National Academies Press: OpenBook

Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings (1989)

Chapter: The Cost of Graduate Medical Education in Outpatient Settings

« Previous: Appendix B:
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 144
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 145
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 146
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 147
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 148
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 149
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 150
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 151
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 152
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 153
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 154
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 155
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 156
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 157
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 158
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 159
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 160
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 161
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 162
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 163
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 164
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 165
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 166
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 167
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 168
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 169
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 170
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 171
Suggested Citation:"The Cost of Graduate Medical Education in Outpatient Settings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
×
Page 172

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

THE COST OF GRADUATE MEDICAL EDUCATION IN OUTPATIENT SETTINGS* Judith R. Lave, Ph.D. Professor of Health Economics University of Pittsburgh Introduction Until recently, medical students and residents received most of their clinical training in hospital inpatient settings. Educators and others who are interested in training physicians for practice in primary care have been critical of the focus on inpatient training for some time (MacLeod, 1970; Schroeder et al, 1986; Karpf and L.evey, 19861; they are now joined by those who realize that, because of changes in medical practice, there is a need to conduct more physician training outside the inpatient setting for all physicians. However, as training is shifted from the inpatient to the outpatient sector, a whole set of issues are raised. How should training in the outpatient sector be organized? How much does it cost to train residents in the outpatient setting? Is it more costly to train medical students in the outpatient setting than in the inpatient setting? What will be the effect of developing a program in outpatient training on the net revenues of an institution? Do we need different ways of paying for services if we change the locus or training? The questions above are very general. The term "outpatient setting" embodies a range of practice settings. Formal outpatient clinics, Health Maintenance Organizations, prepaid group practices, surg~-centers and even doe in the box, are all outpatient settings. Some of these have been training sites for medical students and residents since medical schools were first established. However, in the past these settings have been of very limited importance, and the type of training provided in those sites was not geared towards developing · . · - pr~ma~ care p. Scans. * ~ would like to thank Lester Lave, Gordon MacLeod and Jessica Townsend for helpful comments on an earlier draft; Lawrence CIare for bibliographic help and Bruce Block, Marian Block and Michael Karpf for describing their training programs. ~44

In this paper I address some of the issues related to the cost of training medical students and residents in primary care. I begin by reviewing briefly the literature on approaches to estimating the cost of graduate medical education in the inpatient setting. Next I develop an analytical framework for examining the cost of training in the outpatient sector and the cost of introducing medical students and residents into outpatient clinical practice is explored at some depth. I then examine the relevant empirical literature related to this issue. I go on to examine cursorily the "financial" impact of the implementation of training programs in primary care. I then address a number of other selected issues related to training in primary care and conclude with some recommendations for future research in this area. The Cost of Medical Training in Hospitals Teaching hospitals are multiproduct firms; they produce medical training, patient care, research and community services. For the many services that are joint products, it is impossible to allocate the costs among them in a nonarbitrary fashion. Conceptually, the cost to society of medical education and training in the hospital setting is equal to the difference in total costs (both physician and hospital costs) between a hospital which provides these educational services and one that does not assuming they differ only in the educational programs. It is necessary to look at both physician and hospital costs because the trainees provide patient care services in place of those ordinarily provided by trained trained . · ~ P nys~c~ans. With some exceptions, analysts have not tried to estimate the cost of medical education as defined above because of the difficulty in determining the costs associated with providing physician services in hospital settings. In general, hospital accounting records include information on all of the expenditures incurred by hospitals (nursing salaries, pharmacy drug costs, lab equipment and so forth). These expenditures include the direct costs of the hospital training programs (salaries of teaching physicians, resident stipends and fringe benefits as well as hospital overhead costs that are allocated to the training programs). Data on payments for services rendered to patients by physicians in hospital settings are kept by patients and in the claims Blles of the third party payers. In general analysts have focused on gross costs of graduate medical education. determining what ~ will refer to as the The gross costs of graduate medical education have two components: direct costs of the hospital residency programs (defined above) and indirect costs which are the increase in patient care costs incurred by the hospital because it is involved in graduate medical education. Patient care costs are higher because there are increased space needs, additional 145

record keeping requirements, decreased productivity of other staff members, and excess test ordering by residents because of their inexperience. Estimates of the direct costs of graduate medical education are obtained from hospital accounting records. Since the indirect costs cannot be measured directly, they are determined statistically (Lave, 19851. In most cases, analysts estimate "cost functions" in which hospital inpatient costs (excluding the direct costs of graduate medical education) are regressed against a series of variables known to influence hospital costs such as case-mix, hospital wages, hospital bed size and some indicator of the hospital's teaching status. (Anderson and Lave, 1986; Sloan, Feldman and Steinwald, 1983; Thorpe, 19881. The specification of the estimating equation varies across studies as does the measure of hospital teaching activity. (The most common measures are the number of residents per _ ~ ~ · ~ · ~ ~ ~ ~ ~ · 1 ~ ~ 1 ~ · "01 · ~ · 1 ~ ~ ~ ~ ·1 bed or an indicator of the hospital s teaching Eaten - member of the Bounce of teaching hospitals; teaching hospital but not a COTH hospital, or nonteaching). Analysts thus estimate the incremental effect of teaching on hospital costs (minus the direct costs of teaching) once the effect of other factors known to influence these costs have been taken into consideration. The results of these analyses indicate that the indirect costs of teaching are positive; i.e., that hospital inpatient costs increase with the extent of the hospital's involvement in medical education. However, the estimated size of the indirect costs depends upon the group of hospitals studied as well as measures used to control for other factors known to influence costs across hospitals. Nationally, a one percentage point increase in the number of residents per bed is associated with about a 5 percent increase in inpatient care costs per case. Analysts are aware that these are "gross" costs of graduate medical education. Some investigators have tried to estimate "net costs" by estimating physician costs associated with a hospitalization either by obtaining estimates of physician services from medical records (Arthur Young, 1986) or by merging information on physician claims with cost information from hospital accounting records (Cameron 19851. The results of these studies indicate that residents are partial substitutes for fully trained physicians. Cameron for example, found that in California payments to physicians for services provided to Medicaid inpatients were lower in major teaching hospitals by Medicaid's share of the residents salaries in those hospitals. These studies shed no light on whether graduate medical education programs lead to increased hospital profits (or reduced losses), increase physician incomes, convey prestige on a institution, or are the source of other unmeasured benefits. The profitability of graduate medical education programs will depend on how these programs affect hospital admissions and on how hospitals and other :46

