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OCR for page 230
FINANCING PRIMARY CARE RESIDENCY TRAINING
EXAMPLES AND LESSONS FROM SUCCESSFUL PROGRAMS
Robert A. Walkington
Introduction
The past decade has been a time of ferment in American medicine. The
career of the physician beginning practice in the 1990s watt differ significantly
from that of the physician who began practice in the 1970s. One major difference
will be the greater extent to which that practice is conducted in an ambulatory
setting.
This change has led many people to conclude that the traditional reliance on
the hospital as the site of graduate medical education (GME) must be modified to
include an increased emphasis on ambulatory care. This conclusion has been
strengthened by the changes occurring in the nature of hospital utilization which
has made the hospital a less satisfactory site for the educational experience,
particularly for the primary care physician (AAMC, 1987; New York State Council
on Graduate Medical Education, 1988; Gaste! and Rogers, 1989~.
These factors have led a number of groups and individuals to recommend
strengthening the ambulatory care experience in general internal medicine, general
pediatrics, and family practice residency programs. For example, the report of the
New York State Commission on Graduate Medical Education stated:
"The Commission therefore recommends that the graduate medical education
of specialists in general internal medicine, general pediatrics, general
obstetrics/gynecology and family medicine should include an appropriate
balance of outpatient and inpatient experience".
The Commission went on to state that "a significant part of residency training
should take place in ambulatory care settings." (New York State Commission on
Graduate Medical Education, 19861.
Similar conclusions and recommendations were reached by the Council on
Graduate Medical Education (COGME) which in its 1988 report to the Secretary
of DHHS recommended "... a concerted emphasis on training in ambulatory
settings ..."This recommendation was based on the Council's conclusion that GME
in ambulatory settings is increasingly necessary in many specialties for optimal
training and preparation for practice (Council on Graduate Medical Education
198Sb). Similar views have been expressed by Ebert and Ginzberg (1988), by
230
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participants in the conference on Medical Education in the Ambulatory Setting
(Stanford 1987) the Health Resources and Services Administration (HRSA)
Conference on Primary Care Medical Education (1988) and in a number of recent
articles (Moore, 1986; Perkoff, 1986, 1988; Kosecoff, et. al. 1987, Schroeder, 19881.
While there has been general (though not unanimous) agreement on the
desirability of increasing the ambulatory focus of graduate medical education,
particularly for the primary care specialties, there are a number of practical
barriers to implementing changes. One of the major barriers is how to finance
this new (or in the case of family practice, continuing) emphasis on ambulatory
based education.
The Council on Graduate Medical Education concluded that:
"There are difficulties in financing GME in ambulator setting, related to
lower levels of payment by third parties and to increased logistical problems
in teaching. The current financing of GME results in disincentives for
ambulatory training ... The financing of GME is particularly problematic for
the areas of primary care, geriatrics and preventive medicine" (Council on
Graduate Medical Education, 19881.
In a recent draft position paper, the Association of Program Directors in
Internal Medicine (APDIM) recommends major changes in financing internal
medicine training programs in ambulatory care. The paper declares: "A major
obstacle to the development of educational programs in ambulatory care has been
the failure of the payment system to fully compensate for the educational costs of
post-graduate training in ambulatory settings". The HRSA Conference on Primary
Care Medical Education concluded that "the limited reimbursement for primary
care services and teaching have seriously constrained the success and growth of
primary care education and the production of appropriately trained primary care
physicians" (HRSA, 19881.
A recent article on family practice residency programs concluded that
ambulatory care training suffers from the twin problems of lower revenues and
higher costs (Ricketts et al., 1986). Similarly, in a presentation to COGME's
Graduate Medical Education Programs and Financing Sub-Committee, Dr. Frederic
Berg stated that "there is poor support for ambulatory education in pediatrics."
To remedy this problem he recommended that "any new system of financing GME
should provide support for training of residents in ambulatory settings including
outpatient units and HMOs as well as inpatient settings" (COGME, 1987a).
231
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In addition to urging increased use of the ambulatory setting for GME most
commentators have described problems with the current financing of GME which
inhibit such use.
This paper, which first reviews the major problems in financing primary care
education in ambulatory settings, describes some programs that have succeeded in
making the needed shift in the site of training, and draws lessons from the
experiences of the programs.
