The National Association of Public Hospitals and the Association of American Medical Colleges' Council of Teaching Hospitals conducted a detailed survey on hospital care to patients with acquired immunodeficiency syndrome (AIDS) in major US public and private teaching institutions in 1985. The 169 hospitals treating patients with AIDS that responded to the survey reported providing inpatient services to 5393 patients with AIDS. These patients accounted for 171,205 inpatient days and 8806 inpatient admissions, with an average length of stay of 19 days. The average costs and revenue for patients with AIDS per day were $635 and $482, respectively, with Medicaid representing the most frequent third-party payer. The average inpatient cost per patient per year was $20,320. Using Centers for Disease Control estimates of 18,720 patients diagnosed as having AIDS and alive during any part of 1985, we estimate that the total cost of inpatient care for patients with AIDS was $380 million for that year. We also found significant regional and ownership differences in source of payment for patients with AIDS and regional differences in revenues received for AIDS treatment. Results indicate that the costs of treating patients with AIDS will profoundly affect major public and private teaching institutions, but that public teaching hospitals in states with restrictive Medicaid programs will be most adversely affected.
One year of graduate medical education, the internship, had become the norm for graduates of most U.S. medical schools by 1920, and subsequently was adopted by most states as a criterion for licensure. The original concept of a "resident physician" carried with it responsibility for patients 24 hours per day, seven days per week. Recent public and media attention to the issues of residents' supervision and working hours has led to governmental efforts to restrict their hours and set minimum requirements for supervision. New York is the first state to impose specific requirements. The New York recommendations have implications for the concept of graded responsibility for residents, for learning the natural course of illness, and for the need to provide service in hospitals. Further, the recommendations raise four objections: they do not recognize differences by type of specialty or year of training; they might affect the length of time needed to acquire aggregate clinical skills; they affect different types of hospitals differently; and they would have a major effect on physician manpower. Hospitals and residency programs will face several difficult choices in responding to the regulations. To provide its members with guidelines for action, the Executive Council of the Association of American Medical Colleges has issued recommendations for residency hours and supervision, including the use of an 80-hour work-week averaged over four weeks, the continued use of graded supervision of residents in emergency rooms and in inpatient and ambulatory settings, and control of housestaff moonlighting.
The contemporary academic medical center is a complex organization providing medical and other professional health education, biomedical and behavioral research, and a comprehensive range of patient care services. This paper presents data from the Association of American Medical Colleges' 1989 survey of 125 member faculty practice plans. The survey data showed that 62% of the 74 responding plans were units or associations within the medical school corporate structure. Plans were organized along a broad continuum from the autonomous, departmental model with decentralized governance and management to the group model with centralized governance and management. The growth of managed care, increased competition, and a greater reliance by the medical school on clinical practice income as a financing source are causing the practice plan to expand beyond billing of professional fees. The survey data showed that 75% of the practice plans operated satellite centers, and 61% planned to build new ambulatory care facilities in order to expand and improve services to patients. The practice plans also have adapted to changes in third-party reimbursement and are establishing mechanisms to negotiate managed care contracts involving multiple clinical departments to increase referrals and maintain patient shares; 86% of the plans participate in at least one managed-care organization. The role of the practice plan will continue to evolve in response to the needs of the academic medical center for a cooperative and supportive environment in which to conduct its traditional missions of teaching, research, and patient care.
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