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APPENDIX A
PROGRAM AND PROCEEDINGS OF A WORKSHOP
Held By
The Committee to Study Strategies for Supporting Graduate Medical
Education for Primary Care Physicians In Ambulatory Settings
Institute of Medicine
April 17 and is, 1989
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PROGRAM
April 17, 1988
S:30 am WELCOME AND INTRODUCTION
Samuel 0. Thier, M.D., President, Institute of Medicine
Daniel D. Federman, M.D., Chairman, Committee to Study
Strategies for Supporting Graduate Medical Education in Primary Care
9:00 am CHARACTERISTICS OF PRIMARY CARE GRADUATE MEDICAL
EDUCATION IN THE AMBULATORY SETTING
Evan Charney, M.D., Professor & Chairman, Department of
- Pediatrics, University of Massachusetts Medical School
Jack M. ColwitI, M.D., Professor & Chairman, Department
of Family & Community Medicine, University of Missouri-Columbia
Jordan Cohen, M.D., President APDIM, Dean, School of Medicine,
SUNY at Stony Brook
Fred Tinning, Ph.D., President, Kirksville College of
Osteopathic Medicine & Chairman, Board of Governors,
Association of Colleges of Osteopathic Medicine
Moderator: Richard E. Rieselbach, M.D., Associate Dean, University
of Wisconsin Medical School
10:30 am COST AND REVENUES FOR GRADUATE MEDICAL EDUCATION
Judith R. Lave' Ph.D., Professor of Health Economics,
Universitr of Pittsburgh
Ruth S. Hanft, M.A, Research Professor and Health Policy Consultant,
George Washington University
Robert Derzon, M.B.A., Lewin/ICF, Inc.
Moderator: Sheldon S. King, President, Stanford University Hospital
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11:30 am LESSONS FROM PROGRAM DIRECTORS
Larry ~ Green, M.D., Professor & Chairman, Department
of Family Medicine, University of Colorado Health
Sciences Center
doe! A. Alpert, M.D., Professor & Chairman, Department
of Pediatrics, Boston University School of Medicine,
Chief of Pediatrics, Boston City Hospital
Steven ~ Wartman, M.D., Ph.D., Director of the Division of
General Internal Medicine, Brown University
Moderator: Henry W. Foster, cr., M.D., Professor and Chairman,
Department of Obstetrics & Gynecology, Meharry Medical College
2:00 pm ALLOCATION OF RESOURCES AT THE INSTITUTIONAL LEVEL
Sheldon S. King, President, Stanford University Hospital
Norman G. Levinsky, M.D., Professor & Chairman,
Department of Medicine, Boston University Medical School
John d. Collins, cr., M.D., Vice President for Professional
and Physician Services, Mercy Health Services
Harry N. Beaty, M.D., Dean, Northwestern Medical School
Moderator: Daniel D. Federman, M.D., Dean for Students and Alumni
Professor of Medicine, Harvard Medical School
3:00 pm BREAK
3:30 pm POLICY OPTIONS
Sandra C. Peinado, M.D., Fellow, General Internal Medicine,
University of Pennsylvania
John Eisenberg, M.D., M.B.A, So] Katz Professor of
General Internal Medicine, University of Pennsylvania
Moderator: Daniel D. Federman, M.D., Dean for Students and Alumni
Professor of Medicine Harvard Medical School
5:00 pm ADJOURN
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April 18, 1989
8:30 am POLICY OPTIONS, Continued
Peter Bouxsein, d.D., House Subcommittee on Health and
the Environment
John K. Ki~redge, Former Executive Vice President,
The Prudential Insurance Company of America
C. Ross Anthony, Ph.D., Associate Administrator for Program
Development, Health Care Financing Administration
Arthur M. Fournier, M.D., Associate Dean for Community Health
Affairs, University of Miami Medical School
12:00 pm ADJOURN
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Introduction
_ 1_ ~ 1 ~:1 ~1
There is a growing consensus that changes in the way in which health services
are provided require that residency programs for primary care physicians increase
their emphasis on ambulatory care experiences in order to prepare physicians for the
real world of primary care practice. There is also a growing sense that new
strategies are needed to enable these programs to overcome the financial
disadvantage at which they operate, compared with other medical specialties. The
Institute of Medicine, with support from the Josiah Macy Jr. Foundation and the
Health Resources and Services and Administration of the Department of Health and
Human Services, appointed a committee to plan a workshop and recommend
strategies for surmounting the fiscal constraints that bind primary care training
programs. By bringing together experts from primary care education and practice,
health care institutions, federal agencies, insurance and health care financing and
others, the workshop was to be both a useful event for the participants and provide
the basis for the committee's deliberations. The workshop was held in Washington,
D.C., April, 1988.
