Information on resources involves questions and concerns that are central to the development and financing of the system and its components over time (see Table 3 for illustrative issues). Interviewees were especially concerned about training for providers, especially physicians, given the fact that there is already an oversupply nationwide. Many variables that both influence future training needs and the ability to project these needs are not captured well by existing data systems. For example, are physicians responding to economic circumstances by shifting their practice (e.g., from specialty care to primary care), and what does this imply for future physicians and their training needs? Without consistent data on characteristics and content of medical practice, it is difficult to assess this issue. How are primary care training needs and the challenges they create being met in light of the move to ambulatory care-based delivery and training? Do we have systems to even benchmark the extent of these changes? How do we capture outpatient training in different settings and who should collect this information? What do we know about the current providers of training: how is training and funding being influenced by market change? In an era of concern over cost, how can the relative performance of the many different residency programs be assessed? Capturing information on the financing and outputs of medical education has always been complex because of the multiple entities, cross-subsidies, and joint products involved. The limitations these factors create for analysis become more of a concern in the policy environment and for academic medical center operational planning in an era of managed care growth and increased competition.
Concerns about the financing of care are related to gaps in how resource data on the health industry is captured. There is a need for information on the increasingly influential role of employers in the health care system. What are employers doing? What incentives for action are they facing in terms of trends in insurance premiums? There is also a need for information on the role of consumer financing. How much are consumers paying out of pocket, and how and why is this changing? Estimating consumer spending has always been a problem, and it is becoming more complicated as patient spending becomes partly influenced by choices they make among the great variety of health care options that involve variable in- and out-of- network charges. As states grow more dominant in formulating health policy, what interstate transfers in spending exist? What capital needs do providers face for diverse investments, especially when the providers or the intended uses of capital are ill-suited to equity markets? Do we even know how much is spent on biomedical research and other forms of nonpersonal health spending and who is doing the spending? This question may be important if the funding comes from cross-subsidies of patient care that may be tightening.
QUESTIONS HIGHLIGHTING DATA GAPS: STAKEHOLDER CONCERNS ON
RESOURCES AND STRUCTURE II
A. The Pipeline: Training and Needs*
- What really are physicians doing in their practice versus what they were trained for and how does this affect the needs for training? How are the career paths of physicians with given training changing?
- How many and what kind of providers do we really need?
- How will we know about the amount and kinds of training occurring as it moves toward the ambulatory side of the health care system? How involved are AMCs in ambulatory care delivery?
- How are states paying hospitals for graduate medical education under Medicaid and what are the implications for AMCs with the shift to Medicaid managed care?
- What is the quality and sustainability of curricular innovations under current market conditions?
- What money are states putting toward state supported medical schools (or other health professions) and how much of this is going to meet state needs?
- How can we assess performance of diverse residency programs?
- How are teaching hospitals faring in terms of their three part mission and their ability to finance this? What impact do mergers of community hospitals in the market have on AMCs?
B. Financing of Care
- What are the trends in insurance premiums?
- What role are employers of different types and sizes playing alone or individually to influence the financing and structure of care?
- What is the size of the health care industry and employment base?
- How much are consumers spending out of pocket, is it increasing and why?
- What is the size and nature of interstate transfers in spending?
- How much capital is needed, by who and for what, particularly by those outside equity markets?
- How much are we spending on biomedical research and other forms of nonpersonal health care spending?
*The focus on questions of physical training reflects the current focus of the health care system and could
change in the future.