Primary Care Physicians Financing Their Graduate Medical Education in Ambulatory Settings (1989) / Chapter Skim
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Because of recent changes in the health care system, the hospital is a less suitable principal focus for the GME experience of primary care physicians than the ambulatory setting in which most of the physician's career will be spent. However, because payments for health services and for GME are skewed to favor inpatient and specialty education it is hard for educators to increase the time that residents spend in primal care outpatient settings.
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However, the concern of the committee was to initiate immediate movement in constructive directions. Problems in Financing GME for Primary Care Physicians in Ambulatory Settings The committee reviewed the literature and available data about the costs of training in ambulatory settings and the revenues available to those trying to ensure appropriate ambulatory training experiences for primary care residents.
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Special federal funds for GME in primary care are also available from Title VII of the Public Health Service Act. These are grants to primary care training programs -- family practice, general internal medicine, and general pediatrics -- that require residents to spend at least 25 percent of their time in continuity practice in ambulatory settings.
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The committee reviewed attempts to estimate the adequacy of the future supply of primary care physicians, and indicators of change in the supply of primary care physicians such as the number of medical school graduates selecting primary care specialties. Although projections of both the supply of and need for medical manpower contain much uncertainty, the committee concluded that if measures to improve support of GME in primary care settings would at the same time increase the number of individuals going into primary care, a double benefit would accrue: training would be improved and there would be some correction in the current imbalance between oversupplied specialties and the primary care specialties for which there are possibilities of undersupply.
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Physician Payment Reform The committee noted that increasing payment for primary care services would have the mutually reinforcing effect of enhancing the revenues of primary care training sites and making a career in primary care more attractive by increasing its earning potential. A resource-based relative value scale (RBRVS)
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Primary care residents who spend 25 percent or more of their time in a primary care ambulatory setting (not including specialty clinicsJ should receive a larger weighting factor. The suggested incentive both would make the provision of primary care residencies more attractive to hospitals, and generate revenues needed for the development of quality training programs in community practice sites.
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The committee recommends that states assess their need for primary care physicians, bearing in mind the special roles of these physicians. States that determine that an increased supply of primary care physicians would benefit their citizens, and states that find a potential shortage of primary care practitioners, should increase their financial support of GME and widen their support to include general internal medicine and general pediatrics as well as family medicine.
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Private foundations, both local and national, interested in medical education and the provision of health services, should add their support to such activities thus multiplying the benefit of the limited federal grants funds that are available. Academic Leadership The success of committed leaders in overcoming financial barriers and establishing innovative arrangements for training primary care residents in ambulatory settings underscores the importance of academic leadership.
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