Problems With Current Financing of Ambulatory Primarv Care Education
There is general agreement that it is more difficult to finance ambulatory
primary care GME than inpatient GME but less agreement on whether this is
caused by higher costs, a financing system tilted in favor of education in the
hospital setting, inefficiencies in the delivery of services and education in the
ambulatory setting or some combination of factors. Boufford in a recent article
identified the most important issue as the "fundamental financing of ambulatory
service and education". She states that "patient care revenues appear to be the
major source of support for ambulatory care teaching, though they clearly are not
sufficient to cover costs". This is attributed to the fact that while third-party
payers include education costs as part of their reimbursement for inpatient
services they are much less willing to do this for outpatient services (Boufford,
1989).
John Kasonic identified key sources of current and future support of GME in
the ambulatory setting as patient revenues, governmental subsidies (for both
teaching and indigent care), grants, university general funds, and "networking with
traditionally non-teachina providers". He believes that the maiori~r of financial
_ ~ ~ ~ or
support will continue to come from patient care revenues and that the adequacy of
such financing will depend on improving the economy and efficiency with which
the ambulator settings operate (in terms of patient care and education) (Kasonic,
1987).
Watt (1987) identifies sources of financial support for GME as patient care
funds, direct federal support for education, and direct educational support by state
and local governments. He lists a number of problems in the current financing of
GME in the ambulatory setting. These include more restrictive policies
concerning payment for ambulatory services by third-party payers, the need to
rely on "soft and fragmented funding sources, and the fact that new managed care
systems have "little economic margin to support the costs of medical education".
232
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Family practice residencies provide insight into financing ambulatory focused
primary care GME, since over half of a family practice resident's experience is in
an ambulatory setting. The most recent survey of the costs and financing of
family practice residencies (conducted in 1982-83) indicated that the largest source
of support was the hospital, followed by professional fees from faculty and
residents and state support. Other sources of support include federal and private
grants, non-program managed support and institutional base support (Colwill,
undated).
Colwill sums up the situation with regard to financing of residency education
in family medicine as follows:
"First, revenues from primary care are limited. Second, family practice
centers in which family practice residents spend at least one-third of their
residency in their continuity practice provide an added cost to the residency
program. Consequently, the funding of family practice residency programs
has been precarious and has been dependent upon governmental support in
addition to hospital and patient care income support.'' (Colwill, undated).
The problems that family practice has faced are similar to those that will be faced
by other residency programs as they attempt to expand the amount of time
devoted to ambulatory focused education.
Published Examples of Successful Financing of Ambulatory Based GME
Most of the published reports of successful primary care programs have
focused on educational content and process. Articles on financing have dealt
largely with the problems of the current system and with proposed solutions.
Two recent exceptions are an article by Rosenblatt (1988) and a report from the
Association of American Medical Colleges (19871. While neither focused primarily
on the financial aspects of programs, both discussed fiscal considerations.
In addition to these studies, some other articles describe solutions to problems
which are at least partially under the control of the institutions or which propose
solutions which are feasible without major restructuring of the current system.
Moore (1988) speculates that in the future HMOs will become involved in medical
education because of" their social responsibility, their practical self-interest,
and their desired satisfaction." He believes that as the HMO movement grows
and matures a number of HMOs will see that graduate medical education is in
their self-interest. If self-interest is considered in its broadest sense then all three
reasons are related to benefits that the ambulatory patient care setting will receive
by supporting GME. In another recent article, Moore states that increased
233
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efficiency of ambulatory education and increased revenue from reimbursable
services are the best ways to successfully finance ambulatory education. The same
article makes the point that if it can be shown to have benefits for them, HMOs
and voluntary facula can be successfully involved in ambulatory education (Moore,
undated).
Rieselbach and Jackson (1986) advocate linking ambulatory based GME to
care for the indigent. They argue that such a linkage (through capitation) "would
allow students, residents, and fellows to receive their clinical education in an
environment in which the qualibr and cost of care would be controlled and
supervised ..." The residents and fellows would provide care to the indigent under
faculty supervision and in return the states and or the federal government would
pay for the services and education under a capitation scheme.
