The conditions that academic health centres (AHCs) are encountering at the beginning of the 21st century are associated with the difยฎcult relationships between their energizing, interweaving and sometimes conยฏicting missions (teaching, research and service) and the stresses associated with health care cost containment, managed care and ยฎnancing the variety of AHC programmes. Over time, the evolution of AHCs has also been bound to the role played by government policy to improve access to care, shape the professions in terms of both size and mix of providers, and to advance national goals for research and development. Perhaps more than any other group of non-government organizations in our society, AHCs have been a vehicle for change by government, foundations and other external constituents aspiring to shape health care. It is within the context of these expectations and challenges that AHCs must strategically adapt to their complex and challenging environments.
Eli Ginzberg and his associates, long time observers and analysts of AHCs, have written Teaching Hospitals and the Urban Poor. This is a book about the inยฏuence of US social policy on a set of elite AHCs, containing a succinct review of major federal initiatives to shape health care in America following World War II (Chapter 1) and the infusion of federal dollars into the nation's health care system (Chapter 2). The author and his associates promise to tell the story of the responsiveness of the AHCs to changing health care initiatives and to meet the perceived demands and needs of the urban poor for health care. The book succeeds much better in its attempt to document ยฎscal and workforce policy effect on the AHCs than its promise to allow us to understand the plight of the urban poor seeking health care through the AHC route.
Following the passage of Medicare, the elderly were quickly shifted, in the eyes of health care administrators and physicians, from charity cases to desirable paying patients with virtually all of the beneยฎts of private patients with traditional health insurance. Ginzberg points out that as a result of the new funding and demand for services much also changed structurally for these organizations. New stafยฎng models that embraced a growing clinical faculty emerged, the residency programme size increased, and there was reinforcement for a continued emphasis on specialty rather than generalist training. By the end of the 1990s there was also a substantial growth in private patient generated income through AHC practice plans. Unfortunately, this accounting of the ascendancy of the paying patient as a targeted source of income for