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~ 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
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
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
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
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
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
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
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 ,¢
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.