Summaries of presentations and discussion at the workshop follow.
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CHARACTERISTICS OF PRIMARY CARE GRADUATE MEDICAL
EDUCATION IN THE AMBULATORY CARE SETTING
Primary Care Residency Training in Pediatrics:
Current Status, Current Issues, Suggested Solutions
Evan Charney, M.D.
Professor and Chairman
Department of Pediatrics
University of Massachusetts Medical School
Demographics of Pediatric Training and Practice
There are currently 230 fully approved three-year pediatric residency programs
in the United States with just over 6,000 residents in training. Approximately half
of these programs are in University hospitals and half in community hospital
settings (with varying degrees of university affiliation). Of the 35,000 pediatricians
in the United States (physicians who limit their practice to children and adolescents)
80 per cent are in off~ce-based primary care practice; one-fifth of those physicians
devote a portion of their time to subspecialty as well as general pediatrics. Fifteen
per cent of pediatricians are in full-time subspecialty practice and, except for the age
specific areas of neonatology and adolescent medicine, are in areas comparable to
internal medicine (e.g. organ system specialties, infectious disease, immunology).
The remaining five per cent of pediatricians are in public health and administrative
positions.
The Setting of Residency Training
The hospital setting in which pediatric residency is based presents certain
problems for primary care education:
On hospital inpatient services, children have illnesses more
complex and more severe than in the past. Attending
physicians are increasingly specialized, and children are
often segregated by disease category to more efficiently
pronde that care (separate intensive care units for
neonates and older children with full-time attending
supervision, inpatient units divided by subspecialties,
emergency departments staffed by specialists rather than
generalists). The technology appropriate to such care
becomes correspondingly more complex as well. Moreover, the
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shortened inpatient length of stay further reduces the time
available to absorb (much less metabolize) the available
learning.
2. Patients in most general pediatric clinics are
disproportionately drawn from poor or socially disorganized
families. Those children cared for in the emergency
department tend to have more acute problems than do most
patients in practice, and usually are unknown to the
physician providing care. Those in subspecialty clinics
have more complex or unusual conditions. In fact the
management sale with patients with the same clinical
condition often varies between office practice and hospital
practice. For example, the emergency department physician
commonly orders far more extensive laboratory investigation
for a well-appearing but febrile one year old than does the
office-based physician who knows the child and family.
While each st3rIe is probably appropriate to its own setting,
trainees may get mixed messages about what is optimal or
correct.
3. The community-based practitioner is less visible (perhaps
less welcome) within the hospital and emergency service than
in the past. The average practicing pediatrician
hospitalizes fewer children now and, therefore, spend less
time in the hospital, except for full-term newborn care. As
a result, when a child is hospitalized, pediatricians are
less able to direct that care without consultant help than
they were ten or twenty years ago.
The common denominator of these changes is that in 1989 the average
pediatric resident is less likely to observe the average primary clinician functioning
knowledgeably and comfortably in the hospital setting than was true in the past.
Medical Education as an Apprenticeship Model
Graduate medical education is based on an apprenticeship model, as opposed to
the classroom/seminar approach typical of law and engineering schools, for example.
The core philosophy of this education is to expose trainees to appropriate patients,
in appropriate settings, taught by role-model faculty. This has worked well, by and
large, for the trainee who will go on to become a consultant pediatrician, and
appears to provide a reasonable foundation for further subspecialty training. I
believe it has worked less well for general pediatric education for the reasons stated
above. While general or ambulatory pediatric divisions have been established within
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most teaching programs, The problems of a hospital environment remain. As
noted, the patients in hospital ambulatory settings are often poor, with complex
social and psychological problems that would tax the most skilled practitioner.
