Hospitals face test on family care Clinton health plan counters trend to costlier specialists

October 10, 1993|By Jonathan Bor | Jonathan Bor,Staff Writer

President Clinton's call to increase the supply of family doctors could force hospitals such as Johns Hopkins and the University of Maryland into a battle to preserve their roles as specialty centers.

For Mr. Clinton's reform to work, teaching hospitals would have to train more than double the current number of physicians planning careers in primary care, a field that has been derided as low-paying and lacking the intellectual allure of the medical specialties.

The administration wants to reverse that perception, recognizing that specialists order more tests and perform costlier procedures than do generalists. Accordingly, it has cast family doctors as virtual heroes in its effort to slow the soaring cost of health care and bring preventive medicine to Americans who lack it.

Under the plan, the federal government would require that teaching hospitals train half of their residents in primary care and half in the specialties. The shift would take place over five years, but it would be a radical one. Today, 80 percent of the nation's 100,000 residents are in specialty training, 20 percent in primary care.

The plan doesn't require all hospitals to achieve a 50-50 split, only that the nation's full complement of residency slots break down that way. This leaves room for some hospitals to preserve their overwhelming preference for the specialties. But to make the numbers work, some institutions will have to transform themselves into centers for generalists.

"If an institution can't get enough slots in specialty care, they'll have to expand into primary care," said Dr. Gerard F. Anderson, a professor at the Johns Hopkins School of Hygiene and Public Health who served on Hillary Rodham Clinton's health task force.

"An institution like Johns Hopkins may be able to stay overwhelmingly specialty," he said. "But some other institutions that have trouble competing will need to expand their primary-care programs."

The plan has some hospitals worrying that they may have to surrender their roles as centers of excellence in such prestigious and high- paying fields as surgery, anesthesiology and radiology. Hospitals also worry that without a major restructuring of insurance reimbursements, their finances could be affected adversely.

Residents are the workhorses of many hospitals, rendering much of the hands-on treatment given patients. And when hospitals train a large number of specialists, they profit because insurers reimburse hospitals more for the services of specialists than they do for generalists.

"It's necessary for the financial survival of academic health centers to train and have on board a significant number of specialists," said Dr. Donald E. Wilson, dean of the University of Maryland School of Medicine.

The difficulty of meeting quotas for primary-care residencies will depend partly on how the government defines the term.

Originally, primary care was limited to family medicine, general internal medicine and pediatrics. But already, hospitals appear to have won a major concession: the addition of obstetricians and gynecologists to the field.

This development, judged virtually a sure thing by many with a stake in health care,could prove particularly valuable to elite institutions such as Johns Hopkins, Harvard and Stanford that have no programs in family medicine.

Whether the change in definition makes sense depends on whom you ask.

Dr. Michael E. Johns, dean of the Johns Hopkins School of Medicine, argues that it does in this instance because the obstetrician-gynecologist is the only doctor many women have. "They've been using them for years," he said. "That's what many women want."

Proponents of family medicine argue that obstetrician-gynecologists cannot realistically be expected to cure a skin rash or manage a patient's diabetes or hypertension.

At Hopkins, 74 percent of the residents are training in specialties such as anesthesiology, surgery, psychiatry, orthopedics, otolaryngology (ear, nose and throat), pathology and radiology. At the University of Maryland Medical Center, 65 percent of residents are in specialty programs.

Judging from these figures, the two centers appear to doing better than the national average when it comes to training generalists. But the figures can be deceiving.

At Hopkins, for instance, most of the residencies that would qualify as "primary care" are in internal medicine, a field that more often than not serves as an entry to a medical sub-specialty such as cardiology or gastroenterology.

No matter how primary care is defined, the system of allocating slots to hospitals is bound to be controversial.

fTC Originally, the job was to have been done by regional councils with jurisdictions over multistate areas. The councils were to include consumers as well representatives of health plans, health alliances and hospitals, which would be competing against each other for coveted specialty slots.

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