Kosekoff, et al. (1987) in an article on the efficiency and cost of general
medical ambulator care in teaching hospitals conclude that major increases in
efficiency are possible through improved management, including the development
of more sophisticated information systems. The authors also suggest the
development of stronger incentive systems to link efficiency and performance to
financial rewards. In another article, based on the evaluation of the same general
internal medicine clinics, Brook, et al. (1987) urge linking the ambulatory
education experience to providing care to the underserved. They state that "the
key to making this educational and patient care system work will be aggressive
fiscal management, ...". A 1985 study of the Primary Care Unit at St. Louis
University Medical Center reported that "revenues recovered was limited by low
productivity and collection rate." The authors recommended that efforts be made
to receive credit for ancillary profit and to improve provider productivity (Miller,
et al., 19851.
Delbanco and Calkins (1988) suggest a number of approaches to increasing
the efficiency of ambulatory teaching. The recommendations which deal with
structure of the educational experience are designed to "maximize patient visits
while achieving teaching goals."
Rosenblatt (1988) studied five exemplary programs finding that with fiscal
creativity ambulatory programs could be successfully financed in a wide variety of
ways. He found that efficiency increased as education was merged into the service
function. "The more the teaching setting resembles a real world operation, the
lower the teaching costs." In addition, leadership and institutional commitment
were critical. Rosenblatt believes that there is enough money in the health care
234
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system to support expanded primary care education. However, current educational
patterns provide cheap labor for inpatient services and subspecialties and reward
those currently in control.
The ambulatory programs studied by Rosenblatt included two primary care
residencies - general internal medicine at Brown University and an ambulatory
pediatric residency at the University of North Carolina. In both cases
institutional support and commitment were key to success. Each of the programs
was ..." in harmony with the broad educational and services mission of its medical
school." Also important was the fact that the programs were seen as beneficial -
providing as well as consuming resources. Speaking of the North Carolina
program Rosenblatt notes:
"Critical to the program's fiscal integrity is that the community-based care
is supported entirely by the sponsoring agencies, and the salaries of the
agencies' professional staff are not supplemented by the Department of
Pediatrics. These agencies see the incorporation of physicians as sufficiently
valuable and stimulating to compensate for the extra time and potential lost
productivity involved in teaching." (Rosenblatt, 1988)
The Association of American Medical Colleges studied nine academic health
science centers with successful ambulatory programs. The study found the
presence of a strong leader (initiator) "to create a climate that will accept and
support ambulator care education..." to be a key variable. The report also
identified the importance of institutional and departmental commitment to
ambulatory education. While over all institutional commitment was important,
lacking it, institutional neutrality, combined with departmental commitment could
lead to success. As the report noted:
"Where school wide efforts are not underway, or where particular
departments are not used as role models for change, the role of the
department chairman ... is immensely important." (Association of American
Medical Colleges, 1987)
While this study found that ambulatory programs could succeed financially in
the current system it is important to note that seven of the nine academic health
science centers required extra-institutional money (AHEC funds, foundation or
federal grants, specific state appropriations) to begin their ambulatory initiatives.
The report also concluded that the ability of the project to put together a package
of financial support from a number of different sources was an important
determinant of success:
235
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"The financing used by the programs nsited consisted in each instance of
an apparently delicate idiosyncratic configuration of donated time and space;
faculty patient care revenues; explicit local, state or federal grants and
contracts; physician fee income; and occasionally funded research."
(Association of American Medical Colleges, 1987)
Finally, in a presentation to the AAMC Symposium on Adopting Clinical
Education to New Form and Sites of Health Care Delivers John Kasonic
recommends increased operational efficiency and improved management - including
coordinated planning, improved accounting systems, and improved management
information systems as necessary for the successful financing of ambulatory care
education program Masonic, 1987~.
Other Examples of Successful Financing
Despite the array of problems identified by many observers, as the last section
indicated some programs have succeeded in overcoming the barriers that make the
provision of GME in ambulatory settings difficult. This section describes
additional programs that have been successful in financing ambulatory focused
primary care GME. The purpose is to pronde insights that may be useful to
other programs and to determine what changes in current financing systems may
be necessary if more programs are to be successful in financing ambulatory
primary care GME.