providers of services are paid for the services that they provide. Under the financing arrangements that prevailed in 1989, available information indicates that graduate medical education programs in hospitals were profitable. Cost of Training in The Outpatient Sector: An Analytical Approach In considering the cost of training programs in the outpatient sector, the appropriate question to be raised is: what additional resources are needed to accomplish this task or what is the increased monetary cost of adding this activity (Delbanco and Calkins, 1988; Gavett and Mushlin, 1988)? (If all the resources are costed out, then these questions will have identical answers.) However, these questions are different from an equally important one: will the implementation of this program generate net positive revenues? To the sponsoring institution or the manager of the training program, the impact on net revenues is the more important question. The cost of the training program will depend on its nature. Training programs can range from the development of a residency program in family practice in a nontraditional setting, the enhancement of an outpatient focused primary care component in an internal medicine residency program, or the implementation of a clerkship for medical students in an HMO or family practitioners' office for 4 weeks during the summer. Since the programs differ, so too will their costs. Consider the cost of adding residents to a primacy care practice. (Medical students could easily be added to this example.) This case which addresses the following question - is it more costly to provide medical care in the ambulatory setting in which residents are both being trained and are providing services than it is to provide care by fully trained physicians - is explored in depth because it has generated the most interest. In the discussion that follows, the term FT (Fully Trained) physician is used to describe physicians who have completed their residency training. In the ambulatory setting, residents acquire skills while "learning by doing". However, while they are practicing, they receive faculty input through direct supervision, case conferences, chart review and consultations. The nonphysician component of the cost of care may vary with the level of training of the resident. For example, residents may order more tests, may require more nursing time per visit or may use more examining room time than more experienced physicians; that is, there may be some indirect costs of graduate medical education (as the term is used in the inpatient setting) in the outpatient sector. i47

In order to focus on the most important factors influencing the cost of training, assume that only physician services are needed to produce patient visits. Figure One indicates both how productivity varies with the amount of training that a physician has as well as the amount of faculty input provided to the resident. The figure indicates that a FT physician working full time in the clinical setting provides O] visits per unit time while the number of visits that a resident provides varies with the year of training as indicated by the curve CD. As suggested by the curve EF, the amount of faculty input needed per average visit provided by the resident decreases as the residents become more experienced. In Figure Two, OS indicates the average cost of a visit provided by a FT physicians. RT indicates the average cost of a visit provided by the resident. At first, the cost per visit provided by a resident is higher than that provided by a FT physician, however it begins to fall as faculty input decreases and resident productivity increases. The curve suggests that the cost may begin to increase towards the end of training because the residents' salaries increase and the number of hours worked decrease leading to an increase in the cost per hour. Although the general shapes of Figures One and Two should be true for all settings, the details of the curves will vary from site to site. For example, the position of CD in Figure One will depend upon whether there is an adequate flow of patients through the clinic, the efficiency with which the practice is operated, and the pace at which residents practice. (The pace could influence both the quality of patient care provided and the quality of the clinic experience from the training perspective). The position of EF will vary with the amount of training and feedback the resident actually receives. · ~ ,, ~ , ~ Finally, the relative positions of OS and RT will depend upon the hourly cost of residents and the faculty. Thus, the net cost of training will in large part depend upon the amount of faculty input into the training process, the relative income of the faculty and residents and the flow of patient visits. It will also depend on the mix of residents: in general the net cost will be positive for medical students and for residents early in their training and negative for more senior residents. Because the net cost of training depends upon so many factors, it is not surprising that empirical studies of the cost of training, which usually considers single sites, often reach very different conclusions about both its size and direction. i48

Patients Per Hour Cost Per Visit S o J C O ~7 Output - / Resident t - Output Faculty lo) Input 0 12 24 36 Month of Traintug FIGORE ONE \ Bcsiten~ Fully Trained Ml) Year of "atn FIGURE "0 149 Faculty HD Input Per Resident Vis T

Empirical Studies of The "Net Cost" of Training In The Outpatient Setting Several studies have attempted to estimate the cost of training medical students and residents in the outpatient setting. Some of these studies have examined only the gross costs of education; but many have investigated the net costs of education. In this respect, this research is different from that on the cost of graduate medical education in the inpatient setting. The work on the net cost of graduate medical education can be classified into four groups: time and motion studies, replacement cost studies, relative cost studies and marginal productivity studies. Time and Motion Studies In time and motion studies, the investigators directly observe the various providers of care to determine how they spend their time. However these studies often do not provide useful information into the incremental cost of providing training. This is a particular problem when the faculty members are training residents at the same time that they, the faculty, are providing care or are training a number of people simultaneously. However, time and motion studies can provide some information on the amount of faculty time that the residents use when they, the residents, are the primary providers. In a recent study of the cost and efficiency of prodding services in 15 general internal medicine ambulatory practices in teaching hospitals, Kosecoff and associates (1987) used time and motion studies to determine how much time patients spent with their primary providers) (faculty member, resident or nurse) as well as how much time they spent with the attending physician and nurse during their visit to the primaly providers. The investigators found that for the patients' first visits, PGYls In these practices patients were assigned to one of several types of practitioners, residents or fellows, faculty members or nurses who served as the primary provider during that visit. However, during a visit to a primary provider, other providers would be involved in the care. A nurse could be present in the room or provide distinct services; the attending physician could see the patient being treated by the resident or consult with the resident on the case. i50

