Schwartz W B, Newhouse J P, Williams A P
N Engl J Med. 1985 Jul 18;313(3):157-62. doi: 10.1056/NEJM198507183130305.
The nonmunicipal teaching hospital faces some special challenges in adapting to the increasingly austere fiscal environment in which all hospitals must operate. However, except in a few instances, such developments as constraints on Medicaid expenditures do not appear to be notably more serious for teaching hospitals than for their community counterparts. The teaching hospitals most closely connected with medical schools provide more charity care and carry more bad debt than community hospitals. But other teaching hospitals have about the same burden as their community counterparts. The most serious problem facing teaching hospitals results from new bases of prospective reimbursement, some of which do not adequately compensate hospitals that treat more "difficult" cases--that is, more expensive cases. Competitive providers of health care such as health maintenance organizations promise to reduce admissions at all types of hospitals; whether this reduction will selectively affect teaching hospitals is not yet clear. By contrast, the fiscal state of municipal teaching hospitals is far more precarious than that of their nonmunicipal counterparts. The ability of these institutions to maintain high-quality patient care and teaching programs is in considerable jeopardy.
非市立教学医院在适应所有医院都必须运营的日益严峻的财政环境方面面临一些特殊挑战。然而，除了少数情况外，诸如对医疗补助支出的限制等情况，对教学医院来说似乎并不比对其社区同类医院更为严重。与医学院联系最紧密的教学医院比社区医院提供更多的慈善医疗服务，且坏账负担更重。但其他教学医院的负担与社区同类医院大致相同。教学医院面临的最严重问题源于预期报销的新依据，其中一些依据不能充分补偿治疗更多“疑难”病例（即更昂贵病例）的医院。诸如健康维护组织等竞争性医疗服务提供者承诺减少各类医院的住院人数；这种减少是否会对教学医院产生选择性影响尚不清楚。相比之下，市立教学医院的财政状况比非市立教学医院要危险得多。这些机构维持高质量患者护理和教学项目的能力面临相当大的风险。
