Copyright 2000 Plain Dealer Publishing Co.
The
Plain Dealer
May 15, 2000 Monday, FINAL / ALL
SECTION: METRO; Pg. 1B
LENGTH: 1509 words
HEADLINE:
TEACHING COSTS ARE WOUNDING MANY HOSPITALS;
CENTERS CUT TRAINING PLANS JUST
TO SURVIVE
BYLINE: By REGINA McENERY; PLAIN DEALER
REPORTER
BODY:
The fertile ground that has kept
Cleveland's teaching hospitals in business is being eroded by insurance
pressures, market forces and government cutbacks, advocates say.
In the
last year, two hospitals whose rich history included cutting-edge research in
cancer, cardiology and kidney disease have shut down. Other teaching
institutions, including University Hospitals, the Cleveland Clinic and
MetroHealth Medical Center, have eliminated residency positions and cut funding
to clinics to compensate for three years of operating losses.
"It has
not impacted patient care at this point," said Dr. Edgar B. Jackson, chief of
staff and chairman of graduate medical education at University
Hospitals. "It's more a matter of morale, a fear of future cuts and a fear of
what this will mean to future generations of doctors."
More than 1,100
hospitals across the country train residents, including 400 premier institutions
for medical research. These were the first to transplant organs, test vaccines
or sponsor clinical trials. Today, they are fighting for their lives, after cuts
brought about by the Balanced Budget Act of 1997. Cuts mandated by the act dealt
the battered hospital industry a particularly cruel and, for some, fatal blow.
By 2002, Medicare will be reduced by $116 billion and Medicaid by $15 billion.
The cutbacks have affected hospitals across the country. And teaching
hospitals must also endure smaller reimbursements for the higher costs
associated with academic medical centers. The budget act has reduced the
Medicare Indirect Medical Education adjustment by 29 percent over four years.
"People want us to be bleeding in the streets before they help us," said Dr.
Richard Knapp, executive vice president of government relations for the
Association of American Medical Colleges in Washington, D.C.
Both the
House and Senate have introduced bills that would reduce by about half the
cutbacks in the Education adjustment, but experts say it's going to take more
than legislative Band-Aids to solve the problem.
Five commentaries
appearing in last Wednesday's Journal of the American Medical Association called
for providing universal health coverage, financing medical service under managed
care and reducing the number of teaching hospitals and physicians.
"Bankruptcies, massive deficits, layoffs and merger dissolutions
characterize the ominous state of many U.S. teaching hospitals," wrote Dr.
Herbert Pardes, a New York physician who wrote one of the JAMA articles.
This has been especially true in Cleveland, though the reasons behind
the hospital turmoil seem driven as much by poor management as by funding and
insurance woes.
Cleveland Casualties
St. Luke's Medical Center
and Mt. Sinai Medical Center-University Circle both closed in the last year,
displacing hundreds of workers and patients and uprooting 30 years of medical
education. Both became affiliated with the Case Western Reserve University
School of Medicine in 1970.
Mt. Sinai Medical Center-East in Richmond
Heights, which has an active teaching program, and St. Michael Hospital, once a
training ground for new doctors, barely escaped closing. There is fear that
Cleveland's hospitals haven't seen the end of this crisis.
"It's a
shame," said Dr. Gerald Lackey, a cardiologist active in Mt. Sinai-East's
residency program. "My wife and I have devoted our lives to teaching these
people. It has always been a joy to do this, to support our profession."
Lackey and his wife, Susan, also a physician, used to spend March and
early April selecting interns and medical residents for the hospital's
osteopathic residency program, one of the largest in Northeast Ohio, with 45
slots.
That ended when the hospital's bankrupt owner, Primary Health
Systems, announced March 6 that it was shutting down the Richmond Heights
facility. So instead of greeting a new crop of young doctors, the Lackeys were
saying goodbye prematurely to interns and residents. The medical residents had
to find new hospitals and attending physicians.
Ioanna Giatis had to
transfer to South Pointe Hospital in April. The emergency room resident
physician, who had been at Mt. Sinai-East since June, had about three weeks to
find a new place to hang her stethoscope.
"I was saddened, you know,"
Giatis said. "You make a new family and new friends. At the same time, I felt
terrible for all the people that were losing their jobs."
There is hope
that University Hospitals Health System, the Cleveland-based network that
purchased bankrupt Mt. Sinai-East and St. Michael, will restore the teaching
program.
Still, the disruption seems symptomatic of what national health
care leaders say is the perilous state of teaching hospitals. Frustrated
physicians say the situation is getting worse.