Because these programs were identified as being successful in doing what is
generally conceived~of as difficult they are by definition atypical. They were
identified through review of the recent literature on primacy care and discussions
with knowledgeable individuals. Because of the limited time available only a few
of the successful programs could be investigated. Exhibit i, lists other programs
reported to be successful in financing ambulatory based primary care GME.
i. The McLennan Counter Family Practice Program - Waco Texas
The McL`ennan Counter Family Practice Program has been in existence for 20
years. The program was created following a series of meetings between members
of the medical society and community leaders to address two problems--lack of
health care for the indigent and the aging of the primary care physicians in the
area. Initial funding for the program was essentially the same as is currently in
place and discussed in some detail below. The program is operated by two non-
profit boards (one composed exclusively of physicians and one of physicians and
community leaders) with some overlap of membership and close coordination
236
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between the two boards. Two boards were created because Texas law does not
allow non-physicians to hire physicians, and because a board composed only of
physicians would not provide for needed representation or support from
community leaders.
The program, located at the free-standing Family Practice Center? is affiliated
with two local hospitals and with Baylor University College of Medicine. The
residency program is three years in length, has a total of 24 positions (GYI:~) and
has succeeded in filling all the positions offered in the residency match. In
~ ~ · ~ ~ e ~ ~ ~ ~ ~
ac~ct~t~on to the residency program, the boards operate a grant-funded faculty
development center and a drop-in clinic. Faculty for the residency program
includes five FTE family practitioners, one pediatrician, one OB/GYN, an internist
and a psychiatrist on a part-time basis. In addition, extensive teaching time is
volunteered by practicing physicians in the community.
The operating budget for the residency program is over $3.3 million (including
revenue from the walk-in clinic but excluding the grant-funded faculty
development center). The largest source of revenue is patient care, with billings
in 1988 of $3 million, and $~.6 million in collections. A staff financial counselor
can enroll patients for Medicaid and other forms of state support on site. In
addition to Medicaid and Medicare patients, who account for 30% to 40% of
patient revenue, the clinic cares for patients with private insurance who provide
10% of revenues. A sliding fee scale is used for indigent patients. The clinic
aggressively pursues collections, which have increased by 20% in each of the last
several years. Program administrators expect patient revenue to be an
increasingly important source of support, but improved patient volume and billings
have accounted for only a small part of the recent increase in patient revenues.
The major part results from improved collections and billing from third-party
payers.
An unusual, and apparently successful, incentive plan is used to increase
patient care revenues. Clinic administrators predict patient revenues based on
historical trends. Increases above this amount are shared between the program
and the employees on a 50/50 basis. Each employee receives the same amount.
This system is described as being good for morale and effective in improving the
quality of paperwork.
The second largest source of revenue is the City of Waco. The program
currently receives $840,000 per year from the city to care for medically indigent
residents. Payment is not fee-for-service, but is based on historical analyses of
services provided to city residents. The program in effect functions like a city
department, receiving 12 monthly payments per year. This arrangement has been
237
· ~. . · . . ~
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in place since the beginning (sometimes with county funds augmenting city
resources) and has provided a stable source of support.
The program also receives $358,000 a year from the Texas Coordinating
Board for Higher Education. This is a capitated payment from the state for each
resident in an accredited family practice program. The payment was originally
$15,000 per resident but overall funding by the legislature has not kept pace with
the growth of programs in the state so has fallen to approximately $14,000 per
resident.
The program receives a total of $373,000 from the two community hospitals
with which it is affiliated. Each hospital pays the salaries of t/3 of the residents
in the program with the remaining third paid by the clinic. The program provides
the only residents at each hospital and the hospitals provide the sites of the
resident' inpatient experience. The final major source of support is Baylor College
of Medicine which provides about $220,000 per year, largely for faculty salaries.
Most of the major sources of support have provided stable financing over the
years. However, because of the deteriorating economic situation in Texas, only
patient revenues have increased during the last two years. And this latter
increase is largely attributable to improved third--part~r collections.
The keys to the success of this program include active boards, very good
relationships with the medical and business/political community, and multiple
sources of funds. It has been important that the program is perceived as a benefit
to the community and to the various providers of funds. The patients perceive
they are receiving good care, the city has its indigent care problems solved, the
hospitals receive physician coverage (as do local physicians who provide significant
voluntary teaching services) and Baylor has the opportunity to help solve
physician manpower problems in Texas (90% of program graduates practice in
Texas, two-thirds practice in areas with a population of 26,000 or less).
