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Rabideau B, Richards MR, Whaley CM. Training labor and treatment behavior: Evidence from physician residency programs. HEALTH ECONOMICS 2024; 33:2059-2087. [PMID: 38825987 DOI: 10.1002/hec.4841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 06/04/2024]
Abstract
Public and private investments in physician human capital support a healthcare workforce to provide future medical services nationwide. Yet, little is known about how introducing training labor influences hospitals' provision of care. We leverage all-payer data and emergency medicine (EM) and obstetrics (OBGYN) residency program debuts to estimate local access and treatment intensity effects. We find that the introduction of EM programs coincides with less treatment intensity and suggestive increases in throughput. OBGYN programs adopt the pre-existing surgical tendencies of the hospital but may also relax some capacity constraints-allowing the marginal mother to avoid a riskier nearby hospital.
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Affiliation(s)
| | - Michael R Richards
- Cornell University, Jeb E. Brooks School of Public Policy, Ithaca, New York, USA
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Schut SM. Postgraduate training opportunities for chiropractors: A description of United States programs. THE JOURNAL OF CHIROPRACTIC EDUCATION 2024; 38:104-114. [PMID: 38258466 PMCID: PMC11097216 DOI: 10.7899/jce-23-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/31/2023] [Accepted: 11/04/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE The objective of this study was to describe and compare the current postgraduate training opportunities (PTOs) in the United States (US) for which doctors of chiropractic are eligible, namely, residencies, fellowships, and board certifications. METHODS An internet search of publicly available English-language websites on Google.com was executed using a cache-cleared private browser and key search phrases. Following webpage data extraction, e-mail and telephone follow-up were completed with officials from institutions offering doctor of chiropractic programs possessing accreditation by the Council on Chiropractic Education (CCE) in the US. Additional programs identified were annotated and incorporated into the data set if they met the inclusion criteria. Descriptive statistics were generated following data aggregation. RESULTS Three-hundred internet search results were screened, 70 of which were assessed for eligibility and 47 included for descriptive analysis. Among the 16 CCE-accredited institutions solicited, 13 returned correspondence (81.3% response rate), resulting in the addition of 2 programs to the data set ascertained by the initial web search. There were 49 PTOs for chiropractors. Of programs available, residencies represented 49.0% (24/49) of programs, and fellowships represented 12.2% (6/49) of programs. There were 19 board specialty diplomate programs, constituting 38.8% of PTOs. CONCLUSION This work details preliminary descriptive information on the current state of US-based PTOs for chiropractors.
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Morrissey PJ, Dworkin MS, Quinn MS. Impact of Inflation on Real Resident Wages. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:1237-1238. [PMID: 37506390 DOI: 10.1097/acm.0000000000005353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Affiliation(s)
- Patrick J Morrissey
- Resident physician, Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island; ; ORCID: http://orcid.org/0000-0003-2046-7962
| | - Myles S Dworkin
- Resident physician, Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew S Quinn
- Resident physician, Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island
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Fantasia KL, Demers LB, Steenkamp DW, Modzelewski KL. An Opportunity for Improvement: Evaluation of Diabetes Technology Education Among Adult Endocrinology Training Programs. J Diabetes Sci Technol 2023; 17:1274-1283. [PMID: 35135342 PMCID: PMC10563541 DOI: 10.1177/19322968221077132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite increases in continuous glucose monitor (CGM) and insulin pump use in adults with diabetes, there is room for expansion. Technology adoption may be influenced by the training environment and fellowship education. However, little is known about adult endocrinology trainee comfort with, understanding of, or methods by which trainees receive education about diabetes technology. METHODS Mixed methods, sequential explanatory evaluation using survey and semi-structured interviews of endocrinology trainees and fellowship leadership in Accreditation Council for Graduate Medical Education (ACGME)-accredited adult endocrinology fellowship programs to assess trainee and leadership comfort with, perceived knowledge of, and current methods for diabetes technology education. RESULTS Seventy-seven respondents completed the survey. The majority of training programs have curricula for training on insulin pumps (74%) and CGM (75.3%); 52% of fellows felt curricula are adequate. First- and second-year fellows were more comfortable with CGM than insulin pump use. Only half of third-year fellows felt comfortable with starting insulin pump therapy or recommending insulin dose adjustments based on CGM rate of change arrows. Qualitative interviews identified the importance of both direct instruction and experiential learning in diabetes technology education. CONCLUSIONS Almost half of trainees feel that curricula for learning to use and manage insulin pumps and CGM are inadequate and feel uncomfortable with critical aspects of technology use, demonstrating the need for increased attention to trainee education in the use of diabetes technology. Based on a better understanding of current and preferred methods for instruction, this study provides direction for future development of initiatives to improve fellow education in this field.