Moreover, the "continuity practice" they are enrolled in is an artificial construct, an
educational device that has little resemblance to most practice settings. In contrast,
we do not place residents in artificial intensive care or emergency room settings for
their education and expect that they will learn principles to apply later in ''real'
practice: we place them in functional care systems practicing alongside skilled
clinicians. The point here is that primary care practice within the hospital may not
resemble community-based primary care practice either in setting' patient mix, or
facula.
The Residency Review Committee
The Special Requirements for pediatric residency programs have been modified
(revised in 1985 and 1990) with the goal of making standards more explicit and
more stringent in several areas. Primary care training must now include one half-
day per week in a continuity practice in all three years of training, a more clearly
defined experience in child development, behavior and adolescent medicine, and a
minimum of six months in general ambulatory settings. With the added continuity
clinic time the mandated minimum general ambulatory time now comprises 27 per
cent of the three-year residency. However, other changes in the Special
Requirements will have an impact on general pediatric training; there is an explicit
requirement for more subspecialty faculty available at the parent institution, and the
hospital inpatient setting is more clearly defined as a tertiary referral center for
children with severe~and diverse illness. The result will be that smaller programs
(with fewer subspecialists and less complex inpatient services) may have difficulty
meeting standards, which will lead to an increase in the proportion of pediatric
residents trained in large tertiary care hospitals. What will be the effect of these
changes on primacy care education? Although it is not valid to assume that high
quality primary care education is always characteristic of small training programs, it
is clear that a general pediatric orientation is not easy to cultivate in the climate of
a tertiary care center. Moreover, pediatric department chairs are subspecialists for
the most part. Although they have a strong commitment to pediatricians providing
primary care for children, the demands of running a service, teaching, and
conducting research in a tertiary care environment make issues of primary care
education seem less immediate and compelling.
Challenges of Primal Care Education
Our challenge is to develop education settings and curricula (in the continuity
practice and in the community) to accomplish for primary care what has been
achieved for subspecialty education. Simply stated, trainees need to observe
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successful practice by skilled clinician-teachers in a variety of situations applicable to
practice.
In office practice: residency programs need either to establish (potentially under
hospital auspices) or affiliate with real-life, functional pediatric practices. There are
a variety of such settings which can be utilized, depending on where the residency
program is located. These include urban group practice with indigent or mixed
social class patients; suburban group practice with predominantly middle class
patients, rural practices, which in addition to primary care, may involve a
consultative role with family practitioners, and a major role with hospitalized
children. Such teaching practices should be able to demonstrate the pediatrician's
role with children and adolescents with chronic medical conditions, with behavioral
and developmental problems, as well as with parent and child preventive health
education. The role of allied health professionals and office staff, organization of
practice, medical records, consultation and referral decisions to both medical and
psychosocial resources are all proper subjects for learning.
In community settings: Primary care practitioners (optimally) play important roles
as consultants in community settings outside of their office and trainees should have
the opportunity to observe and learn these roles. These occur, for example, in day
care facilities, schools (elementary through college level), settings for children with
chronic handicapping conditions, and detention facilities for juvenile offenders. The
role of the generalist in a community hospital without housestaff is a very different
one from the practicing physicians whose principal hospital is a regional tertiary
center, with available residents and subspecialists.
Although some of these skills can be learned in short block rotations in office
practice, there is considerable value to learning how skilled primary care physicians
manage problems over time, and that is best achieved by a longitudinal, several year
experience (particularly for the primary care practice). This strategy requires
identifying promising clinician/teachers within the community, and providing them a
structured (and ongoing) educational program to grow as teachers. They need to be
compensated for the time they spend teaching and not practicing. I believe it is
more logical to place residents in "educationally prepared" community settings than
to bring practitioner-teachers into tertiary settings to observe and teach residents in
hospital clinics.
These comments are not meant to ignore the role of subspecialists. They are
vital to graduate education for primary care and, in general, I think subspecialty
teaching is of high quality. At present, subspecialists play a vital role in conveying
to pediatric residents a body of knowledge about disease and up-to-date diagnostic,
technical and management skills in dealing with children with complex illness.
However, if trainees only observe neurologists caring for children with seizures,
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endocrinologists caring for diabetics, and psychologists caring for children with
behavioral disturbances, a powerful message is communicated to the trainee about
who provides optimal care. Our education needs to occur, at least in part, where
excellent generalist teachers are seen to play a central and satisfying role with such
children and their families.