(residents in their first post graduate year) spent a statistically significantly longer period with the patient than did the other classes of primary providers (MDs and nurses); while for follow up visits, faculty physicians spent a significantly shorter time. They also found that the attending physicians spent a significantly longer period of time with PGYl's for both first and follow up visits (when the PGY1 was the primary provider) than they did with did PGY2s and PGY3s. There was no significant difference in the amount of time the patient spent with the nursing staff by type of primaly provider. Kosecoff et al. estimated the direct physician and nursing cost per visit first by estimating the average hourly wage for each type of provider and then by multiplying that by the proportion of time the physicians spent with a patient by type of primary provider. In the institutions studied, the average PGY1 earned $23,000 a year and worked 70 hours a week while the average associate professor earned $85,000 and worked 55 hours a week. The estimated average cost for a visit by type of primary provider is shown in Table 1. The main factor contributing to the difference in the costs across visits by type of primary provider is the amount of faculty time per visits. On average, the faculty members spent very little time interacting with PGY2s and PGY3s. However, there was considerable variation in the amount of time the faculty spent with residents across the 15 practices. For example, for a follow up visit, when the PGY2 was the primary provider, the attending spent on average less than a minute with the patient in 9 of the 15 practices, between 1 and 6 minutes in 4 of the practices and over 6 minutes in 2 of the practices. (The amount of the time the attendings spent discussing the case with the residents outside of the examining room was negligible.) 2 For example, the cost of the first visit is highest when the faculty member is the primary provider because most of the care is provided by the mostly costly provider. The cost of a visit to a PGYl is high because, although the hourly cost of the PGY! is low, the attending physicians spends a significant amount of time with the patient and resident. i5i

Table ~ Average Nurse and Physician Costs of Visits To Fifteen Internal Medicine Group Practices (in 1983 Dollars)* Type of Primacy Prowder First Visit Follow-Up Mean visits cost visits Mean Cost n n up Faculty 87 21.40+ 233 10.43# Postgraduate Year ~32 18.03 80 6.33 Postgraduate Year II 35 9.24 145 5.44 Postgraduate Year Ill 42 9.55 120 5.47 Nurse Practitioner, 10 17.85 91 S.20 Physician Assistant * Based on actual time spent with patient (time-and-motion study). + No significant difference with postgraduate year I; p < 0.01 with postgraduate years I] and ITI. # p ~ 0.01 with all three postgraduate years and nurse practitioner. ~52

Replacement Cost Studies In a replacement cost study, the following question is posed: if outpatient clinics continued to serve the same number and mix of patients, what would be the cost of closing the teaching programs and using full time practicing physicians to provide the services that were previously provided by the residents. Researchers who have used this approach have carefully studied the clinic practice (i.e. examined the number of patients seen per hour by faculty and by residents, asked questions about the use of other personnel, noted the use of examining rooms) and estimated how changing the physician mix would change the costs in that clinic. me '' ' ' ' ' -' ~ ~ ~ data. -sneer estimates are cased on ~uagements not statistical analyses of Two recent replacement cost studies have been reported in the literature. Delbanco and Calkins (1988) studied the effect of replacing residents with full time physicians at Health Care Associates, a primary care practice at the Beth Israel Hospital in Boston; while Gavett and Mushlin (1988) studied the same problem at a primary care practice at the Strong Memorial Hospital in Rochester. Residents in all three post graduate years provided patient care in both sites. Table 2 presents estimates of how replacing residents with FT physicians would change the average cost per visit and its component costs at the two sites. As indicated by these numbers, Gavett and Mushlin assume that residents use space less efficiently than FT physicians; while Delbanco and Calkins assume that residents use relatively more of other staff time than do the FT physicians. Gavett and Mushlin do not indicate that replacing the residents would reduce the time of attending physicians, whereas Delbanco and Calkins indicate that such costs would be decreased by $3.59 per "visit". Neither team of researchers estimated the effect of the change on the use of ancillary services. Gavett and Mushlin conclude that replacing residents with FT physicians would decrease the cost of care, whereas Delbanco and Calkins conclude that such a replacement would increase costs. The main factor leading to these different conclusions is not the different assumptions about how residents and FT physicians differ in their demands on other resources (space, nurses, etc.) but rather the assumptions about the relative costs of residents and FT physicians in the two sites. Delbanco and Calkins allocated about 5 percent of a resident's salary for a half day clinic session (this was based on a resident's work week of ~53

Table 2 Change in Cost Per Visit If Trained Physicians Replace Residents Other Net Faculty Resident Training Fringe Space Staff Change GMi $ 9.09 $-7.92 $-2.85 $ -1.68 DC2 12.67 -1.68 $-3.59 $ 1.34 $-1.34 8.40 iCalculated from data presented in Gavett and Mushlin, 1988. 2Calculated from data presented in Delbanco and Calkins, 1988. ~54