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Affiliation(s)
- Kathryn L. Fantasia
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Lindsay B. Demers
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Devin W. Steenkamp
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Katherine L. Modzelewski
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Oermann CM, Lahiri T, Peterson-Carmichael SL, Weiss P. The history of workforce concerns in pediatric pulmonary Medicine. Pediatr Pulmonol 2023; 58:683-689. [PMID: 32986316 DOI: 10.1002/ppul.25094] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022]
Abstract
Children are affected by a broad spectrum of acute and chronic respiratory disorders. The number of children with respiratory disease is increasing, as are the complexity of disease pathophysiology and the management demands on pediatric pulmonologists. Despite slowly increasing numbers of board-certified pediatric pulmonologists, large areas of the country are underserved and there is a perception of an impending workforce crisis. There are multiple reasons for these concerns. A joint effort between the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association was undertaken to address these issues.
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Affiliation(s)
- Christopher M Oermann
- Department of Pediatrics, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri, USA
| | - Thomas Lahiri
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | | | - Pnina Weiss
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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Kashner TM, Greenberg PB, Henley SS, Bowman MA, Sanders KM. Assessing Physician Resident Contributions to Outpatient Clinical Workload. Med Care 2022; 60:709-717. [PMID: 35899991 PMCID: PMC9365263 DOI: 10.1097/mlr.0000000000001752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics. OBJECTIVE Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners. RESEARCH DESIGN VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units. MEASURES Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity. RESULTS Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care). CONCLUSIONS Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties.
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Affiliation(s)
- T. Michael Kashner
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
- Loma Linda University Medical School, Loma Linda, CA
| | - Paul B. Greenberg
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
- Brown University School of Medicine, Providence RI
| | - Steven S. Henley
- Loma Linda University Medical School, Loma Linda, CA
- Martingale Research Corporation, Plano, TX
| | - Marjorie A. Bowman
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
| | - Karen M. Sanders
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
- Virginia Commonwealth University School of Medicine, Richmond, VI
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Ellsworth WA, Gratzon AC, Friedman JD. The Business of Employed Plastic Surgery: Creating Your Seat at the Table. Plast Reconstr Surg 2022; 149:989-998. [PMID: 35196300 DOI: 10.1097/prs.0000000000008934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND While the landscape of medicine changes, hospital employment continues to gain popularity in surgical specialties. The number of plastic surgeons entering an employed relationship has also grown, offering new opportunities and challenges alike. The authors studied the profitability of plastic surgery to the hospital and the necessity of the specialty to hospital administration through financial net revenue, contribution margin, and payer mix, to help plastic surgeons realize and capitalize on their importance and contribution to the hospital system. METHODS Facility net revenue and contribution margin from Houston Methodist West Hospital were evaluated. Average net revenue and contribution margin for inpatient and outpatient cases for plastic surgery, orthopedic surgery, and all combined surgical specialties were studied for the 2018 and 2019 fiscal years. RESULTS The authors demonstrated net increase per year for both outpatient and inpatient revenue in favor of plastic surgery versus orthopedics and combined surgical specialties. Plastic surgery contributed higher facility net revenue when compared to orthopedics, contributing 20 percent more per outpatient case and 86 percent more per inpatient case. A higher contribution margin for each year was realized for inpatient cases versus orthopedics and combined surgical specialties, increasing by 8 percent and 53 percent and 61 percent and 86 percent, respectively. CONCLUSIONS A surgeon's ability to present objective financial data and develop leadership roles within the hospital system can lead to a favorable outcome for both physician and hospital. An objective dialogue with hospital administration is critical and offers an avenue to negotiate the development of your practice.