Funding Constraints
Funding constraints present a realistic barrier to implementing the changes in
primary care education outlined above. In hospital inpatient and ambulator
settings patient care reimbursement provides a significant portion of resident and
faculty salaries. If residents spend time outside of the hospital in community
settings alternate payment mechanisms need to be devised for resident (and faculty
- supervision) time. Hospital services will continue to require staff time, and either
more residents need to be recruited (but there are a limited number of American
medical school graduates available) or new allied health manpower (physician
assistant, nurse clinician) need to be trained. Moreover, community-based primary
care, child development and behavioral services tend to be poorly reimbursed,
without considering the additional educational expenses required to teach n those
settings. Current Title VII funding for primary care residency training has allowed
for the funding of these activities (apart from usual hospital sources) and can
provide valuable data on the costs of such education.
In summary, pediatrics retains its strong commitment to primary care: the
majority of pediatricians are engaged in that activity. Changes in the Residency
Review Committee Guidelines for pediatrics should enhance primary care education,
but may tend to concentrate residency training in larger tertiary care centers where
such educational experiences must compete with the service demands of complex
patient care. A variety of curricular innovations are needed to strengthen primary
. . .
· ~ e , e
care education In pectlatrlcs, and the flexibility to develop and assess these curricula
is highly desirable. Funding support to place trainees in functioning primary care
settings in the community (and prepare the appropriate faculty) is required, which
will necessitate some restructuring of present reimbursement mechanisms.
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BIBLIOGRAPHY
Bryke C, Tunnessen W. Scully T. Oski F. Pediatric residencies
between 1959/60 and 1984/85. Pediatrics 82:752, 1988.
: Differences
Mathieu O. Alpert d. Residency training in general pediatrics: The role
of federal funding. Am ~ Dis Child 141:754, 1987.
Reuben D, McCue ], Gerbert B. The residency-practice training mismatch.
Arch Int Med 148:914, 1988.
Sargent it, Ashley M. Comparison of patient populations seen by
pediatric residents and by practicing community pediatricians.
Med Ed 61:610, 1986.
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The bottom line is that, in the current climate, federal grant support is
crucial to develop and to sustain the primary care programs. It may prove to be
even more vital in the next few years as economic pressure continues to increase
on teaching hospitals.
Discussion
Discussion of the presentation by program directors noted that if program
directors are to be able to negotiate with hospital administrators and establish
beneficial arrangements, the financial relationship between teaching hospitals and
the primary care residency programs needs to be properly understood. Some
discussants pointed out that hospitals derive greater revenues from patients
admitted by subspecialists than from the smaller volume of admissions by primacy
care physicians. Other discussants however suggested that there needs to be
proper appreciation of the savings that can be derived from the existence of the
primary care outpatient clinic. The length of hospital stay is reduced because
preadmission diagnostic workups as well as post discharge follow-up are performed
in the clinic. This reduction in inpatient costs is particularly important for
hospitals that provide uncompensated care. However, it was also noted that while
such savings to the hospital are real, the benefits to the hospitals of primary care
ambulatory programs are small when compared with the benefits from other
programs.
THE ALLOCATION OF RESOURCES AT THE INSTITUTIONAL LEVEL
This session of the workshop used a case study method of discussion
whereby four panelists were given, in advance, a problem to address. A moderator
guided the discussion. Panelists were the dean of a medical school, the chairman
of a department of medicine, the president of a major teaching hospital, and a vice
president of a major, not-for-profit, hospital system. Each participant was asked
to consider the financial resources that he would try to obtain to support the
residencies, and the negotiations in which he would engage with other actors.
The exercise was developed for to illuminate the following:
o the decisions that need to be made
o the coalitions that must be built
0 the different sets of constraints on people involved in various
positions in the negotiations process
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o the trade-offs and options available
The Problem
An academic health science center with an internal medicine program
wants to establish a primary care track eventually totaling 18
residents -- six per year. The existing internal medicine program has
45 slots, 15 per year. Since it is not possible to expand the overall
size of the program the primary care track will reduce the number of
residency slots for the existing track to 27.
Because the program intends to apply for a federal grant, each
resident must, in the course of three years, meet at least the federal
25 percent continuity requirement. Thus in the first year at least
one half day per week is needed in the ambulatory setting, in the
second year two half days per week, and in the third year four or
five half days per week are needed. Alternatively residents could do
at least three half days per week in the ambulatory setting
throughout three years. The ambulatory experience will be in an
outpatient clinic in your hospital.
