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CHAPTER 3
OPTIONS AND RECOMMENDATIONS FOR FINANCING GRADUATE MEDICAL
EDUCATION FOR PRIMARY CARE PHYSICIANS IN AMBULATORY
CARE SETTINGS*
Numerous individuals and committees have recommended ways to overcome
barriers to financing GME in primary care and GME in ambulatory settings.
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). Eisenberg (1989) offered a number of options
including increased Medicare payment for ambulatory care services, Medicare
teaching adjustments for Part B payments, and contributions from future
employers of physicians in exchange for practice commitments. Bentley et al.
(1989) made several suggestions, including that practice plan revenues could help
finance ambulatory care education, and that the public sector contribute through
targeted grants and appropriations that provide economic incentives for training in
ambulatory settings.
Proposals such as these have identified several potential sources of funds,
with varying implications for such factors as hospital revenues, the costs of
services, state and federal budgets, and physician incomes. The committee
approached the task of developing policy opi;ions for financing GME for primary
care physicians in ambulatory settings first, by identifying existing barriers;
second, by constructing a set of criteria against which to evaluate options; and
finally by developing the committee's recommendations. This chapter will briefly
review the existing barriers, and describe criteria against which proposals for
altering the mechanisms for funding GME in primary care can be evaluated, and
finally lay out the committee's recommendations.
*Parts of this chapter are based on a paper commissioned by the committee:
Financing Graduate Medical Education In Primarv Care: Options for Change by
Appendix
Sandra C. Peinado and John M. Eisenberg. This paper can be found
B.
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BalTiers
Costs of Training
Certain characteristics of training in ambulatory sites account for the high
costs of training in these settings. These characteristics include: the one-on-one
nature of the interactions between residents and faculty; the loss of income
experienced by host physicians for which compensation may be required; and the
need for additional space to accommodate residents. In addition, primary care
teaching clinics are often the site of services for medically indigent individuals.
The provision of uncompensated care may be regarded as a cost or as a reduction
in revenue.
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. In
addition, community-based outpatient clinics are at a disadvantage compared with
hospital-based clinics, because at the latter sites payers sometimes pay for an
overhead assumed to be contributed by the hospital to its clinics.
Academic Barriers
There is widespread recognition that medicine's academic values and reward
systems are not oriented toward the primary care specialties and outpatient
services. In addition, the demands of clinical service, which may be higher for the
less well reimbursed primary care faculty, make it difficult to develop the research
and teaching skills needed to improve the quakier and efficiency of primary care
practice. Moreover, federal funds for primary care research are very limited, and
few academic institutions either recognize or reward the development of the
curricula and special teaching techniques that are needed for effective outpatient
care training. The low esteem in which primary care and clinic work is held is
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transmitted to residents, and the lack of role models of esteemed, successful,
practicing/teaching primary care academicians is detrimental to education.
Finally, faculty support is not sufficient to help programs develop adequately
trained faculty in areas such as decision analysis and quality assurance. These
areas must be emphasized to ensure that they are included in the training of
· · -
prlmalg care p ~yslclans.
Criteria for Evaluating Policy Options
Criteria developed by the committee reflect several concerns; some concerns
have to do with political and fiscal realities--policy should be made with an
understanding of the constraints under which decision makers would try to
implement change; some concerns are based on values held by members of the
committee that were felt to be of such importance that policy options should be
judged in terms of whether these values could be sustained under the proposed
change. The committee reviewed many more criteria than are listed here (most
will be found in the paper by Peinado and Eisenberg in Appendix B). While many
of the criteria have merit, they were considered to be either not of sufficient
importance that they should be a significant part of the committee's deliberations,
or they were too complex to be useful in the limited time available to the
committee. An example of the latter is the notion that all those who benefit from
expenditures on GME in primary care should bear the costs. While this proposal
has evident appeal, the question of who benefits has been the subject of much
discussion, and numerous beneficiaries have been posed. To revisit this debate
and make conclusions that would be operationally helpful for the purposes of this
study would be a large undertaking from which little of immediate use would
result.
Budget Constraints
The committee was convinced that since major new expenditures for GME ~,
the federal government are highly unlikely, only recommendations that are budget
neutral will be seriously considered by policy-makers. 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.