The program is always on the alert for innovative sources of funds. Currently
it is working with the city to see if long-term bond funding might be a viable
alternative to annual city appropriations. The program currently receives a
federal grant support of $58,000 for curriculum development in community based
primary care. This small grant support sum was described as being very
important in making program modifications and improvements, e.g. curriculum
development, redesign of geriatric curriculum, improvement of documentation of
residency activities.
238
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The program director claims that no major financial problems exist. The fact
that their financial supporters believe they receive benefits from the program,
combined with the support of two non-profit boards and a generally positive
community image have all been important factors in developing long-term, stable
financial support.
2. Monetefiore Medical Center Residency Program in Social Medicine; Bronx.
New York.
The Residency Program in Social Medicine (RPSM) provides the organizing
structure for primary care residencies in internal medicine, pediatrics and family
practice. The three residency programs are organizationally distinct but benefit
from the economies of scale of joint activities. The RPSM has a conjoint faculty
which provides the behavioral, social and educational design components to all
three programs. The program in internal medicine has 18 residency positions
(GYM; pediatrics has 12 (GYI:41; and family practice has 24 (GYI:~. Since
neither family practice nor internal medicine filled all of their positions this year
there will be only six f~rst-year residents in family practice and four in internal
medicine. Pediatrics is expanding to six first-year residents. The program
director in internal medicine believes there are several reasons for this, first,
failure to fill positions through the National Resident Matching Program. Reasons
include a decline in interest in the social aspects of medicine, an increasing
tendency for medical schools to retain their graduates for their own residencies,
and a breakdown in the program's recruiting work with medical school counselors.
This description focuses on internal medicine but also provides some
information on the other two programs. The program director describes the
internal medicine residency as "aggressively ambulatory" and "pushing it
(ambulatory based education) to the limit" when compared with other programs in
internal medicine.
The program in social medicine (designed to train physicians to serve the
urban poor through clinical practice, teaching, research or public policy leadership
roles) was organized in 1970 with a grant from the Office of Economic
Opportunity (OEO) and included residents in pediatrics and internal medicine. In
196S, Montef~ore Medical center opened the Martin Luther King Health Center
with an OEO federal grant. Because the medical center had trouble in finding
appropriately trained physicians to practice in that setting they requested and
received a further grant from the OEO to start the residency programs. When
OEO support was discontinued it was replaced by the Robert Wood Johnson
Foundation, whose support was in turn replaced by Public Health Service (Title
239
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VIT) Grants. In 1974 the program was expanded with a federal grant to include
family practice.
Between 1974 and 1978 all three residency program had their ambulatory
experience at the Martin Luther King Health Center, and financial support came
from grants, the hospital and the health center (in return for services provided by
the residents and faculty). By 1978 family practice accreditation standards had
changed to require that the family practice program be a separate department.
The family practice program therefore set up its own community health center
~ At the same time the grant to the Martin Luther
King Health Center was transferred from the hospital to a community board, and
the Health Center began experiencing severe financial problems because of reduced
federal support. The Health Center ceased support of the residency program.
Thus in the late 1970s and early 19SOs only hospital and grant support were
available. By 1982 concern over the stability of federal grants led to renegotiation
with the community board and renewed support from the Martin Luther King
Center. However, Health Center financial problems, as well as the community
board's attitude that they should not support education, worsened until the
program in internal medicine had to move its ambulatory site to newly renovated
space in the out-patient department at St. Barnabus, a small community hospital
ten blocks north of the Martin Luther King Center.
,, ,¢ ,¢ c'
and left Martin Luther King.
.. .. . .. .
The internal medicine program currently receives financial support from three
main sources 1) a $150,000 federal grant 2) $250,000 from St. Barnabus for
services provided by faculty and residents 3) Montefiore Medical Center.
~1 1 · ~ ~1 ~
· ~1 ~
This
batter Is one largest source ana pays residents salaries. The program director
believes that inpatient and outpatient services provided by the resident, and the
reimbursement the hospital receives for medical education through Medicare direct
and indirect payments, probably compensate both Montefiore and St. Barnabus
fully for their budget support.
