[Federal Register Volume 59, Number 124 (Wednesday, June 29, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-15772]


[[Page Unknown]]

[Federal Register: June 29, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service

 

The Effect of Managed Care on Academic Medical Centers--Request 
for Comments

AGENCY: Office of the Assistant Secretary for Health.

ACTION: Notice of request for comments.

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SUMMARY: The Public Health Service (PHS) is seeking public commentary 
concerning the effect of managed care organizations on academic medical 
centers. PHS is interested in examining the role of academic medical 
centers and their financial viability under a health reform system that 
would significantly expand the number of people insured through managed 
care organizations. Respondents are asked to identify issues of 
interest, to be analyzed in a future study.

DATES: The deadline for submission of comments is July 11, 1994.

ADDRESSES: Comments should be sent to: Dan Ermann, Room 740G, 200 
Independence Ave. SW., Washington DC 20201.

SUPPLEMENTARY INFORMATION: Academic Medical Centers (AMCs) are a 
cornerstone of the current medical educational system, and undertake 
three distinct activities: teaching, research, and patient care. 
Funding for AMC programs currently relies heavily on patient revenues.
    Managed care organization (MCOs) have grown rapidly over the past 
decade and are projected to account for approximately 40 percent of all 
insurance coverage by 2000. Under most health reform plans being 
debated, the market share of MCOs would grow even more rapidly than 
this projection. MCOs contract with specific providers to serve their 
enrollees, focusing on providing quality health care at the lowest 
negotiated price. AMCs, with higher charges than most non-teaching 
hospitals, may not be able to offer competitive prices to MCOs for many 
services. With MCOs managing an increasing share of health care 
expenditures and patient volume, and with a growing emphasis on price 
competition in the insurance market, it is possible that relatively 
expensive AMCs will face a reduced patient volume and lower revenues. 
This is likely to affect the way AMCs operate, potentially jeopardizing 
teaching and research quality and/or patient access to specialized care 
procedures.
    The goals and practices of AMCs and MCOs are in many ways 
incompatible. First, since patient expenditures are expected to 
subsidize teaching, research, and the training of interns, many types 
of health services are more expensive at AMCs than at non-academic 
hospitals. Since MCOs seek efficient and low-cost health care 
providers, they may be less likely to contract with an AMC than a non-
academic hospital. Second, most AMCs emphasize hospital-based medical 
education, and a high proportion of their resident physicians are 
training for medical specialties. MCOs emphasize the use of primary 
care physicians to manage patient care and to provide treatment. 
Referral specialties are used only when the primary care physician 
determines that this level of care is required. Third, a common 
perception of academic medicine is that patients find the care to be 
cold and distant and fragmented. MCOs emphasize the relationship 
between the primary care physician and patients, and they were 
structured to provide coordinated health care that assures that the 
primary care physicians is fully involved in all decisionmaking about 
the patient's care.
    In spite of these differences, AMCs and MCOs could benefit through 
cooperation. AMCs would benefit through association with MCOs by: (1) 
having access to a larger, more varied patient base; (2) increased 
market share; and, (3) increased exposure to primary care practice and 
coordination of care. In addition, MCOs could provide AMCs with an 
excellent model for the study of innovations in primary ambulatory care 
delivery. Finally, centralized record keeping, as required by many 
MCOs, would increase the quality of data used and generated by AMCs.
    MCOs could benefit through association with AMCs in several ways: 
(1) AMCs could provide educational opportunities for MCO-affiliated 
physicians, which could increase job satisfaction for these 
practitioners; (2) the quality of health services provided through the 
MCO network could be increased, overall; and (3) affiliation with an 
AMC would be a positive factor in MCO physician recruitment. In 
addition, affiliation with AMCs could provide a positive marketing 
advantage to MCOs, to the extent that potential enrollees judge the 
quality of care offered by the MCO on the basis of the participation of 
a prestigious AMC in the provider network.
    At the present time, there is anecdotal evidence, but little data, 
on the extent to which MCOs contract with AHCs and their teaching 
hospitals. In addition, if they do contract with teaching hospitals, 
MCOs may permit enrollees to use these hospitals for routine hospital 
care or may limit use of these hospitals to specific diagnoses and 
treatments for which they are particularly well-qualified. It would be 
useful to obtain information on these issues, in order to assess the 
potential impact of further growth in managed care on the viability of 
AHCs and their teaching hospitals.
    PHS thus is seeking comment on the potential impact of the growth 
of managed care enrollments on AMCs and their future patient volume and 
financial viability. Responses to the following questions are 
specifically sought (as well as all other pertinent commentary).

Issues for Managed Care Organizations

     Do you have contracts with AHCs and their teaching 
hospitals?
     If you have contracts with AHCs, are your physicians 
permitted to refer patients to the AHC hospital for routine conditions 
or is access limited to patients with specific diagnoses and treatment 
requirements?
     Have you been successful in negotiating discounts with 
AHCs that compare to the prices negotiated with non-teaching hospitals?
     Who in your organization makes the decision about whether 
to contract with a specific hosptial or not? What are the key factors 
in making that decision?