The federal grant award will provide $60,000 in the first year,
$90,000 for the subsequent two years, and there is no assurance that
the grant will be renewed. Because of low Medicaid payments by
your state, and a large non-paying patient load, patient revenues will
cover roughly one third of the cost of the program (residents
stipends, faculty salaries, administrative overhead). This leaves you
with approximately 55 percent of costs unfunded.
The problem for you to address is how to fund the remainder of this
program. In particular we would like to know under what conditions
you would be able to obtain funds from the program, or hospital, the
faculty practice plans or other institutional sources. The state has no
history of support for graduate medical education. Who in the
hospital and the medical school will support and who will oppose
your attempts to fund the program? Also, how would you replace the
inpatient care services lost when the residents move to the outpatient
clinic?
Internal Medicine The director of the department of general internal medicine
greeted the proposal with enthusiasm, believing that the nation needs general
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internists, and that individuals who complete such training programs have a
higher probability of practicing primary care in underserved areas than those
trained in subspecialties. Since most primary care in his state is provided by
internists, establishing the primary care internal medicine track, rather than a
family practice program, articulates well with established, practice patterns.
Moreover, some faculty members have been Urbana the chairman to move to
~ · ~· ~I ~en ~
_# ~
establish a prlmar~r care track. One program is Iortunate, and pOSSloly unusual' in
having faculty with the necessary qualifications, background and interest to
provide a core of teachers for the primary care track, and to write a grant
applying for federal funds. The chairman believes that if a totally primary care
oriented program is the eventual goal, to initially establish a track is the more
prudent approach. It avoids antagonizing subspecially faculty, and allows a period
during which it will be possible to test the availability of support for the training.
One possible source of financial support for the program that is sometimes
controlled by the department chairman is the faculty practice plan. It should,
however, be noted that there exist many of ways of organizing faculty practice
plans. In some schools the dean controls none of the income, in some schools the
dean controls it all; similarly the control of the department chairman varies.
The two principle decisions-makers with whom the chairman must trSr to
negotiate for support are the dean of the medical school, and the president of the
university hospital. The chairman would ask the dean for some faculty support,
arguing that the medical school benefits from the teaching sernces of residents;
that the new thinking and behavior taught in the primary care track would
the education of medical students; and that the work of the facula in
enhance
the new track would be supportive of the educational and research goals of the
medical school as it adapts to the changing environment and the needs of the
twenty first century. The chairman would ask for support from the hospital
administration on the grounds that hospital revenues would be enhanced by
increased admissions.
-
Other sources of funds that the chairman would t~y to tap include:
o
o
o
affiliated hospitals, on the grounds that having residents would help
these hospitals develop faculty and gain prestige.
the local community, on the grounds that the program could help the
locality provide care for low-income, or uninsured populations.
the state, on the grounds that the program could put satellite clinics
in underserved areas and that graduates of the program might settle
in those areas.
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Dean of Medical School In most schools the issue of providing support for the
new primary care track would be discussed between the dean and the chairman,
without much involvement of other departments.
The dean would view a proposal to create a primary care general internal
medicine track from the position of a decision-maker with responsibility first for
medical students. Graduate medical education takes second place. Thus, the
chairman's argument that the new track would strengthen faculty in ways that
mesh with the missions of the medical school would carry weight. The dean would
discuss the ambulatory practice arrangements and the quality of the practice, and
consider whether the model would be one into which he might ultimately want to
integrate the medical students. The dean would agree to provide some support for
faculty, but finds no reason to directly support residents in this track. Since
federal grant support may cease after three years, the dean would not put himself
in the position of offering ongoing financing of residents, which might in the
future conflict with his primary responsibility -- medical students.
Sometimes the dean has substantial control of the faculty practice plan,
making it possible for the dean to make allocation decisions that benefit the
institution as a whole, and the hospitals with which the medical school is closely
affiliated. Even so, the dean must be assured of the support of the members of
other departments. Since he does not believe that the new residents would bring
significant numbers of new patients to the subspecialists, and since it is not clear
that the additional patient volume would be composed of paying patients, it would
be very difficult to make a case for giving the department of medicine a greater
share of the faculty practice plan income for the purpose of supporting the
primary care track. This would be the case despite the fact that there is
precedent for some cross subsidy for support of facula from the high earning
groups to the lower earning groups.
