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

Chapter: Financing Primary Care Residency Training: Examples and Lessons from Successful Programs

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Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 235
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 236
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 237
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 238
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 239
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 240
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 241
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 242
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Page 243
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 244
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 245
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Page 246
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Page 247
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 248
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 249
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 250
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 251
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 252
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 253
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 254
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 255
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 256
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 257
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 258
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 259
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 260
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 261
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 262
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 263
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 264
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 265
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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 266
Suggested Citation:"Financing Primary Care Residency Training: Examples and Lessons from Successful Programs." 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.
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Page 267

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FINANCING PRIMARY CARE RESIDENCY TRAINING EXAMPLES AND LESSONS FROM SUCCESSFUL PROGRAMS Robert A. Walkington Introduction The past decade has been a time of ferment in American medicine. The career of the physician beginning practice in the 1990s watt differ significantly from that of the physician who began practice in the 1970s. One major difference will be the greater extent to which that practice is conducted in an ambulatory setting. This change has led many people to conclude that the traditional reliance on the hospital as the site of graduate medical education (GME) must be modified to include an increased emphasis on ambulatory care. This conclusion has been strengthened by the changes occurring in the nature of hospital utilization which has made the hospital a less satisfactory site for the educational experience, particularly for the primary care physician (AAMC, 1987; New York State Council on Graduate Medical Education, 1988; Gaste! and Rogers, 1989~. These factors have led a number of groups and individuals to recommend strengthening the ambulatory care experience in general internal medicine, general pediatrics, and family practice residency programs. For example, the report of the New York State Commission on Graduate Medical Education stated: "The Commission therefore recommends that the graduate medical education of specialists in general internal medicine, general pediatrics, general obstetrics/gynecology and family medicine should include an appropriate balance of outpatient and inpatient experience". The Commission went on to state that "a significant part of residency training should take place in ambulatory care settings." (New York State Commission on Graduate Medical Education, 19861. Similar conclusions and recommendations were reached by the Council on Graduate Medical Education (COGME) which in its 1988 report to the Secretary of DHHS recommended "... a concerted emphasis on training in ambulatory settings ..."This recommendation was based on the Council's conclusion that GME in ambulatory settings is increasingly necessary in many specialties for optimal training and preparation for practice (Council on Graduate Medical Education 198Sb). Similar views have been expressed by Ebert and Ginzberg (1988), by 230

participants in the conference on Medical Education in the Ambulatory Setting (Stanford 1987) the Health Resources and Services Administration (HRSA) Conference on Primary Care Medical Education (1988) and in a number of recent articles (Moore, 1986; Perkoff, 1986, 1988; Kosecoff, et. al. 1987, Schroeder, 19881. While there has been general (though not unanimous) agreement on the desirability of increasing the ambulatory focus of graduate medical education, particularly for the primary care specialties, there are a number of practical barriers to implementing changes. One of the major barriers is how to finance this new (or in the case of family practice, continuing) emphasis on ambulatory based education. The Council on Graduate Medical Education concluded that: "There are difficulties in financing GME in ambulator setting, related to lower levels of payment by third parties and to increased logistical problems in teaching. The current financing of GME results in disincentives for ambulatory training ... The financing of GME is particularly problematic for the areas of primary care, geriatrics and preventive medicine" (Council on Graduate Medical Education, 19881. In a recent draft position paper, the Association of Program Directors in Internal Medicine (APDIM) recommends major changes in financing internal medicine training programs in ambulatory care. The paper declares: "A major obstacle to the development of educational programs in ambulatory care has been the failure of the payment system to fully compensate for the educational costs of post-graduate training in ambulatory settings". The HRSA Conference on Primary Care Medical Education concluded that "the limited reimbursement for primary care services and teaching have seriously constrained the success and growth of primary care education and the production of appropriately trained primary care physicians" (HRSA, 19881. A recent article on family practice residency programs concluded that ambulatory care training suffers from the twin problems of lower revenues and higher costs (Ricketts et al., 1986). Similarly, in a presentation to COGME's Graduate Medical Education Programs and Financing Sub-Committee, Dr. Frederic Berg stated that "there is poor support for ambulatory education in pediatrics." To remedy this problem he recommended that "any new system of financing GME should provide support for training of residents in ambulatory settings including outpatient units and HMOs as well as inpatient settings" (COGME, 1987a). 231

In addition to urging increased use of the ambulatory setting for GME most commentators have described problems with the current financing of GME which inhibit such use. This paper, which first reviews the major problems in financing primary care education in ambulatory settings, describes some programs that have succeeded in making the needed shift in the site of training, and draws lessons from the experiences of the programs. Problems With Current Financing of Ambulatory Primarv Care Education There is general agreement that it is more difficult to finance ambulatory primary care GME than inpatient GME but less agreement on whether this is caused by higher costs, a financing system tilted in favor of education in the hospital setting, inefficiencies in the delivery of services and education in the ambulatory setting or some combination of factors. Boufford in a recent article identified the most important issue as the "fundamental financing of ambulatory service and education". She states that "patient care revenues appear to be the major source of support for ambulatory care teaching, though they clearly are not sufficient to cover costs". This is attributed to the fact that while third-party payers include education costs as part of their reimbursement for inpatient services they are much less willing to do this for outpatient services (Boufford, 1989). John Kasonic identified key sources of current and future support of GME in the ambulatory setting as patient revenues, governmental subsidies (for both teaching and indigent care), grants, university general funds, and "networking with traditionally non-teachina providers". He believes that the maiori~r of financial _ ~ ~ ~ or support will continue to come from patient care revenues and that the adequacy of such financing will depend on improving the economy and efficiency with which the ambulator settings operate (in terms of patient care and education) (Kasonic, 1987). Watt (1987) identifies sources of financial support for GME as patient care funds, direct federal support for education, and direct educational support by state and local governments. He lists a number of problems in the current financing of GME in the ambulatory setting. These include more restrictive policies concerning payment for ambulatory services by third-party payers, the need to rely on "soft and fragmented funding sources, and the fact that new managed care systems have "little economic margin to support the costs of medical education". 232

Family practice residencies provide insight into financing ambulatory focused primary care GME, since over half of a family practice resident's experience is in an ambulatory setting. The most recent survey of the costs and financing of family practice residencies (conducted in 1982-83) indicated that the largest source of support was the hospital, followed by professional fees from faculty and residents and state support. Other sources of support include federal and private grants, non-program managed support and institutional base support (Colwill, undated). Colwill sums up the situation with regard to financing of residency education in family medicine as follows: "First, revenues from primary care are limited. Second, family practice centers in which family practice residents spend at least one-third of their residency in their continuity practice provide an added cost to the residency program. Consequently, the funding of family practice residency programs has been precarious and has been dependent upon governmental support in addition to hospital and patient care income support.'' (Colwill, undated). The problems that family practice has faced are similar to those that will be faced by other residency programs as they attempt to expand the amount of time devoted to ambulatory focused education. Published Examples of Successful Financing of Ambulatory Based GME Most of the published reports of successful primary care programs have focused on educational content and process. Articles on financing have dealt largely with the problems of the current system and with proposed solutions. Two recent exceptions are an article by Rosenblatt (1988) and a report from the Association of American Medical Colleges (19871. While neither focused primarily on the financial aspects of programs, both discussed fiscal considerations. In addition to these studies, some other articles describe solutions to problems which are at least partially under the control of the institutions or which propose solutions which are feasible without major restructuring of the current system. Moore (1988) speculates that in the future HMOs will become involved in medical education because of" their social responsibility, their practical self-interest, and their desired satisfaction." He believes that as the HMO movement grows and matures a number of HMOs will see that graduate medical education is in their self-interest. If self-interest is considered in its broadest sense then all three reasons are related to benefits that the ambulatory patient care setting will receive by supporting GME. In another recent article, Moore states that increased 233

