Primary Care Physicians Financing Their Graduate Medical Education in Ambulatory Settings (1989) / Chapter Skim
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3. Options and Recommendations
3. Options and Recommendations
Pages 51-64
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From page 51... ...
Recently reported strategies include the expansion of Medicare GME payments to all ambulatory and outpatient settings (Council on Graduate Medical Education, 1988) , and the expansion of state capitation grants to include primary care internal medicine and general pediatrics programs (New York State Council on Graduate Medical Education, 1988)
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From page 52... ...
The Reimbursement Playing Field is Not Level Payment for non-primary care services and inpatient care is often greater than for primary care services and outpatient services. Differences in reimbursement include: incomplete recognition by Medicare of residents' time in outpatient settings; non-recognition by many third-party payers of teaching as a reimbursable cost in outpatient settings; lower payments by third-party payers for services provided by primary care physicians, outpatient physician services, and non-procedural services; and frequent lack of coverage of preventive services.
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From page 53... ...
Thus, rather than risk having recommendations rejected because they violate today's political realities, the committee accepted the need to constrain its recommendations to ways of reallocating resources. Thus if a recommendation is made for significantly increased federal spending on primary care GME, a case for reallocating resources from other areas must also be made.
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From page 54... ...
The ability of some of these hospitals to sustain the level of care, or even to survive, might be threatened by the withdrawal of residents from inpatient care or reductions in some sources of revenues. Matching the Needs of Primary Care Residency Programs Residency programs seeking to expand their primary care ambulatory training can be greatly assisted by grant money at start-up and when major program changes are being made.
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From page 55... ...
Either of these two effects might undermine the ability of some hospitals to continue to provide uncompensated care, or even in the long run to survive. However, primary care training in ambulatory sites, which also provide substantial amounts of uncompensated care, can help lighten the load for their local hospitals by providing timely preventive care.
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From page 56... ...
First, the charge to the committee was to improve the quality of primary care graduate medical education by developing financing mechanisms both to increase the amount of time that primary care residents spend in ambulatory settings, and to increase the number of training sites that closely resemble practice conditions likely to be experienced by the physician in future practice. Second, that because of the time and resource constraints under which this study was conducted, the committee found it feasible to approach change only in an incremental manner.
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From page 57... ...
Because federal budget constraints were perceived to be real and expenditure restraint to be socially desirable, the task for the committee was to identify areas of funding in which resources could be reallocated in ways that would support primary care residencies in ambulatory settings and encourage increases in the supply of primary care physicians. The committee reviewed the major sources of support for GME to assess the extent to which resource redistribution was feasible without endangering other socially desirable goals of paramount importance.
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From page 58... ...
The committee encourages deans and faculty members to emphasize the importance of primary care ambulatory training, and: urges the implementation of academic systems that reward those who provide role models for future generations of primary care physicians and devote time to developing curricula and [caching shills needed to make training in ambulatory settings a useful and positive experience. Efficient Use of Training Resources The committee was convinced that the efficiency with which outpatient training sites are operated makes a significant difference in the financial health of the training program.
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From page 59... ...
The implementation of a physician payment system using a resource based relative value scale will have several effects. The financing of primary care GME in ambulatory settings will be facilitated by an increase in patient care revenues from sponsored patients, and the improved earnings ability of primary care faculty will increase the ability of faculty practice plans to support teaching physicians.
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From page 60... ...
The committee suggests building on this precedent by shaping further incentives in the Medicare direct GME payment. The committee recommends an adjustment to the Medicare payment for the direct costs of GME that would create an incentive to establish residencies in primary care and place those residents in primary care ambulatory settings.
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From page 61... ...
However, since Medicare's indirect GME payment is a recognition of the costs of education, it is appropriate that hospitals use some of this revenue to support the primary care ambulatory care services that are an essential cost of training primary care physicians. The committee urges hospitals to commit a portion of the revenue from the Medicare indirect GME adjustment to direct financing of services at community-based ambulatory sites used for training primary care physicians.
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From page 62... ...
Case studies indicate that state GME capitation payments contribute appreciably to the ability of the funded primary care residencies to support primary care ambulatory residencies. The committee recommends that states assess their need for primary care physicians, bearing in mind the special roles of these physicians.
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From page 63... ...
Rather, grants are important catalysts in the initial development of ambulatory sites, in supporting innovative educational arrangements, in enabling creative financial arrangements to be developed, and in helping develop the faculty needed to initiate a quality program. The committee recommends that the funds available through Nile VII of the Public Health Service Act be targeted to the development of innovative model programs and demonstration sites from which others can learn of nezo Keys of arranging and supporting quality primary care ambulatory training programs.
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From page 64... ...
1988. Medicare Program; Changes in Payment Policy for Direct Graduate Medical Education Costs.
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