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TR: But aren’t academic hospitals such as those in the Partners system, like many health-care providers, starting to require doctors to see a set number of patients, leading to complaints about patient visits and hospital stays that are too short?

THIER: In this marketplace all hospitals must set guidelines on matters such as numbers of patients seen, using industry standards, but for our part we factor in the number of older or sicker patients various doctors’ groups are likely to see. Physicians at Massa-chusetts General and the Brigham and Women’s hospitals, for instance, tend to have sicker patients, so we have to take that into account. We do not have a cookie-cutter, one-size-fits-all approach.

Standards are critical-how can we even measure quality without having them?-but they should be used to improve the results of care rather than just efficiency. And that’s what academic hospitals should focus on as we compete with for-profits.

We also need another boost. An independent task force I’m chairing- organized by the Commonwealth Fund, a philanthropic foundation-has found that the clinical services of academic hospitals can’t fully compete on a cost basis with those of for-profit hospitals. That’s because we care for these patients who cannot pay and we subsidize research. (The National Institutes of Health under-reimburse overhead to ensure cost-sharing by grantee institutions.) We need a trust fund that pays for those services as social goods so that we play on a level field. The federal government should require Medicare, Medicaid, and health insurers to share in financing this fund. Our report also calls for setting up an independent, nongovernmental overseer of the fund to ensure that the money is used appropriately.

TR: What could convince the federal government to agree to finance the fund?

THIER: Congress already agreed to this general notion once, in the Balanced Budget Act of 1995, but President Clinton vetoed that for other reasons. Whether the idea will be reintroduced is unclear, but it should be.

Meanwhile, both federal and state legislatures can help with academic hospitals’ higher costs by insuring at least some coverage for those who really need it. One beginning step has occurred in Massachusetts, for example, where the legislature has determined that hospitals, the state government, employers, and health-care insurers will all contribute to the cost of care for people without any insurance. This is a wonderfully creative approach, as long as insurers don’t turn around and start paying hospitals less for their work. Other states should copy the model.

As a decent society, we should especially make sure that all kids are covered. If we consider such efforts in only the most hard-headed way, we should realize that because the first two to five years of youngsters’ lives are critically important in terms of their future health, their future productivity and participation in society are at stake.

Generally, as a society we need to think about the responsibilities of medicine as a profession. According to a definition proposed by Louis Brandeis, the former Supreme Court justice, a profession must have standards that its members enforce. He said a profession needs to advance and pass on a body of knowledge. That means we must conduct research and teach. According to Brandeis, a profession adheres to a code of ethics and values performance above re-ward. That’s the commitment to provide health care whether or not somebody can pay for it.

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