Changing Health Care Systems and Rheumatic Disease (1996) / Chapter Skim
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10: Issues and Insights Regarding Research, Education, and Training
10: Issues and Insights Regarding Research, Education, and Training
Pages 189-208
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From page 189... ...
10 Issues and Insights Regarding Research, Education, and Training ~9
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From page 191... ...
He contends that when all of these sources are cut, it is questionable if the number of physicians who can train and the opportunities to practice with expensive therapies can be maintained at current levels. It also is unlikely that managed care and integrated care entities, whether they eventually affiliate with teaching hospitals or not, will continue to provide the revenue now given in other forms to make crosssubsidies for care provision and research possible.
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From page 192... ...
Medical schools may decide to affiliate with managed care to form vertically integrated health systems and use managed care practices as training sites for students and residents, or as pointed out by Meenan, they may elect to be free-standing educational enterprises without their complicated missions of today. In his mind the ultimate questions then boil down to the following: (1)
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From page 193... ...
Most of the impacts of health care system change on medical care process and outcome for people with chronic rheumatic diseases will result from two of Reinhardt's factors: management of care and risk-based financing. The major impacts of change on medical research, education, and training, however, will derive primarily from market competition and its direct and indirect effects on academic medical organizations.
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From page 194... ...
Finally, medical research, education, and training will be affected in major ways by the growing market power of managed care organizations in an increasingly competitive health care system. As these entities become major customers for academic medical organizations and as they become progressively larger corporations with growing influence on a range of public and private policies, they will increasingly define their own agendas for research, education, and training.
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From page 195... ...
Medical schools currently underwrite basic research with cross-subsidies from clinical income. As the clinical incomes of academic medical organizations continue to decrease, this cross-subsidization will be markedly attenuated, if not eliminated.
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From page 196... ...
These include major in-house units in larger managed care organizations and numerous private sector companies that are building their health care research capacities. Both of these developments represent direct competition with academic medical organizations in the search for health care research dollars.
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From page 197... ...
Once again, the most immediate and obvious impact of such change will be a progressive, competition-driven decrease in clinical income to medical schools and their clinical faculties. A combination of competition from nonacademic medical care providers and decreases in reimbursement levels from payers will cost academic medical organizations billions of dollars per year in clinical income.
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From page 198... ...
To the extent that academic medical organizations do not change their approaches to training, it is possible that managed care organizations will set up their own training programs, particularly for generalist physicians. It is unlikely, however, that managed care organizations will ever directly support rheumatology training.
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From page 199... ...
RESEARCH, EDUCATION, AND TRAINING 199 competition-driven system takes form, approaches to research, education, and training will arise that are most appropriate for the new system. The question is not how current approaches to research, education, and training can be supported under the new system.
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From page 201... ...
For the 225 major teaching hospitals, about one-third of their DRG payment is based on indirect medical education and disproportionate share hospital (DSH) payments.
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From page 202... ...
What managed care plans want is efficient, patient-friendly care; a work force that can practice in a managed care setting; and research results that help them produce better outcomes at lower cost for their enrollee populations. If academic health centers are going to stay in the forefront of research as power shifts to managed care organizations, they will have to devote greater attention to those goals.
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From page 203... ...
This is one of those balloon-like problems where you press on one end to reduce it and it simply pops out someplace else. International medical graduates not only raise issues about rational planning for graduate medical education, but also raise central questions about the purpose of medical schools in the evolving health care system.
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From page 204... ...
One issue that must be addressed in any restructuring of medical education and training is the consistent instillation of a mind-set that physicians should maximize total benefit without regard for marginal benefit and the cost of the next increment of benefit. A key point I make when I talk to medical students about clinical decisionmaking is that one can look at medical practice as a giant two-by-two table, in which "positive/positive" and "negative/negative" are the preferred boxes to be in.
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From page 205... ...
The health care marketer asks what service, approach, or product can I produce that will have enough value for the market to buy it? One positive result of the evolving health care system would be to produce more marketing and less selling and believing.
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From page 206... ...
It comes in jumps, and sometimes we jump for surprising reasons. BEVRA HAHN: Do you think we should be teaching two separate groups in medical school: one group for efficient outpatient care in a managed care setting and the other for intensive inpatient care, so that the physician groups are different, as they are in Britain?
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From page 207... ...
RESEARCH, EDUCATION, AND TRAINING 207 presented by patients. We should be very careful, as we train the next generations of generalists, to be sure of two things.
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