efficiency of ambulatory education and increased revenue from reimbursable services are the best ways to successfully finance ambulatory education. The same article makes the point that if it can be shown to have benefits for them, HMOs and voluntary facula can be successfully involved in ambulatory education (Moore, undated). Rieselbach and Jackson (1986) advocate linking ambulatory based GME to care for the indigent. They argue that such a linkage (through capitation) "would allow students, residents, and fellows to receive their clinical education in an environment in which the qualibr and cost of care would be controlled and supervised ..." The residents and fellows would provide care to the indigent under faculty supervision and in return the states and or the federal government would pay for the services and education under a capitation scheme. Kosekoff, et al. (1987) in an article on the efficiency and cost of general medical ambulator care in teaching hospitals conclude that major increases in efficiency are possible through improved management, including the development of more sophisticated information systems. The authors also suggest the development of stronger incentive systems to link efficiency and performance to financial rewards. In another article, based on the evaluation of the same general internal medicine clinics, Brook, et al. (1987) urge linking the ambulatory education experience to providing care to the underserved. They state that "the key to making this educational and patient care system work will be aggressive fiscal management, ...". A 1985 study of the Primary Care Unit at St. Louis University Medical Center reported that "revenues recovered was limited by low productivity and collection rate." The authors recommended that efforts be made to receive credit for ancillary profit and to improve provider productivity (Miller, et al., 19851. Delbanco and Calkins (1988) suggest a number of approaches to increasing the efficiency of ambulatory teaching. The recommendations which deal with structure of the educational experience are designed to "maximize patient visits while achieving teaching goals." Rosenblatt (1988) studied five exemplary programs finding that with fiscal creativity ambulatory programs could be successfully financed in a wide variety of ways. He found that efficiency increased as education was merged into the service function. "The more the teaching setting resembles a real world operation, the lower the teaching costs." In addition, leadership and institutional commitment were critical. Rosenblatt believes that there is enough money in the health care 234

system to support expanded primary care education. However, current educational patterns provide cheap labor for inpatient services and subspecialties and reward those currently in control. The ambulatory programs studied by Rosenblatt included two primary care residencies - general internal medicine at Brown University and an ambulatory pediatric residency at the University of North Carolina. In both cases institutional support and commitment were key to success. Each of the programs was ..." in harmony with the broad educational and services mission of its medical school." Also important was the fact that the programs were seen as beneficial - providing as well as consuming resources. Speaking of the North Carolina program Rosenblatt notes: "Critical to the program's fiscal integrity is that the community-based care is supported entirely by the sponsoring agencies, and the salaries of the agencies' professional staff are not supplemented by the Department of Pediatrics. These agencies see the incorporation of physicians as sufficiently valuable and stimulating to compensate for the extra time and potential lost productivity involved in teaching." (Rosenblatt, 1988) The Association of American Medical Colleges studied nine academic health science centers with successful ambulatory programs. The study found the presence of a strong leader (initiator) "to create a climate that will accept and support ambulator care education..." to be a key variable. The report also identified the importance of institutional and departmental commitment to ambulatory education. While over all institutional commitment was important, lacking it, institutional neutrality, combined with departmental commitment could lead to success. As the report noted: "Where school wide efforts are not underway, or where particular departments are not used as role models for change, the role of the department chairman ... is immensely important." (Association of American Medical Colleges, 1987) While this study found that ambulatory programs could succeed financially in the current system it is important to note that seven of the nine academic health science centers required extra-institutional money (AHEC funds, foundation or federal grants, specific state appropriations) to begin their ambulatory initiatives. The report also concluded that the ability of the project to put together a package of financial support from a number of different sources was an important determinant of success: 235

"The financing used by the programs nsited consisted in each instance of an apparently delicate idiosyncratic configuration of donated time and space; faculty patient care revenues; explicit local, state or federal grants and contracts; physician fee income; and occasionally funded research." (Association of American Medical Colleges, 1987) Finally, in a presentation to the AAMC Symposium on Adopting Clinical Education to New Form and Sites of Health Care Delivers John Kasonic recommends increased operational efficiency and improved management - including coordinated planning, improved accounting systems, and improved management information systems as necessary for the successful financing of ambulatory care education program Masonic, 1987~. Other Examples of Successful Financing Despite the array of problems identified by many observers, as the last section indicated some programs have succeeded in overcoming the barriers that make the provision of GME in ambulatory settings difficult. This section describes additional programs that have been successful in financing ambulatory focused primary care GME. The purpose is to pronde insights that may be useful to other programs and to determine what changes in current financing systems may be necessary if more programs are to be successful in financing ambulatory primary care GME. Because these programs were identified as being successful in doing what is generally conceived~of as difficult they are by definition atypical. They were identified through review of the recent literature on primacy care and discussions with knowledgeable individuals. Because of the limited time available only a few of the successful programs could be investigated. Exhibit i, lists other programs reported to be successful in financing ambulatory based primary care GME. i. The McLennan Counter Family Practice Program - Waco Texas The McL`ennan Counter Family Practice Program has been in existence for 20 years. The program was created following a series of meetings between members of the medical society and community leaders to address two problems--lack of health care for the indigent and the aging of the primary care physicians in the area. Initial funding for the program was essentially the same as is currently in place and discussed in some detail below. The program is operated by two non- profit boards (one composed exclusively of physicians and one of physicians and community leaders) with some overlap of membership and close coordination 236

between the two boards. Two boards were created because Texas law does not allow non-physicians to hire physicians, and because a board composed only of physicians would not provide for needed representation or support from community leaders. The program, located at the free-standing Family Practice Center? is affiliated with two local hospitals and with Baylor University College of Medicine. The residency program is three years in length, has a total of 24 positions (GYI:~) and has succeeded in filling all the positions offered in the residency match. In ~ ~ · ~ ~ e ~ ~ ~ ~ ~ ac~ct~t~on to the residency program, the boards operate a grant-funded faculty development center and a drop-in clinic. Faculty for the residency program includes five FTE family practitioners, one pediatrician, one OB/GYN, an internist and a psychiatrist on a part-time basis. In addition, extensive teaching time is volunteered by practicing physicians in the community. The operating budget for the residency program is over $3.3 million (including revenue from the walk-in clinic but excluding the grant-funded faculty development center). The largest source of revenue is patient care, with billings in 1988 of $3 million, and $~.6 million in collections. A staff financial counselor can enroll patients for Medicaid and other forms of state support on site. In addition to Medicaid and Medicare patients, who account for 30% to 40% of patient revenue, the clinic cares for patients with private insurance who provide 10% of revenues. A sliding fee scale is used for indigent patients. The clinic aggressively pursues collections, which have increased by 20% in each of the last several years. Program administrators expect patient revenue to be an increasingly important source of support, but improved patient volume and billings have accounted for only a small part of the recent increase in patient revenues. The major part results from improved collections and billing from third-party payers. An unusual, and apparently successful, incentive plan is used to increase patient care revenues. Clinic administrators predict patient revenues based on historical trends. Increases above this amount are shared between the program and the employees on a 50/50 basis. Each employee receives the same amount. This system is described as being good for morale and effective in improving the quality of paperwork. The second largest source of revenue is the City of Waco. The program currently receives $840,000 per year from the city to care for medically indigent residents. Payment is not fee-for-service, but is based on historical analyses of services provided to city residents. The program in effect functions like a city department, receiving 12 monthly payments per year. This arrangement has been 237 · ~. . · . . ~

in place since the beginning (sometimes with county funds augmenting city resources) and has provided a stable source of support. The program also receives $358,000 a year from the Texas Coordinating Board for Higher Education. This is a capitated payment from the state for each resident in an accredited family practice program. The payment was originally $15,000 per resident but overall funding by the legislature has not kept pace with the growth of programs in the state so has fallen to approximately $14,000 per resident. The program receives a total of $373,000 from the two community hospitals with which it is affiliated. Each hospital pays the salaries of t/3 of the residents in the program with the remaining third paid by the clinic. The program provides the only residents at each hospital and the hospitals provide the sites of the resident' inpatient experience. The final major source of support is Baylor College of Medicine which provides about $220,000 per year, largely for faculty salaries. Most of the major sources of support have provided stable financing over the years. However, because of the deteriorating economic situation in Texas, only patient revenues have increased during the last two years. And this latter increase is largely attributable to improved third--part~r collections. The keys to the success of this program include active boards, very good relationships with the medical and business/political community, and multiple sources of funds. It has been important that the program is perceived as a benefit to the community and to the various providers of funds. The patients perceive they are receiving good care, the city has its indigent care problems solved, the hospitals receive physician coverage (as do local physicians who provide significant voluntary teaching services) and Baylor has the opportunity to help solve physician manpower problems in Texas (90% of program graduates practice in Texas, two-thirds practice in areas with a population of 26,000 or less). The program is always on the alert for innovative sources of funds. Currently it is working with the city to see if long-term bond funding might be a viable alternative to annual city appropriations. The program currently receives a federal grant support of $58,000 for curriculum development in community based primary care. This small grant support sum was described as being very important in making program modifications and improvements, e.g. curriculum development, redesign of geriatric curriculum, improvement of documentation of residency activities. 238

