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Research and teaching are potential casualties of the managed care revolution because of changes in how clinical operations are funded, said Joseph Hopkins, medical director for health plans at Stanford Hospital and Clinics. Hopkins, who last year testified to a state task force on managed care issues, told the Jan. 21 meeting of the Stanford Hospital deputy chiefs committee that "everyone knows that the mission of the academic medical center [AMC] is education, research and patient care, but what is less well known is that the education, research and patient care funding is intimately intertwined, and once you start monkeying with one of these funds flows, you cause major changes in the whole system," negatively impacting all three aspects of the mission. Hopkins talked to the deputy chiefs about testimony he had prepared for the State of California Managed Health Care Improvement Task Force on Sept. 23. That task force, which in January issued more than 60 recommendations for changes in managed care, was chaired by Alain C. Enthoven, the Eccles Professor of Public and Private Management in the Graduate School of Business. "In effect, managed care is providing a revealing demonstration of the sensitivity of all AMC activities to destabilizing influences in one area. The results have led to crisis in AMCs and dire predictions [from experts] if the trend continues," Hopkins wrote to the task force. For example, Hopkins told the deputy chiefs about a trend he has seen among managed care patients who transfer their capitation to Stanford for a month or two when they need complex or high-technology interventions. During the episode of advanced treatment, Stanford receives only the capitation fee, which reverts to the patient's former medical group following the expensive procedure carried out here. "Frequent switching in and out of AMC care results in dramatic underpayment of AMCs and is inconsistent with the basic actuarial principles of capitated care," Hopkins said. Furthermore, "there are insufficient guidelines for determining when care is beyond the expertise of local medical groups and should be referred to AMCs." One solution that Hopkins proposed is to restrict patients from transferring their capitated benefits at the first of each month. Hopkins has recommended that when patients transfer their managed care benefits from one group to another, they become fee-for-service patients for approximately 60 days to reduce the impact on the specialty center. The task force has recommended that payments to at-risk providers be adjusted for severity of illness in the patient population, which Hopkins says will offer some relief. Managed care organizations also contract with centers such as Stanford for tertiary and quaternary care, such as organ transplantation, "and insurers are now seeing the financial benefits of consolidating this highly specialized care, including improved outcomes and lower costs" because of efficiency. Risk-adjusted capitation needs to be more fully developed, Hopkins said. Hopkins also told the deputy chiefs that a 1995 study in the Journal of the American Medical Association disclosed that academic medical centers located in areas with a high managed care penetration receive significantly less federal research funding than comparable institutions in areas where fee-for-service is still dominant or at least co-equal with managed care. While the precise reason has not been determined, Hopkins said the evidence suggests a variety of causes, including less time available to busy clinical researchers to undertake projects - even to fill out grant applications - as well as less time and fewer resources to mobilize patients to participate in trials. Because of the pressures to see larger numbers of patients, young faculty members are leaving academic centers because they perceive they can make more money in private practice "doing the same thing, since there's little time for research and teaching any way," Hopkins said. Teaching has been affected, Hopkins said, because not only do faculty find they have less time to teach but voluntary clinical faculty members from the community are also busier and have less time to devote to teaching. Overall, the clinical enterprise has become more important because academic medical centers are increasingly drawing a larger percentage of their funding from clinical practice. For example, a 1996 study by Lewin-VHI, a Fairfax, Va., consulting firm, noted that clinical income accounted for 22 percent of total revenues in 1980-81 but had grown to 46.5 percent in 1993-94. The study was based on data collected nationally from the Liaison Committee on Medical Education (LCME). |
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