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This study examined how competitive market dynamics between 1994 and 2000 have affected the financial stability of Academic Health Center (AHC) hospitals and their ability to support their academic and social missions. It looked at the financial challenges facing AHC hospitals through a survey involving 1,138 teaching hospitals. Findings demonstrate that fewer financial resources are currently available to subsidize mission-related activities than at any other time since 1994. Although the analysis focused on AHC hospitals, the authors considered other teaching hospitals and other types of hospitals. The financial strength of AHC hospitals has decreased to the point that their ability to fulfill their social missions appears to be at risk. In the aggregate, AHC hospitals derived their entire financial surplus from nonoperating revenue, which was used to offset operating losses. By 200l, less than half of AHC hospitals had positive operating margins. If these trends continue, or even stabilize, AHC hospitals might not be able to maintain their traditional commitments to education, research, and their communities. The observed decrease in private payer payments relative to costs for AHC hospitals may not be due to increased hospital costs. In recent years, AHC hospitals have controlled costs and generally become more cost efficient, but it is difficult to predict the form insurance payments will take and the future of employer's health care plans. An appendix contains a hospital efficiency model. (Contains 32 exhibits.) (SLD)

This report focuses on strategies documented by the Commonwealth Fund Task Force on Academic Health Centers (AHCs) concerning AHCs' management of patient care and research missions. Whatever challenges AHCs face in the future, their ability to respond effectively will be determined by the quality of their governance and management. To improve their capabilities, AHCs are adopting organizational reforms, including unified clinical and academic governance, increased autonomy for the clinical enterprise, reforms in faculty governance, mission management, and improved information systems. To date, AHCs have devoted relatively little attention to leadership development. Most of their time and energy has been directed toward designing reforms to enhance their clinical market share while reducing clinical costs. Strategies to this end include developing primary care capabilities and protecting specialty care markets. Virtually every AHC has made efforts to reduce costs over the last decade, and some have turned to strategies to reduce dependence on the clinical enterprise. AHCs must continue to support research activities, attracting new sources of funding and improving the management of research funds and activities. In spite of all their efforts, AHCs have missed some important opportunities to increase their competitiveness and efficiency. Development of the capacity for innovation is essential for the future success of AHCs. (Contains 66 references.) (SLD)

This report addresses financial problems faced by the four medical schools belonging to the State University of New York (SUNY) which operate their own teaching hospitals and conduct graduate medical education (GME) programs. These hospitals necessarily have higher costs than do nonteaching hospitals. Prior to 1997, the higher costs were absorbed by all payers in the state. Subsequently, changes in federal and state legislation, deregulation of rates, and changes in Medicare, led to reduced reimbursement to hospitals, incentives to reduce the number of residents, and to shift funds from specialty to primary care programs. The study addressed two questions for the period January 1, 1995 to February 28, 1999: (1) whether the three teaching hospitals had adequately planned for the reductions in funding; and (2) whether they had reduced the number of residents in their GME programs and increased the percentage of residents who were in primary care programs. The study concluded that for a variety of reasons, SUNY had not planned for reduced funding, nor had it reduced the number of residents or shifted residents from specialty to primary care programs. Two appendixes list the major contributors to the report and the comments of SUNY officials. (RH)

This paper describes a method used to evaluate 48 medical residency programs at one institution. It presents the background rationale, logistics, and results obtained by surveying alumni, in the context of their current practice, for relevant data on the value of their training experience. Surveys were sent for 3 years to all alumni of Cleveland (Ohio) Clinic residencies who had graduated three years earlier. A total of 187 (28.4 percent) of alumni responded to the survey. Consistency of results across the 3 years was found. Ninety-six percent of respondents replied that they would recommend their residency program, noting such positive qualities as the excellent teaching, knowledge and skills of the staff, and the variety of experiences and patients. Suggestions for improvement centered on learning and practice of primary or community/outpatient care, management or business skills, computer uses in medicine, and improved didactics. Qualitative content analysis of written comments also indicated positive evaluations of respondents' residency experiences, and supported suggestions for more business training and practice and for more responsibility given to residents. The methodology is seen as lending itself to direct program improvement on a yearly basis. (Contains 10 references.) (DB)