Although the committee accepted this limitation on its recommendations,
members were concerned that it should not be interpreted as indicating a belief
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that the problem of shifting the focus of primary care GME to ambulatory settings
is either unimportant or of little public benefit. It is therefore emphasized that,
while recognizing today's political realities, the urgent need to initiate actions that
will accelerate the needed change in primary care GME should not be
underestimated.
Since state budgets are also under pressure, it is unlikely that increases in
state contributions to GME are likely to occur unless the case can be made that
the state will benefit. For instance, some states may benefit from a change in
physician specialty mix toward a greater proportion of primary care physicians.
State (and local) budgets may be a source of support for primary care ambulatory
training if mutually beneficial ground can be found, such as arrangements between
the primary care ambulatory training sites and the state or locality to provide care
for medically needy populations.
The concept of health budget neutralizer suggests that, unless a source of
additional health care funds has been identified, proposals for change should be
evaluated in terms of resource redistribution within the health care system. Thus,
for example, increases in funding for primary care GME may cause reductions in
hospital or physician income or some services may be reduced. The impact of
changes on the health system must be evaluated, and particularly valuable
institutions and services should be protected. These include such institutions as
teaching hospitals that make a substantial contribution to access to care for
medically needy populations. 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. However, in general, to enable directors to
engage in relatively long term planning, programs need predictable financing that
will not vain greatly from year to year. The predictability and stability of
the funding stream should therefore be a criterion by which a proposal is
evaluated.
Changes that encourage the support of primary care should not include such
narrowly prescriptive language that the autonomy of educators is unduly
constrained and the development of innovative approaches to training is
hampered.
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Economic incentives aimed at achieving desired goals should be incorporated
into proposals. These may include incentives that encourage the following: an
increase in the number of primary care residencies; a refocusing on primary care
and ambulatory care activities in traditional programs; the development of
curricula that will prepare primary care physicians in skills and settings that
match the requirements of practice; efficient operations of training sites; and
physicians to select careers in primary care.
Do No Harm to Valued Institutions and Activities
Frequently, alterations in the status quo have unintended side effects. This
is particularly likely to occur when making budget neutral changes that, by
definition, reallocate resources. The committee identified some areas that are
specially vulnerable when GME funding is shifted, and that are of sufficient value
that their preservation should be a criterion against which changes are evaluated.
In altering GME funding it is important to ensure that high-quality
programs are not adversely affected. Programs that are of less high quality are
not the subject of this concern, and programs training physicians to practice
specialties in which supply is substantially in excess of the nation's needs are also
of less concern. The committee recognizes that defining and identifying high-
quality programs is a difficult task--that criteria for excellence such as pass-rates
on examinations are not perfect--but believes that moderate reductions in GME
financing for some specialties, as recommended by the committee, are not likely to
impair the viability of good programs.
Some teaching hospitals today are in precarious financial health. Many of
these hospitals also provide substantial amounts of uncompensated care.
Alterations in the funding of GME could exacerbate the already serious financial
problems of these hospitals. First, reductions in Medicare direct or indirect GME
payments would have important adverse effects on the operating margins of some
hospitals. Second, any reduction of residents' inpatient service time that would
result from successful financing of primary care outpatient training would also
require that hospitals employ substitute labor. The cost to the hospital of this
change may be significant. 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. In addition,
there are examples of arrangements between local or state agencies and primary
55
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care training sites whereby an agency has funded care for medically indigent
people at the ambulatory site and thus help support primary care training.
The committee's concern that changes not undermine existing arrangements
for the care of indigent people, and the committee's interest in furthering the
interaction between primaly care GME and care for indigent people, derives from
an interest in maintaining or increasing the provision of care for indigent people.
This position does not imply that the committee believes that those unable to pay
for care should receive a different quality of service than those able to pay.
Furthermore, ambulatory sites of GME do, and should continue to, attract paying
patients.
Finally, policies that reduce hospital margins run the risk of backfiring in
terms of support of primary care GME. If hospitals begin to reduce residency
support the most likely candidates for elimination are the primary care residency
programs rather than the specialties that earn more revenue.
Administration
Proposals to increase the support of primary care GME should not be so
administratively complex or costly as to overwhelm administrators and divert the
funds intended for education into administration.
Conclusions and Recommendations
The committee developed its recommendations mindful of four major
considerations. 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. The committee was concerned with developing
recommendations that would immediately begin to move the policy process in
appropriate directions, and acknowledges that there are complex issues that this
committee did not address. Third, that proposed changes should foster the
attainment of two secondary goals: (~) expand primary care physician manpower,
(2) sustain or enhance access to care for medically indigent people. Fourth, that
recommendations be developed, as far as possible, in accordance with the criteria
set at the beginning of this chapter.