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Affiliation(s)
- Warren A Ellsworth
- From the Houston Methodist West Hospital; Department of Plastic and Reconstructive Surgery Residency Program, Houston Methodist Hospital; and Houston Methodist Institute of Reconstructive Surgery
| | - Andrew C Gratzon
- From the Houston Methodist West Hospital; Department of Plastic and Reconstructive Surgery Residency Program, Houston Methodist Hospital; and Houston Methodist Institute of Reconstructive Surgery
| | - Jeffrey D Friedman
- From the Houston Methodist West Hospital; Department of Plastic and Reconstructive Surgery Residency Program, Houston Methodist Hospital; and Houston Methodist Institute of Reconstructive Surgery
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Weinstein DF, Choi JG, Mercaldo ND, Stump NN, Paras ML, Berube RA, Hur C. Is Resident-Driven Inpatient Care More Expensive? Challenging a Long-Held Assumption. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1205-1212. [PMID: 33496432 DOI: 10.1097/acm.0000000000003939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE The financial impact of graduate medical education (GME) on teaching hospitals remains poorly understood, while calls for increased federal support continue alongside legislative threats to reduce funding. Despite studies suggesting that residents are more "economical" than alternative providers, GME is widely believed to be an expensive investment. Assumptions that residents increase the cost of patient care have persisted in the absence of convincing evidence to the contrary. Thus, the authors sought to examine resident influence on patient care costs by comparing costs between a resident-driven service (RS) and a nonresident-covered service (NRS), with attention to clinical outcomes and how potential cost differences relate to the utilization of resources, length of stay (LOS), and other factors. METHOD This prospective study compared costs and clinical outcomes of internal medicine patients admitted to an RS versus an NRS at Massachusetts General Hospital (July 1, 2016-June 30, 2017). Total variable direct costs of inpatient admission was the primary outcome measure. LOS; 30-day readmission rate; utilization related to diagnostic radiology, pharmaceuticals, and clinical labs; and other outcome measures were also compared. Linear regression models quantified the relationship between log-transformed variable direct costs and service. RESULTS Baseline characteristics of 5,448 patients on the 2 services (3,250 on an RS and 2,198 on an NRS) were similar. On an RS, patient care costs were slightly less and LOS was slightly shorter than on an NRS, with no significant differences in hospital mortality or 30-day readmission rate detected. Resource utilization was comparable between the services. CONCLUSIONS These findings undermine long-held assumptions that residents increase the cost of patient care. Though not generalizable to ambulatory settings or other specialties, this study can help inform hospital decision making around sponsorship of GME programs, especially if federal funding for GME remains capped or is subject to additional reductions.
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Affiliation(s)
- Debra F Weinstein
- D.F. Weinstein is vice president, Graduate Medical Education, Mass General Brigham, and associate professor of medicine, Harvard Medical School, Boston, Massachusetts
| | - Jin G Choi
- J.G. Choi is a second-year medical student, University of Chicago Pritzker School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0001-8517-8374
| | - Nathaniel D Mercaldo
- N.D. Mercaldo is statistician, Department of Radiology and Institute for Technology Assessment, Massachusetts General Hospital, and instructor of radiology, Harvard Medical School, Boston, Massachusetts
| | - Natalie N Stump
- N.N. Stump is a fourth-year medical student, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Molly L Paras
- M.L. Paras is infectious disease fellowship director, Mass General Brigham, and instructor of medicine, Harvard Medical School, Boston, Massachusetts
| | - Rhodes A Berube
- R.A. Berube is senior administrative director for clinical operations, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Hur
- C. Hur is director, Healthcare Innovations Research and Evaluation, and professor of medicine, Columbia University, New York, New York
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Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK. Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration. MDM Policy Pract 2021; 6:23814683211057902. [PMID: 34820527 PMCID: PMC8606928 DOI: 10.1177/23814683211057902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background. Veterans' access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.
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Affiliation(s)
- Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Gordon WE, Mangham WM, Michael LM, Klimo P. The economic value of an on-call neurosurgical resident physician. J Neurosurg 2021; 135:169-175. [PMID: 32916653 DOI: 10.3171/2020.3.jns193454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The cost of training neurosurgical residents is especially high considering the duration of training and the technical nature of the specialty. Despite these costs, on-call residents are a source of significant economic value, through both indirectly and directly supervised activities. The authors sought to identify the economic value of on-call services provided by neurosurgical residents. METHODS A personal call log kept by a single junior neurosurgical resident over a 2-year period was used to obtain the total number of consultations, admissions, and procedures. Current Procedural Terminology (CPT) codes were used to estimate the resident's on-call economic value. RESULTS A single on-call neurosurgical resident at the authors' institution produced 8172 work relative value units (wRVUs) over the study period from indirectly and directly supervised activities. Indirectly supervised procedures produced 7052 wRVUs, and directly supervised activities using the CPT modifier 80 yielded an additional 1120 wRVUs. Using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the 2-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually. CONCLUSIONS Neurosurgery residents at the authors' institution theoretically produce enough economic value exclusively from on-call activities to far exceed the cost of their education. This information could be used to more precisely estimate the true overall cost of neurosurgical training and determine future graduate medical education funding.