90 hours) and assumed that the annual salary of a full time internist was $75,000. Gavett and Mushlin allocated 10 percent of a resident's salary for a half day clinic session and assumed that the salary for the board certified internist was $44,7600. (It is not clear why the assumed salaries for the internists are so different.) Before and After Studies In before and after studies, the investigators examine the effect of introducing residents or medical students into the practice setting. The introduction of medical students and residents would be expected to lead to a decrease in the hourly productivity of the "faculty" physicians because they will now be spending some of their time training and supervising. However, residents and medical students open the door to additional visits. The net effect of residents and students on the overall practice productivity can be determined. The information on the change in productivity along with salary data for FT physicians and residents can be used to estimate the net cost of training. (Information on the net change in practice productivity and the level of the resident's salary can be used to determine whether the residents are profitable.) Kahn, Wirth and Perkoff (1978) studied the effect of introducing second year residents into a prepaid group practice in which both internists and pediatricians practiced. For the pre and post periods, they determined total visits; and using time and motion studies, they examined the way that the faculty physicians allocated their time. They also studied the relative use of examining rooms. They found that the introduction of the residents in internal medicine was accompanied by a 23 percent decrease in patient equivalents (PE) seen per faculty internist per hour (2.6 to 2) while at the same time the residents saw 2 PEs per hour. They estimated that if net increase in PEs generated by the residents had been provided by salaried general internists (who worked the same number of hours as the faculty internist), it would cost 23 percent more than the cost of the resident. The introduction of pediatric residents into the practice was accompanied by only a three percent decrease in the number of PEs per hour (2.9 to 2.8) seen by the pediatricians while at the same time the residents saw 1.7 PEs per hour. Kahn et al. estimate that, if the increased PEs had been seen by salaried pediatricians, it would cost 17 percent more than the cost of the resident. (In making these estimates, they assumed the cost of a full time resident was slightly less than half that for a full time faculty member). They did not find any differences in the use of examining room between the residents and the faculty. 155

These data indicate that in this case the "net cost" of teaching is negative. This finding is not too surprising since the residents were second year residents. The estimated savings may be exaggerated because the practice' particularly the pediatric practice, was underutilized prior to the introduction of the residents. It should be pointed out, however, that the internists spent 18 percent of their time teaching, the pediatricians spent less than 3 percent of their time teaching. There have been a number of similar studies which have focused on the cost of introducing medical students into the ambulatory practice setting (Pawlson, Schroeder and Donaldson, 1979; Kirz and Larsen, 1986; Pawlson, Watkins and Donaldson, 19801. These studies indicate that medical students lead to a decrease in overall practice productivity. For example, Pawlson, Watkins and Donaldson estimated the effect of introducing medical students in the ambulatory clinical practices in a number of different practice settings. In some settings the students just observed whereas in other sites they participated in the care of the patient. The investigators found that the presence of students as observers did not effect the overall practice productivity but it did have a small effect on the cost of care. They found that when students participated in care the practice productivity decreased significantly; but the decrease in productivity was related to the level of training of the students. Comparative Cost Studies One approach to determining the "net cost" of education is to determine the differences in the cost per visit across different sites which vary only in the extent to which residents are involved in caring for patients. However, since it is unlikely that sites will vary only along that one dimension, statistical controls should be used to adjust for differences in factors such as case-m~x and quality of care as well as the flow of patients through the different practice sites. Pawlson and Watkins (1979) compared the cost per visit at a model family practice residency center in which residents (all three years) and fully qualified family practitioners practiced together with the average cost of a number of family practice sites in the same large prepaid group practice. Costs for materials and supplies were taken from expense data and each site was allocated its proportion share of indirect costs for space and general clinic administration. It was assumed that the unit was responsible for the residents' salad when they were present in that particular clinic setting. They found that the cost per visit was about 12 percent higher at the mode] family practice residency center than it was on average in the other family practice sites. ~56

It is, however, impossible to interpret the outcome of this study. The difference in the costs across sites may be due to the teaching program or to a number of other factors. The investigators suspect that compared to the other sites, the utilization rate of the family practice residency center may have been low. This possibility seems likely given the very small difference in visit physician costs ($7.45 vs $8.77) and the large difference in nursing costs ($5.72 and 2.31) across these sites. Differences in the Use of Ancillary Services There have been many studies which examine the differences in test ordering behavior of residents and FT physicians in the inpatient setting (see for example, Schroeder and O'Leary, 1977). (In fact these studies have provided some of the insights into the factors generating the measured indirect costs of graduate medical education.) In none of the studies of the net cost of training in ambulatory practice did the researchers analyze the use of ancillary services. Test ordering practices were usually not examined because of data limitations. There is, however, one study that does examine this issue. Berkelhamer (1986) collected data on office based procedures, and hospital laboratory and radiology tests for 450 consecutive visits for pediatric residents and pediatricians. He found, controlling for age and patient visit category (health maintenance or illness), that the average charge per patient visit was higher for the residents' patients than for the pediatricians' patients. On average, the residents ordered laboratory and radiology tests in 35.8 percent of the visits while faculty members ordered them in only 14.4 percent of them. (There was considerable difference among both the residents and faculty members in their propensity to order tests.) Summary The studies reviewed above looked at only one aspect of the cost of training medical students in primary care: the net costs of having residents and medical students in the ambulatory setting, where they are both providing services and being trained. The conclusions of these studies can be summarized as follows. The cost of training medical students in the outpatient setting is positive. There is, however, no clear cut answer to the question: what is the cost of training residents in the outpatient setting? The answer to that question is: it depends. It depends on the general level of utilization and efficiency of the office practice, the level of skill of the resident which increases with the years of training, the amount of faculty input into the training process and the differences in the i57

