Friday, July 11, 2008

Medical Instruction: Dying on the Vine

It's happening more and more:
The program to train cardiologists at Los Angeles County-USC Medical Center has been stripped of its national accreditation by the Accreditation Council for Graduate Medical Education. The decision marks the first time a residency or fellowship program at the facility has lost accreditation. The council faulted the program for "insufficient teaching time by the faculty."
It's really not unexpected, though. Clinical faculty at medical schools are increasingly pressured to maintain "productivity" standards based on Medicare's RVU system, while rarely being compensated for the time spent teaching students. As a result, training programs suffer.

Then, after being slapped by residency-review committees about their deficiencies and threatened with a sudden drop in federally-mandated funds for teaching, hospitals jump to action:
County-USC hopes to fix the problems and have the 21-year-old cardiology program recertified before June 30, 2009, when the accreditation is to be withdrawn.
Teaching subsidies must flow more consistently to the people doing the teaching and not to support the training program "overhead:"
A main argument for reducing IME payments is supported by data demonstrating that teaching hospitals have substantially higher margins on their Medicare business than other hospitals. In 1999, inpatient Medicare margins for all hospitals were, on average, 11.9 percent. For major teaching hospitals this figure was 22.3 percent versus 11.6 percent for other teaching hospitals, and 6.5 percent for non-teaching hospitals.

Finally, some point out that the logic of providing support for the social mission of teaching hospitals under Medicare IME is not rational, and that it is a "disguised" payment that should be more transparent. This argument suggests that these types of payment mechanisms provide little accountability for the funds provided for the social missions of teaching hospitals.
Only when such transparency is evident to the instructors will there be a long-term incentive to maintain most clinical training programs.


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