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THE COST OF GRADUATE MEDICAL EDUCATION IN OUTPATIENT SETTINGS* Judith R. Lave, Ph.D. Professor of Health Economics University of Pittsburgh Introduction Until recently, medical students and residents received most of their clinical training in hospital inpatient settings. Educators and others who are interested in training physicians for practice in primary care have been critical of the focus on inpatient training for some time (MacLeod, 1970; Schroeder et al, 1986; Karpf and L.evey, 19861; they are now joined by those who realize that, because of changes in medical practice, there is a need to conduct more physician training outside the inpatient setting for all physicians. However, as training is shifted from the inpatient to the outpatient sector, a whole set of issues are raised. How should training in the outpatient sector be organized? How much does it cost to train residents in the outpatient setting? 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? Do we need different ways of paying for services if we change the locus or training? The questions above are very general. The term "outpatient setting" embodies a range of practice settings. Formal outpatient clinics, Health Maintenance Organizations, prepaid group practices, surg~-centers and even doe in the box, are all outpatient settings. Some of these have been training sites for medical students and residents since medical schools were first established. However, in the past these settings have been of very limited importance, and the type of training provided in those sites was not geared towards developing . - pr~ma~ care p. Scans. * ~ would like to thank Lester Lave, Gordon MacLeod and Jessica Townsend for helpful comments on an earlier draft; Lawrence CIare for bibliographic help and Bruce Block, Marian Block and Michael Karpf for describing their training programs. ~44

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In this paper I address some of the issues related to the cost of training medical students and residents in primary care. I begin by reviewing briefly the literature on approaches to estimating the cost of graduate medical education in the inpatient setting. Next I develop an analytical framework for examining the cost of training in the outpatient sector and the cost of introducing medical students and residents into outpatient clinical practice is explored at some depth. I then examine the relevant empirical literature related to this issue. I go on to examine cursorily the "financial" impact of the implementation of training programs in primary care. I then address a number of other selected issues related to training in primary care and conclude with some recommendations for future research in this area. The Cost of Medical Training in Hospitals Teaching hospitals are multiproduct firms; they produce medical training, patient care, research and community services. For the many services that are joint products, it is impossible to allocate the costs among them in a nonarbitrary fashion. Conceptually, the cost to society of medical education and training in the hospital setting is equal to the difference in total costs (both physician and hospital costs) between a hospital which provides these educational services and one that does not assuming they differ only in the educational programs. It is necessary to look at both physician and hospital costs because the trainees provide patient care services in place of those ordinarily provided by trained trained . ~ P nys~c~ans. With some exceptions, analysts have not tried to estimate the cost of medical education as defined above because of the difficulty in determining the costs associated with providing physician services in hospital settings. In general, hospital accounting records include information on all of the expenditures incurred by hospitals (nursing salaries, pharmacy drug costs, lab equipment and so forth). These expenditures include the direct costs of the hospital training programs (salaries of teaching physicians, resident stipends and fringe benefits as well as hospital overhead costs that are allocated to the training programs). Data on payments for services rendered to patients by physicians in hospital settings are kept by patients and in the claims Blles of the third party payers. In general analysts have focused on gross costs of graduate medical education. determining what ~ will refer to as the The gross costs of graduate medical education have two components: direct costs of the hospital residency programs (defined above) 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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record keeping requirements, decreased productivity of other staff members, and excess test ordering by residents because of their inexperience. Estimates of the direct costs of graduate medical education are obtained from hospital accounting records. 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) are regressed against a series of variables known to influence hospital costs such as case-mix, hospital wages, hospital bed size and some indicator of the hospital's teaching status. (Anderson and Lave, 1986; Sloan, Feldman and Steinwald, 1983; Thorpe, 19881. The specification of the estimating equation varies across studies as does the measure of hospital teaching activity. (The most common measures are the number of residents per _ ~ ~ ~ ~ ~ ~ ~ ~ 1 ~ ~ 1 ~ "01 ~ 1 ~ ~ ~ ~ 1 bed or an indicator of the hospital s teaching Eaten - member of the Bounce of teaching hospitals; teaching hospital but not a COTH hospital, or nonteaching). Analysts thus estimate the incremental effect of teaching on hospital costs (minus the direct costs of teaching) once the effect of other factors known to influence these costs have been taken into consideration. The results of these analyses indicate that the indirect costs of teaching are positive; i.e., that hospital inpatient costs increase with the extent of the hospital's involvement in medical education. However, the estimated size of the indirect costs depends upon the group of hospitals studied as well as measures used to control for other factors known to influence costs across hospitals. Nationally, a one percentage point increase in the number of residents per bed is associated with about a 5 percent increase in inpatient care costs per case. Analysts are aware that these are "gross" costs of graduate medical education. Some investigators have tried to estimate "net costs" by estimating physician costs associated with a hospitalization either by obtaining estimates of physician services from medical records (Arthur Young, 1986) or by merging information on physician claims with cost information from hospital accounting records (Cameron 19851. The results of these studies indicate that residents are partial substitutes for fully trained physicians. Cameron for example, found that in California payments to physicians for services provided to Medicaid inpatients were lower in major teaching hospitals by Medicaid's share of the residents salaries in those hospitals. These studies shed no light on whether graduate medical education programs lead to increased hospital profits (or reduced losses), increase physician incomes, convey prestige on a institution, or are the source of other unmeasured benefits. The profitability of graduate medical education programs will depend on how these programs affect hospital admissions and on how hospitals and other :46