The program director claims that no major financial problems exist. The fact that their financial supporters believe they receive benefits from the program, combined with the support of two non-profit boards and a generally positive community image have all been important factors in developing long-term, stable financial support. 2. Monetefiore Medical Center Residency Program in Social Medicine; Bronx. New York. The Residency Program in Social Medicine (RPSM) provides the organizing structure for primary care residencies in internal medicine, pediatrics and family practice. The three residency programs are organizationally distinct but benefit from the economies of scale of joint activities. The RPSM has a conjoint faculty which provides the behavioral, social and educational design components to all three programs. The program in internal medicine has 18 residency positions (GYM; pediatrics has 12 (GYI:41; and family practice has 24 (GYI:~. Since neither family practice nor internal medicine filled all of their positions this year there will be only six f~rst-year residents in family practice and four in internal medicine. Pediatrics is expanding to six first-year residents. The program director in internal medicine believes there are several reasons for this, first, failure to fill positions through the National Resident Matching Program. Reasons include a decline in interest in the social aspects of medicine, an increasing tendency for medical schools to retain their graduates for their own residencies, and a breakdown in the program's recruiting work with medical school counselors. This description focuses on internal medicine but also provides some information on the other two programs. The program director describes the internal medicine residency as "aggressively ambulatory" and "pushing it (ambulatory based education) to the limit" when compared with other programs in internal medicine. The program in social medicine (designed to train physicians to serve the urban poor through clinical practice, teaching, research or public policy leadership roles) was organized in 1970 with a grant from the Office of Economic Opportunity (OEO) and included residents in pediatrics and internal medicine. In 196S, Montef~ore Medical center opened the Martin Luther King Health Center with an OEO federal grant. Because the medical center had trouble in finding appropriately trained physicians to practice in that setting they requested and received a further grant from the OEO to start the residency programs. When OEO support was discontinued it was replaced by the Robert Wood Johnson Foundation, whose support was in turn replaced by Public Health Service (Title 239

VIT) Grants. In 1974 the program was expanded with a federal grant to include family practice. Between 1974 and 1978 all three residency program had their ambulatory experience at the Martin Luther King Health Center, and financial support came from grants, the hospital and the health center (in return for services provided by the residents and faculty). By 1978 family practice accreditation standards had changed to require that the family practice program be a separate department. The family practice program therefore set up its own community health center ~ At the same time the grant to the Martin Luther King Health Center was transferred from the hospital to a community board, and the Health Center began experiencing severe financial problems because of reduced federal support. The Health Center ceased support of the residency program. Thus in the late 1970s and early 19SOs only hospital and grant support were available. By 1982 concern over the stability of federal grants led to renegotiation with the community board and renewed support from the Martin Luther King Center. However, Health Center financial problems, as well as the community board's attitude that they should not support education, worsened until the program in internal medicine had to move its ambulatory site to newly renovated space in the out-patient department at St. Barnabus, a small community hospital ten blocks north of the Martin Luther King Center. ,, ,¢ ,¢ c' and left Martin Luther King. .. .. . .. . The internal medicine program currently receives financial support from three main sources 1) a $150,000 federal grant 2) $250,000 from St. Barnabus for services provided by faculty and residents 3) Montefiore Medical Center. ~1 1 · ~ ~1 ~ · ~1 ~ This batter Is one largest source ana pays residents salaries. The program director believes that inpatient and outpatient services provided by the resident, and the reimbursement the hospital receives for medical education through Medicare direct and indirect payments, probably compensate both Montefiore and St. Barnabus fully for their budget support. A significant factor in funding is state Medicaid reimbursement for ambulatory care. Article 28 of the New York Medicaid Statute authorizes institutional provider rates for qualified institutions. The state determines costs for each institution and then the institution can bill on an average per-visit cost. The per visit cost at the ambulatory clinic at St Barnabus is $55. At the family practice Community Health Center it is $80. This reimbursement is said to be sufficient to provide quality care, break even in a teaching setting. but not to ~ ~1 ~ ~ - 0' cover the administrative costs of the educational programs or the support of non- revenue generating faculty. The program has been successful in maintaining financial viability for an extended period of time. That the program has a specific mission has contributed 240

to its ability to develop a dedicated staff in spite of relatively poor salaries, and has helped in getting grant support. The state Medicaid system has allowed the program to break even on ambulatory services activities. Combining three programs under the umbrella of the Residency Program in Social Medicine has allowed the programs to share costs of planning, program development, administration, and recruitment of shared staff in areas such as the social and behavioral sciences. The integration of the three programs has other benefits. For example, when federal funding (Title VIT) was not available for internal medicine, New York State support of family practice prevented the loss of shared behavioral science faculty. In addition the clustering of programs with like social goals has enriched each. And finally the leadership of the overall medical center has been willing to pronde long-te~-~ support for the program. 3. State University of New York at Buffalo. - Family Practice. Buffalo. New York. - SUNY Buffalo has a large family practice residency program with 60 positions (GYI-20 expanding to GY1-24 in 1989-901. The ambulatory component is operated from four separate family practice centers (two urban, one suburban, one small city). Offering residents a choice of site is seen as helping in recruitment. In 1988 the program filled 10 of 20 positions in the National Resident Matching Program, and filled the other 10 with domestic graduates (dropouts of other types of residencies, osteopathic graduates, etc.~. Revenues come from three major sources, i) federal and state grants (10% - 15%), 2) hospital support (50% - 55%) and 3) faculty practice plan (approximately 35%~. New York State provides $15,000 for each family practice resident, and the Department of Family Practice also has four federal grants. While only one grant is specifically for residency support they all strengthen the department and increase resources. These federal grants are not large, but they are described by the department chairman as supporting activities and individuals that are diff~cully or impossible to fund in other ways. Examples include non-revenue generating faculty and staff (social workers, education specialists, etc.), administration and coordination support personnel, and research associates. Area hospitals pay about half the costs of the total program - funding residents and some faculty salaries in return for inpatient services. This funding is similar to that found in most GME programs. The third major source of financial support is the faculty practice plan. Revenue is generated at the four family practice centers and twelve facult3r-staffed ambulatory sites that were developed in conjunction with local hospitals. These 241

twelve sites are new or recently remodeled, and are used to train medical students, and for a mandatory one month urban or rural rotation for the residents. The faculty sites provide admissions to the hospitals, generate revenues and faculty income, and serve as a pool from which localities recruit physicians. A major reason for the programs financial success is the way the state Medicaid reimbursement system operates. While New York Medicaid pays only $10 to $12 for a physician's office visit it has an institutional provider rate - currently in the $70 - $80 range for most institutions in the Buffalo area. With this level of reimbursement the hospitals can utilize facula physicians at the ambulatory sites, the residency program is supported, and a reasonable quality of care is provided to the poor and everyone (except possibly the physicians in private practice) appears to be satisfied. The residency programs are described by the department chairman as being well financed. In fact, significant expansion of the program could be supported. The hospitals are anxious to have more facula clinics and there is a need for more family practitioners in the Buffalo region. The major deterrent to expansion, and the major current and future problem, is lack of interest by medical students and residents in primary care and family practice. According to the chairman, there appears to be a lack of interest in serving people. It is not clear whether poor reimbursement, large educational debt, or changing societal values~are causing decreased interest in primary care. A number of factors have contributed to growth of the program: direct state support, and even more importantly, indirect support through reimbursement levels that enhance the faculty practice plan. In addition, in the early to mid 19SOs, Buffalo was significantly over-bedded and hospitals discovered that association with primary care prodders can increase or protect market shares. This, coupled with the availability of funding and the insight to the department chairwoman, led to the organization of the Department of Family Medicine Family Faculty Associates which could meet the needs of the hospitals, provide stable funding for the program and serve as a recruitment device. The program as it expanded has been able to serve large numbers of indigent patients in faculty clinics and in nursing homes. This has led to increased political support for family practice in the state legislature as well as local political goodwill. It is also important that SUNY Buffalo is the only medical school in a geographic region of some 2 1/2 million people. This results in strong local loyalties on the part of physicians, politicians and the community. Although New York State has the largest number of residents in the nation, the residencies are concentrated down state and in non-primar~r care specialties and do not provide competition. 242