relative incomes of the trained physician and the resident. Since these factors will vary from site to site, the net cost of training will also vary from site to site. In general, the net cost of training for second and third year residents is likely to be negative. The findings of the empirical studies indicate that there are likely to be "indirect costs of graduate medical education" in the outpatient setting. Many researchers found that nursing costs, space and/or the use of ancillary services were higher in settings where residents practiced. In no study was the use of these services found to be lower in settings where residents practiced. Care? What Is The Financial Impact Of Training Programs In Primary The discussions above examined the "net cost" of training in primary care in clinical ambulatory settings. However, that cost, is only part of the cost of primary care training programs. In this section we look at a broader question: what is the effect of the training program in primary care on the financial status of the overall institution; i.e. what is the difference between the costs incurred and the revenues received because there is a program in primary care. (Occasionally some writers refer to this as the cost of the program.) To answer these questions, we need to look at the components of costs and revenues in more detail. The costs of a training program are the additional costs which are incurred as a result of the program. In many cases the primary care training program is responsible for the management of the postgraduate educational experience for those residents who have selected primary care. In this case the costs of the program can be classified into three groups: the costs of providing the services which are generated in the clinical setting in which the training in primary care is taking place, the administrative costs of running the training program; and the costs that are incurred when the primary care residents rotate through other outpatient services (such as dermatology, gynecology, psychiatry and orthopedics), the emergency room and inpatient services. Each of these cost categories is discussed briefly below. Training in an ambulatory care setting is an integral part of all training programs with a focus on primary care. In general this training is designed to train residents to provide continuous, coordinated and comprehensive care. To accomplish these goals, continuity clinics are established in which the residents assume primary responsibility for a pane} of patients over their training period. Sometimes special ambulatory clinics are established for this purpose or the i58

residents are introduced into already existing practice settings. The costs of the services provided include the costs of the faculty and residents assigned to the clinic, and the other costs which are incurred as a result of providing those visits. Clinic costs (and costs per visit) will depend upon the efficiency with which the clinic is operated as well as the flow of patients through the clinic. As a result of visits to the clinic, diagnostic tests will be ordered and hospital admissions will be generated. If these patients would not have had the these tests or would not have been admitted to the hospital, had not the clinic been present, then the costs of these services should be attributed to the program. However, if the patients would have been cared for in another part of the provider organization, only the incremental costs (i.e. the indirect costs) should be attributed to the program. Program Management: Resources are needed to manage a training program in primary care. In general, the program coordinates the rotations through the other services. The program may also be responsible for some faculty salaries which are not directly allocated to the primary care clinical setting. Finally the program is usually responsible for the full salary of the residents. (It will be noted that in the studies discussed above, only a proportion of the resident's salary were allocated to the clinic costs - a proportion that reflected the proportion of time they spent there.) Costs of the Subspecialty Training: There may be increased costs incurred at the hospital level or in other ambulatory clinics where the primary care residents are being trained. In these other clinics, regardless of their residency year, the residents are likely to act more like first year residents; that is, their productivity will be relatively low and they will need a fair amount of faculty supervision. These costs would include the "indirect costs" attributed to these residents in these settings. Other Costs: There are some other costs that should be considered in determining the cost of expanding outpatient training. As programs increase the amount of time that residents are being trained in the outpatient settings, it necessarily follows that the amount of time they spend in the inpatient setting necessarily decreases. As the residents were providing patient care services in the inpatient setting, some arrangements will have to be made to replace them. These arrangements can include hiring of salaried physicians, more nurses or physician assistants of increased visits by the community physicians. The effect on the cost of inpatient care will depend on the relative cost of the substitute providers and their relative productivity. Income: As a result of the training program, there will be some revenues that the institution would not have otherwise had. There are many different types of revenues. ~59

Practice Revenues: The most important revenues are those received from the patient visits that are provided in the primary care ambulatory clinic. These revenues will depend upon a number of factors including: the number of patients seen, the level of charges, the insurance coverage of the patient population treated and the collection ratio. In addition to the revenues received from providing visits, the hospitals will receive revenues from the ancillary tests provided to the clinic patients as well as from any hospital admissions. (If the training is taking place in a fee for service setting, then hospitals will receive additional revenues from ancillary tests order on outpatients. If the training is taking place in a capitated setting, the hospital will not receive additional payments.) Other Program Revenues: These include grants from the federal and state governments as well as foundations. Other Hospital Revenues: In addition to the revenues that the hospital receives because of the increased testing and patient admissions directly attributed to the presence of primary care clinic, the hospital may receive revenues because of services provided by these residents when they are being trained on other services. The hospital may also receive income because it is the setting for a training program; i.e. the Medicare payments for the direct costs of graduate education and the add on to the DRG payments to pay for the "indirect costs of graduate medical education. It is very complicated to trace the flow of costs and revenues resulting from the implementation of a training program in primary care. Most of the studies which examine the financial impact of a training program, are interested in only a subset of these revenues and costs. In general, they are interested in the extent to which revenues from patient visits provided in the primary care clinics cover the costs of the training program for which the program is responsible. No study has examined the costs and revenues attributed to the primary care residents when they are being trained in settings other than the primacy care practice clinic. Nor has any study addressed the question of the cost of replacing services that were previously provided by residents when more of their training took place in the inpatient units. Below we discuss studies which have examined the financial impact of three different types of programs: a training program in primary care, residency programs in family practice, and general internal medicine ambulatory practices in teaching hospitals. ~60

Net Revenues from a Program in Primary Practice Stern et al (1977) estimated the financial requirements needed to establish an educational program in primary care where the residents received their training in primary care at one of four different sites (two fee-for-service clinics and two prepaid plans). Costs examined included the costs associated with the clinic visits provided by the residents, the residents' salaries, the cost of staff teaching hours and the cost of managing the program - coordinating subspecialty rotations, etc. All of the residents' salaries were attributed to the program. The patient revenues associated with the services provided by the residents were estimated. (The investigators did not estimate "net revenues" associated with the ancillary services and hospital admissions that resulted from the clinic visits or with the activities of the residents during their time away from the primary care practice). The investigators found that the payments received for the services rendered by the residents covered approximately 77 percent of the cost of the program. They simulated the financial effect of increasing visit charges, collection rates or the number of patients seen in the clinics. However, they found that, with current practice volume, charges or collection rates would have to double if the program were to break even - an unrealistic goal. They argued that both patient care and residency training would suffer if visits were increased enough to make the program break even. It is not surprising that practice revenues do not cover the cost of the primary care training program. The program is responsible for 100 percent of the residents' salary, yet the residents spend considerably less than 50 percent of their time in the primary care clinic; the rest of the time was spent on other speciality outpatient clinics and in inpatient rotations. Programs in Family Practice There have been many studies of single family practice residency programs as well as surveys of multiple programs. These surveys usually ask for information on both the costs of the residency programs as well revenues sources. Program costs include the salary of the faculty members, residents, and other nonacademic personnel as well as the costs of operating the clinic which is the site of the outpatient training. (The costs will depend in part on how the hospital or sponsoring institution allocates its overhead costs to the primary care center). Program revenues include revenues from seeing patients in the residency clinics, ~ 64