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providers of services are paid for the services that they provide. Under the financing arrangements that prevailed in 1989, available information indicates that graduate medical education programs in hospitals were profitable. Cost of Training in The Outpatient Sector: An Analytical Approach In considering the cost of training programs in the outpatient sector, the appropriate question to be raised is: what additional resources are needed to accomplish this task or what is the increased monetary cost of adding this activity (Delbanco and Calkins, 1988; Gavett and Mushlin, 1988)? (If all the resources are costed out, then these questions will have identical answers.) However, these questions are different from an equally important one: will the implementation of this program generate net positive revenues? To the sponsoring institution or the manager of the training program, the impact on net revenues is the more important question. 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. Since the programs differ, so too will their costs. Consider the cost of adding residents to a primacy care practice. (Medical students could easily be added to this example.) This case which addresses the following question - is it more costly to provide medical care in the ambulatory setting in which residents are both being trained and are providing services than it is to provide care by fully trained physicians - is explored in depth because it has generated the most interest. In the discussion that follows, the term FT (Fully Trained) physician is used to describe physicians who have completed their residency training. In the ambulatory setting, residents acquire skills while "learning by doing". However, while they are practicing, they receive faculty input through direct supervision, case conferences, chart review and consultations. The nonphysician component of the cost of care may vary with the level of training of the resident. For example, residents may order more tests, may require more nursing time per visit or may use more examining room time than more experienced physicians; that is, there may be some indirect costs of graduate medical education (as the term is used in the inpatient setting) in the outpatient sector. i47

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In order to focus on the most important factors influencing the cost of training, assume that only physician services are needed to produce patient visits. Figure One indicates both how productivity varies with the amount of training that a physician has as well as the amount of faculty input provided to the resident. The figure indicates that a FT physician working full time in the clinical setting provides O] visits per unit time while the number of visits that a resident provides varies with the year of training as indicated by the curve CD. As suggested by the curve EF, the amount of faculty input needed per average visit provided by the resident decreases as the residents become more experienced. In Figure Two, OS indicates the average cost of a visit provided by a FT physicians. RT indicates the average cost of a visit provided by the resident. At first, the cost per visit provided by a resident is higher than that provided by a FT physician, however it begins to fall as faculty input decreases and resident productivity increases. The curve suggests that the cost may begin to increase towards the end of training because the residents' salaries increase and the number of hours worked decrease leading to an increase in the cost per hour. Although the general shapes of Figures One and Two should be true for all settings, the details of the curves will vary from site to site. For example, the position of CD in Figure One will depend upon whether there is an adequate flow of patients through the clinic, the efficiency with which the practice is operated, and the pace at which residents practice. (The pace could influence both the quality of patient care provided and the quality of the clinic experience from the training perspective). The position of EF will vary with the amount of training and feedback the resident actually receives. ~ ,, ~ , ~ Finally, the relative positions of OS and RT will depend upon the hourly cost of residents and the faculty. Thus, the net cost of training will in large part depend upon the amount of faculty input into the training process, the relative income of the faculty and residents and the flow of patient visits. 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. i48

