[Congressional Record Volume 143, Number 105 (Wednesday, July 23, 1997)]
[Extensions of Remarks]
[Page E1487]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




   GROWTH IN MANAGED CARE MAY BE RESPONSIBLE FOR DECLINE IN MEDICARE 
                                RESEARCH

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Wednesday, July 23, 1997

  Mr. STARK. Mr. Speaker, in recent months, the future of graduate 
medical education [GME] has been one of the most frequently discussed 
topics, both by this Congress and the interested public. While the 
budget reconciliation bills currently underway in the Congress make 
some changes in GME, the key long-term problems are not being 
addressed, and time is running out for our Nation's premier academic 
teaching and research institutions.
  Health care in 1997 is far different than it was in 1965 when 
Medicare was established. The environment and methods for training the 
next generation of physicians and other health care providers has 
changed, but the way we fund that training has not kept pace. The 
evolution of managed care has had a definite impact on our medical 
schools and our academic health centers. Governmental support in the 
form of Medicare has been sufficient in the past, but similar 
guarantees no longer exist. Now is the time to consider revolutionary 
changes in graduate medical education. The establishment of an all-
payer trust fund, supported by the Government, as well as by all users 
of health care, is a reasonable option to consider. If we don't begin 
to rethink and change the way in which we currently fund graduate 
medical education, the quality and stability of health care in America 
may be the price we pay.
  The most recent edition of ``The Journal of the American Medical 
Association'' [JAMA] includes an alarming study that may represent the 
direction we are heading if we continue to treat graduate medical 
education the same way it has always been treated. The study focuses on 
the decreasing levels of research being conducted in academic medical 
centers. The authors found that, ``Anecdotal evidence suggests that 
managed care has the potential to affect research conducted in academic 
medical centers by challenging clinical revenues.'' Their findings 
provide evidence of the existence of an inverse relationship between 
growth in awards by the National Institutes of Health [NIH] and managed 
care penetration among U.S. medical schools. They found that medical 
schools in markets with high-managed care penetration had slower growth 
in dollar amounts and numbers of NIH awards compared to schools in 
markets with low- or medium-managed care penetration.
  If managed care has the potential to affect research levels in a 
negative manner, then we must find a way to provide for alternative 
funding mechanisms to continue research in our medical schools and 
academic health centers. An all-payer trust fund could help support 
vital and necessary research activities in appropriate settings.
  The authors state:

       Managed care plans often select physicians and hospitals on 
     the basis of cost. As managed care entities negotiate 
     discounted fees with the faculty practice plans and teaching 
     hospitals that support medical schools, the ability of 
     medical schools to maintain their research base may be 
     jeopardized.

  It is a known fact that medical schools in the United States rely 
heavily on clinical revenues generated by their faculty. These revenues 
help support a wide variety of medical school functions, including the 
core academic programs, undergraduate and graduate medical education, 
and biomedical research. According to the study in JAMA, this clinical 
support was estimated to total $2.4 billion in 1993. Of this, 
approximately $816 million or $0.10 of every faculty practice plan 
dollar collected was used to finance research. If the emergence and 
growth of managed care has had a demonstrable impact, as suggested by 
the article, then we must explore other avenues to ensure that valuable 
research activities are not sacrificed in the process.
  Establishing an all-payer trust fund would better ensure that all 
components of medical education receive adequate support. For years, 
Medicare has been the single best source of reliable funding for 
teaching and research hospitals, but the available funds are already 
shrinking in relative terms as we struggle to maintain solvency of the 
Medicare trust fund while preparing for the aging of the baby boom 
population. An all-payer trust fund would help alleviate some of the 
current drain on Medicare through GME while concurrently increasing the 
total amount of funds available to qualified institutions. A trust fund 
would rely on support from a broader patient population than exists 
today. It would require fair and equal contributions from all those who 
benefit from care provided by physicians and health care professionals 
trained in the world's most advanced and well-respected institutions.
  The idea has been discussed previously. Research today. What about 
tomorrow? What activities will be sacrificed next because of 
insufficient funds in the world of health care? If we continue to 
delay, we may discover the hard way what the answer to that question 
is. That's one risk I don't intend to take. The time for support is 
now. The report of a decline in research activities should be a call to 
action.

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