the income the faculty receive as attendings when family practice patients are hospitalized as well as income from foundation grants, state allocations, federal grants as well as contributions from the sponsoring institutions. In 1982 Ciriacy et al. surveyed a national sample of family practice residency programs asking about program costs and revenues. They found that, on average, patient income covered 31 percent of the total costs of the programs. In 1984, Ramsay conducted a national survey of family practice residency programs. He too found that that patient revenues accounted for 31 percent of the costs of the program. (In both surveys there usable response rate was about 50 percent). The proportion of program costs covered by revenues from the family practice clinics appears to be low. Three explanations have been offered: (~) The volume of patients seen is small. Ramsay believes that the number of patients could be increased by about 30 percent without impairing either patient care or residency training (in fact it could even enhance training). If the patient volume met his suggested targets (see Table 3), then practice revenues would cover about 45 percent of the program costs. (2) Collection rates are lower than necessary. (3) Fees may be set too low. However, the fees charged at these clinics have to be competitive with fees charged for visits in the clinic's market area. Since insurance coverage for outpatient services is much less generous than it is for inpatient coverage, clinic prices cannot be much higher than those at private physician offices. General Internal Medicine Ambulatory Practices in Teaching Hospitals In 1980 the Robert Wood Johnson Foundation sponsored a program to develop general internal medicine primacy care practices in 15 teaching hospitals. These practices were established to deliver primary care and to train residents. In theo~, they were to replace the old clinic practices and to emphasize continuity in care, and to be a setting in which residents were trained in the behavioral and social aspects of being a primary provider. These practices were established in low income areas. Kosecoff et al. (1987) and Brook et al. (1987) evaluated the demonstration sites. They looked at the cost of teaching, the efficiency with which care was provided and the financial impact of the ambulatory practices on the sponsoring hospitals. (They were not not interested in the financial impact of establishing a training program in primacy care but rather on the financial impact of establishing ambulatory practices which served low income populations and in which residents would be trained in primary care). 162

Table 3 Visit Targets for the Residency Sessions Level Session/wk Pts/Session Pts/wk # wks Total 1 1 5 5 48 240 2 3 10 30 48 1,440 3 4 12 48 48 2,304 TOTAL 8 27 83 48 3,984 Average visit/resident .R fi4R = 1,328 4 Expected income per resident 1,328 x $27.06* = $35,936 Actual income per resident 1,015 x $27.06 = $97 4fi4 Difference per resident $ 8,472 *Income per visit derived from study data. ~63

The investigators found that the revenues associated with these practices exceeded the costs the hospitals incurred in operating them. Defined revenues include not only revenues received for the visits but also revenues received from ancillary tests as well as any resulting hospital admissions. However, depending upon the assumptions that were made about staffing patterns, Practice revenues (revenues from the sernces directly provided by the residents and faculty members) did not always cover practice costs. ~ , _ _ · · ~,,~ In general, the researchers found that the practices were managed veer inefficiently; that staff time was not well utilized, that patient scheduling was poor and that the use of space was inefficient. Summary The implementation of a training program in primaly care is accompanied with a complicated flow of costs and revenues throughout the sponsoring institutions. No study has tried to trace these flows in their entirety. but each ~., A, study nas focused on a few or teem. In general, patient care revenues which are received as a result of the provision of services in the primal care practices will cover the costs of those practices, if the practices are allocated only a proportion of the residents and faculty members costs - a proportion that reflects the time they spend in the clinics. Clinic revenues, however, are not sufficient to cover the full cost of the residents' salary and the salary of the faculty and administrative staff who are directly the responsibility of the program. The practices associated with the training program may be a new source of patients to the sponsoring hospitals. In this case, the hospital may make profits off the ancillary services and admissions that result from the program. Other benefits and costs of which are a consequences of these training programs have not been measured. Discussion: Other Issues Issues touched on too briefly above include: the efficiency of the training process; some of the differences between training in the inpatient and the outpatient setting; the level of efficiency in the production of ambulatory services in teaching settings, and some of the differences between training in an HMO and a fee for service setting. i64

The Efficiency of the Training Process There were only a few studies which systematically examined the way that physicians were being trained. Most of these studies described the structure of the training programs, rather than indicate what actually happened in the residency settings (Goodson et al., 19861. The quality of the training received in the primary care clinic will depend in part on the amount of faculty input as well as the volume of patients that are seen. Figures Three and Four below display some hypothetical relationships between resident "learning' and faculty input and patient flow. Since faculty input and patient flow are the two variables that influence the cost of training, it would be useful to know something about actual quantitative relationships depicted in these figures. The importance of this knowledge is underlined by the fact that faculty member input is the most important factor influencing the cost of care provided by residents (and medical students) and because the studies discussed above indicate that there is ode variation in the amount of faculty time actually given to training in the outpatient setting. There is also very little known about the level of training required of the physician "trainer". In the inpatient setting, the resident is both a student and a teacher. Residents spent some proportion of their time training medical students (Institute of Medicine, 19761. However, at least as reported in the published literature, the teaching role of the resident seems to be nonexistent in the ambulatory setting. This points to the question: What is the role of the resident, particularly the third year resident, as teacher in the ambulatory setting. It is important to determine ways of decreasing the costs of training - particularly for medical students and junior residents. Educators have suggested the use of professional patients, computers, and simulations. Shueser et al (1985) describe an interesting use of the wdeo in training medical students in the emergency room. The Patient's Role The patient, a necessary ingredient in the training process, is different in the inpatient than in the outpatient setting. In the inpatient setting the patient is usually in bed. Consequently, rounds can be organized solely for the convenience of the physicians. House staff can interact with the patient when they want to. Patients rarely refuse to answer yet another resident or student asking the same set of questions or being examined more than once. In the outpatient setting, ~ 65