A significant factor in funding is state Medicaid reimbursement for
ambulatory care. Article 28 of the New York Medicaid Statute authorizes
institutional provider rates for qualified institutions. The state determines costs
for each institution and then the institution can bill on an average per-visit cost.
The per visit cost at the ambulatory clinic at St Barnabus is $55. At the family
practice Community Health Center it is $80. This reimbursement is said to be
sufficient to provide quality care, break even in a teaching setting. but not to
~ ~1 ~
~ - 0'
cover the administrative costs of the educational programs or the support of non-
revenue generating faculty.
The program has been successful in maintaining financial viability for an
extended period of time. That the program has a specific mission has contributed
240
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Table 3
Types of Clinical Education Support
(Number of States - 48~)
OPERATING
SUBSIDIES
ONLY
Hawaii
Missouri2
North Dakota
New York2
Utah
Oregon4 2
DIRECT
SUPPORT ONLY
Arkansas
Arizona3
Delaware
Idaho
Indiana
Nevada
Oklahoma
South Dakota
Tennessee
Vermont
Washington
West Virginia
Wyoming
Michigan
BOTH
Alabama
California
Colorado
Connecticut
Florida
Georgia
Illinois
Iowa2
~ · ~
L`ou~s~ana
Minnesota2
~ ,. . . .
MlSSlSSlppl
Nebraska
North Carolina
New Jersey
Kansas2
Kentucky:
New Mexico2
Ohio
Pennsylvania
South Carolina
Texas
Virginia5
Wisconsin
~ Insufficient data on Maine and Maryland to classify these two states.
2 Data not available.
3 Arizona discontinued its operation subsidy to the University Hospital.
4 Clinical support for hospital in appropriation to medical school.
5 Part of support is in medical school budget.
SOURCE: Mandex, Inc. (1987), Issue Paper #2.
State Support for Clinical Education.
257
NO SUPPORT
Alaska
Massachusetts
Montana
New Hampshire
Rhode Island
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Table 4
STATE SUPPORT FOR FAMILY PRACTICE, 1986
Clinical MedicineFamily Practice
State Total $ $ %
.
Alabama 3,341,000 2,480,000 74
California 2,800,000 2,800,000 100
Colorado 2,142,000 2,142,000 100
Connecticut 34,000 34,000 100
Georgia 4,812,000 4,812,000 100
Idaho 50,000 50,000 100
Indiana 4,533,000 1,000,000 22
Iowa 1,383,000 1,383,000 100
Minnesota 168,000 168,000 100
Ohio 12,006,000 7,236,000 60
Oklahoma 5,805,000 2,715,000 47
Tennessee 3,940,000 3,808,000 97
Texas 10,875,000 7,875,000 72
Virginia 3,261,000 3,261,000 100
Wisconsin 5,390,000 5,390,000 100
West Virginia 1,643,000 458,000 28
Wyoming 8,386,000 8,386,000 100
Total $119,182,000 $53,998,000 45
SOURCE: Mandex Inc., (1987), Issue Paper #2.
State Support for Clinical Education.
258
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family practice. Since these tables do not include state programs which indirectly
facilitate but are not targeted at education, the amount of state support is
probably understated.
State support can be direct or indirect. Direct support can include grants for
specific projects, as in Florida and North Carolina; it can include payments for
residents in primary care programs, or it can include direct payments to support
the medical school faculty or to subsidize a teaching hospital. States have also
played an important role in supporting primary care residencies by providing
direct subsidies. Family practice has been especially successful in using local
project directors to obtain direct state support - particularly where the legislature
is dominated by representatives of rural areas. One faculty member commented:
"Rural legislators see support for our (FP) residency programs as an insurance
policy against losing their local doc.~'
The amount and method by which the state pays for indigent care can also be
important in the development of ambulatory education. This support can be
explicit, as where education is included as a component of the Medicaid payment
or it can be a secondary result of a state policy. Both the Montef~ore Social
Medicine Program and the SUNY- Buffalo Family Practice programs receive
.
~, ~. .
Em. . .