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Affiliation(s)
- William E Gordon
- 1Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis
| | - William M Mangham
- 1Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis
| | - L Madison Michael
- 1Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis
- 2Semmes Murphey, Memphis; and
| | - Paul Klimo
- 1Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis
- 2Semmes Murphey, Memphis; and
- 3Le Bonheur Children's Hospital, Memphis, Tennessee
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Royce TJ, Jones GP, Muralidhar V, Chowdhary M, Holmes GM. US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019. J Grad Med Educ 2021; 13:385-389. [PMID: 34178264 PMCID: PMC8207908 DOI: 10.4300/jgme-d-20-00941.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 02/24/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized. OBJECTIVE We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care. METHODS Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system. RESULTS Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22). CONCLUSIONS We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.
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Affiliation(s)
- Trevor J. Royce
- Trevor J. Royce, MD, MS, MPH, is Assistant Professor, Department of Radiation Oncology, University of North Carolina at Chapel Hill
| | - Gavin P. Jones
- Gavin P. Jones, MD, is a Resident Physician, Department of Radiation Oncology, University of Kentucky
| | - Vinayak Muralidhar
- Vinayak Muralidhar, MD, MSc, is Chief Resident, Department of Radiation Oncology, Dana Farber Cancer Institute
| | - Mudit Chowdhary
- Mudit Chowdhary, MD, is a Resident Physician, Department of Radiation Oncology, Rush University
| | - George M. Holmes
- George M. Holmes, PhD, is Professor, Department of Health Policy and Management, University of North Carolina at Chapel Hill
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Chen JX, Shah SA, Rathi VK, Varvares MA, Gray ST. Graduate Medical Education in Otolaryngology: Making Dollars and Sense of Reform. Otolaryngol Head Neck Surg 2021; 165:762-764. [PMID: 33845661 DOI: 10.1177/01945998211004263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals.
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Affiliation(s)
- Jenny X Chen
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Sloan FA. Quality and Cost of Care by Hospital Teaching Status: What Are the Differences? Milbank Q 2021; 99:273-327. [PMID: 33751662 DOI: 10.1111/1468-0009.12502] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care. CONTEXT The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy. METHODS Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers. FINDINGS Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures. CONCLUSIONS Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.
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Lo Sasso AT. Regulating high-skilled immigration: The market for medical residents. JOURNAL OF HEALTH ECONOMICS 2021; 76:102436. [PMID: 33556781 DOI: 10.1016/j.jhealeco.2021.102436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 12/24/2020] [Accepted: 01/18/2021] [Indexed: 06/12/2023]
Abstract
The effect of high-skill immigration remains central to many US industries and policy debates. Beginning in 2009, the federal government heightened enforcement of existing laws and increased employer fees for the cost of obtaining certain common immigration visas. The change can be viewed as a de facto tax on immigrant labor. I estimate the extent to which high-skill non-citizen workers, in the form of international medical school graduates seeking residency training in US teaching hospitals, are displaced by US citizens who received their medical school training abroad. Changes in immigration policy can have important effects in this labor market with implications for the larger health care system. I find that demand for medical residents among teaching hospitals based on immigration status is highly responsive to increased regulatory cost.
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Affiliation(s)
- Anthony T Lo Sasso
- Department of Economics, DePaul University, 1 East Jackson, Chicago, IL, 60604, United States.
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Hidden Costs in Resident Training: Financial Cohort Analysis of First Assistants in Reduction Mammaplasty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3333. [PMID: 33564574 PMCID: PMC7859249 DOI: 10.1097/gox.0000000000003333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022]
Abstract
Graduate medical education (GME) programs are vital to developing future plastic surgeons. However, their cost-efficiency has yet to be contextualized. This cohort quality improvement (QI) project aimed to measure the indirect costs an institution assumes in training surgical residents, by comparing the differences in operative time and procedural charges between a resident and a physician assistant (PA) first-assisting during adolescent reduction mammaplasty.