Residents Residents Learning / a a ~ _ FIGURE _ 166 AD Input P6r V1sic Pat1~nt#s Su./Hour

however, patients may be less willing to donate their time to the educational process. This setting requires coordination of the activities of the residents and the attendings. It also means that the number of residents (and medical students) who can learn from a given patient is limited. Secondly, patients in the outpatient setting are more likely to want a doctor who is fully trained rather than one who is still being trained. Although in the inpatient setting people of all social and economic backgrounds are used to interacting with the house staff, many patients have "their own doctor". However, in the outpatient setting, one physician (either resident or FT physician) becomes the patient's primary doctor. Many people, particularly in the higher social economic groups, may be unwilling to be assigned to the resident's panel of patients. This problem will be exacerbated in establishing a panel of patients for the first year residents. Thirdly, in the outpatient setting patients are more mobile. With the increasing supply of physicians, people have more choices. This means that the University based practices have to be competitive with community physicians in order to get patients. However, this may exacerbate town and gown relationships (Medical News, 19891. These observations lead to the conclusion that the socio-economic background of people in the residency practices will be different from those seen by the faculty in their private practices. This difference means that that patients in the residency clinics are less likely to have health insurance coverage. If the patients are insured, they are more likely to be covered by less generous insurance programs such as Medicaid. The Efficiency with Which the Practice is Operated Almost all studies which compared the cost of treating people in the outpatient clinics as opposed to private physician offices have found the costs in the former to be higher (Lion et al., 19851. Kosecoff et al. in their evaluation of the ambulatory practices supported by the Robert Wood Johnson Foundation found that the practices were very inefficiently run. They found that there were problems with patient scheduling and scheduling of physicians. Once in the office, patients waited longer to see the physician than they do in the offices of community physicians. Some of these problems may be due to the differences between the types of patients seen in these practices compared to those in private physicians offices. For example, Kosecoff found that the no show rate was much higher than that in private physician offices. A high no-show rate makes it particularly difficult to schedule appointments. It may be possible to reduce the ~ 67

no-show rate but it is possible that it is related to the socio-economic characteristics of the patient population. These observations lead to the conclusion that it will be very important to pay attention to the efficiency with which the primary practice clinics are managed. Training in the Health Maintenance Organization There is increasing interest (Isaacs and Madoff, 1984) in using the health maintenance organization as training sites. In both HMOs and other settings the training of medical students and junior residents will add to the cost of care. There is, however, one difference between the implications of training in the two sites. We noted above that there were two sources of "indirect costs of graduate medical education" in the ambulatory setting: one is the higher (nonphysician costs) of residents visits (we noted that there were data suggesting that nursing costs and space may be higher ); the second is increased ancillary testing and perhaps increased admissions. In both the fee for service sector and the HMO there is no increased revenue to offset the first type of increased costs; however, in the fee for service setting there is increased revenue to offset those indirect costs whereas in the health maintenance organization there is not. Conclusions There are many different ways of looking at the question of the cost of training medical students and residents in the outpatient setting. A number of analysts have been interested in the net cost of education in the ambulatory setting where net cost is defined as the difference in the cost of producing a given number of patient visits by residents who are also being trained and by full time physicians. The net cost was found to depend upon a number of factors including: the flow of patients through the clinics, the faculty members' input into the resident's practice and the relative salaries received by the resident and the FT physician. In general, we found that if the outpatient settings are allocated a proportion of the resident's salary (that proportion that they spend at the clinic), then the net cost of graduate education is negative for second and third years residents, and positive for some of the first year students. This finding, however, was not universal. This conclusion needs to be accompanied by a caveat. While the net cost of training in the primary care clinic may be negative for a second and third year resident, it does not follow that the net cost of training second and ~68

third year residents is negative. These residents spend time in subspecialty clinics such as orthopedics, dermatology and gynecology where their productivity level is not as high as it is in the primary care clinic. Most, but again not all, studies found that there were indirect costs of graduate medical education in the outpatient setting. Most of this work has concentrated on the indirect costs associated with the provision of patient visits (space, time and ancillary personnel). There needs to be more work done on examining resident practice as it relates to the ordering or tests and to hospital admission decisions. The income generated by primary care practices is not sufficient to cover the cost of the primary care training program where the training programs is responsible for the resident's full salary. The main reason for this discrepancy is that the residents spend significantly less than 50 percent of their time in the . · - prlma~y care c. .lnlcs. There is some evidence that the primary care clinics are not efficiently run. There also is some evidence that a number of clinics - particularly those that are part of residency programs in family practice programs do not have as many patient visits as they would like. It is not clear whether the shortage of patients is due general competition from private physicians or because of certain attributes of the clinics per se. It is reasonable to conjecture that the insurance coverage of patients being seen at the primary care clinics will be less complete that that of patients seen at the faculty physicians private practice of by community physicians. More needs to be known about the training process. Training in the outpatient setting is probably more costly than it is in the inpatient setting. Not only is more training done by attendings rather than residents, but also there appears to be a higher attending/resident ratio. In the studies that were examined, there was considerable variation in the amount of faculty time that was provided to the resident in the clinic setting. Since faculty time is very expensive, research on the training process per se would seem to be called for. i69