The program has created a w~n-w~n situation. All the major players in the system appear to be benefiting and therefore will continue to support the family practice residency program. 4. Florida's Medically Indigent Demonstration Projects Unlike the first three examples, the Florida Medically Indigent Demonstration Projects are new. They are also unusual in that they represent efforts by the state and three of its medical schools (the University of Miami, the University of Florida and the Southeastern University of Health Sciences) to develop projects that explicitly link care for the medically indigent, medical education, and manpower issues (both recruitment and distribution). In 1984 the state legislature enacted a tax on hospital beds to help finance indigent care. In 1987 the legislature authorized use of a portion of the funds generated by the tax to support two medically indigent demonstration projects (one rural, one urban) "to link the provision of primary health care services to low income persons with the education of medical students, interns, and residents." (Florida, 1987) In 1988 the law was amended to add a second rural demonstration project. Currently the state legislature is considering a bill that would use the three demonstration projects as the basis of a state-w~de Area Health Education Center Network (AHEC) operated by the four state medical schools (The University of Miami, The University of Florida, The Southeastern University of health Sciences and The University of South Florida). Each school would be responsible for a service area jurisdiction in which it would coordinate the recruitment, retention and training of medical student, residents, and interns as well as other health profession students. The legislation would also authorize the medical schools to "utilize current community resources such as departmental counter public health units, federally supported primary care centers and other providers of primary health care as community based sites for training of medical students, interns and residents" (Florida, 1989~. The bill calls for an annual appropriation of up to $6 million dollars. The governor opposes the bill on the grounds of cost. The state Department of Health and Rehabilitation Services and several key legislators support the bill. While it is not clear what will happen, the best estimate seems to be that the three demonstration projects will continue to be funded at their current level of $! million each for another year. There is also interest in making the demonstration projects part of permanent legislation (rather than being incorporated into the 243

annual appropriations bill) and changing the funding source from the Public Medical Assistance Trust Fund (hospital tax) to general revenues. The original demonstration legislation (passed in 1987) was strongly championed by two state legislators interested in health issues and particularly care for the indigent. One of these legislators was also strongly supportive of the AHEC concept based on exposure to the state-wide AHEC in North Carolina. The demonstrations were also advocated by the AHEC directors from the University of Miami and the Southeastern University of Health Sciences. Much less interest was expressed by the two other medical schools in the state. a) University of Miami - The medical school has used the demonstration grant to establish community based ambulatory residency experiences in internal medicine, family medicine, pediatrics and obstetrics and gynecology at community health centers. The amount of time spent in the community health center by the residents varies, being greatest in family medicine and least in OB/GYN. Developments in internal medicine pronde some detail on how the program has evolved. The director of the internal medicine grant was frustrated by the large indigent inpatient load which he believed increasingly distorted the educational experience. He was simultaneously facing grant renewal problems while trying to integrate the primacy care focus into the large overall program in internal medicine (total positions 118; GYI-451. The solution that the program director decided was most viable was to convert the entire program to general internal medicine. He was able to convince the various groups and individuals involved (the Department of Medicine, Jackson Memorial Hospital, the Veterans Administration Hospital) that such a change would create a stronger overall residency program in internal medicine. At about the same time a federal grant cycle for AHEC funding was announced and the University of Miami (under the leadership of the Department of Medicine) applied for and received a grant. The AHEC grant has been important not only because it provided additional funds for decentralized educational activities but because it i) pronded longer term support than the training grant, 2) had a multidisciplinary focus and 3) created a permanent organizational structure. The state demonstration project pronded a third major source of funds and an additional impetus for development of the increased commun~ty/ambulato~r focus for internal medicine residency activities. The specific ambulatory experience in internal medicine that is made possible by the state grant is one month in a community health center. The majority of the funds from the demonstration project funds have been used to hire contract physicians to staff the 244

emergency room. The project director said that "it is our impression that our residents have more than enough emergency room experience in their current rotations" (Fournier, 19891. Demonstration funds have freed residents from some of their hospital responsibilities, which allows time for the ambulatory block experience. This is in addition to the continuity experience at either Jackson Memorial Hospital or the Veterans Administration Hospital. The entire residency program meets the federal 25% continuity requirement. Some 50% of the residents are said to go into primary care - up from 30% a few years ago. Overall, the project is described as making good progress. There has been opposition from more traditional members of the Department of Medicine and there was also some initial resistance from the residents caused more by scheduling changes than from the increases ambulatory experience. Some changes and accommodations have been made and residents are now said to be supportive of the program's focus. Key participants at the school, without whose support the change could not have taken place, were the dean, the chairman and vice chairman of the Department of Medicine, the chairman of Family Medicine and the AHEC director. A major factor in the success of the program was the availability of sufficient money from several sources, which increased flexibility. For example, since the federal training grant is not use to support resident's salaries, residents need not sign a Statement of Intent to Practice General Internal Medicine. In this way the program can expose all of the internal medicine residents to primaly care and an expanded ambulatory experience. Timing was also said to be critical - many individuals were becoming concerned over the inadequacy of the inpatient experience for graduate medical education. According to the AHEC Director all of the trends occurring nation wide (huge service loads, sicker inpatients, non-representative patient conditions) are compounded in Miami. The combination of a major problem, the availability of new and flexible resources, and an individual with an idea created significant opportunities. Impediments to implementation were described as two-fold -- achieving consensus and getting people to make the agreed upon changes. Other problems include financial viability of the demonstration grants and long-term support for education in the ambulatory setting. It is hoped that this latter goal can be achieved through the development of capitated plans to serve the medically needy. Such a plan for the Jackson Memorial Hospital Clinics was negotiated with the state Medicaid Program and initiated in January of this year. The school is also negotiating with Dade County for a capitated system to serve medically needy county residents and hopes to initiate it later this year. 245

b) The Southeastern University of Health Sciences The Southeastern University of Health Sciences (until recently known as the Southeast College of Osteopathic Medicine, SECOM), like the University of Miami, has received a $! million Medically Indigent Demonstration Project Grant for the past two years. In addition, the State, through the Community Hospital Education Council, supports selected residencies. The Council pays $14,000 a year for family medicine residents, lesser amounts for other primary care residents including OB/GYN, and selected psychiatry residents. The SECOM project is a rural demonstration involving medical students and residents. While the University of Miami project is focused on shifting the site of training from inpatient to outpatient and from hospital clinic to Community Health Centers, the SECOM project is different. Because the osteopathic residency program already has a heavy ambulator focus the SECOM project is aimed more at expanding the number of ambulatory sites and shifting some of the ambulatory training to rural areas. The 16 SECOM general practice residents will have a required two-month ambulatory block in a rural site this year and a three-month block next year. The school is also attempting to start a fully rural based residency program. The demonstration project is operated at four sites--two rural community health centers, a rural county health department and a school-operated AHEC site. Although the community health centers and county health units are said to be very supportive, the local rural hospitals are less so. Grant funds are used in a variety of ways; half time support of faculty at each site, partial support of resident stipends, support for a Medical Director who is shared by the sites, living and transportation expenses for the residents, and library and audio visual resources. From the start the project was actively supported by SECOM administration without significant opposition. A Vice President of the Southeastern University of the Health Sciences, who is also a state legislator, was instrumental in having the legislation approved. According to the project director the residents support the project and look forward to the expanded program next year. The major concern expressed was about future funding. The SECOM administration support legislation that would use the demonstrations as the base for a state-wide AHEC. However, given the financial problems of the state and the governor's opposition, they are not optimistic that the legislation will be approved. 246

