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PRIMARY CARE PHYSICIANS: FINANCING THEIR GRADUATE MEDICAL EDUCATION IN AMBULATORY SETTINGS A Report of a Study by a Committee of the Institute of Medicine Division of Health Care Services National Academy Press Washington, D.C. 1989

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been renewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was- chartered Sciences to enlist distinguished members examination of policy matters nerta~n~n~ Institute acts under both the Academy's . . . ~ in 1970 by the National Academy of of the appropriate professions in the to the health of the public. In this, the 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. This project received support from the Josiah Macy, dr. Foundation (Grant #BS92003) and the Health Resources and Services Administration, Department of Health and Human Services (Order Numbers 89-287 (P) and 89-288 (P)~. 2101 Constitution Avenue, N.W Washington, D.C. 20418 (202) 33~3300 Library of Congress Catalog Card No. 89-639~34 International Standard Book Number 0-309-0413~! Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washingcon, DC 20418 S051 Printed in the United States of America IOM 89-10 F=t Printing, December 1989 Second Printing, Navanber 1990 .

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INSTITUTE OF MEDICINE COMMITTEE TO STUDY STRATEGIES FOR SUPPORTING GRADUATE MEDICAL EDUCATION FOR PRIMARY CARE PHYSICIANS IN AMBULATORY SETTINGS DANIEL D. FEDERMAN,* (Chairman), Dean for Students and Alumni, Professor of Medicine, Harvard Medical School, Boston, Massachusetts. EXALTON A. DELCO, dR., Vice President for Academic Affairs, Austin Community College, Austin, Texas. HENRY W. FOSTER, dR.,* Professor and Chairman, Department of Obstetrics and Gynecology, Diehard Medical College, Nashville, Tennessee. JOHN P. GEYMAN,* Professor and Chairman, Department of Family Medicine, University of Washington, Seattle, Washington, RUTH T. GROSS,* Professor of Pediatrics, Stanford Universitr, Stanford, California. RUTH S. HANFT,* Research Professor and Health Policy Consultant, Department of Health Services Administration G,`~or~r~ Wn~Lin~t~n University, Washington, D.C. ~_ ~ ~ _ ~ ~ ~O vent DAVID A. KINDIG, Professor of Preventive Medicine, Director of Administrative Medicine and Health Services, University of Wisconsin, Madison, Wisconsin. SHELDON S. KING,* President and Chief Executive Officer, Cedars-Sinai Medical Center, Los Angeles, California. GORDON T. MOORE, Director of Teaching Programs, Harvard Community Health Plan, Boston, Massachusetts. -

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WILBUR B. PITTINGER, Chief Operating Officer, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan. RICHARD E. RIESELBACH, Associate Dean, University of Wisconsin Medical School, Milwaukee, Wisconsin. NEAL A VANSELOW,* Chancellor, Tulane University Medical Center, New OrIeans, Louisiana. MICHAEL ZUBKOFF,* Professor and Chairman, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire. INSTITUTE OF MEDICINE STAFF JESSICA TOWNSEND, Study Director KARL D. YORDY, Director, Division of Health Care Services DEE SUTTON, Senior Secretary WALLACE WATERFALL, Editor * Member, Institute of Medicine -~v

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CONTENTS SUMMARY INTRODUCTION Scope of the Study Conduct of the Study ....... 10 ~ e ~ ~ ~ e ~ e ~12 CHAPTER 1. CONCERNS ABOUT PRIMARY CARE RESIDENCY TRAdNING 15 New Directions for Primary Care Residencies Other Policy Issues Relating to Financing Primacy Care GME . . . . . . . . . . . . CHAPTER 2. COSTS AND REVENUES FOR PRIMARY CARE RESIDENCIES IN AMBULATORY SETTINGS Introduction Costs Revenues CHAPTER 3. OPTIONS AND RECOMMENDATIONS Barriers Criteria for Evaluating Policy Options Conclusions and Recommendations . . . APPENDIX A. Workshop Program and Proceedings -v- 20 35 35 35 38 52 53 56 65

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APPENDIX B. The Cost of Graduate Medical Education in Outpatient Settings. Judith R. Lave . . . . Financing of Medical and Graduate Medical Education: Issues in Primary Care Education Support. Ruth S. Hanft . . . . Financing Graduate Medical Education in Primary Care: Options for Change. Sandra C. Peinado and John M. Eisenberg Financing Primary Care Residency Training: Examples and Lessons from Successful Programs Robert A. Walkington . -V1 .... 144 .. 173 197 - ... 230