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The committee considered the options presented in the paper by Peinado and
Eisenberg (see Appendix B), as well as the other papers and discussion at the
workshop. 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.
The committee also considered whether some new sources of funds could be
found. Believing that support of GME is the responsibility of the private as well
as the public sector, such sources as contributions from commercial insurance, a
tax on all hospitals or non-teaching hospitals, and an extension of outpatient
insurance were considered, but were found not to be practical. For instance,
voluntary, explicit payment of education costs from commercial insurance is
unlikely to occur. If such a payment were made mandatory, or were captured
through a new tax, the cost would be passed on by insurers, many of whom claim
that health insurance is already a low margin business. The customer to whom
the cost would be passed is most often the employer, and further premium
increases would be likely to hasten the move to self insurance, thus defeating the
purpose of the initiative. A tax on hospitals was thought to be undesirable
because some states were already employing this method to create a pool of money
for care for the medically indigent. In addition, such an increase in hospital costs
would not be budget neutral, and would likely be passed on to the consumer.
Expansion of outpatient coverage would not be budget neutral either for the
federal budget or for overall health care spending.
In view of the wide variety of primary care teaching programs and of
existing and potential sites for ambulatory training, the committee believes that no
single approach to overcoming financial barriers will solve the financing problems
of all primary care programs. Rather, the committee sought to develop a group of
recommendations that together would have a significant positive impact on the
ability to establish high quality, appropriate primary care GME programs.
Academic I~eadersh~p
The influence of academic leadership in helping training programs to develop
in innovative and useful ways should not be underestimated. Committed leaders
have had significant success in overcoming financial barriers and establishing
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arrangements for training primary care residents in ambulatory settings. These
leaders also have an important function in developing the professional values and
mores that will encourage young physicians to enter primary care specialties with
an understanding of their place in the health care system, and with the respect
that will sustain them throughout a career in primary care. 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. Such factors as patient volume and flow, the use of non-
physician health personnel, and the effectiveness of bill collection are worthy of
managers' attention. The committee believes that budgeting and planning
for primary care ambuZatory training sites should take into account the
need to develop effective clinic management. In addition, to fAe extent
that economies of scale can be achieved by the joint use across specially
lines of facilities arm other resources, these cost savings should be sough!
and interapeciaZ!y barriers towered.
Physician Payment Reform
Reimbursement for patient care services is potentially the most
powerful financial policy instrument available for influencing
physician's career decisions and the medical education system
....Reimbursement ... affects all health care providers on a
continuing basis (Sloan, 1980, p.57~.
Much of the care provided by primal care physicians for their patients is
paid for at a relatively lower price than the services provided by other specialists.
Many have suggested that some services, for example surgical and diagnostic
services, are relatively overpaid while such services as cognitive and preventive
care are relatively underpaid. In order to correct these inequities, as well as to
change the financial incentives that may result in patients receiving inappropriate
care, a fee scale has been developed that is based on the costs of resources
(including time) used to provide a unit of service. This fee scale, the Resource
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Based Relative Value Scale, has been proposed as the basis for Medicare physician
payment by a commission created to advise Congress on the reform of physician
payment methods. The commission, also charged with restraining the rate of
Medicare cost increases, developed a Medicare budget neutral fee schedule under
which internal medicine and family practice physicians are expected to increase
their income from Medicare, while some specialties would experience a decrease.
However, volume control mechanisms may be needed to sustain budget neutrality.
In addition, confining Resource Based Relative Value Scale payment to federal
programs affects only a portion of physicians' incomes. There is a possibility that
total private sector physician service costs will increase if primary care charges
rise to the level paid by Medicare, and procedure charges continue at the current
level or even rise to make up for lost Medicare income. Thus, to achieve health
care budget neutrality and to bring pediatricians into the fee schedule, all payers
should adopt a resource based relative value scale payment system. This will also
have the effect of redistributing more than only the Medicare portion of physician
Income.
The committee supports the proposal that Medicare adopt a
resource based relative value scale method of payment for physicians,
and recommends that all payers adopt such a payment scale.
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.
