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Ellen Zane, who heads Partners Community Healthcare, Inc., the network arm, aims to increase that number to 850 in about five years -- though she faces intense competition from two other networks that are also signing up doctors at a frenzied pace. At times the competition gets bizarre: the 20-physician Concord Hillside Medical Associates in a Boston suburb was bought out by the Lahey Hitchcock network earlier this month. But Emerson Hospital in Concord, where the Hillside group sends many of its patients, is simultaneously negotiating to join the rival Partners network. "The situation is filled with fault lines and tensions,'' says Geoffrey Cole, president of Emerson. Cole doesn't want "to start a nuclear war,'' observes Zane. "But he's going to have a nuclear war either way.''
Meanwhile, substantial reductions in Medicare and NIH subsidies for teaching and research could wipe out much of the benefit from these economies so painfully achieved. "We look at cuts as unfunded mandates,'' says Mark Laret, deputy director of the Medical Center at ucla, which stands to lose some $16 million. "We are supposed to provide all the same services and do it with less. Medicare, to its credit, is the only payer that contributes anything to the cost of medical education, and that has got to change.'' UCLA has already talked with several local hmos about a premium tax to finance teaching functions. Others have suggested imposing such a surtax on all insurance premiums. Says Bruce Kelly, the director of government relations at Mayo: "We endorse a set-aside program to fund research and teaching.'' But a delegation of teaching-hospital administrators who visited Capitol Hill in mid-May, sensing the draconian political climate, made only an exceedingly modest plea: if Medicare funding is cut, say, 13%, O.K., cut us 13% too -- but no more.
Whatever happens, no one doubts the teaching hospitals will survive. Besides revenues that in some cases compare favorably with those of Fortune 500 corporations -- the Mayo Foundation in 1993 took in $1.6 billion -- many also have generous endowments. But will they purchase institutional survival by lowering the standards of excellence in care, training and research that have been their fundamental reason for existence? Some experts are deeply worried. "We're coming close to the edge of impacting quality," says Dr. Michael O'Sullivan, chairman of Mayo's regional-practice board. That may sound like the standard whine of anyone threatened with a cut in federal subsidy, but in this case, the consequences if he is right are dire enough to prompt some serious examination. It would be easy enough to turn the crown jewels of American medicine into paste, but who then would develop tomorrow's effective treatments for AIDS and Alzheimer's?
--Reported by Sam Allis/Boston, John F. Dickerson/Washington, Edwin M. Reingold/Los Angeles and Elizabeth Taylor/Rochester