Primary Care Physicians Financing Their Graduate Medical Education in Ambulatory Settings (1989) / Chapter Skim
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Financing Graduate Medical Education in Primary Care: Options for Change
Financing Graduate Medical Education in Primary Care: Options for Change
Pages 197-229
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From page 197... ...
The majority of graduate medical education funding comes from patient care reimbursement through Medicare Part A direct and indirect payments, and other third party payers. This scheme results in difficulties for primary care programs in resident and faculty compensation, as well as general difficulties for primary care program development.
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From page 198... ...
The current mechanisms for funding GME will be reviewed briefly here and the resulting difficulties encountered by primary care programs discussed. We delineate a set of criteria by which any alternative method of graduate medical education financing should be judged.
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From page 199... ...
Medicaid has lagged behind Medicare in its reimbursement to teaching hospitals for the costs of GME. Of 37 states with Medicaid prospective payment systems, 23 include "some type of adjustment for teaching costs."2 Some states have threatened to withdraw their support of graduate medical education through Medicaid.
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From page 200... ...
primary care programs generally include substantial amounts of formal education in topics such as prevention, medical decision-making, and doctor-patient communication, and this time in conferences and workshops may occur at the expense of service time. From the point of view of primary care residencies, the current scheme of financing graduate medical education principally through hospital payment is flawed.
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From page 201... ...
This has almost certainly led to inequities among teaching hospitals in their ability to fund primary care programs and to support reform of residency education.
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From page 202... ...
Adoption ot a Resource based Relative Value Scale may partially compensate for this differential if it redresses the perceived inequity in payment levels for evaluation/management and procedural services. · ~ Be Faculty billing for outpatient visits may be paid at a rate that may provide more net income for hospital-based clinics than for non-hospital-based clinics (this results, in part, from the way in which payers assume overhead is paid by the hospital and thus pay a fee corrected for what overhead is assumed to have been)
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From page 203... ...
, smaller programs might benefit. Whether this relatively fixed rate of indirect payment per resident helps or hinders primary care programs is not known.
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From page 204... ...
Therefore, increases in funding for primary care graduate medical education would be likely to require decreases in funding in other federal expenditures, not necessarily but probably in other expenditures related to GME. The ideal of social budget neutrality also suggests that a reduction in other outlays will probably be required to identify additional funds for primary care education.
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From page 205... ...
Curricula for primary care residencies will change, of necessity, and funding should be flexible enough both to adapt to those changes and to allow the decisions for curricular change to remain in the hands of qualified educators. The percentage of residents' time spent in an ambulatory setting is expected to increase in the next few years and "sufficient" funding options should be able to cover the cost of that increase.
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From page 206... ...
Change in GME financing should provide incentives for the development and strengthening of primary care in established programs. This applies not only to the creation of primary care elements within traditional internal medicine and pediatric programs, but also to the support of family medicine curricula and already established programs in primary care internal medicine and pediatrics.
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From page 207... ...
4. Incentives should favor high-quality primary care programs.
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From page 208... ...
7. Non-Teaching Hospitals: graduate medical education.
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From page 209... ...
Change in Existing Medicare GME Payments Additional funding for graduate medical education in primary care could be obtained from cuts in existing programs which support GME. The only substantial programs, however, are Medicare Part A direct and indirect payments.
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From page 210... ...
Such a tax on services provided by non-teaching hospitals would recognize their dependence on teaching hospitals to train their future staff physicians and would partially offset the price advantage that non-teaching hospitals have in offering their services. A program that would more directly encourage primary care education would be one that levied a tax on hospitals without primely care programs.
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From page 211... ...
among all primary care programs for the support of a specific aspect of primary care education (e.g., office supervision or behavioral science curriculum) , or the encouragement of teaching hospitals and faculties to redistribute their clinical income to eliminate the discrepancy in primary care versus subspecialty clinical income (#281~9.
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From page 212... ...
The elimination or reduction in Medicare Part A direct and/or indirect payments to all teaching hospitals (options #~-5) in order to free money that could be redistributed for the benefit of primary care programs can be analyzed as a group.
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From page 213... ...
It would not, however, necessarily provide any additional funds to foster the growth of quality primary care programs and it would limit non-primary care residencies. If used in combination with a spending plan that called for a reallocation of the savings toward improving primary care residencies, this alternative may be more favorable.
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From page 214... ...
The proposal that Medicaid programs conform with Medicare Part A direct cost reimbursement (option #in would foster growth and development of primaw care programs, since primary care residencies probably care for a disproportionate share of Medicaid patients. It would not specifically encourage quality primary care programs but it would also not hurt non-primary care programs.
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From page 215... ...
would provide primary care programs with more clinical income relative to other specialties. It would be predictable, administratively feasible, and as long as it does not coincide with an increased volume of service, budget neutral.
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From page 216... ...
The development of cost estimates for the adjustment may be difficult. However, such a payment could aid primary care programs, in particular if criteria are established regarding circumstances in which physicians' bills may be supplemented by a direct teaching adjustment.
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From page 217... ...
While it would increase the scope of beneficiaries contributing to primary care GME, its focus would likely be narrow. VA funding of primary care education would principally aid internal medicine since few family medicine and pediatrics programs receive VA support.
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From page 218... ...
It would help support primely care programs in large teaching hospitals but not in smaller community hospitals with fewer physicians on a medical center practice plan. As a voluntary effort, or one instituted by medical center leadership on a local level, it is to be encouraged.
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From page 219... ...
Judged against the criteria proposed here, our preferred options for raising money for primary care graduate medical education are as follows: 0 Adopt a Resource Based Relative Value Scale for payment of physicians and improve coverage of outpatient services.
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From page 220... ...
The spending options we judge best would involve division of the funds on a per resident basis to residencies in internal medicine, pediatrics, and family medicine for the development of primary care curricular elements through faculty stony site costs, curricular support, academic unit and primary care cooperative efforts, or to use as the individual residency chooses. This base funding would be coupled with competitive grant funding to stimulate innovation and faculty development.
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From page 221... ...
The first would involve options that redistribute GME funds to bolster payment for ambulatory care education, and would thus support not only primary care programs but all specialty training programs with an important outpatient component. The second method would seek those options that are specifically targeted to aid primary care training.
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From page 222... ...
4. Incentives should favor high-quality primary care programs.
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From page 223... ...
Non-teaching hospitals O ~ .
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From page 224... ...
Limit Part A direct and indirect payments to first certification 7. Add incentives and disincentives to Part A direct payments Increase in Categorical GME funding S
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From page 225... ...
Redistribute Title VIT money 28. Redistribute clinical income within teaching hospitals and faculties 225
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From page 226... ...
Increased ambulatory time for primary care residents H Primary care cooperative efforts 226
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From page 227... ...
Outs ~ appreciate the contr~ut~ns of James S E~ricb, Edna P
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From page 228... ...
Financing graduate medical education in family medicine. Academic Medicine, in press.
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From page 229... ...
Dilemmas in Medicare reimbursement of teaching physicians in primary care residency programs. Family Medicine Teaching 1979; Summer:20-22.
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