Primary Care Physicians Financing Their Graduate Medical Education in Ambulatory Settings (1989) / Chapter Skim
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The Cost of Graduate Medical Education in Outpatient Settings
The Cost of Graduate Medical Education in Outpatient Settings
Pages 144-172
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From page 144... ...
Is it more costly to train medical students in the outpatient setting than in the inpatient setting? What will be the effect of developing a program in outpatient training on the net revenues of an institution?
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From page 145... ...
and indirect costs which are the increase in patient care costs incurred by the hospital because it is involved in graduate medical education. Patient care costs are higher because there are increased space needs, additional 145
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From page 146... ...
Since the indirect costs cannot be measured directly, they are determined statistically (Lave, 19851. In most cases, analysts estimate "cost functions" in which hospital inpatient costs (excluding the direct costs of graduate medical education)
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From page 147... ...
The cost of the training program will depend on its nature. Training programs can range from the development of a residency program in family practice in a nontraditional setting, the enhancement of an outpatient focused primary care component in an internal medicine residency program, or the implementation of a clerkship for medical students in an HMO or family practitioners' office for 4 weeks during the summer.
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From page 148... ...
It will also depend on the mix of residents: in general the net cost will be positive for medical students and for residents early in their training and negative for more senior residents. Because the net cost of training depends upon so many factors, it is not surprising that empirical studies of the cost of training, which usually considers single sites, often reach very different conclusions about both its size and direction.
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From page 149... ...
Patients Per Hour Cost Per Visit S o J C O ~7 Output / Resident t - Output Faculty lo) Input 0 12 24 36 Month of Traintug FIGORE ONE \ Bcsiten~ Fully Trained Ml)
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From page 150... ...
In this respect, this research is different from that on the cost of graduate medical education in the inpatient setting. The work on the net cost of graduate medical education can be classified into four groups: time and motion studies, replacement cost studies, relative cost studies and marginal productivity studies.
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From page 151... ...
; while for follow up visits, faculty physicians spent a significantly shorter time. They also found that the attending physicians spent a significantly longer period of time with PGYl's for both first and follow up visits (when the PGY1 was the primary provider)
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From page 152... ...
Table ~ Average Nurse and Physician Costs of Visits To Fifteen Internal Medicine Group Practices (in 1983 Dollars)
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From page 153... ...
Delbanco and Calkins (1988) studied the effect of replacing residents with full time physicians at Health Care Associates, a primary care practice at the Beth Israel Hospital in Boston; while Gavett and Mushlin (1988)
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From page 154... ...
Table 2 Change in Cost Per Visit If Trained Physicians Replace Residents Other Net Faculty Resident Training Fringe Space Staff Change GMi $ 9.09 $-7.92 $-2.85 $ -1.68 DC2 12.67 -1.68 $-3.59 $ 1.34 $-1.34 8.40 iCalculated from data presented in Gavett and Mushlin, 1988. 2Calculated from data presented in Delbanco and Calkins, 1988.
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From page 155... ...
Before and After Studies In before and after studies, the investigators examine the effect of introducing residents or medical students into the practice setting. The introduction of medical students and residents would be expected to lead to a decrease in the hourly productivity of the "faculty" physicians because they will now be spending some of their time training and supervising.
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From page 156... ...
and fully qualified family practitioners practiced together with the average cost of a number of family practice sites in the same large prepaid group practice. Costs for materials and supplies were taken from expense data and each site was allocated its proportion share of indirect costs for space and general clinic administration.
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From page 157... ...
(There was considerable difference among both the residents and faculty members in their propensity to order tests.) Summary The studies reviewed above looked at only one aspect of the cost of training medical students in primary care: the net costs of having residents and medical students in the ambulatory setting, where they are both providing services and being trained.
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From page 158... ...
In general, the net cost of training for second and third year residents is likely to be negative. The findings of the empirical studies indicate that there are likely to be "indirect costs of graduate medical education" in the outpatient setting.