c) University of Florida The University of Florida Medical School received a medically Indigent Demonstration Project grant in 1988. The Dean of the medical school sub- contracted (approximately $200,000) with the Center for Health Policy Research for the initial research and planning tasks--develop an agenda, conduct community needs assessments, review the literature on retention of physicians and develop optimal program models. According to the director of the center, most of this work has been done, and he and the dean will meet with the representatives of the four primary care departments to discuss to what degree they wish to be involved in the project. While the exact nature of the educational experience has not been decided, it will probably include both medical students and residents, be a block experience, and be conducted at two sites (a small non-tertiary care hospital and a county health department). As currently conceived, grant funds would be used to pay for student and resident travel and housing, individuals to serve as preceptors at the sites, and the conduct of both an ongoing and a final evaluation. The director of the Center for Health Policy Research indicated that the University of Florida was veer skeptical about the project because of its demonstration nature. Without permanent funding the university did not want to become involved in an activity that might raise community expectations and leave the University with an unfunded commitment. He indicated that the University of Florida sees its major health care commitment to be the operation of a tertiary care hospital. He also~described the state's financial problems and the fact that the Public Medical Assistance Trust Fund would be broke next year. d) Summary The rapid development of the projects at the University of Miami and the Southeastern University of Health Sciences can be attributed to the compatibility of the state's ideas with needs perceived by the medical schools. The state was concerned with adequate staffing for health departments and community health centers and with recruiting replacements for National Health Services Corps physicians as they finish obligated service. The medical schools were interested in expanding the sites of, and securing funding for, an ambulatory based educational experience. The fact that several key legislators were interested in health issues and that there were individuals at the two schools anxious to make changes were also critical factors in program development. 247

5) North Carolina - AHEC Program North Carolina has a long history of support for higher education and health, particularly primary care. The follo~ng events illustrate the continuing state- wide effort to improve the health of the states citizens. When the University of North Carolina-Chape] Hill Medical School, was expanded to four years after WW Il. the authorizing legislation required that it concern itself with manpower distribution in the state. In the mid 1960s the university created an Office of Community Medical Care within the medical school. In 1967 the legislature appropriated $! million for community outreach activities to be directed by this office. Also in the late 1960s the medical school created a Department of Family Medicine. In the early 1970s the university took the lead in developing a state- w~de AHEC program based on the ideas of the Carnegie Commission report (calling for the decentralization of a significant portion of the undergraduate medical education program) and aided by substantial federal funds. The philosophy of the AHEC program includes a multidisciplinary approach to health care and health professions education. The program supports not only undergraduate and graduate medial education but also health profession education in nursing, dentistry, pharmacy, public health and allied health. The state in 1974 authorized grants to primal care residents in the state. Today there are 300 resident grants of $15,000 each through a state appropriation to the AHEC. The grants are allocated to the four medical schools and to the state AHEC sites having residency programs. Currently the state is the major source of funds for the AHEC, providing approximately $30 million (including the $4.5 million for primary care residents). A significant portion of the total AHEC budget is used to support faculty and facilities at the nine AHEC sites around the state. It should be noted that decentralizing the educational process is not necessarily the same as increasing the focus on ambulatory education. While there is significant ambulatory education at the AHEC sites majority of education is still conducted in the inpatient hospital setting. Currently the state is concerned about responding to the twin challenges of the shift of the setting of health care delivery to locations outside the hospital and the declining interest of medical students and residents in primary care. In North Carolina, in 1988 44% of the first-year residency positions in Family Practice were unfilled by the match - as compared with less than 10% in each of the previous three years. Acknowledging the complex nature of these problems the medical school and the state-wide AHEC have concluded: 248

"This combination of circumstances is creating profound difficulties for medical education which will require a dramatic shift in the setting of medical education and in the nature of faculty supervision of the individual medical students if it is to be overcome" (North Carolina AHEC, 19881. The AHEC, in association with the four schools of medicine, has proposed to the legislature a full scale state-w~de planning effort beginning this year. The plan would be completed in about one year. Significant state funding for implemention would start in late 1990. While the major focus is on increasing the ambulatory content of undergraduate education, significant attention will also be paid to primary care GME. The plan is designed to build upon the past success and reputation of the AHEC program. It ties the educational needs of the schools to the manpower and service concerns of the public and the legislators. It is important that the four medical schools are united in the effort and have the AHEC structure and its reputation as an honest broker to serve as a vehicle for change. Other important factors include a history of generous state funding for higher education (within the top three nationally on a per capita basis), knowledgeable and politically astute leadership within the AHEC program, and several key legislators who are supportive of primary care. The major problem in selling the new plan is to tie it to the overall AHEC concept, and the need to ensure adequate availability of care for all - including the indigent. The current move to ambulatory care education has arisen within the medical schools, not the community, making it necessary to relate the proposed program to issues which concern state legislators and the general population. 6. Medical College of Wisconsin - Pediatrics. Milwaukee. Wisconsin Medical students and the 42 residents (GY1:14) in pediatrics from the Medical College of Wisconsin receive their ambulatory experience in the Pediatric Primary Care Clinic (PPCC) of Childrens Hospital of Wisconsin. Throughout their three years, residents spend one half day a week obtaining continuity experience in the PPCC, as well as block time in both their first and second years. Until 1984 the PPCC was a typical hospital clinic staffed by hospital personnel and faculty from the Medical College of Wisconsin. There was ongoing friction between the faculty and hospital administration over finances and management. Hospital studies showed net losses by the clinic of $401,000 in 1981 and $512,000 in 1982. Additional problems, according to the hospital, included 249

the fact that faculty were more interested in research and education than the efficient provision of care, thus productivity was low and faculty billings and collections were inadequate. The hospital also claimed that although it did not have financial responsibility for education, by running the clinic with a deficit the hospital was indirectly supporting both undergraduate and graduate education. The faculty was also unhappy, charging that hospital operations were poorly run, that the claimed losses were more bookkeeping artifacts than reality (shifting hospital inpatient costs to the PPCC), and that in return for services provided by faculty and residents the hospital had an educational responsibility. During this time of discontent the state of Wisconsin announced that all patients receiving medical care under the State Aid to Families with Dependent Children (AFDC) would be enrolled in HMOs. Since this population provides the bulk of both inpatients and outpatients at the hospital and the PPCC, and since with the current operational structure services were not competitive, both the hospital and the faculty were faced with a major problem. The solution was for the hospital to form an "HMO, called Total Care to serve as a home for AFDC/MA patients followed at the PPCC and by private physicians who used Childrens Hospital ... the PPCC became a faculty managed, prepaid group practice under the Department of Pediatrics". The group then contracted with the hospital HMO to provide health care on a capitated basis for members selecting the PPCC and contracted with the hospital to pay for clinic space and housekeeping services. According to the medical director of the PPCC and the Chairman of the Department of Pediatrics, the changes have been very successful. Most of the friction between the faculty and the hospital has disappeared. The costs, particularly personnel costs, have been sharply reduced. Continuity of care, and the educational process have been improved. Although the PPCC is viewed as a financial success, there is still some concern over costs. The faculty believe that the hospital should continue to pay the educational subsidy that it had paid for the first 18 months. Success is seen as resulting both from improved operational efficiencies and the system of capitated payments. The medical director believes that they can provide quality care and education at a cost which is competitive with an IPA though not with a staff model HMO. Key factors contributing to success include a situation requiring action, strong leadership within the department and the interest and commitment of a medical director willing to devote time and energy to making the system work. It was also critical that the capitated system provide a sure source of revenues (approximately 80% of revenues come from the capitation payments). The medical director commented "Capitated care does make the process simpler and (assuming 250