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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) Year of "atn FIGURE "0 149 Faculty HD Input Per Resident Vis T

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Empirical Studies of The "Net Cost" of Training In The Outpatient Setting Several studies have attempted to estimate the cost of training medical students and residents in the outpatient setting. Some of these studies have examined only the gross costs of education; but many have investigated the net costs of education. 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. Time and Motion Studies In time and motion studies, the investigators directly observe the various providers of care to determine how they spend their time. However these studies often do not provide useful information into the incremental cost of providing training. This is a particular problem when the faculty members are training residents at the same time that they, the faculty, are providing care or are training a number of people simultaneously. However, time and motion studies can provide some information on the amount of faculty time that the residents use when they, the residents, are the primary providers. In a recent study of the cost and efficiency of prodding services in 15 general internal medicine ambulatory practices in teaching hospitals, Kosecoff and associates (1987) used time and motion studies to determine how much time patients spent with their primary providers) (faculty member, resident or nurse) as well as how much time they spent with the attending physician and nurse during their visit to the primaly providers. The investigators found that for the patients' first visits, PGYls In these practices patients were assigned to one of several types of practitioners, residents or fellows, faculty members or nurses who served as the primary provider during that visit. However, during a visit to a primary provider, other providers would be involved in the care. A nurse could be present in the room or provide distinct services; the attending physician could see the patient being treated by the resident or consult with the resident on the case. i50

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(residents in their first post graduate year) spent a statistically significantly longer period with the patient than did the other classes of primary providers (MDs and nurses); 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) than they did with did PGY2s and PGY3s. There was no significant difference in the amount of time the patient spent with the nursing staff by type of primaly provider. Kosecoff et al. estimated the direct physician and nursing cost per visit first by estimating the average hourly wage for each type of provider and then by multiplying that by the proportion of time the physicians spent with a patient by type of primary provider. In the institutions studied, the average PGY1 earned $23,000 a year and worked 70 hours a week while the average associate professor earned $85,000 and worked 55 hours a week. The estimated average cost for a visit by type of primary provider is shown in Table 1. The main factor contributing to the difference in the costs across visits by type of primary provider is the amount of faculty time per visits. On average, the faculty members spent very little time interacting with PGY2s and PGY3s. However, there was considerable variation in the amount of time the faculty spent with residents across the 15 practices. For example, for a follow up visit, when the PGY2 was the primary provider, the attending spent on average less than a minute with the patient in 9 of the 15 practices, between 1 and 6 minutes in 4 of the practices and over 6 minutes in 2 of the practices. (The amount of the time the attendings spent discussing the case with the residents outside of the examining room was negligible.) 2 For example, the cost of the first visit is highest when the faculty member is the primary provider because most of the care is provided by the mostly costly provider. The cost of a visit to a PGYl is high because, although the hourly cost of the PGY! is low, the attending physicians spends a significant amount of time with the patient and resident. i5i

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Table ~ Average Nurse and Physician Costs of Visits To Fifteen Internal Medicine Group Practices (in 1983 Dollars)* Type of Primacy Prowder First Visit Follow-Up Mean visits cost visits Mean Cost n n up Faculty 87 21.40+ 233 10.43# Postgraduate Year ~32 18.03 80 6.33 Postgraduate Year II 35 9.24 145 5.44 Postgraduate Year Ill 42 9.55 120 5.47 Nurse Practitioner, 10 17.85 91 S.20 Physician Assistant * Based on actual time spent with patient (time-and-motion study). + No significant difference with postgraduate year I; p < 0.01 with postgraduate years I] and ITI. # p ~ 0.01 with all three postgraduate years and nurse practitioner. ~52