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From page 159... ...
As programs increase the amount of time that residents are being trained in the outpatient settings, it necessarily follows that the amount of time they spend in the inpatient setting necessarily decreases. As the residents were providing patient care services in the inpatient setting, some arrangements will have to be made to replace them.
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From page 160... ...
Below we discuss studies which have examined the financial impact of three different types of programs: a training program in primary care, residency programs in family practice, and general internal medicine ambulatory practices in teaching hospitals.
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From page 161... ...
The program is responsible for 100 percent of the residents' salary, yet the residents spend considerably less than 50 percent of their time in the primary care clinic; the rest of the time was spent on other speciality outpatient clinics and in inpatient rotations. Programs in Family Practice There have been many studies of single family practice residency programs as well as surveys of multiple programs.
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From page 162... ...
Since insurance coverage for outpatient services is much less generous than it is for inpatient coverage, clinic prices cannot be much higher than those at private physician offices. General Internal Medicine Ambulatory Practices in Teaching Hospitals In 1980 the Robert Wood Johnson Foundation sponsored a program to develop general internal medicine primacy care practices in 15 teaching hospitals.
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From page 163... ...
Table 3 Visit Targets for the Residency Sessions Level Session/wk Pts/Session Pts/wk # wks Total 1 1 5 5 48 240 2 3 10 30 48 1,440 3 4 12 48 48 2,304 TOTAL 8 27 83 48 3,984 Average visit/resident .R fi4R = 1,328 4 Expected income per resident 1,328 x $27.06* = $35,936 Actual income per resident 1,015 x $27.06 = $97 4fi4 Difference per resident $ 8,472 *
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From page 164... ...
Other benefits and costs of which are a consequences of these training programs have not been measured. Discussion: Other Issues Issues touched on too briefly above include: the efficiency of the training process; some of the differences between training in the inpatient and the outpatient setting; the level of efficiency in the production of ambulatory services in teaching settings, and some of the differences between training in an HMO and a fee for service setting.
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From page 165... ...
In the inpatient setting, the resident is both a student and a teacher. Residents spent some proportion of their time training medical students (Institute of Medicine, 19761.
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From page 166... ...
Residents Residents Learning / a a ~ _ FIGURE _ 166 AD Input P6r V1sic Pat1~nt#s Su./Hour
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From page 167... ...
Secondly, patients in the outpatient setting are more likely to want a doctor who is fully trained rather than one who is still being trained. Although in the inpatient setting people of all social and economic backgrounds are used to interacting with the house staff, many patients have "their own doctor".
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From page 168... ...
Conclusions There are many different ways of looking at the question of the cost of training medical students and residents in the outpatient setting. A number of analysts have been interested in the net cost of education in the ambulatory setting where net cost is defined as the difference in the cost of producing a given number of patient visits by residents who are also being trained and by full time physicians.
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From page 169... ...
Most, but again not all, studies found that there were indirect costs of graduate medical education in the outpatient setting. Most of this work has concentrated on the indirect costs associated with the provision of patient visits (space, time and ancillary personnel)
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From page 170... ...
Cameron dM, "The Indirect Costs of Graduate Medical Education," New England Journal of Medicine 312~19)
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From page 171... ...
Panton DM, Mushlin Al and Gavett dW, "Marginal Ambulatory Teaching Costs Under Varying Levels of Service Utilization," Medical Care, (XVITI: 61: 668-674, June 1980. Pawlson EG and Watkins R., "The Costs of a Family Practice Residency Ambulatory Care Program," Journal of Family Practice 9~61: 1059-1061, 1979.
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From page 172... ...
"A CostEffective Emergency Medicine Clerkship, Journal of Medical Education 60: 288-292, April 1985. Sloan FA, Feldman RD and Steinwald AB, "Effects of Teaching on Hospital Costs," Journal of Health Economics 2: 1-2S, 1983.
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