Earlier reports and studies have endorsed the consortia concept as a vehicle for reorganizing medical education and restructuring the physician workforce. This report by the Council on Graduate Medical Education, which serves in an advisory capacity to the Secretary of the Department of Health and Human Services and to Congress, concurs in this assessment. In support, the report reviews the background of the consortia concept, noting that there is no common operative description that defines current medical education consortia. To sort out the many variations, the Council surveyed several current consortia, collecting and analyzing data on how they perceive themselves, and on their organizational and administrative structures. The report examines and tabulates data on key attributes (mission/membership, governance/authority, administration/management, and medical education programs); measures outcome (educational enhancement, workforce reform, improved administration); takes note of barriers to success (market competition, financial constraints); probes weaknesses; offers a vision of an idealized model; and advocates the funding of several demonstration projects. The report reiterates support of consortia-run medical schools, teaching hospitals and community training sites; and calls for a "shared responsibility" approach to funding graduate medical education; development of national standards for education consortia, and health care reimbursement incentives that promote consortia development. (Contains 160 references.) (JLS)

This study, conducted for the Maryland legislature, evaluated the current method for financing graduate medical education in hospital rates, particularly whether the costs of graduate education at the state's two academic medical centers are too high. The study involved discussions with the Health Services Cost Review Commission (HSCRC), monitoring briefings to and deliberations of the HSCRC Advisory Committee on Graduate Medical Education, meetings with stakeholders, and a literature review. The study found that direct costs for residents at the two academic medical centers rose by almost 70 percent between 1989 and 1994; that health care delivery trends are away from inpatient care though medical training has not yet shifted to non-hospital settings; and that the nation and Maryland in particular has an oversupply of physicians but an undersupply of general practitioners. The HSCRC has considered seven alternative funding strategies, and the Advisory Committee has made three recommendations for change. This study concluded, however, that the current financing system is preferable to any of the proposed alternatives; that if the state should intervene to meet physician workforce goals, the all-payer system might provide a source for financial incentives; and that training and financing should move toward ambulatory care settings. (JB)

This audit examined State University of New York (SUNY) at Brooklyn's University Hospital's controls over contracting for food and nursing services, sole source contracts, accounts payable controls, supplies inventories, and equipment inventories. It examined selected practices from April 1, 1990, through March 31, 1993, through staff interviews, review of records, and comparison with comparable costs at similar facilities. The audit found that the Hospital had not made enough effort to attract qualified bidders before it awarded contracts. At the time of the food service contract renewal the Hospital received only two bids. The audit also found that the Hospital did not award per-diem nursing contracts to the lowest bidder and could not explain why certain bidders were disqualified. In addition, nursing staff were permitted to work for contractors outside their regular hours resulting in the Hospital paying nursing contractors for services not provided making a total overpayment of about $35,000 during the audit period. The audit also found that the Sterile Supply Unit was significantly overstated in value. Regarding equipment, some improvements were needed to ensure that new items were recorded on control records and that items removed were eventually returned. SUNY officials agreed with the report and their comments are included. (JB)

An audit was done of selected expenditure controls at the State University of New York (SUNY) at Stony Brook University Hospital particularly payroll costs and procurement practices. The Hospital reported an operating loss of $24 million in 1992. The audit reviewed Hospital management and staff and applicable policies and procedures as well as records of expenditure transactions. Overall findings were that certain purchasing practices could be improved. More importantly the Hospital is not adequately controlling payroll costs for oncall and recall services and is making unnecessary payments to some employees. Employees oncall receive $2.25 an hour for time oncall. employees on recall receive time and a half for a minimum of one-half day or hours worked, whichever is greater. The audit found that many employees are scheduled and receive payments for oncall status but are rarely recalled. Questionable and improper practices identified include payments to employees for working overtime or on recall basis while they are being paid for oncall status, recalling staff who are not oncall while staff on oncall in the same unit are never recalled, and staff use of sick leave during normal shifts while also remaining oncall. The original audit was in January 1992. A return visit in June 1993 found many of the same practices in place. Comments of SUNY officials are included. (JB)