In addition, as the earnings of primary care physicians increase and the
differential between the primary care specialties and other specialties decreases,
the economic incentives that deter some physicians from entering primary will
diminish. To the extent that economic considerations are a determinant of
specialty choice, diminishing negative incentives will increase the number of
primary care physicians and help rectify the imbalance in the physician labor force
between primary care and non-primary care specialists. Finally, the adjustment of
fees will signal an appreciation of the importance of primary care services and
should enhance the standing of those specialties.
Medicare Direct Graduate Medical Education Payment
Medicare payment for the direct costs of medical education is based on the
number of full-time equivalent residents in a hospital, multiplied by a hospital-
specific amount per resident. However, a proposed rule would introduce a
weighting factor that diminishes the payment for a resident who has passed the
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initial residency period (the period of board eligibility plus one year, not to exceed
five years). Thus, for example, internal medicine subspecialties receive full
funding for four years--three years prerequisite for the general internal medicine
program plus one additional year. The second year of subspecialty training has a
reduced weight factor because it exceeds the initial board eligibility plus one year.
For surgical specialties, where five or more years are required for board eligibility,
only the first five years receive the full weighting (Federal Register, 1988). Thus,
Medicare's direct GME payment will not only recognize the direct costs of
training, but by incorporating financial incentives--reduced payments for
subspecialties that are generally oversupplied--it will become a tool of physician
manpower policy that has the potential of altering the composition of the
physician workforce.
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. The
mechanism shouM be a differential in the full-time equivalent
calculation between primary care residents and other residents.
Residents in genera Z internal medicine, genera' pediatrics, and family
medicine shouH receive a higher weighting factor than other residents.
Primary care residents who spend 2{i percent or more of their time in a
primary care ambulator setting (not including specialty clinics) would
receive a larger weighting factor.
The committee was unable to calculate the weighting factors that should be
applied in order to achieve its goal of creating a sufficient incentive to have an
impact on the numbers and sites of primary care residencies. Although some data
on hospitals' direct per-resident costs exist, there is no available itemization by
specialty. Moreover, 1984 data indicate a wide range ($7,500 to $~87,500) in
hospital per-resident costs, much of which is not yet explained (Council on
Graduate Medical Education, 1988). The committee supports the recommendation
of the Council on Graduate Medical Education that a study of the variation in
per-resident direct costs be carried out expeditiously. The findings of this study,
and further analyses of data pertaining to the Medicare direct GME payment,
should provide a basis for the development of incentive weighting factors.
However, if such studies cannot be accomplished with alacrity, weighting factors
should be introduced and adjusted as suggested by monitoring of the outcomes.
The committee believes that the incentives in their recommendation both will
make the provision of primary care residencies more attractive to hospitals and
generate revenues needed for the development of quality training programs in
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community practice sites. In addition, the committee believes that it is reasonable
to offer extra support to needed specialties while directing small amounts of
resources away from those that are better financed and for which the supply is
considered to be more than adequate. The committee considered the implications
of making incentive payments directly to department chairmen or others, but
concluded that the hospitals must accept responsibility for the entire residency
program. In so doing the hospital would respond to the financial incentives by
making the shifts to true primary care residencies that the committee seeks, and
utilize the additional revenues that accrue to them by helping the development of
appropriate training sites. If necessary the additional revenues could, in part,
support personnel needed to replace resident time lost to outpatient training.
Medicare Indirect Graduate Medical Education Adjustment
In its review of the major sources of GME funding, the committee directed
its attention to the Medicare indirect medical education adjustment as a potential
source of funds that might be reallocated to support primary care education.
However, for several reasons the committee decided not to suggest radical changes
in this item. For example, the revenue from the indirect adjustment is of major
significance to some hospitals that provide large amounts of uncompensated care.
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.
The Medicare indirect medical education adjustment was originally developed
to compensate for a number of factors that increase the costs of teaching hospitals
but are not directly attributable to the support of residents or faculty. Such costs
derive from a variety of factors such as the test-ordering behavior of residents.
Evidence suggests that outpatient sites of residency training experience costs
associated with teaching activities similar to those recognized by the Medicare
indirect medical education teaching adjustment.
The committee recommends that Medicare include in the calculation
of the indirect medical education adjustment time spent by primary care
residents in all primary care ambulatory settings.
This recommendation, which is not budget neutral, would extend the
Medicare indirect medical education adjustment to all primary care outpatient
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sites, making additional money available to help support the costs of training in
those sites.