_ ~ ~
extensive indirect support for education because of generous Medicaid
reimbursement for institutional providers of ambulatory care. Some states such as
California, New York, and Massachusetts, fund ambulatory care for the poor by
providing adequate reimbursement for their care through hospital clinics. This
revenue contributes to the support of residents in these setting. Some studies
show that the services provided by residents can offset the costs of their education
in well-run settings.~ However, this can only occur if payers provide adequate
reimbursement.
The federal government also plays an important role in supporting
residencies. Overall Medicare payments are the major source of support for
graduate medical education. In almost every case discussed in this paper the
hospitals associated with the residency programs contributed funds for residents'
salaries. Much of this support is possible because of the indirect and direct
medical education payments made by Medicare.
Direct federal grant programs have also been important, particularly in the
initiation phase of programs. A 1987 evaluation of federally funded primary care
residency programs (both internal medicine and pediatrics) concluded that the
federal grant support had been essential for the initiation of these residency
training programs and the support of the behavioral science curriculum (Health
Resources and Services Administration, 1987~. Interviews with program directors
259
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for this paper produced similar responses. Because the training grants are
directed toward the support of primary care education they do not have to serve a
dual purpose (such as the support of services). For the same reason they are
valuable in supporting parts of the residency program which do not produce
revenue, for example, the conjoint faculty at Montefiore or the curriculum redesign
at the McLennan County program in Texas. Because they can be used for
planning and development activities the grants are also of obvious use in initiating
a new program.
Familv practice Programs that have been successful in establishing strong,
~· ~-
stable, financial support for ambulatory-focused graduate medical education
provide some lessons for other specialties. Although their success is in part due
to their longer involvement in ambulatory care residencies--an involvement that is
required by Accreditation Requirements--a more detailed study of their programs
would be valuable.
Examples from the literature and the case studies indicate that some other
differences between family practice residencies and other residencies may account
for the former's greater financial success in the ambulatory setting. The fact that
they are frequently the only residency program in a hospital may make them a
more valuable resource to the hospital. Similarly their locations in community
hospitals and in less urban areas may have contributed to their greater success in
convincing state legislators that they are a valuable resource, and thus to their
greater success in securing direct state support. The necessity of securing
financial support from a variety of sources may have aided in building coalitions
and in generating non-monetary support. Finally, since the basis of family
practice is ambulatory, it is likely that most department chairmen (a key
ingredient in success) will be strong supporters of the programs.
Summaly
Overall the examples presented confirm the previous findings in the literature.
However, we found that a large number of factors (See Table 1) must come
together if a program is to be financially successful. Most of the successes
reported previously identified only a few key factors relating to financial viability.
Factors that received greater attention in the programs described in this paper
than in the literature included the existence of a specific problem, the need for a
single leader with a clear goal, and the role of the state. Other factors described
in the literature, such as efficient management, multiple funding sources, merging
of education with service functions, development of services to benefit others, were
also important to the success of the programs we studied.
260
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Exhibit 1
Other Examples of Successful Financing:
In addition to the programs described in this paper, a number of other states,
schools and departments were reported to be successful in teas of having or
supporting stable long-term funding for ambulatory based primary care graduate
medical education. These include:
a) States
Washington; specifically for state support of family practice and for the WAM!
(Washington, Alaska, Montana, Idaho) system overall.
South Carolina; for the support of family practice and the development of a
state-wide primary care network.
Arkansas; for support of primary care education through its ALEC network.
b) Medical schools reported to have a general interest in ambulatory care
education include:
Rush Medical College
Bowman Grey School of Medicine
University of California, Los Angeles, School of Medicine
Michigan State University College of Human Medicine
Southern Illinois University School of Medicine
University of Minnesota Medical School
Texas Tech University Health Science Center School of Medicine
West Virginia University School of Medicine
University of Utah School of Medicine
c) Residency programs reported to have long-term stable financing and a
significant ambulatory component.
Internal Medicine
University of California, Los Angeles School of Medicine
Beth Israel Hospital (Boston)
Brigham and Womens Hospital Program (Boston
Brown University/Rhode Island Hospital
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F~i~ Practice
Memor1~1 F~1~ Prschce Hang Beach' ^)
Santa Monics F~1~ Prachce (Santa Monica' ^)
Locater F~1~ Practice (Lsnc~te~ ^)
Ped1~1cs
H~=d Bedim School Promo
267
Representative terms from entire chapter:
family practice