Issues for Academic Medical Centers

     How many contracts with MCOs do you currently have?
     What proportion of patients treated in your hospitals are 
enrolled in MCOs?

--With which you have a formal contract?
--With which you have no formal contract?

     If you have contracts with MCOs, do you treat patients for 
routine conditions or is treatment limited to patients with specific 
diagnoses and treatment requirements?
     What is the average negotiated price under managed care 
contracts relative to the full charges and to discounts you offer 
traditional insurers?
     Who in your organization makes the decision to contract 
with a specific MCO or not? What are the key factors in making that 
decision?

Background

    AMCs are defined by the functions that they provide to the medical 
community: research, education, and health care services. They are 
composed of three related entities that perform the broadly defined 
tasks undertaken by AMCs: (1) the teaching hospital, (2) the faculty 
practice plan (FPP), and (3) the medical school. The teaching hospital 
and the FPP serve as revenue sources, as well as an avenue for the 
applied teaching of students and a locus of research activity. In 
particular, the FPP bills patients for physicians' services and 
distributes revenues to the medical school, its clinical departments, 
and its faculty. AMCs have become increasingly dependent on FPP 
revenue, with the FPP providing approximately 30 percent of all medical 
school revenue in 1990.
    MCOs are structured to provide quality health services in a cost-
effective manner. Preferred provider organizations (PPOs) provide 
financial incentives for patients to use specific providers. In 
exchange for higher volumes of patients, these providers agree to 
receive discounted fees for services. The staff model health 
maintenance organization (HMO) vertically integrates health care 
providers. The physicians are employed by the health plan and are paid 
a fixed salary. Group model and network model HMOs generally contract 
with physicians for comprehensive services on a capitation basis. 
Independent practice model (IPA) HMOs contract with physicians on 
either a discount fee-for-service or capitation basis. While some staff 
and group model HMOs own hospitals, most HMOs contract for hospital 
services on a preferred financial basis.
    The goals and practices of MCOs are in many ways inconsistent with 
those of AMCs. MCOs seek efficient medical providers that operate at a 
low cost, while AMCs must use patient revenues to subsidize research 
and teaching, and thus tend to be relatively more expensive. MCOs tend 
to emphasize primary ambulatory care, while AMCs tend to provide 
specialized and inpatient hospital care. MCOs must be concerned about 
patient satisfaction in order to maintain their customer base, while 
the focus of AMCs includes the training of new physicians and the 
development of cutting edge techniques, often at a substantial cost in 
dollars and convenience to the patient.

Historical Overview

    AMCs have been tied historically to federal support and influence. 
The National Institutes of Health (NIH) have provided extensive support 
in the areas of research and research training, and has been 
responsible for a significant share of the expansion of full-time 
medical faculties. The NIH has provided grant-based support, allowing 
researchers a degree of independence from routine institutional duties.
    Congress has made several legislative attempts to stimulate medical 
training. The Health Professions Educational Assistance Act of 1963 
authorized federal funds for the construction and renovation of medical 
schools, and made substantial loans available for medical training. The 
Health Manpower Act of 1968 and the Comprehensive Manpower Training Act 
of 1971 provided additional financial incentives to students studying 
medicine and other health-related fields. The Family Practice Medicine 
Act of 1970 and the Health Professions Educational Assistance Act of 
1976 attempted to target the financial assistance provided to medical 
students to a desired mix of primary care and specialist physicians.
    The Department of Medicine and Surgery was established within the 
Veterans Administration (VA) to ensure that veterans of World War II 
would have access to high-quality health care. The Department 
affiliated itself with a large number of medical schools, providing 
expanded full-time faculty, additional residency positions, and 
research funding. In 1972 the VA provided assistance to several 
affiliated medical schools, allowing the creation of new medical 
centers.
    An additional government-sponsored revenue source was provided in 
1965 with the creation of Medicare and Medicaid, increasing the number 
of insured patients, and dramatically increasing FPP revenues. Direct 
and indirect payments to AMC's from the federal government, including 
NIH, Medicare and Medicaid, have reached $5 billion annually. Funding 
for research and teaching are also provided by state and local 
government, as well as through higher charges by AMC's to patients. In 
recent years, direct federal payments to medical centers have fallen as 
a share of total revenues and patient revenues have increased. In 1990, 
patient revenues accounted for nearly 30 percent of AMC funding. Thus, 
AMCs are dependent on a continuous stream of patients to fund their 
teaching and research programs, in addition to funding received from 
government sources.
    MCOs are rapidly becoming the dominant players in the market for 
health care. The number of HMO enrollees increased from 10.2 million to 
38.8 million in the ten years ending in 1992. PPO enrollment is thought 
to equal or even exceed that of HMOs. Over the past decade, both 
Medicare and Medicaid have encouraged the growth of managed care 
options for their recipients. In addition, most health reform proposals 
currently being discussed include provisions that would increase the 
market share of MCOs beyond the currently projected growth. In markets 
where managed care is a well-established option, AMCs and MCOs are 
involved in a number of arrangements or have limited contacts. The 
experience that these organizations have gained, and the outcomes with 
respect to negotiations, payment arrangements, and the volume of 
patients directed to AMCs by MCOs can provide information and insight 
into the potential effects of future growth in managed care enrollments 
on AMCs.

