While its methodology and percentage vary by university, 典型的“院长税”(dean 's tax)是一种适用于商学院临床教员创造的专业收入的评估. It provides much-needed funding to the dean for overhead costs of the medical school, cross-subsidization of mission-critical programs, and/or start-up packages (e.g., for department chairs and faculty). However, 如果我们把政治放在一边,在今天的市场上考察一个学术医疗中心(AMC)的宏观经济, we find that the dean’s tax is often misplaced and outdated, and it can be an impediment to partnerships with health systems and other providers. 报销水平和其他市场因素要求医学院和附属教学医院之间的经济利益紧密结合。, but the legacy dean’s tax does not promote this—in fact, it accomplishes the opposite.
Origin of the Dean’s Tax
The emergence of the dean’s tax was rational. It was born in the late 1970s and early 1980s when the Center for Medicare & 医疗补助bet8娱乐(CMS)成立了,联邦政府建立了100亿美元的预算,将医疗保健覆盖范围扩大到1900万美国人.1
这给医学院的临床部门带来了意想不到的收入. At the time, 各科室能够从自己的临床手术中获得正的营业利润(很少或根本没有附属医院的支持). 他们通过以收入为基础的评估,即后来被称为院长税,对学术事业进行了必要的投资.Current State
Fast forward to 2019: The median loss per physician/faculty member is $228,000 as professional reimbursement has declined significantly, particularly for medical specialties (on average; it varies by specialty), and technical revenue has shifted to the hospitals.2 近年来,用于支持医学院运作和教师薪酬的医学教育和研究相关收入已趋于平缓或下降. Physician/faculty compensation continues to rise for most specialties. From the perspective of the three core AMC entities, common scenarios are as follows:
- Medical schools carry additional costs allocated by the university, seek increases in discretionary funding, and are under pressure from affiliated clinical partners to justify ROI for additional funding.
- Faculty group practices (FGPs) only generate a net positive margin with the help of Medicaid supplemental programs; lucrative service agreements and program support from affiliated teaching hospitals; and/or commercial reimbursement in the top 10th percentile (which is out of reach in most markets).
- Teaching hospitals have an average operating margin of 3.7%3 ; are under pressure to gain cost efficiency in a market demanding value; are in need of capital for reinvestment in facilities and technology; and are hesitant to provide an increase in funding to medical schools and/or faculty practices without greater control and integration.
Irrational (and Somewhat Circular) Funds Flow
Keeping in mind the common disposition of the three core AMC entities described above, figure 1 below depicts an internally focused, cyclical funds flow conundrum that many AMCs experience today. At the center of it all is an outdated approach to dean’s tax and interentity mission support:
大多数实体间的资金流模型都包含一系列复杂的合同,这些合同无法使各方的战略利益和财务利益保持一致. 各个实体之间拼凑的财政协议为奖励富有成效的教师提供了必要的资金, invest in programs of strategic importance, and keep the departments solvent despite the prevailing economics of academic medicine. For many academic health systems, hospital partners provide additional funding directly to departments, recognizing the need to support and retain the clinical faculty. 这些财务安排最初是临时协议,目的是稳定一个特定的部门或一组教员. Over time, however, 在全国范围内,支持fgp的协议数量随着所附金额的增加而增加.
这种情况引出了一个问题:对于bet8网站备用来说,是否有一种更有效和简化的方法来为医学院提供支持,使其经济利益与优化整体表现保持一致? The short answer is yes; however, it will require bold leadership and likely an investment of political capital.
This question does not contest a medical school’s need for revenue generated by the dean’s tax; it is related more to how the medical school should receive those funds and where they should come from. The dean’s tax mechanism burdens the FGP, its departments, and the faculty and is not aligned with today’s market. Most notably, 对每个教员的收入基数不断下降征税,既不是医学院可行的筹资模式,也不是院系可持续发展的未来. Furthermore, at a time when FGPs need to be as innovative as possible, 院长税通常对外部各方起到威慑作用,否则他们可能会与FGP签订合同,购买bet8网站备用bet8娱乐(并为医学院提供急需的收入来源)。.
Reengineering Funds Flow
Rather than taxing faculty, which oftentimes exacerbates an existing deficit, 现代学术bet8网站备用正在以合理的方式重新设计其资金流动,考虑到当前的市场动态,并确保院系和医学院的可持续性. 许多资产管理公司正在用源自bet8网站备用的使命支持资金取代院长税. Instead of relying solely on the professional fees generated by faculty, 这些资产管理公司正在利用该系统可用的更广泛的收入来源,以确保医学院获得足够的资金, regardless of changes in reimbursement for physician services.
图2突出了院长税的一些主要特点和局限性,与更现代的资金流模式(由bet8网站备用提供特派团支持)相比.
医疗系统对医学院的支付更加慎重,为管理学术企业提供了所需的灵活性,并提高了透明度, giving the system insight into its investments. In the future, 更多的学术医疗中心将采用具有以下属性的基于绩效的特派团支助模式:
- 为医学院预留的一笔固定金额,既可靠又可预测(取代院长税)。
- 与集体临床企业绩效挂钩的可变激励金额
- 对临床和学术企业具有战略重要性的领域进行有时间限制的投资
简化了bet8网站备用和医学院之间的资金流动方法,确保没有隐性补贴,消除了所有临床专科都能产生利润的不切实际的期望.
Ready for Change?
As the healthcare market has evolved, 许多学术组织没有调整其资金流来反映当前的环境. A critical first step in the process is to delineate what you want your funds flow to achieve. 您是否希望推动AMC旗下各个实体的整合,并对您所看重的企业进行有目的的投资? Are simplicity and transparency important to your organization? 您当前的资金流是否具有有效管理业务和指导决策所需的平等和完整性? Do you need a funds flow that is flexible, nimble, and not a deterrent to potential partners? If so, 也许是时候废除院长税,代之以一种现代的学术使命支持方式.
Footnotes
- 1.
The initial budget of $10 billion was established in 1965 with the signing of H.R. 6675 by Lyndon Johnson. 预期支付制度是由CMS根据1983年的《bet8网站备用》建立的.
- 2.
ECG 2017 Medical Group Cost and Infrastructure Survey.
- 3.
Optum360 2017 Almanac of Hospital Financial & Operating Indicators.
Published May 1, 2019