With new data supporting the concern that competition in the health care marketplace and pressures to reduce costs are hampering clinical research, academic researchers, managed care leaders, pharmaceutical representatives, and patient advocates gathered at the Institute of Medicine in Washington, D.C., to debate the issues troubling clinical research and to discuss a new proposal to bring substantial funds to this enterprise.
Although some participants blamed managed care for squeezing research budgets, others, like Herbert Pardes, MD, of Columbia University College of Physicians and Surgeons in New York, disagreed. "Managed care organizations aren't the problem. They are the messengers from society saying we need to cut medical costs."
Cost cutting is having an impact. One study found that medical schools in areas with a high penetration of managed care had slower growth in research awards from the National Institutes of Health than did medical schools in areas with low or medium penetration (JAMA. 1997; 278:217-21). A second study found indicators that young investigators in competitive markets are being required to spend more time on patient care duties and less time doing and publishing clinical research (JAMA. 1997; 278:222-6).
Speakers warned that a shift away from clinical research will create a roadblock when the clinical research system is unable to keep pace with the dramatic advances occurring in basic research. The research system will not be prepared to move laboratory advances to the clinic for testing to improve patient care.
The magnitude of support needed to revive clinical research will not be found in the private sector. "None of us will do well without robust public sector support of clinical research," said Steven M. Paul, MD, of Eli Lilly Research Laboratories in Indianapolis.
Kenneth Shine, MD, president of the Institute of Medicine, introduced a proposal to open a new stream of income from the public. He is calling for a 1% "assessment" or tax on health care premiums implemented over a 4-year period (JAMA. 1997; 278:245-6). Shine expects the assessment to raise approximately $4 billion to $8 billion for clinical research. The charge should not affect competition because it would be assessed across all health insurance plans. Shine said it would be similar to the 10% tax on airline tickets or the gasoline tax that is levied to maintain U.S. highways.
Similarly, the tax would support the clinical research infrastructure. Shine called for establishment of national centers of excellence for training clinical researchers, and for distribution of the funds by peer review to academic medical centers, managed care organizations, and others.
The public may like the idea. Mary Wooley, president of Research! America of Alexandria, Virginia, said that the public sincerely wants medical research and researchers to succeed. A 1997 survey supported by her organization found that two thirds of respondents say that the national commitment to research should be doubled. About 50% of respondents would support a surcharge, if everyone paid, Wooley said.
Private sector representatives did not balk, either. George C. Xakellis, MD, director of health care quality at Ford Motor Company in Dearborn, Michigan, wanted to be assured that the extra funds would result in enhanced health. Eli Lilly's Paul said he liked the idea. Benjamin Safirstein, MD, medical director of Oxford Health Plan in New York, indicated that he would support the surcharge if accountability was tied to the funding.
However, even advocates for the 1% assessment admitted that the U.S. budget deficit and the Medicare crisis will have to be resolved before Shine's proposal, or anyone else's, is given serious attention.
-Cori Vanchieri
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