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The aim of such empire building is to maintain a flow of patients to the teaching hospital. His health-insurance company initially tried to talk Daniel Vonk, a teacher from Fernandina Beach, Florida, out of going to the Mayo branch in Jacksonville because its fees were so high. Vonk went anyway, on a referral from a sports-medicine specialist who had done an mri when he learned that an ache in Vonk's leg had persisted for more than a year. Mayo specialists diagnosed the problem as bone cancer and subjected Vonk to three operations; Vonk also spent six months in a partial body cast and a year on crutches. The bills were high, all right: even with his insurance benefits Vonk, now 33, wound up owing Mayo $15,000. He appealed under an "indigent patient" program and got that reduced to $5,000, but he will still be paying Mayo $100 a month for a long time. Nonetheless Vonk is so delighted to be walking around cancer-free that he has named a newborn son after his Mayo surgeon.
Nowhere has the transformation of the teaching hospital been more dramatic than in Boston. Last year, in the medical merger of the century, Massachusetts General Hospital hooked up with Brigham and Women's Hospital; they had been ranked No. 1 and No. 2 in federal research dollars received. A few months earlier, Daniel Tosteson, dean of the Harvard Medical School, with which both hospitals are affiliated, wrote that "no single institution has the resources required to respond effectively to managed care and other external pressures ... while at the same time maintaining excellence across the full range of services."
The merged institution is cutting costs by, among other things, consolidating operations: for example, Brigham sends all liver-transplant patients to Massachusetts General. The total number of beds has been reduced from 1,700 to 1,514, and Samuel Thier, president of Massachusetts General, hopes to get that number down to 1,000. A first-year saving of $47 million out of a total combined budget of $1.1 billion seems to confirm what critics of the old teaching-hospital model, such as Alan Sager, professor at Boston University's School of Public Health, have long maintained: these blue-chip institutions had fat "marbled throughout the system like a prime steak.''
Certainly the next round of cuts will hit meat as well as fat. Thier has vowed to bring the ratio of specialists to primary-care physicians in the two hospitals, currently 8 or 9 to 1, down to 1 to 1, while also reducing the total staff. "We're all going to get killed,'' says a Harvard Medical School executive close to the situation. "Now the primary-care physicians have the specialists by the short hairs.''
"The primary-care doctors have more power than they ever had,'' agrees Boston health-center administrator Rina Spence. Because they act as ''gatekeepers'' for all further treatment, "they're holding all the cards: the patients.'' So the other key strategy for Massachusetts teaching hospitals involves the neighborhood clinics and suburban practices, where primary-care physicians can be acquired in bulk. Partners Healthcare Systems, a newly formed holding company for the merged hospitals, has organized 402 doctors into a network covering eastern Massachusetts.