capitation rates are adequate) possible. Fee-for-service reimbursement would require subsidies from some other source" (Torphy, 1989~. The medical director is concerned that his managerial role takes him away from research opportunities which are more highly esteemed in academic settings. He is also concerned that the need to run the clinic in an economic and efficient manner may take away from the educational mission in the long run (though it has not done so up to this time). The Department chairman believes that the faculty's experience in running an ambulatory clinic is transferable to other settings and that a faculty run system provides a better educational experience and reduces friction between faculty and hospital administrators. He also believes that the fact that faculty and residents have to worker about costs is all to the good. in. Lessons for the Future Successful financing of ambulator~r-based graduate medical education is as uncertain and confusing as anything else related to the cost and financing of graduate medical education. Given the uncertainty over costs and financing it is not surprising that it is difficult to find examples of successful programs. In attempting to identify programs with either innovative or strong and stable financing I received a variety of responses ranging from "are you delusional?" and "there aren't any" to a program director who, in describing the financial situation of his program, commented "we have so much money I don't know how to spend it intelligently." While this latter response was less typical than that of the AHEC director who said, "I moan and groan and cry a lot" it was not unique. Although many programs with a significant ambulatory focus have financial problems, others appear to be successful. A variety of factors contribute to financial success and stabilizer. Table 1 indicates factors that appear to have been important in the success of the programs described in this section. Table 2 briefly defines each of the factors. The absence of a "x" mark in Table ~ means that the factor was not mentioned, not necessarily that it did not exist. A minus after the "x" means that the factor was described as important but not critical or that it was important at some time but not continuously. It is evident that many of the factors were important in each of the successful programs. This does not necessarily mean they were of equal importance, indeed the individual cases indicate some factors were much more important than others. 251

1 1 x x x - ~ - o ~ c~ - :> - ~ ~ t: ~- - o ~ } q , ~n I- V ~ ~ V, - C ~X o ~, o o - C~ C C ~ o ~ P. o C o o o ~ X - E <7 _ ~- o _ C- ~ Y X t X X X X X X X X XX X XX X X X XX X X X X X XX X X X X X X X X X X X X XX X X X X X X X a) a X X X Q. Q} X X X X X X X X X X X X X X 252 X X X X

Table 2 Definitions of Factors 1. Problem - the existence of a problem, either critical or chronic which required significant changes in a program. 2. Leadership - the presence of an individual willing to accept responsibility for making changes. 3. Institutional Commitment - the willingness of the institution to support or encourage the change. In the case of states it refers to a general climate of support. 4. Management Skills - the presence of someone, or several people, with the skills necessary to ensure the project operates economically and efficiently. 5. Goal or Mission - the existence of a clearly articulated outcome or desired end result of the active 6. Multiple Sources of Funding - the presence of at least three independent . : :lnanclng sources. 7. Mutual or Compatible Benefits - the congruence of interests between the project and the sources of financial support. S. Merging of Education with Service - the ability to merge the educational experience into the provision of services. 9. Direct State Support - the availability of state funds directly for use in educational programs. 10. Indirect State Support - the availability of state resources for the provision of services which therefore indirectly assist the educational goal of the project. In the case of the McLennan Texas project the indirect support was from local government. 11. Federal/Private Grants - the presence of grant funds designed to support primary care education. 253

A problem; the existence of a serious problem appears to be a prerequisite for the development of a successful program. None of the cases developed simply from the desire for a better mouse trap. In each instance there was a significant problem that was not being addressed or an impending crisis that could not be handled by the current system. The problems varied: a potential loss of the patient base in Wisconsin, the impending retirement of physicians in Texas, the need for a new type of physician at Montef~ore, and the health of the state's citizens in North Carolina. But in each case it was thought that there was a need for a major change in current programs or the creation of a new ambulatory based . . ec .ucatlon program. Leadership; a leader is needed who has a concept and is willing to push for its implementation. This person needs to have both entrepreneurial and charismatic traits which can be used to mobilize disparate scarce resources. Another important aspect of the leadership role is persuasion. In most instances it was necessary to convince both the overall institutional leadership, and in many cases outside financial sources, that the ambulatory focus will be in their long- term best interest. The presence of strong leadership with a clear goal was a critical element in the success of the programs described in this paper. In each of the cases discussed, an individual (a department chairman, a residency program director, a medical director of a clinic) was identified as being key to the success of the program. While achieving agreed upon consensus concerning institutional direction appears necessary, it is inadequate unless a leader has a strong commitment to change. Closely related is the need to have a specific goal. The program at Montefiore was described by its director as being aggressively ambulatory. The program in Texas recruits residents who will remain in its area to practice primary care. In all of the programs studied, individuals could clearly articulate the goals and objectives of the program. External leadership can also prove helpful. The interviews as well as the literature contain numerous examples of how a state legislator, member of the University Board of Regents or some other "outside" source facilitated financing and acceptance of a new concept. In both North Carolina and Florida individual legislators played significant roles in gaining approval for an activity. While this external support cannot substitute for internal leadership it can help overcome opposition and create a supportive climate. To some degree grant support - either federal or private - can also provide external validation and impetus. North 254

Carolina was adept at using its Federal AHEC contract to justify its actions and to deflect criticism by more traditional medical school facula. While dynamic leadership can facilitate the accomplishment of many of the tasks associated with establishing ambulatory care residencies, one function of leadership is to garner institutional support - a vital element that is discussed next. Institutional commitment: ambulatory based programs are most easily implemented and sustained if they fit into the natural environment of the overall institution. Lacking this fit, leadership attempting to establish residencies in ambulatory care settings will have to fight institutional resistance to a reallocation of resources, and overcome an institutional structure that lacks incentives for individuals to encourage education in ambulatory settings. A number of people, including federal policy makers, policy analysts, and program directors said that commitment not resources was the key issue. As one federal official commented "The issue is not money, but marshalling resources and institutional commitment. Leadership in the medical center has to be willing to make changes". Similar comments include: "The support of the [hospital] for primary care and its willingness to pay resident salaries is crucial." "Institutional leadership is critical in obtaining financing." In at least four of the cases described here there was significant institutional commitment to the concept of primary care. In the other two cases, Buffalo and Milwaukee, there was strong departmental support and commitment. Management skills are critical to the operational efficiency needed to control the costs of new residency arrangements. Several people interviewed mentioned that improving the current operation of hospital clinics would be a significant step in helping finance ambulatory based GME. As one hospital consultant commented: "There isn't any new money available, the key is restructuring ambulatory services to make them more efficient and effective." Faculty takeover of the operation of a hospital clinic does not necessarily mean that efficiency will improve. Ensuring efficiency is a difficult and time consuming task that requires tact, determination and commitment. Both the PPCC in Milwaukee and the increased success in collection and the incentive plan at the family practice clinic in Waco provide examples of the importance of efficient management. Financial resources are by definition necessary to achieve financial stability. The cases described in this section and those previously described show that if the leadership and institutional support are present the current financial system can, 255

in at least some cases, be adequate to provide ongoing support for ambulatory educational innovations. A number of the key factors interrelate. The successful programs all had multiple funding sources, the program leadership had convinced a number of organizations and individuals that they would benefit from the ambulator based education program, frequently because of the value of the services being provided by the residents. ~~ ~ ~ ~ ~ ~ -~ · ., All of the programs had merged the educational aspects of the r ~· ~1. 1 ~·1 ~ program with successful service delivery activities, and state and federal funding had played important roles. All of the successful programs had at least three major sources of support most had significantly more. Shared financial support may also lead to shared commitment, and on a very practical level, not putting "all your eggs in one basket" means that the program's director has greater flexibility. The cases provide several examples where loss of one financial source could be overcome by increasing support from another source. - Mutual benefit can be an important factor in success. That is, the program needs to be able to convince groups or institutions with different objectives that support of ambulatory education will be mutually beneficial, that it wait generate ancillary services and inpatient revenue for the hospital, help the state or locality provide care for its indigent population at reasonable costs, help recruit future staff to community health centers, provide physicians for rural constituents of a key state Senator, or some other similar related or compatible interest. Obviously patient care revenues have been, and continue to be, a key ingredient in financial Lability. Thus the level of payment from government and private payers is crucial to financial viability, and is a significant factor in the uncompensated care burden that the program shoulders. Almost all, of the successful programs developed well-run ambulatory operations. In the projects reviewed, efficiently conducted ambulatory services coupled with government payments for indigent care were a key ingredient in the program's financial success. In many ways the state is a key player in determining financial viability. There are limited comparative data on state support for medical education - particularly clinical education. The most extensive recent information is contained in "State Support for Clinical Education" (Mandex, 1987~. Tables 3 and 4, taken from that report, show types of clinical education supported and state support for 256