Hospital President Before embarking on discussions of what support the hospital
would offer the primary care track, the hospital president wanted to clarify some
notions that the chairman of internal medicine may have.
First, it is often stated that the prime reason that hospitals have residents
is because they provide less expensive care than fully trained physicians. It would
be more accurate to say that hospitals support house staff programs in response
to faculty definition of what the residents need, and that despite its own service
needs a hospital would not create a residency program unless there was a
qualified department head, adequate patient volume, and a belief that it is
appropriate to train the particular type of resident.
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Second, the notion that the hospital benefits from the revenue from
ancillary services generated by house staff is false. Hospitals are increasingly
reimbursed on a per diem, per case. or cavitation basis. ~
·~ ~e ~`_ · ~ ~
_ ~_ .
ancillary services is financially negative, not positive.
Thus increased use of
The approach that the hospital president would take to a request for
support of the primary care track residency is one of bargaining. How would the
faculty help with coverage of the inpatient services that are left uncovered by the
reduction in inpatient service time of the residents? Would the faculty build a
cadre of non-teaching patients for whom they would be responsible? The
department must help the president of the hospital reconcile the competing values
of sustaining a financially viable hospital while fulfilling the requirements of a
quality teaching program. Thus the more important question for the hospital
president is whether the size of the residency programs relates to the population
being served, and whether the residency programs together form a coherent and
uniformly strong whole. These are the overarching considerations within which
the question of financing a residency is considered.
Community Hospital Administrator The principle question that the administrator
must ask, is whether the ambulatory care residency fits into the hospital's long
range plans. Will the residency undermine plans for the relationship with
community physicians? How does it mesh with the plans for physician
recruitment? The administrator must also ask whether the hospital has the
prestige needed to recruit physicians into the primacy care residency program. To
enhance its academic standing an affiliation with a nearby medical school might
be warranted. However, this is feasible only if the teaching hospital and the
community hospital do not compete with each other. Whether an affiliation can
be established is to a large extent dependent on the leadership of the institutions,
particularly on how the department chairman views the role of the community
hospital. With interested leaders the chances of establishing a successful
affiliation are high.
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POLICY OPTIONS
Sandra C. Peinado, Fellow,
General Internal Medicine
end 'John M. Eisenberg,
Sol Katz Professor of General
Internal Medicine
University of Pennsylvania School of Medicine
(This presentation summarizes the paper that can be found in Appendix B).
To satisfy the nation's need for well-trained primary care physicians,
graduate medical education in primary care requires adequate financial support.
The current mechanisms of GME financing favor inpatient and procedural care,
making the support of primary care programs difficult, since they are more
oriented towards outpatient evaluation and management. The majority of
graduate medical education funding comes from patient care reimbursement
through Medicare Part A direct and indirect payments, and other third party
payers. This scheme results in difficulties for primary care programs in resident
and faculty compensation, as well as general difficulties for primary care program
development.
Criteria for evaluating proposals that aim to improve the financial support
of primary care programs include financial, administrative, and educational
implications of the options, as well as the views of interested stakeholders. The
financial criteria are: 1) Any proposal should be budget neutral, at least in terms
of the federal budget; 2) All those who benefit from GME in primary care should
contribute to paying its costs; and 3) Funding should be both predictable and
sufficient. The administrative criteria are: 1) The implementation of any proposal
should be administratively feasible; 2) The ongoing administration of any new
funding scheme should be both simple and 3) inexpensive. The educational
criteria include: 1) Any proposal should maintain curricular autonomy and
flexibility for primary care educators; 2) The growth and development of primary
care curricular elements in already established residencies should be fostered; 3)
High quality programs in non-primary care specialties should not be adversely
affected; and 4) Proposals should include incentives that favor hi~h-nllr~lit.v
primacy care programs.
~^~ ~ ~ ~ ^ ~ ~ _~ ^ VJ
Stakeholders are the entities that are most likely to be interested in and/or
affected by change in GME financing. These stakeholders include the following:
society; the federal government; the Health Care Financing Administration; state
governments; private payers; teaching and non-teaching hospitals; physicians;
primary care specialties' educators and residents; non-prima~g care specialties,
educators and residents; and patients.
