEALTH CARE
teenth and early twentieth centuries, clin-
ical teaching activities have taken place almost
exclusively in public or not-for-profit insti-
tutions. The modern experience with for-
profit companies with teaching hospitals goes
back only a few years. Through the 1970s-
the first decade of its existence Tulane
Hospital in New Orieans was managed by
Hospital Affiliates International. Hospital
Corporation of America (HCA) has been
managing the hospital of the College of
Medicine and Dentistry of New Jersey since
late 1982 and more recently has contracted
for management of the University of Mis-
sissippi Hospital. However, only in the past
two years have the first leases and acquisi-
tions of teaching hospitals by investor-owned
companies begun to take place. Recent de-
velopments include
· Humana's lease of the new teaching
hospital at the University of Louisville (now
known as Humana Hospital University)
· American Medical International's (AMI)
acquisition of St. Joseph Hospital, a 539-bed
teaching and tertiary care hospital of
Creighton University
· the proposed construction and lease by
the Forum Group of Indianapolis (a com-
pany whose acute care and psychiatric fa-
cilities have more recently been acquired
by Hospital Corporation of America) of a
psychiatric hospital at the University of South
Florida
· HCA's recent agreements to purchase
Wesley Medical Center in Wichita, Kansas,
and Methodist Hospital in Oklahoma City,
Oklahoma
~ AMI's agreement to purchase Presby-
terian-St. Luke's Hospital in Denver, Col-
orado
~ National Medical Enterprises' agree-
ment with the University of Southern Cal-
ifornia to build a teaching hospital
~ AMI's joint venture with Me George
Washington University for ownership of the
GWU Health Plan (an HMO)
~ an agreement for a joint venture be
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IMPLICATIONS FOR EDUCATION AND RESEARCH
tween Vanderbilt University and HCA for
construction and management of a psychi-
atric hospital
· discussion about the sale or lease of sev-
eral other teaching hospitals, including the
George Washington University Hospital.2
The interest of investor-owned hospital
companies in owning or leasing teaching
hospitals has attracted the most discussion,
and no small amount of controversy (the ma-
jor example being Massachusetts General
Hospital's proposed and aborted sale to HCA
of McLean Hospital, a Harvard University
teaching hospital). However, smaller agree-
ments about specific services such as mag-
netic resonance imaging, psychiatric services,
and outpatient surgical centers are prolif-
erating rapidly.
A variety of motivations have led to the
discussions and negotiations between major
teaching hospitals and investor~wned firms.
These are summarized in Table 7.3. Each
_
instance in which an investor-owned com
pany has entered into the ownership or
management of a major teaching hospital
has hac! its own unique circumstances and
has culminated in a unique arrangement;
145
undoubtedly the mix of motives also is
unique.
Concerns About For-profit Involvement
in Education
As is true of the debate about for-profit
health care generally, much of the concern
is about broad questions of values about
what is the right or wrong way to run a
hospital or to prepare tomorrow's physi-
cians. The proposed or actual takeover of a
major teaching hospital by an investor-owned
company has, in each case, been a visible,
controversial event. In particular, medical
school faculties, who serve as the medical
staff of these hospitals, have viewed such
changes in ownership or management as
threats to traditional values, missions, op-
erating procedures; and power relationships
within He hospital and between it and other
components of academic health centers. More
specifically, faculty physicians have been
concerned that in the interests of satisfying
their investors, these companies sooner or
later will institute changes to
· reduce faculty control over unclergrad-
uate and graduate medical education
TABLE 7.3 Motivations for Negotiations Between Investor-Owned Health Care
Companies and Teaching Hospitals
Motives for Teaching Hospitals and Their Parent
Institutions
Motives for Investor-Owned Companies
To obtain the capital needed for future renovation,
acquisition of equipment, etc., without adding to
hospital cost base
To gain greater cost-effectiveness from advantages in
management, scale, and bottom-line discipline and
freedom from civil service or university personnel,
procurement, and contracting systems
To gain access to new sources of revenues through
referral networks, marketing skills, and emphasis
on patient care
To reduce some governance problems, and reduce
diffusion of the decision-making process
To respond to criticism that they have avoided their
social responsibility by not supporting education
and research
To achieve greater legitimacy, prestige, and visibility
To achieve profits from individual teaching institu-
tions or from regional networks of hospitals and
other health care providers that include these hos-
pitals
To gain access to the capability for technology assess-
ment and other research activities
To provide expert consultations for physicians at
company-owned nontertiary care institutions
To gain access to a pool of physician trainees for pos-
sible fixture recruitment
OCR for page 146
146
· reduce the institutional priority given
to education and research
· narrow the patient mix needed for
teaching and research
· change the values transmitted to health
professional students
· lessen institutional commitment to the
community (including indigent care)
· threaten academic freedom through
pressure to control faculty appointments or
to influence the size and nature of the ed-
ucation and research programs
· reduce funds that are supporting fac-
ulty for their supervision of residents, ser-
vice on hospital committees or as service
chiefs, or other education-related activities.