BIBLIOGRAPY Anderson OF and Lave JR, "Financing Graduate Medical Education Using Multiple Regression to Set Payment Rates," Inquiry 23: 191-199, 1986. Arthur Young, Study of the Financing of Graduate Medical Education: Report Il. Hospital Cost Analysis, October 1986. Bankhead CD, "Town and Gown," Medical World News, pp. 44-52, Manual 23, 1989. BerkeThamer ATE, "Charges by Residents and Faculty Physicians in a University Hospital Pediatric Practice," Journal of Medical Education 61: 303-307, April 1986. Brook RH, Fink A., Kosecoff d., et al, "Educating Physicians and Treating Patients in the Ambulatory Setting: Where Are We Going and How Will We Know We Arrived?" Annals of Internal Medicine 107~3~: 392-398, 1987. Cameron dM, "The Indirect Costs of Graduate Medical Education," New England Journal of Medicine 312~19), May 9, 1985. Ciriacy EW, Liang FZ, Godes dR, et al, "The Cost and Funding of Family Practice Graduate Medical Education in the U.S.," Journal of Family Practice 20~3~: 285-295, 1985. Colwill dM and Glenn ~K, "Patient Care Income and the Financing of Resident Education in Family Medicine," Journal of Family Practice 13~41: 529-536, 1981. Delbanco TE and Calkins OR, "The Costs and Financing of Ambulatory Medical Education," Journal of General Internal Medicine 3 (Supplement): S34-S43, 1988. Gavett JW and Mushlin AI, "Calculating the Costs of Training in Primary Care," Medical Care 24~4~: 301-312, April 1986. Goodson ~D, Goroll AH, Barsly AJ, Treadway KK, Thibault GE and Stoeckle JD, "The Training of Physicians Outside the Hospital," Archives of Internal Medicine 146: 1805-~809, September 1986. . 170

Page 2 Hadley J. Medical Education Financing: Policy Analyses and Options for the l980s, PRODIST (New York, NY) 1980. Institute of Medicine, National Academy of Sciences, Medicare-Medicaid Reimbursement Policies: Social Security Studies. Final Report, March 1976. Isaacs JO and Madoff MA, "Undergraduate Medical Education in Prepaid Health Care Plan Settings," Journal of Medical Education 59, August 1984. Kahn L, Wirth P and Perkoff G. "The Cost of a Primary Care Teaching Program in a Prepaid Group Practice," Medical Care (XVI): 61-71, 1978. Karpf M. and Levey GS, "Training Internists for the Changing Medical Scene," Annual of Internal Medicine 104(4), April 1986. Kirz HE and Larsen C, "Costs and Benefits of Medical Student Training to a Health Maintenance Organization," Journal of the American Medical Association 256~6~: 734-739, August 8, 1986. Kosecoff J. Brook RH, Fink A., et al, "Providing Primary General Medical Care in University Hospitals: Efficiency and Cost," Annals of Internal Medicine 107: 399-405, 1987. Lave JR, "The Medicare Adjustment for the Indirect Costs of Medical Education: Historical Development and Current Status," Association of American Medical Colleges, ~Janua~g 1985. Lion J. Malbon A, Henderson MG and Friedman RH, "A Comparison of Hospital Outpatient Departments and Private Practice,' Health Care Financing Review 6~4~: 69-81, September 1985. Panton DM, Mushlin Al and Gavett dW, "Marginal Ambulatory Teaching Costs Under Varying Levels of Service Utilization," Medical Care, (XVITI: 61: 668-674, June 1980. Pawlson EG and Watkins R., "The Costs of a Family Practice Residency Ambulatory Care Program," Journal of Family Practice 9~61: 1059-1061, 1979. 171

Page 3 PawIson KG, Schroeder SA and Donaldson M, "Medical Student Instructional Costs in a Primary Care Clerkship," Journal of Medical Education 54~71: 551-555, 1979. Rabkin, MT, "Reducing the Costs of Medical Education," Health Affairs, Fall 1986. Schroeder SA, "Group Practice Recommendations of the Committee on the Costs of Medical Care," Milbank Memorial Fund Quarterly 56~2~: 169-~86, 1978. Schroeder SA, Showstack, JA and Gerbert B., "Residency Training in Internal Medicine: Time For a Change?," Annals of Internal Medicine 104~41: 554-561, April 1986. Shanke] SW and Mazzaferri EL, "Teaching the Resident in Internal Medicine: Present Practices and Suggestions for the Future," Journal of the American Medical Association 256~6), August 8, 1986. Shesser R. Smith M, Kline P. Rosenthal R. Turbiak T and Chen H. "A Cost- Effective Emergency Medicine Clerkship, Journal of Medical Education 60: 288-292, April 1985. Sloan FA, Feldman RD and Steinwald AB, "Effects of Teaching on Hospital Costs," Journal of Health Economics 2: 1-2S, 1983. Stern RS, et al, "Graduate Education in Primary Care: An Economic Analysis," New England Journal of Medicine 297(12): 683-643, 1977. Thorpe KE, "The Use of Regression Analysis to Determine Hospital Payment: The Cost of Medicare's Indirect Teaching Adjustment," Inquiry 25~2~: 219-231, 1988. 172

Next: Financing of Medical and Graduate Medical Education: Issues in Primary Care Education Support »
Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings Get This Book
×
Buy Paperback | $53.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Because of changes in the health care system, the hospital has become less suitable as the primary focus of graduate medical education for primary care physicians. However, the current system of financing health care education and services makes it difficult to accomplish the needed shift to training in primary care ambulatory settings. This book suggests ways of lowering financial barriers to primary care training in ambulatory settings.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!