"I am not cutting my
teaching time," said Dr. Frederic W. Lafferty, an internist at University
Suburban Health Center in Cleveland. "The only reason I'm not is I'm in the
twilight of my career and I can afford to have less income. The younger doctors
are in a different situation."
Even thriving hospitals are faltering.
For the first time in years, University Hospitals, the area's largest teaching
hospital, eliminated eight residency slots ranging from family medicine to
orthopedic oncology. And volunteer faculty have cut teaching time because they
can't afford to break away from their practices, which are being squeezed by
shrinking revenues from managed care.
The Cleveland Clinic Health System
significantly scaled back operations at its home health agency and cut or froze
expenses because of the cutbacks to its teaching program.
The medical
colleges association said that although the number of teaching hospitals had
remained stable in recent years, the number of residency slots declined by 760,
from 98,143 in 1997-98 to 97,383 in 1998-99.
Applications to medical
school are also on the decline nationally.
Dr. Nathan Berger, dean of
the medical school, said there had been a gradual decrease in the number of
residency positions and fellows at all of its member hospitals in the last five
years. None of these cuts has hampered patient care, he said, but Berger worries
about the long-term effect if the trend continues. "There is no doubt the
situation is worsening," Berger said.
Convincing the legislators
Knapp, the medical colleges association official, likens the current
situation in academic medicine to a pot of water on a slow burner. "Drop a
program here, decrease the staffing there. If you let the water gradually heat,
you don't realize how hot it has gotten," Knapp said.
The federal cuts
in medical education occurred, in part, because teaching hospitals had made out
well on those federal dollars.
Even today, some legislators do not
believe the doomsayers.
When pressed for proof of a crisis, Knapp cites
Mt. Sinai Medical Center and Cleveland's hospital crunch, or refers to an
analysis by the Lewin Group that projects 59 percent to 68 percent of U.S.
hospitals will show negative balances in the next several years.
"The
only mechanism for resolution of the problems plaguing academic health centers
and health care in the United States is for physicians to take back from
business organizations the ultimate responsibility for patient care, the
education of physicians and new medical discovery," wrote Dr. Catherine D.
DeAngelis, author of a JAMA editorial.
Sen. Michael DeWine, who voted in
favor of the Balanced Budget Act, is now a co-sponsor of the Senate legislation
that would restore some funding to Ohio's 56 teaching hospitals. Ohio, which
ranks fourth in the money it receives from Medicare Indirect Medical Education,
once received as much as $292 million out of a $5 billion pot. If the Senate
bill passes, it would restore $126 million to Ohio over five years.
"The
problem is, even though the bill has 28 co-sponsors, we don't know if we can get
it passed," DeWine said. "It's of great concern to me."
Like other
cities, Cleveland experienced a drop in medical residents in the mid-1980s, when
a new reimbursement method referred to as Diagnosis Related Group caused a
precipitous drop in hospital occupancies. That's because hospital charges were
being based on the type of procedure rather than the length of stay. Though
interns and residents are often seen as a form of cheap labor, the cost of
personnel needed to train the new doctors became prohibitive for smaller
hospitals like Lutheran Hospital, St. Luke's and St. Michael, then known as St.
Alexis.
"This is a big teaching town and the big guys didn't lose
anything," said Wayne Dechambeau, president of Lutheran. "Sinai kept theirs, the
Clinic kept theirs and UH kept theirs."
Today, those hospitals are all
feeling the pinch. And Congress must act.
"Academic centers have reduced
staff, re-engineered, cut positions and initiated mergers," CB>Pardes said in
the JAMA. "They are playing their part, but political leadership and the public
must save an academic fabric that has the potential to improve the approach to
disease exponentially."
GRAPHIC: PHOTOS:; PHOTO 1 by
LONNIE TIMMONS / PLAIN DEALER PHOTOGRAPHER (on page 5B):; Dr. Steven Feinlieb, a
third-year internal medicine resident at University Hospitals, works on a
patient's chart in the cardiac intensive care unit. To combat the effects of
government cutbacks in medical education, UH has reduced its fellowship slots
for the first time in many years.; PHOTO 2 by ROADELL HICKMAN / PLAIN DEALER
PHOTOGRAPHER (on page 5B):; Teaching hospitals have been the hardest hit by
cutbacks in Medicare and Medicaid brought about by the Balanced Budget Act.
Internal medicine residents Douglas Haghighi, left, Franjo Vladic, back, and Rae
F. Boganey check patient David Van Zanten of Hudson during early morning rounds.
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