An audit was done of the Health Science Center, a teaching hospital in the State University of New York (SUNY) system at Syracuse. The audit addressed whether Syracuse has effective controls over selected payroll, equipment and inventory expenses. Syracuse reported an operating loss for 1990 of over $21 million dollars. The audit found that management's controls were not effective in ensuring that payments for certain payroll costs were reasonable and proper with the consequence that Syracuse may spend too much on staffing. To ensure that staff is available to meet patient needs, Syracuse uses an "on-call" and a "re-call" service. As a result of reviewing 499 employee timecards, the audit recommends that management implement better monitoring and control of on-call and re-call activities. Appendixes contain information on major contributors to the report, comments of SUNY officials, and State Comptroller's notes. (JB)

In response to the critical need for nurses in New York City, the Borough of Manhattan Community College (BMCC), with support from two local unions and a foundation, initiated the Evening/Weekend Program designed for working adult nursing students in fall, 1989. While the 3-year, part-time program was open to any qualified BMCC student, a special recruitment and academic support plan was developed with the unions. The following support mechanisms, combining existing college-wide resources with new initiatives developed specifically for the program, were provided: (1) a mandatory basic skills assessment and placement program; (2) a free Pre-Freshman Immersion Program, offering remediation to those students who require it (70% of BMCC's student body) prior to regular enrollment; (3) special group orientations, assessment testing sessions, admissions appointments, and registration dates for union members; (4) a full-time college counselor available evenings and Saturdays for Nursing students; (5) union counselors available evenings and Saturdays for union members; (6) non-credit preparatory courses for chemistry, anatomy, and physiology, supplemented by an innovative science tutoring program; (7) peer tutoring in the Nursing Tutorial Lab; (8) basic skills classes for students offered on-site at union headquarters; and (8) monthly meetings between BMCC and union administrative staff to review the progress of the program. Using the union-based model, BMCC also developed a hospital-based program in cooperation with Harlem Hospital, targeting local residents, as well as hospital employees. (MAB)

A study was done of the characteristics of institutional research in 51 academic health centers. Overall, slightly less than half of the centers had an identifiable institutional research unit. In general, the more autonomous the center from its parent campus, the more likely it was that it would have a separate institutional research unit. The organizational location and the background of the staff of academic health center institutional research units were found to be comparable to those of other institutions. Academic health center institutional researchers were involved in a wide variety of tasks. They were less frequently involved in enrollment-related studies and student characteristic studies than are their counterparts in other institutions. Among academic health centers, the tasks commonly associated with institutional research differed based on the location of the office (main campus or health center) and the type of office. Offices on the main campus are more often involved in enrollment analyses and in salary studies. Included are 4 tables and 11 references. (Author/JB)

An examination was conducted of the control chart as a quality improvement statistical method often used by Total Quality Management (TQM) practitioners in higher education. The examination used an example based on actual requests for information gathered for the Director of Human Resources at a medical center at a midwestern university. The request was for an analysis of the relationship between the number of hours for which employees were being paid, the employees' budgeted full-time equivalency, and the actual hours being worked. The data were illustrated using three types of control charts--two described controlling process variability and one described controlling a process mean. The analysis showed that for the most part the number of regular hours being worked was stable, with the only exceptions occurring during pay periods which included holidays. The graphics of the analysis and an accompanying report were reviewed with a favorable reaction from the Human Resources department due to the informative nature of the data. The study concluded that TQM methodologies provided the researcher with tools to aggregate and present data in an informative manner. Included are five figures, two tables, and eight references. (JB)

This report presents results of a comparative cost study of nursing education programs provided by community colleges, general academic institutions, and health science centers. The study delineates and explains differences in costs and recommends a formula to allocate all general revenue funds appropriated for nursing education programs. The report first presents the study's findings and conclusions about the health care industry, Texas nursing education, and funding recommendations. Next, the report provides background information on the health care industry and a description of nursing education in Texas as it has evolved in the community colleges, general academic institutions, and health care centers. Tables compare the total costs per student to complete the certification or degree program, based on type of institution and type of program. Finally, formula recommendations for funding are presented. Appendices include the recommended formulae for state-support of vocational-technical programs, for faculty salaries and departmental operating budgets, and for nursing faculty salaries in health science centers. Contains 10 references. (GLR)

