HCFA and work force issues
Some policy-makers may consider the HCFA demonstration project that will pay hospitals to reduce their residency slots an innovative way to address physicians work force issues. ("New HCFA project means fewer slots, more pressure," September ACP Observer, p. 8.) Others consider it a bonanza for helping hospitals protect their bottom line while risking a possibly dangerous increase in the workload of residents. In reality, the HCFA demonstration project is continuing evidence of medicine's inability to reform graduate medical education (GME) and of the lobbying power of teaching hospitals.
In 1988, after an 18-month study of the supervision and working conditions of residents, New York state revised its health code in an effort to improve the quality of care in teaching hospitals. The new legislation limited the number of hours residents were permitted to work and defined the criteria for supervising housestaff.
To comply with the new legislation, hospitals, recognizing that the federal government would pay them $100,000 for each new resident they hired, increased the number of residents by almost the exact number they are now agreeing to cut. The increase in the number of residents occurred overwhelmingly in internal medicine, and to a lesser extent, pediatrics. Incidentally, most of the new residents were international medical graduates, who are now expected to bear the brunt of the new cutbacks.
New York state allocated $200 million per year to the hospitals to cover the cost of better supervision and to hire ancillary help to do the "scut work" of housestaff, as well as to help alleviate the problems of chronic fatigue associated with sleep deprivation.
This money comes from a different pool of state and federal sources (New York City hospitals also received money from the city) than the funds the hospitals used to increase their housestaff.
It is sad to report that the efforts to reform GME in New York state by paying hospitals and training programs to change have failed miserably. Studies by New York City Public Advocate Mark Green and others have indicated that many hospitals do not comply with the new regulations. Mr. Green noted in a 1994 report that despite an influx of more than $1 billion in extra funding since 1994, hospitals have "routinely and regularly" violated the regulations. It is also clear that enforcement by the state health department has been hampered by inadequate funding and low prioritization; penalties for breaking the law are mild.
Unless HCFA has an effective way to oversee how hospitals will find and finance other ways to care for patients, this new infusion of money will be no more useful in reforming the culture of teaching hospitals than the more than $2 billion that has already been spent in New York state with a similar purpose.
Bertrand M. Bell, FACP
Prescribing under pressure?
Over the past 15 years, an increasing percentage of my practice has been managed care, but I have not encountered a closed formulary so narrow that I could not appropriately and effectively treat all but the most unusual clinical situation. ("Prescribing under pressure," October ACP Observer, p. 1.)
Managed care is reality. Physicians should stop whining and continue to manage patient care. Those of us in ACP can handle difficult clinical problems, and we should certainly be able to learn to handle the administrative problems that surround the practice of medicine today. They are simply challenges like the many we have overcome in the past. For the sake of quality medicine and in the interests of our patients, we must overcome these too.
Stanton P. Fischer, FACP
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