MOST academic surgeons now find themselves in the midst of a payer-driven revolution in which many university hospitals are at a real disadvantage. In an effort to control costs and compete for a fixed or decreasing health care dollar, both for-profit hospital corporations and not-for-profit community and community teaching hospitals compete successfully with university hospitals for "bread and butter surgery" and tertiary cases. In most markets, university hospitals invariably cost 20% to 30% more than community or community teaching hospitals because of the increased burden of time to educate students and residents as well as an increased burden of indigent care and highly complex care. Worse, many payers are now "profiling" hospitals by procedure, diagnosis, or diagnosis-related group and trying to leverage patients into the lowest-cost hospital, which, in most environments, will not be the university hospital. Thus, university hospitals (and their faculty) find themselves at a disadvantage for managed care contracts, a disadvantage for the proximity of the clinical caseload to the academic resources of the university, and a disadvantage for the case volume necessary to train a well-rounded general surgeon.
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