Areas of Conflict

    The primary area of conflict between AMCs and MCOs is the cost of 
AMC services. AMCs require that their facility members split their time 
between patient and academic research or teaching pursuits. Thus, AMC 
physicians may be less efficient in providing services than are 
physicians in non-teaching environments. This inefficiency is partly 
offset by the utilization of resident physicians who work for 
relatively little pay, but these less experienced staff members tend to 
order more tests and hold patients longer for observation. In addition, 
AMCs tend to attract a sicker-than-average distribution of patients, 
which results in higher average costs per patient overall.
    Traditionally, these higher costs per patient to support teaching 
activities and due to a sicker case mix have been passed on to the 
patient in the form of higher charges. Insurers paying these higher 
charges pass the cost on in the form of higher insurance premiums. MCOs 
may be unwilling to pay these higher than average rates, because they 
emphasize efficient health services and competitive premiums. These 
plans often negotiate payment arrangements on a per diem or per case 
basis that allow, in part, for the sicker patient mix, but do not 
provide a payment sufficient to subsidize the academic objectives of 
the AMC. In addition, by contracting on a per diem or per case basis 
with MCOs that serve Medicare and Medicaid enrollees, the AMCs stand to 
lose the supplemental teaching reimbursement portion of Medicare and 
Medicaid payments for these patients.
    Aside from the cost issue, there are several other aspects of AMC 
practice that may be inconsistent with MOC's goals:
    1. Inefficient organization. AMCs tend to be organized very much 
like a medical school department, usually divided by function, and 
again by subspecialty. These departments often operate independently of 
one another, and are allowed to determine their own sets of policies, 
priorities, and business practices. There is no centralized authority 
and little communications between departments. This lack of centralized 
control make the implementation of consistent MCO arrangements 
problematic.
    2. Resistance to medical oversight. Each department within an AMC 
operates, for the most part, independently of all the other 
departments. There is no mechanism in place that provides a physician 
with oversight regarding what care is appropriate for any given 
patient.
    3. Patient satisfaction. MCOs are concerned about their patients' 
satisfaction. Patients' perception of physician competency is 
influenced by many things, including how much the physician values the 
patient's time. Measurable influences include: (a) Elapsed time between 
requesting an appointment and the time of the appointment; (b) time 
required to register a new patient; (c) elapsed time between the 
scheduled appointment and actually being seen by the doctor; and (d) 
the length of time they are ``put on hold'' while calling with problems 
or for information. AMC physicians often must weigh their academic 
duties against the desires of their patients, which tends to lead to 
lower patient satisfaction rates.
    Current practices in many AMCs may represent significant barriers 
to participation in Managed Care plans. Most of these non-cost issues 
stem from the traditional structure of the AMCs, and are not 
necessarily required for the institutions to pursue their academic 
function. However, physicians employed within the academic environment 
may be resistant to the standardization and coordination among 
departments that may be necessary to satisfactory arrangements with 
many MCOs.

Areas of Mutual Benefit

    Despite the differences in goals and practices between MCOs and 
AMCs, there are benefits available to both types of organizations 
through cooperation. These benefits may account for the fact that some 
MCOs and AMCs are already working together under ongoing relationships. 
In 1990, 15 percent of all HMOs responding to one survey indicated that 
they were directly involved to some extent in medical education; and 14 
percent had an agreement to serve as an ambulatory care rotation site 
with an AMC or teaching hospital that was not owned or operated by the 
HMO. The HMOs most likely to report involvement in medical education 
were those that were older and well-established.
    AMCs stand to benefit substantially, both financially and by 
expanding their research opportunities, through ongoing relationships 
with MCOs. These benefits could include:
    1. Access to a more varied patient base.
    2. Access to a larger market share.
    3. Increased primary care practice opportunities.
    4. Centralized record keeping.
    MCOs would also profit from associating with an AMC in several 
ways:
    1. Increased MCO physician satisfaction.
    2. Improved continuing education opportunities.
    3. Improved physician recruitment.
    4. Marketing to new enrollees.

Conclusion

    The proposition of the population enrolled in MCOs has grown 
dramatically over the past two decades. Under a number of health reform 
proposals, this trend would accelerate, with the result that within a 
few years nearly all Americans would obtain health services through 
managed care provider networks. If MCOs choose not to contract with 
AMCs and their teaching hospitals, because of their higher prices or 
inefficiencies related to their educational role, then the implications 
of these trends for the current system of training health professionals 
may be profound. This announcement seeks comments and suggestions on 
issues related to this topic, that may be analyzed in a future study.

    Dated: June 23, 1994.
John Gallivan,
Federal Register Liaison Officer.

Bibliograpy

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51A-44A.

[FR Doc. 94-15772 Filed 6-28-94; 8:45 am]
BILLING CODE 4160-17-M