University Times

Almost all academic administrators of universities that own or control teaching hospitals are re-examining their relationship to them. In fact, several universities are seeking to spin off their teaching hospitals or merge with other medical centers. These universities include Columbia, George Washington, Tulane and Iowa. Why not Pitt? Two years ago, Jonathan Cole, provost of Columbia University, wrote in the journal Daedalus, "It [federal funding] has led to enormous growth of health science divisions at research universities, has altered the relative size of health science compared with the arts and sciences and other professional schools, and has produced uncertainty about the future of scientific research at universities dependent on continued government support." Many academic administrators now acknowledge that we have moved into a period when the country and all its health care institutions must come to grips with burgeoning medical care costs. There is widespread concern that the portent of economic constraints will soon cause significant shortfalls in financing clinical specialty training and research. Of unique concern to academic medical centers are changes due to:

1. The growing inability to shift funds from insurance payments to training and research.

2. Cutbacks in government funding for specialty training in academic medical centers.

3. Plunging revenues as a consequence of competitive pricing for health care services by managed care plans.

Academic medical centers, which had been reimbursed by the insurance industry for much higher charges than the actual costs of medical care, are now left without those funds for research and training support.

The capacity of academic medical centers to amass sizable reserves of government funds from excess Medicare revenues could soon end.

Despite a commitment by some HMOs to the contrary, the rapidly growing managed care industry has almost totally neglected the need for funding medical education, clinical specialty training or biomedical research. Without access to new sources of funding, research and training programs will have to be curtailed.

These changes did not happen overnight but Pitt, like some other academic medical centers, failed to acknowledge them. The 20th century in the United States saw medical care undergo a metamorphosis from generalist to specialist, from solo to group practice, from direct payment to group insurance, from fee-for- service to capitation payments, and from a cottage industry to the corporate management of health care services. At the same time, tuition-supported university-based medical schools became increasingly assimilated into overstaffed academic medical centers that depended on federal funds for training and research.

The loss of private sector payments along with scheduled fiscal reductions of both direct and indirect costs of clinical specialty training have caused some to question whether a university should bear any responsibility for staffing, managing, or operating an academic medical center or whether it should be responsible only for administering its own medical school.

Put another way, should the university assume its peerless responsibility for instructing medical students during their four years of medical education while teaching hospitals reassume their obligation for clinical specialty training in the community after students finish medical school? One solution is for Pitt to separate medical education from clinical specialty training administratively.

With such a separation, Pitt's medical school would require little, if any, restructuring of its library, classroom, computer and laboratory space. Clinical instruction for medical students could continue to be provided in a variety of settings: from tertiary care teaching hospitals to community teaching hospitals, from HMOs to individual doctors' offices, from rural clinics to neighborhood health centers, from half-way houses to alcohol, drug abuse and mental health centers, and from long term care facilities to home health agencies. Much of what was formerly inpatient care now is taught on out-patients far beyond hospital wards or operating suites.

Some well known examples for the dispersion of students to community sites already exist. Harvard Medical School has long been linked to numerous outstanding teaching hospitals, each with its own set of satellite clinical services. The university, however, is not financially responsible for any of them; each of the Harvard hospitals provides clinical instruction for medical students and also serves as a free-standing academic medical center. Another such example is the Mayo Medical School. With such linkages, the clinical components of medical education can take place in association with accredited clinical training sites for providing specialty training programs for primary care physicians and specialists.

The need for a wide variety of community-based hospitals and health care organizations stems from the changing nature of health care financing which, along with advances in science and technology, has triggered the formation of specialized facilities to deliver health care services.

Locally, witness the acclaim and prestige enjoyed by highly specialized institutions such as the community-based Children's and Magee-Womens hospitals, which exist alongside but are not part of the University of Pittsburgh Medical Center (UPMC).

Awareness of the current financial volatility affecting academic medical centers should necessarily prompt a cautious approach by the University to assume any fiduciary responsibility for clinical specialty training. But before assuming academic responsibility again for medical education, Pitt would need to review carefully whether any encumbrances exist from past dealings with UPMC.

If UPMC were to be recast as a freestanding tertiary care medical center, its teaching hospitals could be closely affiliated with the medical school but would not have to be administered by a senior vice chancellor for Health Administration. Medical staff incomes would more closely reflect those in the community. The staff from University affiliated hospitals could then be requested to provide clinical instruction deemed appropriate for medical students, much as the faculty does now at Children's and Magee.

Basic science coursework and coordination of clinical instruction and electives for Pitt medical students could readily be handled by a small cadre of full-time medical school faculty members instead of the more than one thousand physicians now employed full-time by the University to teach, conduct research and provide patient care in UPMC.

These proposed changes could well steer the balance of the faculty from the School of Medicine to closer working relationships with the rest of the University. Dissimilarities in perquisites and other organizational arrangements that currently differentiate the two faculties could also be reduced.

By creating a free-standing medical academic center, affiliated with its medical school, Pitt could become a national role model for other academic medical centers facing the same or similar problems. By restructuring its academic medical center, Pitt could avoid the likelihood of administrative and financial chaos that might well result from diminished federal funding and the unforeseen financial repercussions of managed care in an academic setting.

Gordon K. MacLeod is a professor of Health Services Administration in the Graduate School of Public Health and a clinical professor of medicine in the School of Medicine.