The sale of a facility can also mean relin-
quishing control over such major future pos-
sibilities as the resale or closure of the facility.
On the other hand, some opportunities
may be involved beyond the factors (such
as access to capital) that motivate the hos-
pital to explore relationships with for-profit
organizations. It can be argued, for exam-
ple, that it is valuable to expose the health
professional in training for health care de-
livery in an environment where concern for
the bottom line perhaps weighs more heav-
iTy than in traditional settings; to provide
experience with the type of large-scare or-
ganizations that some observers see as con-
stituting the future of health care; or, perhaps,
to increase student access to community
hospitals, nursing homes, and freestanding
ambulatory care centers that companies own.
It is as yet impossible to assess the extent
to which the potential positive and negative
outcomes will come to pass. There are sev-
eral reasons for this.
First, instances of the takeover of a teach-
ing hospital by an investor-owned company
are so recent that there is very little expe-
rience on which to base an assessment. The
number of cases is too small to permit sta-
tistical study, and not enough time has passed
for careful case studies, although such case
studies would be of great value.
.
FOR-PROFIT ENTERPRISE IN HEALTH CARE
Second, in response to financial pres-
sures, many changes are taking place in
teaching hospitals that would undoubtedly
occur even if investor-owned companies did
not exist. The advent of hospital prospective
payment, aggressive cost-containment ac-
tivities by employers and third-party pay-
ers, the establishment of PPOs, and so forth,
are causing reduced hospital admissions,
shortened lengths of stay, and increased
pressure for greater cost-effectiveness. Fed-
eral support for education and research has
declined, as has state support.
Teaching hospitals have not been imper-
vious to these pressures. Their responses,
some of which have been dramatic, include
establishing for-profit subsidiaries
~ changing governance structures, for in-
stance, becoming independent of the uni-
versity
~ changing management styles and ad-
missions policies
~ reducing the autonomy within the in-
stitution of those whose primary concerns
are educational
~ joining multi-institutional arrangements.
Thus, the status quo is unlikely to be
maintained, even at institutions that do not
become involved with an investor-owned
company. Isolating the ejects of ownership
changes in the presence of so many other
forces for change will be difficult at best.
Third, teaching hospitals are a very di-
verse lot. Something that might represent
a significant change in one institution may
not be a change at all in another. Teaching
is not the highest priority at all teaching
hospitals. Although teaching hospitals as a
whole carry a disproportionate burden of
uncompensated care, not all teaching hos-
pitals do so, and not all teaching hospitals
support unfilnded clinical research (lIanft,
19861. Teaching hospitals have a wide range
of case mixes, and they vary in the extent
of their involvement with education; in the
nature and extent of their university/medi-
cal school ties; in their type of ownership
OCR for page 147
IMPLICATIONS FOR EDUCATION AND RESEARCH
(some are private, some are public and re-
ceive state appropriations); in their size; and
so forth. Thus, there is no one "standard
model" teaching hospital against which to
measure changes introduced by a manage-
ment contract or the sale or lease of insti-
tutions.
Fourth, the goals of providing teaching
and research may not be inconsistent win
the Tong-term corporate goals of investor-
owned firms. Conversely, medical schools
and academic health centers are not without
entrepreneurial interests and endeavors.
Faculty group practices, for example, have
for many years been an important source of
fiends for medical schools. By 1983, income
Tom medical service represented Dom one-
fourth to one-half of medical school reve-
nues (Petersdorf, 1985~. This means a con-
siderable shift in emphasis from teaching
and research toward practice. As one med-
ical school dean recently described matters,
Most faculty of medicine are, to a progressively
greater extent, engaged in practice or in its ad-
ministration. More and more hours of the faculty
are spent in the operating room, the consulting
room, or the clinic, and more and more chairmen
and deans are investing their time in the admin-
is~ation of practice plans and in conferring with
lawyers and accountants (Petersdorf, 1985:2546~.