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Replacement Cost Studies In a replacement cost study, the following question is posed: if outpatient clinics continued to serve the same number and mix of patients, what would be the cost of closing the teaching programs and using full time practicing physicians to provide the services that were previously provided by the residents. Researchers who have used this approach have carefully studied the clinic practice (i.e. examined the number of patients seen per hour by faculty and by residents, asked questions about the use of other personnel, noted the use of examining rooms) and estimated how changing the physician mix would change the costs in that clinic. me '' ' ' ' ' -' ~ ~ ~ data. -sneer estimates are cased on ~uagements not statistical analyses of Two recent replacement cost studies have been reported in the literature. 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) studied the same problem at a primary care practice at the Strong Memorial Hospital in Rochester. Residents in all three post graduate years provided patient care in both sites. Table 2 presents estimates of how replacing residents with FT physicians would change the average cost per visit and its component costs at the two sites. As indicated by these numbers, Gavett and Mushlin assume that residents use space less efficiently than FT physicians; while Delbanco and Calkins assume that residents use relatively more of other staff time than do the FT physicians. Gavett and Mushlin do not indicate that replacing the residents would reduce the time of attending physicians, whereas Delbanco and Calkins indicate that such costs would be decreased by $3.59 per "visit". Neither team of researchers estimated the effect of the change on the use of ancillary services. Gavett and Mushlin conclude that replacing residents with FT physicians would decrease the cost of care, whereas Delbanco and Calkins conclude that such a replacement would increase costs. The main factor leading to these different conclusions is not the different assumptions about how residents and FT physicians differ in their demands on other resources (space, nurses, etc.) but rather the assumptions about the relative costs of residents and FT physicians in the two sites. Delbanco and Calkins allocated about 5 percent of a resident's salary for a half day clinic session (this was based on a resident's work week of ~53

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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. ~54

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the income the faculty receive as attendings when family practice patients are hospitalized as well as income from foundation grants, state allocations, federal grants as well as contributions from the sponsoring institutions. In 1982 Ciriacy et al. surveyed a national sample of family practice residency programs asking about program costs and revenues. They found that, on average, patient income covered 31 percent of the total costs of the programs. In 1984, Ramsay conducted a national survey of family practice residency programs. He too found that that patient revenues accounted for 31 percent of the costs of the program. (In both surveys there usable response rate was about 50 percent). The proportion of program costs covered by revenues from the family practice clinics appears to be low. Three explanations have been offered: (~) The volume of patients seen is small. Ramsay believes that the number of patients could be increased by about 30 percent without impairing either patient care or residency training (in fact it could even enhance training). If the patient volume met his suggested targets (see Table 3), then practice revenues would cover about 45 percent of the program costs. (2) Collection rates are lower than necessary. (3) Fees may be set too low. However, the fees charged at these clinics have to be competitive with fees charged for visits in the clinic's market area. 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. These practices were established to deliver primary care and to train residents. In theo~, they were to replace the old clinic practices and to emphasize continuity in care, and to be a setting in which residents were trained in the behavioral and social aspects of being a primary provider. These practices were established in low income areas. Kosecoff et al. (1987) and Brook et al. (1987) evaluated the demonstration sites. They looked at the cost of teaching, the efficiency with which care was provided and the financial impact of the ambulatory practices on the sponsoring hospitals. (They were not not interested in the financial impact of establishing a training program in primacy care but rather on the financial impact of establishing ambulatory practices which served low income populations and in which residents would be trained in primary care). 162

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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 *Income per visit derived from study data. ~63

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The investigators found that the revenues associated with these practices exceeded the costs the hospitals incurred in operating them. Defined revenues include not only revenues received for the visits but also revenues received from ancillary tests as well as any resulting hospital admissions. However, depending upon the assumptions that were made about staffing patterns, Practice revenues (revenues from the sernces directly provided by the residents and faculty members) did not always cover practice costs. ~ , _ _ ~,,~ In general, the researchers found that the practices were managed veer inefficiently; that staff time was not well utilized, that patient scheduling was poor and that the use of space was inefficient. Summary The implementation of a training program in primaly care is accompanied with a complicated flow of costs and revenues throughout the sponsoring institutions. No study has tried to trace these flows in their entirety. but each ~., A, study nas focused on a few or teem. In general, patient care revenues which are received as a result of the provision of services in the primal care practices will cover the costs of those practices, if the practices are allocated only a proportion of the residents and faculty members costs - a proportion that reflects the time they spend in the clinics. Clinic revenues, however, are not sufficient to cover the full cost of the residents' salary and the salary of the faculty and administrative staff who are directly the responsibility of the program. The practices associated with the training program may be a new source of patients to the sponsoring hospitals. In this case, the hospital may make profits off the ancillary services and admissions that result from the program. 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. i64