State and Local Roles
The committee recognized the importance of state funding of GME generally, and
in funding state schools and family practice programs in particular. State
Medicaid programs also can play an important role in enabling primary care
ambulatory training to remain financially functional. The committee
encourages Medicaid programs that cio no! now support GME to follow
Medicare GME payment policies. However, the committee appreciates that
states and localities face budget pressures that are often no less severe than those
faced by the federal government. In particular, the committee applauds the
expansion of Medicaid to increase the coverage of pregnant women and children,
and believes that financing such services is a high priority.
By some estimates, the nation now faces an insufficient supply of primary
care physicians, which already is reflected in some states. 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. States
that determine that an increased supply of primary care physicians
would benefit their citizens, and states that find a potential shortage of
primary care practitioners, should increase their financial support of
GME arm widen their support; to include genera! internal medicine and
genera! pediatrics as we!! as family practice.
To encourage involvement of state and local governments, training programs
should take the initiative in finding ways to exploit the natural affinity of primary
care training and services to medically needy populations. Case studies offer
numerous examples of ways in which committed leaders have negotiated
arrangements mutually beneficial to ambulatory training sites and to states or
localities seeking cost-effective care for specific populations. Such arrangements
can offer a stream of new patient care revenues needed to make feasible the
support of residents in an ambulatory clinic. In trying to encourage state and local
support of primary care GME, programs must be ready to demonstrate the ways
in which support of specific GME components or services will be beneficial to the
relevant governments. Program directors should become aware of local needs,
such as health care for the homeless, which their ambulatory clinics may be
uniquely able to fulfill. The committee recommends that primary care GME
programs assume the responsibility of informing [egisiators and agencies
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of ways in which primary care ambulatory GME could provide services
that would benefit needy populations as well as the education programs.
The programs shouH also make efforts to endure continued support by
maintaining contact zaith the relevant agencies and legislators through
such means as nezasletters.
Grants
The committee looked at the uses of short terms funds that can be obtained
from government and private grants. Bearing in mind that residency programs
cannot make needed long-range plans in the face of insecure funding, grants
should not be regarded as protracted operating support. 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. In addition, these grant programs can
continue to play a role in faculty development in the early years of
programs. Private fourufations, both local aru] national, interested in
medical education and the provision of health services, should add their
support to such activities, thus multiplying the impact of the limited
federal grants furu]s that are available.
In conclusion, believing that quick action is needed to ensure the future
supply of appropriately trained primary care physicians, the committee has
developed the foregoing recommendations for ways of improving the ability of
educational programs and health care providers to support GME for primary care
physicians in ambulatory settings. These recommendations are intended to
motivate several different entities to act decisively and expeditiously; entities to
whom the committee addresses recommendations include federal, state, and local
governments, hospitals, and private foundations. This dispersion of responsibility
for making needed changes reflects the committee's belief that GME is of benefit
to, and is correctly the concern of, numerous participants in the health care
system. The committee's recommendations are not addressed to all those whose
influence could appropriately be brought to bear on the problem, nor do the
recommendations cover all possible solutions. Rather, the recommendations are
intended as first, immediate, steps in a direction that the committee believes must
be pursued.
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REFERENCES
Bentley, James D., Knapp, Richard M. and Petersdorf, Robert G. 1989. Education
in Ambulatory Care - Financing is One Piece of the Puzzle. Special Article.
New England Journal of Medicine. 320~23~: 1531-1534.
Council on Graduate Medical Education. 1988. First Report of the Council. U.S.
Department of Health and Human Services, Public Health Service, Health
Resources and Services Administration, Bureau of Health Professions,
Division of Medicine. Rockville, Md.
Eisenberg, John M. 1989. How Can We Pay for Graduate Medical Education in
Ambulatory Care? Special Article. New England Journal of Medicine. 320~231:
1525-1531.
Federal Register. 1988. Medicare Program; Changes in Payment Policy for Direct
Graduate Medical Education Costs. Proposed Rules. Wednesday, September
21. 53(183):36589-36608.
New York State Council on Graduate Medical Education. 1988. First Annual
Report, 1988. Albany, New York: New York State Council on Graduate
Medical Education.
Sloan, Frank A. 1980. Patient Care Reimbursement: Implications for Medical
Education and Physician Distribution, in Medical Education Financing. Ed.
Jack Hadley. New York: Prodist.
64
Representative terms from entire chapter:
care physicians