This study examines the evidence of deteriorating financial status for many of the nation's teaching hospitals, and the continuing underrepresentation of minorities in medicine. The study of teaching hospitals used existing financial data and information on both non-federal and Veterans Administration teaching hospitals. Results suggested the following: hospital and patient margins have decreased; hospital bond rating changes were primarily downgrades; high levels of uncompensated care and low third-party payments threaten the financial health of hospitals and jeopardizes quality medical education and service to the poor; operating margins have fallen steadily; and cost controls must be vigorously pursued. The examination of minority representation in medicine drew on presentations and data from a comprehensive range of authorities in the field. Findings suggested the following conclusions: the minority applicant pool continues to decrease; problems of minority recruitment are linked to poor academic preparation and insufficient encouragement; minority students incur higher debt levels and are more severely impacted by rising tuition costs; and underrepresentation of minorities on medical faculty discourages recruitment, enrollment, retention, and graduation of minority students. Included are commentaries from the Health Resources and Services Administration and the Health Care Financing Administration, and a list of 25 references. (JB)

The report focuses attention on those areas of medical school education that may have a negative effect on women students' confidence and competence. It examines the different ways that male and female medical students experience their training and the particular stresses that women may face, including: role conflicts; questions about commitment; balancing career and personal needs; parental and childbearing leave; and sexual harassment and discrimination. Several model programs are highlighted that address women's concerns at various levels of medical training, and a set of recommendations are provided for medical school and teaching hospital administrators, most of which are based on strategies that have been implemented successfully at institutions around the country. Suggestions include ideas for encouraging more women to enter medicine and to improve outreach and retention. A selected list of organizations and additional resources is also included. Contains 42 references. (GLR)

This report presents a fiscal analysis of Howard University (District of Columbia) including: (1) general education revenues; (2) education and general expenditures; and (3) faculty salaries. The study compared Howard University to four different groups of higher education institutions: similar private institutions with hospitals; public universities with hospitals; competitor institutions (institutions preferred by students who declined Howard University admittance); and historically Black colleges and universities (HBCUs). Key findings with respect to revenues included: the university received more than twice as much revenue as competitor institutions and three times more revenue than HBCUs but less than that of private institutions with hospitals, and the university received 1% of total revenues from endowment income. Key findings with respect to expenditures included: Howard University spent $22,843 per full-time equivalent student, midway between private and public universities with hospitals; Howard spent only 6% of its expenditures on research; and Howard spent more for plant operation and maintenance than any of the comparison groups did. Other findings indicated that 78% of Howard's full-time faculty had Ph.D.'s and that its faculty salaries and benefits were comparable to those at public institutions with hospitals. An appendix includes a comparative fiscal analysis. (DB)

Reviews the rural physician shortage and related policy and research needs. Discusses geographic distribution of physicians, quality of rural care, rural recruitment and retention, rural residency training, factors in medical education affecting entry into rural practice, physician productivity and income, reimbursement, federal and state programs addressing rural shortages, nurses, other health personnel, workforce analysis, and 14 areas of policy needs. (Contains 101 references.) (SV)

Health Manpower Legislation and related research aspects are the topics of this report. The program of the Comprehensive Health Manpower Training Act of 1971 played a major role in the medical school enrollment expansion that occurred between 1971 and 1973. Medical school admissions decisions have been responsible to federal policy objectives and broader social concerns regarding equality of access for women and minorities. Primary care physicians need and are choosing speciality training, whether in family medicine or one of the more traditional specialities of internal medicine, pediatrics, or obstetrics-gynecology. Although public schools and private schools have increased real tuition levels during the past decade, the spread between the two has increased. The strong technical interdependencies among patient care, research, and education in academic health centers mean that there are strong interdependencies between federal decisions in the health manpower field and federal decisions in other health care areas. Greater reliance on clinical faculty earnings for institution support will require that clinical care in teaching hospitals be oriented more toward secondary and tertiary than toward primary care. Government proposals for the use of special projects to promote primary care may compensate for the financial problems associated with primary care training as well as for those created by cutbacks in general institutional support. (Author/PG)