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The Efficiency of the Training Process There were only a few studies which systematically examined the way that physicians were being trained. Most of these studies described the structure of the training programs, rather than indicate what actually happened in the residency settings (Goodson et al., 19861. The quality of the training received in the primary care clinic will depend in part on the amount of faculty input as well as the volume of patients that are seen. Figures Three and Four below display some hypothetical relationships between resident "learning' and faculty input and patient flow. Since faculty input and patient flow are the two variables that influence the cost of training, it would be useful to know something about actual quantitative relationships depicted in these figures. The importance of this knowledge is underlined by the fact that faculty member input is the most important factor influencing the cost of care provided by residents (and medical students) and because the studies discussed above indicate that there is ode variation in the amount of faculty time actually given to training in the outpatient setting. There is also very little known about the level of training required of the physician "trainer". 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. However, at least as reported in the published literature, the teaching role of the resident seems to be nonexistent in the ambulatory setting. This points to the question: What is the role of the resident, particularly the third year resident, as teacher in the ambulatory setting. It is important to determine ways of decreasing the costs of training - particularly for medical students and junior residents. Educators have suggested the use of professional patients, computers, and simulations. Shueser et al (1985) describe an interesting use of the wdeo in training medical students in the emergency room. The Patient's Role The patient, a necessary ingredient in the training process, is different in the inpatient than in the outpatient setting. In the inpatient setting the patient is usually in bed. Consequently, rounds can be organized solely for the convenience of the physicians. House staff can interact with the patient when they want to. Patients rarely refuse to answer yet another resident or student asking the same set of questions or being examined more than once. In the outpatient setting, ~ 65

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Residents Residents Learning / a a ~ _ FIGURE _ 166 AD Input P6r V1sic Pat1~nt#s Su./Hour

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however, patients may be less willing to donate their time to the educational process. This setting requires coordination of the activities of the residents and the attendings. It also means that the number of residents (and medical students) who can learn from a given patient is limited. 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". However, in the outpatient setting, one physician (either resident or FT physician) becomes the patient's primary doctor. Many people, particularly in the higher social economic groups, may be unwilling to be assigned to the resident's panel of patients. This problem will be exacerbated in establishing a panel of patients for the first year residents. Thirdly, in the outpatient setting patients are more mobile. With the increasing supply of physicians, people have more choices. This means that the University based practices have to be competitive with community physicians in order to get patients. However, this may exacerbate town and gown relationships (Medical News, 19891. These observations lead to the conclusion that the socio-economic background of people in the residency practices will be different from those seen by the faculty in their private practices. This difference means that that patients in the residency clinics are less likely to have health insurance coverage. If the patients are insured, they are more likely to be covered by less generous insurance programs such as Medicaid. The Efficiency with Which the Practice is Operated Almost all studies which compared the cost of treating people in the outpatient clinics as opposed to private physician offices have found the costs in the former to be higher (Lion et al., 19851. Kosecoff et al. in their evaluation of the ambulatory practices supported by the Robert Wood Johnson Foundation found that the practices were very inefficiently run. They found that there were problems with patient scheduling and scheduling of physicians. Once in the office, patients waited longer to see the physician than they do in the offices of community physicians. Some of these problems may be due to the differences between the types of patients seen in these practices compared to those in private physicians offices. For example, Kosecoff found that the no show rate was much higher than that in private physician offices. A high no-show rate makes it particularly difficult to schedule appointments. It may be possible to reduce the ~ 67

