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Barach P. Teaching Hospitals in Trouble: Finding Solutions. JAMA. 1999;282(17):1686. doi:10.1001/jama.282.17.1686
Last week's Resident Physician Forum column explained some of the financial
challenges facing teaching hospitals and the threat that reduced funding poses
to graduate medical education (GME). To address these challenges, legislators
and medical educators have proposed several ways to strengthen GME funding.
Sen Daniel Patrick Moynihan (D, NY) has introduced a bill to revamp
the financing of GME in the United States. His plan calls for freezing the
GME subsidy at its current level and not permitting further annual reductions.
Another suggestion has been to pay teaching hospitals directly for treating
low-income patients and training nurses, rather than continuing to pay Medicare
managed care plans for those services.
The National Bipartisan Commission on the future of Medicare and the
Medicare Payment Advisory Commission have spent a great deal of time analyzing
Medicare and its role in funding GME. Both groups recommended reducing the
number of GME positions, providing transitional support for institutions that
choose to downsize their GME programs, and providing stable support for teaching
hospitals. They suggest that Medicare's direct medical education funding,
which pays for the direct operating costs of a residency program, including
resident and attending salaries and benefits, either be funded through a separate
entitlement program or through a multiyear discretionary appropriations. They
believe this would separate the needs of teaching hospitals from the prevalence
of political machinations.
Some, including the American Medical Association, have suggested establishing
a separate medical education trust fund that would be financed by a fee levied
on private health insurance premiums, as well as contributions from Medicare
and Medicaid. Maryland for example, has an all-payer statute, which requires
contributions to GME funding by all insurers. This proposal has the advantage
of broadening the burden of paying for medical education.
All stakeholders must come to regard the financial well-being of teaching
institutions as vital to America's health care system. The ultimate standard
for these institutions must be not only superior training and the dissemination
of specialized knowledge, but also the ability to deliver the best medical
care available anywhere. We must shore up this key part of the nation's biomedical
infrastructure. All changes should aim to preserve the cost-containment measures
included in the 1997 law. Simply plugging holes in the current funding patchwork
will not ensure stability for the future.
If we want to continue at the cutting edge of research and provide the
highest quality patient care, we must revamp the archaic system of financing
medical education in the United States. For physicians to have any say in
this critical debate, GME financing and infrastructure must become part of
the undergraduate, graduate, and CME curriculum. If we do not make our voices
heard, others will make these crucial decisions for us—decisions that
will have ramifications for many generations to come.