Fifth, the arrangements by which inves-
tor-owned companies have become in-
volved with teaching hospitals vary
considerably. Specific safeguards can be built
into contractual agreements. The details of
the agreement may be at least as important
as involvement with an investor-owned firm.
Crucial issues include
sale
· whether the agreement is a lease or a
· how the medical school, the company,
and other interested parties (e.g., the com-
munity) will be represented on the board
· the relative authority of the hospital
board and the company regarding such mat-
ters as medical staff composition and gov-
ernance, mix of services provided, purchase
147
of major equipment, hospital staffing (par-
ticularly nursing), allocation of space, and
. . it..
at mission policies
· the nature of provisions, if any, for end-
ing the relationship (Are there buy-back
provisions? How are they invoked?)
· provisions for continuing historical mis-
sions (e.g., a formula perhaps based on
percentage of revenues fixing a continuing
financial commitment to teaching, research,
or uncompensated care)
~ whether the hospital or university shares
in profits.
What will happen in the joining of cor-
porate medicine and educational medicine
depends to some extent on such details in
agreements between companies and insti-
tutions, as weD as on the reasons why the
parties are interested in the relationship.
Hospital interest seems to stem primarily
from a need for capital and, to a lesser ex-
tent, from a need to reduce or eliminate
operating deficits. Also, the boards of some
institutions may wish to improve their po-
sition in an increasingly difficult and com-
petitive environment (or to extricate
themselves and the capital for which they
are trustees from this environment). The ex-
planation of the companies' interest is more
speculative, but it nonetheless will have a
great deal of impact on the way the acquired
hospitals are operated. The particular com-
bination of motivations that underlie the in-
terest of investor-owned companies in
teaching hospitals will doubtless have much
to do with which of the predicted benefits
and problems come to pass.
The fact that the number of major teach-
ing hospitals is small enough to facilitate
communication and sharing of information
has two important implications. First, cor-
porate reputations are at stake to an unusual
degree. Second, institutions cart learn from
each other's experiences in a way that sel-
dom has happened among the smaller, more
isolated institutions that have been acquired
over the years by investor-owned compa
OCR for page 148
148
nies. It is also likely that the experiences of
the first few teaching hospitals to be ac-
quired may not be good predictors for the
long run, because of their visibility, and be-
cause of the interest of the investor-owned
companies in achieving legitimacy and
avoiding negative reports (and the hospitals
in having made sound decisions). Both the
terms that can be reached between the com-
panies and the hospitals (or their owners)
and the consequences of involvement of
investor ownership in teaching hospitals may
be different in the fixture. In EgdahI's (1986)
terms, early acquisitions (and, presumably,
prestigious institutions that are acquired later)
may have a kind of"flagship" status in the
companies and, as such, may be tolerated
as "prestige loss leaders."
Research
The growing involvement in research by
investor-owned health care companies now
takes several forms. As has been discussed,
these corporations have begun to purchase
or lease hospitals in which research is done.
In addition to the examples of teaching hos-
pitals already discussed, at least one ex-
ample of a nonteaching hospital can be cited
(Humane Hospital Audubon, home of the
Humana Heart Institute). Corporations also
enter agreements with researchers, or com-
panies such as pharmaceutical manufactur-
ers, enabling them to use the health care
companies' multiple facilities or data bases
for research purposes. Some corporations
have also begun to provide support for re-
search and development activities. Hu-
mana's pledge to provide resources for
support of its Heart Institute and Dr. Wil-
liam DeVries's artificial heart implant pro-
gram is well known. Humana and HCA
(through a company-established foundation)
have made substantial grants for biomedical
research (e.g., a Humana grant of $320,000
to Vanderbilt University School of Medi-
cine). HCA has made several grants (to Har
FOR-PROFIT ENTERPRISE IN HEALTH CARE
yard University, He University of Minnesota,
the University of Pennsylvania, Vanderbilt
University, Washington University, North-
western University, and the University of
Wisconsin) for health services research, and
several companies have cooperated in or-
ganizational studies of multi-institutional
systems. A chair in law, medicine, ant! pub-
lic policy was created at the University of
Southern California by an endowment from
National Medical Enterprises. Other health
services research and technology assess-
ment are conducted in the corporation ei-
ther for internal management purposes or
to make information public about the com-
pany and its activities.
