By Lisa Seachrist

Washington Editor

WASHINGTON — As cost considerations and managed care have come to dominate the health care system in the United States, public concerns have centered on the effect these changes will have on a patient's access to needed health care.

That debate is far from over, but it is clear that controlling health costs will remain a driving force in the health care industry. And that drive for cost-cutting has put the squeeze on academic health centers and, inadvertently, on clinical research resources as well.

Representatives of academia, managed care organizations, government and the pharmaceutical and biotechnology industries met in a town meeting this week sponsored by the Institute of Medicine to evaluate the extent of the problem and possible solutions, including a proposal to assess a 1 percent tax on all existing health premiums. The Institute of Medicine is part of the National Academy of Sciences, in Washington.

"Managed care is not the problem, they are the messengers of the problem," said Herbert Pardes, dean of medicine at Columbia University's College of Physicians and Surgeons, in New York. "We have to find ways to replace the money that is being taken out of the system."

Much of the problem lies in the way academic medical centers have funded clinical investigations of its faculty members in the past. The reimbursement scheme from both private and federal sources such as Medicare and Medicaid has allowed the centers to collect more than the cost of services from insurers and use these patient care revenues to underwrite research, indigent patient care and medical education.

With the advent of managed care and expected reductions in funds from Medicare and Medicaid, academic centers are not only faced with restructuring the way they provide medical care in order to be more competitive, but also with finding other ways to fund their clinical research activities.

And institutions are having difficulty serving both missions, according to a study in the July 16 issue of the Journal of the American Medical Association.

Ernest Moy, a research director for the Association of American Medical Colleges, in Washington, found that medical schools in markets with high managed care penetration had a slower growth in numbers of National Institutes of Health (NIH) awards compared to schools in markets with less managed care.

Benjamin Safirstein, medical director with the Oxford Health Plan, in New York, noted that their focus on managing a patient's condition can reduce the number of times that patient ends up in a hospital. He said Oxford Health Plan's asthma program resulted in 70 percent fewer hospitalizations. "If patients aren't in the hospital, they won't provide revenue," he said.

Safirstein proposed academic health centers change their strategy to build consortia between managed care, the biotechnology and pharmaceutical industries and patient organizations to find ways to fund valuable clinical investigations.

Steven Paul, a vice president for Eli Lilly and Co., of Indianapolis, noted that industry does collaborate often with academia. But he also observed that academic centers often aren't the best partners.

"Many clinical investigators aren't well versed in clinical trial methods and we do better with contract research organizations," he said.

Nevertheless, Paul said without the public investment into medical research the vast majority of drugs wouldn't be around today. The biotechnology industry, he added, was spawned largely on the investment made by the NIH.

Noting what the public investment has achieved, Kenneth Shine, president of the Institute of Medicine, proposed that clinical research and the training of clinical investigators be funded by a tax on health care premiums.

"The 1 percent tax could be viewed in the same way that gas taxes pay for major road projects," Shine said.

Public Supports Tax For Research

Mary Woolley, president of Research! America, an Alexandria, Va.-based organization that promotes medical research, said surveys indicate that 70 percent of people are willing to support clinical research even if it means an additional tax.

But one of the problems with having a dedicated source of funds for clinical research will be that recipients of that money will come under scrutiny from Congress and the public. Currently, academic medical centers use their patient care revenues entirely as discretionary funds that don't have to be reported to the Health Care Financing Administration (HCFA), in Washington, which oversees Medicare.

Bruce Vladeck, an administrator with HCFA, said directed funding of clinical research in medical centers will subject them to accountability and they may not be prepared for it.

Shine noted the institutions must be willing to account for the ways in which they spend taxpayers' money. "You have to be accountable," he said. "But we must be willing to be flexible in allowing institutions to spend the money for their most urgent needs, whether that is a new facility or specialized training."

Whether Congress would consider an additional tax remains to be seen, and such a proposal is not currently on the table. However, the Senate has passed a resolution that NIH funding be doubled by the year 2000. *