A coalition of large group practices sent a letter to the Clinton administration late last month asking that they be considered "academic health centers," as defined in the president's healthcare reform plan.
The request is based on much more than semantics. The group practices want access to the protections and special financing given the nation's 102 academic medical centers in the Clinton reform initiative.
Typically, academic medical centers comprise a medical school, other health profession schools or programs, and one or more teaching hospitals. They offer medical research, graduate medical education and have the capabilities for providing specialized patient care.
In the Feb. 22 letter to Philip Lee, M.D., assistant secretary for health at HHS, the medical groups noted that they have sizable teaching and research programs, likening them to" academic programs that follow the more traditional medical school model."
Also, they said, "We have sizable relationships with medical schools and other allied schools in training the health professionals."
What types of institutions will be included under academic health center funding isn't the only issue surrounding the financing of medical education. The funding stream for medical education included in the Clinton plan-which teaching hospitals say is already insufficient to replace both direct and indirect medical education payments-is under budgetary attack on Capitol Hill.
"We can demonstrate, based on Medicare methodology, that the current funding levels included in the (Clinton) plan are low, but we are concerned that it could always go down, especially in light of the (Congressional Budget Office) study," said Robert Dickler, vice president of clinical services at the Association of American Medical Colleges, Washington.
The CBO's study predicted that the Clinton plan would cost as much as $133 billion more during a six-year period than the administration had estimated.
"The funding stream for medical schools is vulnerable because it is visible and members of Congress can look at it and make judgments on it," Mr. Dickler added.
The Clinton plan would essentially replace the current Medicare payments for direct and indirect medical education, which totaled about $5.5 billion in 1993, with two new funding streams.
The first is called the Health Professions Workforce Account (see chart, this page), which is designed to pay the direct costs of training medical personnel and to provide transitional payments to institutions that would lose residency positions because of changes caused by reform.
That account would be funded by Medicare payments and by assessments on both regional health alliances and health alliances formed by corporations. The corporate alliances would pay 1% assessment on payroll, while the regional alliances would contribute at the rate of 1.5% of premiums.
The second funding stream would be an Academic Health Center Account, which would be funded in largely the same way as the Health Professions Workforce Account.
The AAMC generally supports the funding mechanism included in the Clinton plan because it removes the funding for medical schools from the federal budget process.
However, they argue that the funds won't be enough to cover all costs related to medical education and research.
But with Congress looking for ways to cut the cost of healthcare reform, it could be extremely difficult to locate more money to fund the needs of teaching hospitals. In fact, it may not be easy to keep the funding that's now included in the bill.
One reason is there's rising opposition from corporations that believe the 1% of payroll contribution is unfair. They argue that this and other regulations make it prohibitively expensive for corporations to form their own alliances.
"The `assessment' appears to be intended to force large firms into regional alliances rather than to create a level playing field between regional and corporate alliances," said Richard Smith, director of healthcare policy for the Association of Private Pension and Welfare Plans, Washington.
In testimony before the House Ways and Means Committee, Mr. Smith raised the argument that no additional funding streams for academic health centers were necessary. That statement by Mr. Smith shows how difficult it will be to get corporations to contribute to the education fund.
"The justification for any assessment for these purposes is open to question." Mr. Smith said. "The argument that the market will not recognize the value of efficiently operated academic health centers and graduate medical education is overstated.
"The wisdom of creating pools of money that could be used to reinforce the behavior of institutions whose conduct has played a key role in driving costs up is questionable," Mr. Smith added.
Corporations aren't the only threat faced by academic health centers. Many provider groups are telling Congress that reform of the graduate medical education system should wait and be done separately from reforming the nation's healthcare system.
"I don't think (Congress) has really focused on this issue yet," contends James Scott, president of the American Healthcare Systems Institute. "There is only so much they can do. I hope (reforming graduate medical education) falls off the table until next year."
Other providers are delivering essentially the same message.
Darlene Burgess, vice president of corporate government relations for the Henry Ford Health System, Detroit, said she told powerful Rep. John Dingell (D-Mich.) recently that the "whole concept of academic health centers should be dropped out of the bill.
"We look at this as very important, but second-order reform," Ms. Burgess added. "Let the basic changes to the system be done first, then see where we are. By trying to help one group with their legitimate concerns, this plan would end up hurting another group."