These developments are mostly very re-
cent and have yet to be systematically stud-
ied. Some are typical of corporate
philanthropic activities; others are peculiar
to the circumstance of acquiring an insti-
tution where research is conducted. Al-
though the conduct or support of research
is generally recognized as a public good,
there are a number of concerns about the
research involvement of health care com-
panies, including the acquisition of institu-
tions where research is conducted.
First is the concern that unsponsored re-
search may be curtailed at acquired insti-
tutions. Although most biomedical research
studies receive outside support (from the
National Institutes of Health, the pharma-
ceutical industry, or other sources), some
unsponsored research is conducted at many
institutions. The extent and quality of such
research is largely undocumented, but
teaching hospitals traditionally have allowed
medical investigators access to their patients
and patient records and have provided small
amounts of resources to facilitate studies.
Much of the research that is supported is
preliminary work that can lead to a filll-
fledged research proposal, for which outside
Ending can be obtained. However, because
it may not contribute to (and may, in fact,
detract from) the bottom line, it is feared
OCR for page 149
lMPLlCATIONS FOR EDUCATION AND RESEARCH
that unsponsored research is vulnerable in
a change to for-pro~St ownership.
Second, there is concern that investor-
owned hospitals may limit access by outside
researchers. Although there have been ex-
ceptions, health care institutions generally
have been very open to study. A degree of
openness to responsible research has been
a part of the public accountability of health
care institutions. The world of business is
generally not so open, and, as competitive
conditions increase, health care institutions
generally are becoming less open. It is im-
portant to note, however, that a number of
examples can be cited in which an investor-
owned hospital company has cooperated with
requests from outside researchers for access
to, or information about, the company or
institutions that it operates.
Third, some checks and balances against
excesses done in the name of research may
not be present when the same institution
that owns patient care institutions also has
commercial interests in research that in-
volves patients as subjects. An example is
provided by Humana's commitment to the
artificial heart program in one of its hospitals
and its ownership of stock in SYmbion~ the
company that makes the larvik-7 artificial
heart. Perhaps because of the danger that
Humana's investment in the artificial heart
might conflict with its responsibilities to pa-
tients in its hospitals, Humana reported in
its 1984 Annual Report that it is selling its
Symbion stock, although Humana's execu-
tives continue to own stock, and one sits on
the Symbion board. Similar issues would
have arisen had the proposed merger taken
place between lICA and the American Hos-
pital Supply Company, the manufacturer of
many devices used in patient care (e.g., ar-
tificial valves for hearts). If research on new
drugs, devices, or procedures is contem-
plated in hospitals owned or managed by
companies with a commercial interest in the
particular drugs, devices, or procedures, He
need for some additional safeguards beyond
149
local institutional review boards may de-
serve consideration by the appropriate reg-
ulatory agencies (e.g., the Food and Drug
Administration).
Fourth, the possibility of changes in the
operation of the norms of science at re-
search/health care institutions operated by
for-profit firms gives rise to concern. The
linkage of health services research and com-
mercial interests in a field that is highly sen-
sitive to public policy may make it more
important than ever for the consumer of re-
search to be wary. However, this linkage is
hardly peculiar to the for-profit setting. It
is also possible that large, well-financed
companies may seek competitive advantage
in the conduct of proprietary research whose
fruits are not shared outside of the company,
although a return to nineteenth century pro-
prietary therapeutic practices does not now
seem likely.
CONCLUSION
Investor-owned companies have only be-
gun to have substantial involvement in ed-
ucation and research within the time span
of this study. The most visible and contro-
versial form of involvement has been the
purchase, lease, or management of teaching
hospitals, but these firms have also begun
to engage in research internally and to fund
research by academic investigators. The
committee believes that experience is now
too limited to allow an informed evaluation
of the consequences of such arrangements.
Because there are so many unique aspects
of each institution and each agreement, it
may be a Tong time indeed before general
conclusions can be drawn. Carefi~! case
studies by disinterested investigators, as wed
as evaluations by interested parties (AAMC,
companies, medical schools, etc.), should be
conducted to maximize what can be learned
from these early examples.