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The alternatives for sources of funds to support primary care GME include
changes in existing Medicare payments, an increase in categorical GME funding,
an increase in ambulatory payment, an increase in grants, commitments from
future employers, and a redistribution of current funds. Alternatives for spending
these funds to aid primary care programs include dividing the sources in three
ways: on a per-resident basis, by competitive grants, or by incentives for primary
care education. Each alternative for changing GME financing was analyzed using
the criteria and stakeholder views outlined.
No single remedy will be sufficient to rectify current GME financing
mechanisms. Instead, several solutions will be needed simultaneously. Judged
against the proposed criteria, the preferred options for raising money for primary
care graduate medical education are as follows:
0 Adopt a Resource Based Relative Value Scale for payment of physicians
and improve coverage of outpatient services.
o Include residents' primary/ambulatory care time in the calculation of
resident FTEs for Medicare direct and indirect medical education payment, add
incentive for primary care training in direct payment, and recalibrate payment per
resident to maintain budget neutrality.
0 Increase state support through Medicaid participation in payment for
GME and through grants for primary care education.
0 Require participation in payment for GME by other payers, including
HMO's and private insurers, coupled with a surcharge or tax on revenues of non-
teaching hospitals.
O Increase and redistribute Title VI] funding for faculty development,
curriculum design and other innovations. Encourage foundation support for
similar purposes. Faculty development, in particular, should be allowed a separate
funding stream.
0 Experiment with programs to commit residents to future employers, who
in turn would support primary care GME.
O Experiment with a direct medical education subsidy for outpatient
payments to complement payment to hospitals to cover the costs of medical
education. Consider an indirect adjustment to compensate for the higher cost of
practice (e.g., overhead, more severely ill patients) in teaching setting.
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The spending options judged best would involve division of the funds on a
per resident basis to residencies in internal medicine, pediatrics, and family
medicine for the development of primary care curricular elements through faculty
support, resident support, ambulatory site costs, curricular support, academic unit
costs, increased ambulatory time, and primary care cooperative efforts, or to use
as the individual residency chooses. This base funding would be coupled with
competitive grant funding to stimulate innovation and faculty development.
In addition, the appropriate and designated use of Medicare direct payments
should be enforced by HCFA.
Discussion
Discussion of the paper presented by Dr Pienado and Dr Eisenberg focused
mainly on the implications of the options for change listed in the paper. A theme
that underlay most of the discussion was the pervasive sense that health policy
today is being driven by the politics of deficit reduction. Thus the federal, state
or local government budget impact of recommendations was frequently the subject
of comment.
I, The option of paying for services on the
basis of a resource based relative value scale (RBRVS) was generally thought to
have potential for both facilitating the financing of primary care residency
programs, and for making the primary care specialties more attractive to
physicians by decreasing the income differential between primary care and other
specialties. There was also support for the elimination of the differential in
payment for the same services when performed by different specialists that occurs
under the customary, prevailing and reasonable basis of payment used by
Medicare.
While the adoption of the RBRVS by Medicare would effect only Medicare
payments, (by one estimate the impact would be on only 10 percent of the
revenues of the average family physician) it would be an important move signaling
to the medical profession and others an enhanced appreciation of the importance
of primary care services. Equally important, it would increase revenues available
to faculty practice plans thus easing the financial stress of financing ambulatory
training. On the other hand RBRVS would not substantially increase support for
training programs with substantial numbers of non-paying patients.
Unless all payers adopt a RBRVS, is a strong possibility that physicians
who provide procedurally-oriented care will continue their usual charges for
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services, or even increase them to make up for income lost by reductions in
Medicare payments, while primary care physicians are likely to charge all payers
at the increased medicare level. Thus total costs for physician services in the
private sector would be at risk of escalation. Whether third park payers would
be able to counteract this is doubtful. However, groups such as Preferred
Provider Organizations may be able to negotiate RBRVS payments on a budget
neutral basis.
