Managed care may be choking clinical research.

Over the past 5 years, medical research institutions in Massachusetts, northern California, northern New York, and Minneapolis have become less competitive for federal grants than centers in most other areas of the United States. One reason, two new studies suggest, is the growing adoption of managed care.

With medical costs soaring faster than the rate of inflation, insurers have increasingly been taking an active role in managing patients' medical care. Many insurers require not only that a physician receive their authorization before prescribing unusual or costly treatments, but even that general medical services be covered only when provided by hospitals or laboratories that charge the lowest fees.

The move has hit teaching hospitals and medical research institutions especially hard. In the past, they have charged a premium for their services, using some of the extra revenues to subsidize clinical research, which involves patients.

A new study by Ernest Moy and his colleagues at the Association of American Medical Colleges in Washington, D.C., now finds that the greater the penetration of managed care into a region, the less successfully its medical schools compete for National Institutes of Health research grants. NIH, located in Bethesda, Md., provides roughly 80 percent of federal financing for health research.

Overall, from 1986 to 1990, the 115 medical schools examined fared about the same, receiving steadily more money. Schools in regions where less than 40 percent of the community was insured under managed care saw a continued increase in NIH funding through 1995.

However, 9 of the 13 medical schools in areas where managed care now accounts for more than 40 percent of medical services experienced a sharp drop in such grants. Indeed, the relative slowdown in NIH grant increases for medical schools in these regions represented a loss of $98 million in 1995, Moy's team concludes in the July 16 Journal of the American Medical Association (JAMA).

In the same issue, Eric G. Campbell and his colleagues at Boston's Massachusetts General Hospital document a related trend. Medical schools where managed care's cost-reining changes were least prevalent published 13 percent more peer-reviewed research papers over a 3-year period than did their counterparts in areas with more managed care and 17 percent more than colleagues in regions with the most managed care.

Moreover, they found that investigators who conduct clinical research in the most cost-conscious medical centers were most likely to report tension among researchers, lack of cooperation from colleagues, and competition for resources--features that earlier studies showed could jeopardize research quality and productivity. In contrast, laboratory scientists in the same medical schools whose research did not involve patients experienced no extra pressure or shortfall in publishing relative to peers in regions with less managed care.

The result, Moy says, would seem to suggest that physicians bent on a clinical research career may encounter less frustration if they work in a market with less managed care--such as Omaha, Neb., or Charlottesville, Va. Unfortunately, he adds, "managed care is growing everywhere. You can't avoid it."

Kenneth I. Shine, head of the National Academy of Sciences' Institute of Medicine, offers a scheme for raising $4 billion to $8 billion annually to offset managed care's erosion of the clinical research infrastructure. His commentary in JAMA advocates a 1 percent tax on health care charges--a levy analogous to the federal gasoline tax or airport ticket tax-to be distributed to research institutions on the basis of a peer review.