Corporate involvement with teaching
hospitals comes at a time when there is a
,¢
OCR for page 150
150
great deal of pressure by society to reduce
the cost of health care, and, of particular
relevance here, to stop paying for health
services at levels that enable hospitals to
subsidize education and research. The in-
direct education support enacted with pro-
spective payment for the Medicare program
has been a target for reduction or elimina-
tion, and teaching hospitals are facing greater
and greater difficulty in competing for pa-
tients with lower-cost hospitals. Teaching
hospitals, whether for-profit or not-for-profit,
are going to have to face some hard choices.
There seems little doubt that many teaching
hospitals will take actions to reduce their
level of involvement in research and edu-
cation (as they are reducing their level of
indigent care), to find new revenues to sup-
port these programs, or both.
Teaching hospitals and large companies
are complex organizations with multiple ob-
jectives, a primary one being continued ex-
istence and a niche in the community.
Because of their complexity and the com-
plexity of the changes talking place, the eval-
uation of change wiD be very difficult. Also,
because of the formidable amounts of capital
required, the complexity of the institutions
and their long traditions' and their ques-
tionable profitability, the committee does
not expect to see a large number of teaching
hospitals coming under the control of inves-
tor-owned companies in the near fixture, al-
though more limited relationships, involving
specialized facilities or programs, may con-
tinue to proliferate.
NOTES
~ More than 1,150 U. S. hospitals have affiliations win
medical schools (American Hospital Association, 1984~;
424 hospitals were members ofthe Council of Teaching
Hospitals (COTH) in 1984, membership that requires,
among other things, four major residency programs and
close affiliation with a medical school. Depending on
definitions, there are between 100 and 175 "major"
teaching hospitals in the United States (Hanft, 1986~.
Sixty-four hospitals have common ownership with a
medical school (Association of American Medical Col-
leges, 1984a:5~. The hospitals comprising the Council
FOR-PROFIT ENTERPRISE IN HEALTH CARE
of Teaching Hospitals are disproportionately large (more
than half have at least 500 beds), and they are found
in disproportionate numbers in a few states (39 percent
of the COTH members are located in the northeast
region ofthe country) (Association of American Medical
Colleges, 1982~.
2At least 12 other teaching facilities are now managed
by investor-owned corporations. For a list and discus-
sion of how interested parties view the issues raised
by investor-related academic health centers, see Gold-
smith (1985~.
REFERENCES
American Hospital Association (1984) Hospital Sta-
tistics. Chicago, Ill.: American Hospital Association.
Association of American Medical Colleges (1982) A
Description of Teaching Hospital Characteristics.
Washington, D.C.: Association of American Medical
Colleges.
Association of American Medical Colleges (1984a)
New Challenges for the Council of Teaching Hospitals
and the Department of Teaching Hospitals: A Discus-
sion Paper. Washington, D.C.: Association of Arneri-
can Medical Colleges.
Association of American Medical Colleges (1984b)
Statement on Financing Undergraduate and Graduate
Medical Education, presented to the Subcommittee on
Health, U. S. Senate, Committee on Finance, October
1, 1984. Published in Background Information and
Selected Readings, Preparedfor the Committee on Fi-
nancing Graduate Medical Education (revised, No-
vember 1984~. Washington, D.C.: Association of
American Medical Colleges.
Egdahl, Richard G. (1986) A Perspective on the In-
volvement of For-Profit Hospital Chains with Teaching
and Research Institutions. Paper prepared for the 1984
Harold and Jane Hirsh Symposium, The George Wash-
ington University, and published in Warren Greenberg
and Richard McK. F. Southby (eds.), For-Profit Hos-
pitals: Access, Quality, Teaching, Research. Colum-
bus, Ohio: Battelle Press.
Goldsmith, Marcia F. (1985) Investor-related Aca-
demic Health Centers: An "Uncertain Courtship"?
Journal of the American Medical Association 253Qune
1):304 307.
Hanit, Ruth (1986) For Profit Hospitals: Lee Impli-
cations for Teaching and Research. Paper prepared for
the 1984 Harold andiane Hirsh Symposium, lee George
Washington University, and published in Warren
Greenberg and Richard McK. F. Southby (eds.), For-
Profit Hospitals: Access, Quality, Teaching, Research.
Columbus, Ohio: Battelle Press.
Petersdorf, Robert G. (1985) Current and Future
Directions for Hospital and Physician Reimbursement:
Effect on the Academic Medical Center. Journal ofthe
American Medical Association 253(May 3~:2543-2548.
Representative terms from entire chapter:
medical colleges