Medicare Payment for Direct GME Costs The Pienado and Eisenberg paper
suggests the option of incorporating incentives for the development of primary
care GME programs into the Medicare direct GME payments, and recalibrating
the per resident payment to maintain budget neutrality. This idea was included
in a bill introduced by Congressman Henry Waxman in 1985. Although some
other restructuring of Medicare direct payments has been accomplished, this
proposal was not adopted. It is now, however, a more familiar concept than when
first proposed, and may therfore have a greater chance of success. While this
proposal incorporated incentives to expand primary care programs, it did not
directly tackle the question of funding residencies in ambulatory settings
However, the additional revenues obtained by primary care programs should help
make available resources to succors ambulatory training.
_. ~ , ~ . . . . . . . . . ~ , _. . .
O ~ ,, {I
Policy approaches to improving the specialty distribution of physicians and
the appropriateness of primary care training that try to equalize the financing of
training for primary care and other specialties are based on the assumption of
deficiencies in the revenues streams, and excesses in the costs of Primarv and
~ ~ -~
ambulatory training for which compensation must be found. This policy approach
requires analyses of comparative costs and revenues for which the data are today
inadequate, and is subject to change as methodologies develop. A policy that
creates financial incentives for primacy care training uses a simpler concept. It is
based on the notion that if existing funding patterns do not generate the desired
outcome incentives should be introduced that will encourage the desired behavior.
Such a policy can be evaluated by the extent to which its goals of furthering
primary care manpower are achieved, rather than by using cost accounting
methods to calculate whether a level playing field between primary care and other
specialties has been achieved.
Medicaid The option of mandating that Medicaid programs should support GME
by following Medicare regulations, or any other procedure, in an era of
constrained budgets requires a reallocation of resources. It will be difficult, and
undesirable, to persuade policy-makers that GME deserves support at a time when
states are attempting to assemble resources to sustain or improve coverage of such
populations as pregnant women and children.
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Medicare Payment for the Indirect Costs of Education It is argued that
ambulatory settings that train residents incur additional costs similar to those
incurred by inpatient GME training. This provides a rationale for fully extending
Medicare indirect payments to ambulatory settings. Furthermore, Medicare
indirect cost payments are roughly double the direct cost payments, therefore
reallocation within that pool wait be less painful to the losers. However. since the
level of Medicare indirect payments is being reexamined and cuts are likely to
occur, the impact of a policy based on manipulation of this shrinking revenue
sources is likely to be weakened. Furthermore, cuts in revenues from Medicare
indirect cost payments that erode hospital operating margins are likely to reduce
commitment to GME, with primary care bearing the brunt of cuts.
, ,
Federal Grant Programs Grants to sunnort family medicine. general internal
medicine, and pediatrics training programs have played a major role in generating
new primary care residency programs. However, it is unrealistic to believe that
any expansion of the grant programs will occur, and even if additional money
were to become available it would not be prudent to rely on grant money to
rectify the fundamental financial problems of placing primary care residents in
ambulatory settings. Grants can be vital to the initiation phases of a programs
and provide the impetus for innovation, but should not be relied upon for ongoing
support.
Third Party Payers Policy options to improve GME financing through
contributions from third party payers are sometimes based on the proposition that
This proposition is disputed on the
third party payers do not contribute to GME.
grounds that GME is incorporated in charges paid by third partner payers.
However, this contribution is being eroded as payers increasingly negotiate
discounted charges.
A proposal to urge third party payers to make voluntary contributions to
GME is unrealistic. The insurance industry is highly competitive and operates
with low margins, as evidenced by the number of companies that have abandoned
health insurance because of low or zero profitability. In such a market the
industry wait neither absorb the cost nor be able to pass it on to the payers,
generally employers, who are becoming increasing concerned about the cost of
health care coverage.
The alternative -- trying to pass legislation to tax the insurance infusing
is also problematical. The increase would be passed on to employers, who are
vocal in legislative arenas. Furthermore, such a tax would be inequitable since it
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could not be imposed on self-insuring corporations, and by increasing insurance
costs it would also be likely to cause greater numbers of employers to turn to self
insurance.
Another, indirect, approach to taxing third party payers would be to tax
hospitals which, in turn, pass the cost on to the third party payers. This strategy
poses dangers to hospitals that provide large amounts of uncompensated care and
may lack a sufficient base of charge paying patients on whom to pass the cost.
Furthermore, some states use a tax on hospitals to garner revenues with which to
pay for uncompensated care, making this mechanism less accessible for use by
policy makers attempting to enhance GME revenues.
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Representative terms from entire chapter:
family medicine