Table 3 Types of Clinical Education Support (Number of States - 48~) OPERATING SUBSIDIES ONLY Hawaii Missouri2 North Dakota New York2 Utah Oregon4 2 DIRECT SUPPORT ONLY Arkansas Arizona3 Delaware Idaho Indiana Nevada Oklahoma South Dakota Tennessee Vermont Washington West Virginia Wyoming Michigan BOTH Alabama California Colorado Connecticut Florida Georgia Illinois Iowa2 ~ · ~ L`ou~s~ana Minnesota2 ~ ,. . . . MlSSlSSlppl Nebraska North Carolina New Jersey Kansas2 Kentucky: New Mexico2 Ohio Pennsylvania South Carolina Texas Virginia5 Wisconsin ~ Insufficient data on Maine and Maryland to classify these two states. 2 Data not available. 3 Arizona discontinued its operation subsidy to the University Hospital. 4 Clinical support for hospital in appropriation to medical school. 5 Part of support is in medical school budget. SOURCE: Mandex, Inc. (1987), Issue Paper #2. State Support for Clinical Education. 257 NO SUPPORT Alaska Massachusetts Montana New Hampshire Rhode Island

Table 4 STATE SUPPORT FOR FAMILY PRACTICE, 1986 Clinical MedicineFamily Practice State Total $ $ % . Alabama 3,341,000 2,480,000 74 California 2,800,000 2,800,000 100 Colorado 2,142,000 2,142,000 100 Connecticut 34,000 34,000 100 Georgia 4,812,000 4,812,000 100 Idaho 50,000 50,000 100 Indiana 4,533,000 1,000,000 22 Iowa 1,383,000 1,383,000 100 Minnesota 168,000 168,000 100 Ohio 12,006,000 7,236,000 60 Oklahoma 5,805,000 2,715,000 47 Tennessee 3,940,000 3,808,000 97 Texas 10,875,000 7,875,000 72 Virginia 3,261,000 3,261,000 100 Wisconsin 5,390,000 5,390,000 100 West Virginia 1,643,000 458,000 28 Wyoming 8,386,000 8,386,000 100 Total $119,182,000 $53,998,000 45 SOURCE: Mandex Inc., (1987), Issue Paper #2. State Support for Clinical Education. 258

family practice. Since these tables do not include state programs which indirectly facilitate but are not targeted at education, the amount of state support is probably understated. State support can be direct or indirect. Direct support can include grants for specific projects, as in Florida and North Carolina; it can include payments for residents in primary care programs, or it can include direct payments to support the medical school faculty or to subsidize a teaching hospital. States have also played an important role in supporting primary care residencies by providing direct subsidies. Family practice has been especially successful in using local project directors to obtain direct state support - particularly where the legislature is dominated by representatives of rural areas. One faculty member commented: "Rural legislators see support for our (FP) residency programs as an insurance policy against losing their local doc.~' The amount and method by which the state pays for indigent care can also be important in the development of ambulatory education. This support can be explicit, as where education is included as a component of the Medicaid payment or it can be a secondary result of a state policy. Both the Montef~ore Social Medicine Program and the SUNY- Buffalo Family Practice programs receive . ~, ~. . Em. . . _ ~ ~ extensive indirect support for education because of generous Medicaid reimbursement for institutional providers of ambulatory care. Some states such as California, New York, and Massachusetts, fund ambulatory care for the poor by providing adequate reimbursement for their care through hospital clinics. This revenue contributes to the support of residents in these setting. Some studies show that the services provided by residents can offset the costs of their education in well-run settings.~ However, this can only occur if payers provide adequate reimbursement. The federal government also plays an important role in supporting residencies. Overall Medicare payments are the major source of support for graduate medical education. In almost every case discussed in this paper the hospitals associated with the residency programs contributed funds for residents' salaries. Much of this support is possible because of the indirect and direct medical education payments made by Medicare. Direct federal grant programs have also been important, particularly in the initiation phase of programs. A 1987 evaluation of federally funded primary care residency programs (both internal medicine and pediatrics) concluded that the federal grant support had been essential for the initiation of these residency training programs and the support of the behavioral science curriculum (Health Resources and Services Administration, 1987~. Interviews with program directors 259

for this paper produced similar responses. Because the training grants are directed toward the support of primary care education they do not have to serve a dual purpose (such as the support of services). For the same reason they are valuable in supporting parts of the residency program which do not produce revenue, for example, the conjoint faculty at Montefiore or the curriculum redesign at the McLennan County program in Texas. Because they can be used for planning and development activities the grants are also of obvious use in initiating a new program. Familv practice Programs that have been successful in establishing strong, ~· ~- stable, financial support for ambulatory-focused graduate medical education provide some lessons for other specialties. Although their success is in part due to their longer involvement in ambulatory care residencies--an involvement that is required by Accreditation Requirements--a more detailed study of their programs would be valuable. Examples from the literature and the case studies indicate that some other differences between family practice residencies and other residencies may account for the former's greater financial success in the ambulatory setting. The fact that they are frequently the only residency program in a hospital may make them a more valuable resource to the hospital. Similarly their locations in community hospitals and in less urban areas may have contributed to their greater success in convincing state legislators that they are a valuable resource, and thus to their greater success in securing direct state support. The necessity of securing financial support from a variety of sources may have aided in building coalitions and in generating non-monetary support. Finally, since the basis of family practice is ambulatory, it is likely that most department chairmen (a key ingredient in success) will be strong supporters of the programs. Summaly Overall the examples presented confirm the previous findings in the literature. However, we found that a large number of factors (See Table 1) must come together if a program is to be financially successful. Most of the successes reported previously identified only a few key factors relating to financial viability. Factors that received greater attention in the programs described in this paper than in the literature included the existence of a specific problem, the need for a single leader with a clear goal, and the role of the state. Other factors described in the literature, such as efficient management, multiple funding sources, merging of education with service functions, development of services to benefit others, were also important to the success of the programs we studied. 260

REFERENCES Aday, L., et al. 1988. National Study of Internal Medicine; XIl. The Future of Graduate Medical Education in Internal Medicine: What Do Program Directors Predict? Archives of Internal Medicine. 148:1509-1514. July. Association of American Medical Colleges. 1987. Studv and Comnarison of Transition of Medical Education Programs From Hospital Inpatient to Ambulatory Training Programs. AAMC. Washington, D.C. Association of American Medical Colleges. 1987. Adapting Clinical Education to New Forms and Sites of Health Care Delivery. Washington, D.C. Association of Program Directors in Internal Medicine. Undated. Financing Internal Medicine Training in Ambulatory Care. Draft Position Planer APnTM Washington, D.C. _,= ~. ~ ~ en, . . Association of Program Directors in Internal Medicine. 1987a. Ambulators Settings In Internal Medicine ResidencY Programs. Executive Summary. APDIM. Washington, D.C. Association of Program Directors in Internal Medicine. 1987b. Ambulatory Settings in Internal Medicine Residency Programs. Final Report. APDIM. Washington, D.C. Brook, R.H., et al. 1987. Educating Physicians and Treating Patients in the Ambulatory Setting. Annals of Internal Medicine. 107:392-298. Ciraicy, E.W., et al. 1985. The Cost and Funding of Family Practice Graduate Medical Education in the United States. The Journal of Family Practice. Vol.20, No.3:285-295. Colwill, J.M. Undated. Characteristics of Family Practice Residency Programs. University of Missouri. Columbia, Missouri. Colwill, J.M. Undated. Financing Graduate Medical Education in Family Medicine. University of Missouri. Columbia, Missouri. 261