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no-show rate but it is possible that it is related to the socio-economic characteristics of the patient population. These observations lead to the conclusion that it will be very important to pay attention to the efficiency with which the primary practice clinics are managed. Training in the Health Maintenance Organization There is increasing interest (Isaacs and Madoff, 1984) in using the health maintenance organization as training sites. In both HMOs and other settings the training of medical students and junior residents will add to the cost of care. There is, however, one difference between the implications of training in the two sites. We noted above that there were two sources of "indirect costs of graduate medical education" in the ambulatory setting: one is the higher (nonphysician costs) of residents visits (we noted that there were data suggesting that nursing costs and space may be higher ); the second is increased ancillary testing and perhaps increased admissions. In both the fee for service sector and the HMO there is no increased revenue to offset the first type of increased costs; however, in the fee for service setting there is increased revenue to offset those indirect costs whereas in the health maintenance organization there is not. 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. The net cost was found to depend upon a number of factors including: the flow of patients through the clinics, the faculty members' input into the resident's practice and the relative salaries received by the resident and the FT physician. In general, we found that if the outpatient settings are allocated a proportion of the resident's salary (that proportion that they spend at the clinic), then the net cost of graduate education is negative for second and third years residents, and positive for some of the first year students. This finding, however, was not universal. This conclusion needs to be accompanied by a caveat. While the net cost of training in the primary care clinic may be negative for a second and third year resident, it does not follow that the net cost of training second and ~68

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third year residents is negative. These residents spend time in subspecialty clinics such as orthopedics, dermatology and gynecology where their productivity level is not as high as it is in the primary care clinic. 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). There needs to be more work done on examining resident practice as it relates to the ordering or tests and to hospital admission decisions. The income generated by primary care practices is not sufficient to cover the cost of the primary care training program where the training programs is responsible for the resident's full salary. The main reason for this discrepancy is that the residents spend significantly less than 50 percent of their time in the . - prlma~y care c. .lnlcs. There is some evidence that the primary care clinics are not efficiently run. There also is some evidence that a number of clinics - particularly those that are part of residency programs in family practice programs do not have as many patient visits as they would like. It is not clear whether the shortage of patients is due general competition from private physicians or because of certain attributes of the clinics per se. It is reasonable to conjecture that the insurance coverage of patients being seen at the primary care clinics will be less complete that that of patients seen at the faculty physicians private practice of by community physicians. More needs to be known about the training process. Training in the outpatient setting is probably more costly than it is in the inpatient setting. Not only is more training done by attendings rather than residents, but also there appears to be a higher attending/resident ratio. In the studies that were examined, there was considerable variation in the amount of faculty time that was provided to the resident in the clinic setting. Since faculty time is very expensive, research on the training process per se would seem to be called for. i69

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BIBLIOGRAPY Anderson OF and Lave JR, "Financing Graduate Medical Education Using Multiple Regression to Set Payment Rates," Inquiry 23: 191-199, 1986. Arthur Young, Study of the Financing of Graduate Medical Education: Report Il. Hospital Cost Analysis, October 1986. Bankhead CD, "Town and Gown," Medical World News, pp. 44-52, Manual 23, 1989. BerkeThamer ATE, "Charges by Residents and Faculty Physicians in a University Hospital Pediatric Practice," Journal of Medical Education 61: 303-307, April 1986. Brook RH, Fink A., Kosecoff d., et al, "Educating Physicians and Treating Patients in the Ambulatory Setting: Where Are We Going and How Will We Know We Arrived?" Annals of Internal Medicine 107~3~: 392-398, 1987. Cameron dM, "The Indirect Costs of Graduate Medical Education," New England Journal of Medicine 312~19), May 9, 1985. Ciriacy EW, Liang FZ, Godes dR, et al, "The Cost and Funding of Family Practice Graduate Medical Education in the U.S.," Journal of Family Practice 20~3~: 285-295, 1985. Colwill dM and Glenn ~K, "Patient Care Income and the Financing of Resident Education in Family Medicine," Journal of Family Practice 13~41: 529-536, 1981. Delbanco TE and Calkins OR, "The Costs and Financing of Ambulatory Medical Education," Journal of General Internal Medicine 3 (Supplement): S34-S43, 1988. Gavett JW and Mushlin AI, "Calculating the Costs of Training in Primary Care," Medical Care 24~4~: 301-312, April 1986. Goodson ~D, Goroll AH, Barsly AJ, Treadway KK, Thibault GE and Stoeckle JD, "The Training of Physicians Outside the Hospital," Archives of Internal Medicine 146: 1805-~809, September 1986. . 170

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