The report represents the results of a 1973 survey of senior students in hospital schools of nursing. Prepared by the American Hospital Association (AHA) Division of Career Information, the report is based on data compiled by the AHA Division of Survey Research. More than 11,000 students in 388 schools completed and returned a questionnaire which was divided into three major sections: career goals, career guidance, and individual information. Some of the questions required only checks, others required ranking factors in order of importance, and a few asked for open-ended responses. The study findings underscore the influence of the educational program on job selection. The major findings were that a large percentage of seniors expected to continue their education either on graduation or in the future, that the majority who had accepted job offers selected hospitals as their first employer, that clinical experience appears to influence choice of specialty, and that most students would be willing to work in manpower shortage areas. Several pages of comments interpreting the findings are followed by 41 tables of data. Among the appendixes are the survey questionnaire and tables showing breakdowns of data concerning AHA member and nonmember schools and States and regional data. (Author/AJ)

The report investigates production and the cost effects of teaching within hospital departments. Models of primary production show that the cost effects of teaching are determined by the salaries paid to students (including residents, interns, medical students, and technical trainees) and physicians, by the levels of student inputs used in production, and by the productivity of student and nonstudent inputs. The models of departmental production developed permit costs to be related to the level of student inputs rather than to the more abstract variable, teaching output. Empirical analyses of radiology costs in 90 general medical and surgical hospitals in the Veterans Administration system were conducted. The empirical results suggest that, with the exception of one variable whose interpretation is suspect, teaching reduces costs for most individual radiology procedures. Although the VA system differs from non-VA hospitals in many respects, the apparent cost reductions for many radiology outputs suggest that students can be substituted for nonstudent inputs in radiology. If costs of primary products can be reduced through teaching, as the radiology results suggest, it would be possible for teaching hospitals to provide a given medical program for patients at lower costs than in nonteaching hospitals. (Author/JR)

Policies on U.S. citizens studying medicine abroad are reviewed, based on visits to six foreign medical schools in the Caribbean, Mexico, and Europe, which have about 5,400 U.S. citizens studying medicine, or about half of the total estimated number. The following areas are considered: education and training provided, clinical training in U.S. hospitals provided by U.S. citizens studying in foreign medical schools, avenues available for entering the American medical system, and federal financial assistance in the form of guaranteed student loans and educational benefits provided to these students. It is found that many U.S. citizens attend foreign medical schools with the goal of returning to practice in this country; however, the education and training provided by some of these schools vary greatly and may not be comparable to that offered in U.S. schools. It is recommended that more appropriate mechanisms be developed to ensure that all students who attend foreign medical schools demonstrate that their medical knowledge and skills are comparable to those of their U.S.-trained counterparts before they are allowed to enter the mainstream of American medicine. Alternatives to be considered in accomplishing this objective are suggested, including admission with advanced standing. Recommendations concerning guaranteed student loans and educational benefits, and U.S. hospital clinical training of foreign medical school students are also offered. Appendices include information on qualifying examinations, foreign medical schools, accrediting organizations in the United States, and communications among agencies. (SW)

The problem-oriented medical record, developed by Lawrence L. Weed, M.D., involves an interactive computer system and has been operational on two wards at the University Hospital in Burlington, Vermont, a teaching hospital. The Problem-Oriented Medical Information System (PROMIS) consists of terminals that feed into the central memory units; the terminals can be wheeled to the patient's bedside. Displays indicate first the common and then less common diseases that can be attributed to the patient's symptoms. Other displays logically lead the physician to a treatment plan through references from the medical literature and other considerations. The system also maintains problem-oriented progress notes. The system is designed to educate a new physician and other health practitioners who are patient-centered, team-oriented, and who relate to patients as mutual participants. Physicians must be trained and educated differently under this system. Under a restructured medical curriculum, it should be possible to train more people for less expense. The system creates conditions under which medical care can become coordinated in its delivery and potentially less costly both because tests are not done unless absolutely necessary and because the physician is warned not to do something in treating one problem that will complicate another. To the extent that "experts" create guidance tools that other members of the health team can use, costs can be lowered. The present system of provider-centered health care will be restructured to be patient-centered if the PROMIS system is accepted by the medical community. (SW)