Primary Care Physicians Financing Their Graduate Medical Education in Ambulatory Settings (1989) / Chapter Skim
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Financing Primary Care Residency Training: Examples and Lessons from Successful Programs
Financing Primary Care Residency Training: Examples and Lessons from Successful Programs
Pages 230-267
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From page 230... ...
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".
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From page 231... ...
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)
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From page 232... ...
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".
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From page 233... ...
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)
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From page 234... ...
advocate linking ambulatory based GME to care for the indigent. They argue that such a linkage (through capitation)
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From page 235... ...
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.
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From page 236... ...
i. The McLennan Counter Family Practice Program - Waco Texas The McL`ennan Counter Family Practice Program has been in existence for 20 years.
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The program, located at the free-standing Family Practice Center? is affiliated with two local hospitals and with Baylor University College of Medicine.
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From page 238... ...
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.
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From page 239... ...
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.
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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.
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From page 241... ...
New York. SUNY Buffalo has a large family practice residency program with 60 positions (GYI-20 expanding to GY1-24 in 1989-901.
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From page 242... ...
This has led to increased political support for family practice in the state legislature as well as local political goodwill. It is also important that SUNY Buffalo is the only medical school in a geographic region of some 2 1/2 million people.
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From page 243... ...
In 1987 the legislature authorized use of a portion of the funds generated by the tax to support two medically indigent demonstration projects (one rural, one urban) "to link the provision of primary health care services to low income persons with the education of medical students, interns, and residents." (Florida, 1987)
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From page 244... ...
a) University of Miami - The medical school has used the demonstration grant to establish community based ambulatory residency experiences in internal medicine, family medicine, pediatrics and obstetrics and gynecology at community health centers.
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From page 245... ...
In this way the program can expose all of the internal medicine residents to primaly care and an expanded ambulatory experience. Timing was also said to be critical - many individuals were becoming concerned over the inadequacy of the inpatient experience for graduate medical education.
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The school is also attempting to start a fully rural based residency program. The demonstration project is operated at four sites -- two rural community health centers, a rural county health department and a school-operated AHEC site.
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From page 247... ...
The state was concerned with adequate staffing for health departments and community health centers and with recruiting replacements for National Health Services Corps physicians as they finish obligated service. The medical schools were interested in expanding the sites of, and securing funding for, an ambulatory based educational experience.
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From page 248... ...
Currently the state is concerned about responding to the twin challenges of the shift of the setting of health care delivery to locations outside the hospital and the declining interest of medical students and residents in primary care. In North Carolina, in 1988 44% of the first-year residency positions in Family Practice were unfilled by the match - as compared with less than 10% in each of the previous three years.
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From page 249... ...
The major problem in selling the new plan is to tie it to the overall AHEC concept, and the need to ensure adequate availability of care for all - including the indigent. The current move to ambulatory care education has arisen within the medical schools, not the community, making it necessary to relate the proposed program to issues which concern state legislators and the general population.
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From page 250... ...
Key factors contributing to success include a situation requiring action, strong leadership within the department and the interest and commitment of a medical director willing to devote time and energy to making the system work. It was also critical that the capitated system provide a sure source of revenues (approximately 80% of revenues come from the capitation payments)
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From page 251... ...
in. Lessons for the Future Successful financing of ambulator~r-based graduate medical education is as uncertain and confusing as anything else related to the cost and financing of graduate medical education.
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10. Indirect State Support - the availability of state resources for the provision of services which therefore indirectly assist the educational goal of the project.
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The presence of strong leadership with a clear goal was a critical element in the success of the programs described in this paper. In each of the cases discussed, an individual (a department chairman, a residency program director, a medical director of a clinic)
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From page 255... ...
Institutional commitment: ambulatory based programs are most easily implemented and sustained if they fit into the natural environment of the overall institution. Lacking this fit, leadership attempting to establish residencies in ambulatory care settings will have to fight institutional resistance to a reallocation of resources, and overcome an institutional structure that lacks incentives for individuals to encourage education in ambulatory settings.
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From page 256... ...
Mutual benefit can be an important factor in success. That is, the program needs to be able to convince groups or institutions with different objectives that support of ambulatory education will be mutually beneficial, that it wait generate ancillary services and inpatient revenue for the hospital, help the state or locality provide care for its indigent population at reasonable costs, help recruit future staff to community health centers, provide physicians for rural constituents of a key state Senator, or some other similar related or compatible interest.
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From page 257... ...
State Support for Clinical Education. 257 NO SUPPORT Alaska Massachusetts Montana New Hampshire Rhode Island
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From page 258... ...
, Issue Paper #2. State Support for Clinical Education.
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From page 259... ...
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.
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From page 260... ...
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.
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From page 261... ...
Undated. Characteristics of Family Practice Residency Programs.
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From page 262... ...
The Journal of Family Practice.
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From page 263... ...
Prepared for the Council on Graduate Medical Education. Health Resources and Services Administration.
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From page 264... ...
1986. Trends in the Growth of Family Practice Residency Training Programs.
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From page 265... ...
Prepared for Subcommittee on Graduate Medical Education Programs and Financing. Council on Graduate Medical Education.
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From page 266... ...
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)
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From page 267... ...
F~i~ Practice Memor1~1 F~1~ Prschce Hang Beach' ^) Santa Monics F~1~ Prachce (Santa Monica' ^)
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