Page 2 Cow, d.M., and d.K. Glenn. 1981. Patient Care Income and the Financing of Residency Education in Family Medicine. The Journal of Family Practice. Vol.13, No.4:528-536. Council on Graduate Medical Education. 198Sa. Minutes of the Plenary Session. November. Health Resources and Services Administration. RocknIle, Ma~riand. Council on Graduate Medical Education. 198Sb. First Report of the Council. Vol. and Il. Health Resources and Services Administration. Rockville, MarsrIand. Council on Graduate Medical Education. 198Sc. Meeting Minutes. February 18-19. Health Resources and Services Administration. Rockville, Maryland. Council on Graduate Medical Education. 1987a. Meeting Minutes. September. Subcommittee on Graduate Medical Education Programs and Financing. Health Resources and Services Administration. Rocknlle, Maryland. Council on Graduate Medical Education. 1987b. Meeting Minutes. June. Subcommittee on Graduate Medical Education Programs and Financing. Health Resources and Services Administration. Rocknlle, Maryland. Council on Graduate Medical Education. 1987c. Meeting Minutes. March. Subcommittee on Graduate Medical Education Programs and Financing. Health Resources and Services Administration. Rocknlle, Mar~riand. Dale, D.C., et al. 1988. The Regional Graduate Medical Education Program of the University of Washington. Journal of Medical Education. Vol. 63, 347-355. May. Delbanco, T.L., and Calkins, D.R. 1988. Journal of General Internal Medicine. Vol. 3, S34-S43. (Mar/Apr Supplement). Ebert, R.H., and Ginzberg, E. 1988. The Reform of Medical Education. Health Affairs. Vol. 7, No.2 Supplement, 6-37. Florida. 1989. Proposed State Statue. Amendment to 409:2661. Section 6. Tallahassee, Florida. 262

Page 3 Florida 1987. State Statue. 409:2661.-Section 10. Tallahassee, Florida. Gastel, B., and Rogers, D.E. 1989. Clinical Education and the Doctor of tomorrow. The New York Academy of Medicine. New York, New York. Gavett, J.W., and Mushlin, A.I. 1986. Calculating the Costs of Training in Primary Care. Medical Care. Vol. 24, No.4:301-312. Gellhorn, A. 1986. Graduate Medical Education in Internal Medicine. Annals of Internal Medicine. Vol. 104, No.4:569-570. April. Ginzberg, E. 1987. Academic Health Centers--Can They Afford to Relax? Journal of American Medical Association. Vol. 25S, No.14:1936-1937. October. Greer, David. 1989. The Move Into The Ambulatory Setting. Prepared for the Council on Graduate Medical Education. Health Resources and Services Administration. Rockville, Maryland. Health Resources and Services Administration. 1987. Assessment of The Development and Support of Primary Care Residency Training: General Internal Medicine and Pediatrics. September. Rockv~lle, Maryland. Health Resources and Services Administration. 1988. Proceedings of the HRSA Conference: Primary Care Medical Education. HRSA. Rockville, Maryland. Kahn, L., et al. 1978. The Cost of a Primary Care Teaching Program in a Prepaid Group Practice. Medical Care. Vol. 16, No.~:61-71. January. Kasonic, John. 1987. Outline of Issues Relating to Cost and Financing of Medical Education in the Ambulatory Setting. In Adapting Clinical Education to New Forms and Sites of Health Care Delivery. Association of American Medical Colleges. Washington, D.C. Kosecoff, et al. 1987. Providing General Medical Care in University Hospitals: Efficiency and Cost. Annals of Internal Medicine 107:399-405. Lewis, C.E. 1986. Training in Internal Medicine: Time to Retool the Factory? Annals of Internal Medicine. Vol. 104, No. 4:570-572. April. 263

Page 4 Mandex, Inc. 1987. An Assessment of State Support for Health Professions Education Programs. issue paper NO.~. ManDeX. ~pRln~lelD, Vlr~nla. Miller, et al. 1985. Time and Financial Analysis of an Academic General Internal Medicine Unit. Archives of Internal Medicine. 145:2093-2097. Moore, G.T. Undated. How Will We Pay for Ambulatory Teaching? Harvard University. Moore, G.T. 1986. HMOs and Medical Education: Fashioning a Marriage. Health Affairs. Spring. 147-163. National Health Policy Forum. Issue Brief 493. 1988. A Guide to the Patchwork Quill of Medical Education Financing. A Technical Briefing with Ruth Hanft. George Washington University. Washington, D.C. New York State. 1986. Report of the New York State Commission on Graduate Medical Education. Department of Health, New York. Albany, New York. New York State Council on Graduate Medical Education. 1988. Annual Report. Albany, New York. North Carolina AHEC Program. 1988. Medicine and Medical Education in the 2Ist Centu~r-Beyond the Hospital. Preliminary Working Paper. Chapel Hill, North Carolina. Perkoff, G.T. 1988. Graduate Medical Education Confronted. Journal of American Medical Association. Vol. 259:402-404. January. Perkoff, G.T. 1986. Teaching Clinical Medicine in the Ambulatory Setting. The New England Journal of Medicine. Vol. 314, No. t:27-31. January. Reuben, D.B., et al. 1988. The Residency-Practice Training Mismatch; A Primary Care Education Dilemma. Archives of Internal Medicine. Vol. ITS, 914-919. April. Ricketts, T.C., et al. 1986. Trends in the Growth of Family Practice Residency Training Programs. Health Affairs. Winter. 84-96. 264

Page 5 Rieselbach, R.E., and Jackson, T.C. 1986. In Support of a Linkage Between the Funding of Graduate Medical Education and Care of the Indigent. The New England Journal of Medicine. Vol. 314, No.~:32-35. January. Rosenblatt, R.A. 1988. Current Successes in Medical Education Beyond the Bedside. Journal of General Internal Medicine. Vol.3. S44-S59. (Mar/Apr Supplement). Ross, R.S. and Johns, M.E. 1989. Changing Environment and the Academic Medical Center. Academic Medicine. January. I-6. Schroeder, S.A. 1988. Expanding the Site of Clinical Education: Moving Beyond the Hospital Walls. Journal of General Internal Medicine. Vol. 3:S5-SI4. (Mar/Apr Supplement). Stern, R.S., et al. 1977. Graduate Education in Primary Care. The New England Journal of Medicine. Vol. 297, No. 12:638-643. September. Torphy, D.E., et al. 1988. Effects of a Faculty Prepaid Group Practice In a Pediatric Primary Care Clinic. Journal of Medical Education. Vol. 63:839-847. November. Torphy, D.E. 1989. Personal Communication. Wartman, S.A. 1988. Moving Toward The Ambulatory-Based Residency. In Proceedings of the HRSA Conference on Primarv Care Medical Education. Health Resources and Services Administration. Rockville, Maryland. Watt, M.~. 1987. The Costs and Financing of Graduate Medical Education. Prepared for Subcommittee on Graduate Medical Education Programs and Financing. Council on Graduate Medical Education. September. Health Resources and Services Administration. Rockv~le, Maryland. 265

Exhibit 1 Other Examples of Successful Financing: In addition to the programs described in this paper, a number of other states, schools and departments were reported to be successful in teas of having or supporting stable long-term funding for ambulatory based primary care graduate medical education. These include: a) States Washington; specifically for state support of family practice and for the WAM! (Washington, Alaska, Montana, Idaho) system overall. South Carolina; for the support of family practice and the development of a state-wide primary care network. Arkansas; for support of primary care education through its ALEC network. b) Medical schools reported to have a general interest in ambulatory care education include: Rush Medical College Bowman Grey School of Medicine University of California, Los Angeles, School of Medicine Michigan State University College of Human Medicine Southern Illinois University School of Medicine University of Minnesota Medical School Texas Tech University Health Science Center School of Medicine West Virginia University School of Medicine University of Utah School of Medicine c) Residency programs reported to have long-term stable financing and a significant ambulatory component. Internal Medicine University of California, Los Angeles School of Medicine Beth Israel Hospital (Boston) Brigham and Womens Hospital Program (Boston Brown University/Rhode Island Hospital 266

F~i~ Practice Memor1~1 F~1~ Prschce Hang Beach' ^) Santa Monics F~1~ Prachce (Santa Monica' ^) Locater F~1~ Practice (Lsnc~te~ ^) Ped1~1cs H~=d Bedim School Promo 267

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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.

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