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Zinoviev R, Krumholz HM, Pirruccio K, Forman H. Association of Graduate Medical Education With Hospital Performance and Patient Outcomes. JAMA Netw Open 2021; 4:e2034196. [PMID: 33507257 PMCID: PMC7844596 DOI: 10.1001/jamanetworkopen.2020.34196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Graduate medical education (GME) funding consists of more than $10 billion annual subsidies awarded to academic hospitals to offset the cost of resident training. Critics have questioned the utility of these subsidies and accountability of recipient hospitals. OBJECTIVE To determine the association of GME funding with hospital performance by examining 3 domains of hospital operations: financial standing, clinical outcomes, and resident academic performance. DESIGN, SETTING, AND PARTICIPANTS This study is an economic evaluation of all academic centers that received GME funding in 2017. GME funding data were acquired from the Hospital Compare Database. Statistical analysis was performed from May 2016 to April 2020. EXPOSURES GME funding. MAIN OUTCOMES AND MEASURES This study assessed the association between GME funding and each aspect of hospital operations. Publicly available hospital financial data were used to calculate a financial performance score from 0 to 100 for each hospital. Clinical outcomes were defined as 30-day mortality, readmission, and complication rates for a set of predefined conditions. Resident academic performance was determined by Board Certification Examination (BCE) pass rates at 0, 2, and 5 years after GME funding was awarded. Confounder-adjusted linear regression models were used to test association between GME funding data and a hospital's financial standing, clinical outcomes, and resident academic performance. RESULTS The sample consisted of 1298 GME-funded hospitals, with a median (IQR) of 265 (168-415) beds and 32 (10-101) residents per training site. GME funding was negatively correlated with hospitals' financial scores (β = -7.9; 95% CI, -10.9 to -4.8, P = .001). Each additional $1 million in GME funding was associated with lower 30-day mortality from myocardial infarction (-2.34%; 95% CI, -3.59% to -1.08%, P < .001), heart failure (-2.59%; 95% CI, -3.93% to -1.24%, P < .001), pneumonia (-2.20%; 95% CI, -3.99% to -0.40%, P = .02), chronic obstructive pulmonary disease ( -1.20%; 95% CI, -2.35% to -0.05%, P = .04), and stroke (-3.40%; 95% CI, -5.46% to -1.33%, P = .001). There was no association between GME funding and readmission rates. There was an association between higher GME funding and higher internal medicine BCE pass rates (0.066% [95% CI, 0.033% to 0.099%] per $1 million in GME funding; P < .001). CONCLUSIONS AND RELEVANCE This study found a negative linear correlation between GME funding and patient mortality and a positive correlation between GME funding and resident BCE pass rates in adjusted regression models. The findings also suggest that hospitals that receive more GME funding are not more financially stable.
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Affiliation(s)
- Radoslav Zinoviev
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
- now with Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute Cleveland Clinic, Cleveland, Ohio
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Kevin Pirruccio
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Howard Forman
- Yale School of Management, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
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17
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Grischkan JA, Friedman AB, Chandra A. Moving the Financing of Graduate Medical Education Into the 21st Century. JAMA 2020; 324:1035-1036. [PMID: 32857138 DOI: 10.1001/jama.2020.15480] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | - Ari B Friedman
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Leonard David Institute of Health Economics, Philadelphia, Pennsylvania
| | - Amitabh Chandra
- Harvard Kennedy School, Cambridge, Massachusetts
- Harvard Business School, Cambridge, Massachusetts
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Alonso-Arroyo A, González de Dios J, Calvo C, Calduch-Losa Á, Aleixandre-Benavent R. Scientific impact and bibliometric contextualisation of paediatrics compared to other specialities☆. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Alonso-Arroyo A, González de Dios J, Calvo C, Calduch-Losa Á, Aleixandre-Benavent R. [Scientific impact and bibliometric contextualisation of Paediatrics compared to other specialities]. An Pediatr (Barc) 2020; 92:172.e1-172.e12. [PMID: 32067927 DOI: 10.1016/j.anpedi.2019.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The purpose of this paper is twofold. On the one hand, to identify and characterise the production, citation, impact and collaboration indicators of the Pediatrics area of the Journal Citation Reports, and on the other hand, to place the journal Anales de Pediatría in the context of the Spanish journals of another twenty areas and medical specialties. MATERIAL AND METHOD The sources of information used to obtain the indicators were Science Citation Index-Expanded, Journal Citation Reports, and Scimago Journal & Country Rank. A regression analysis was performed to determine the correlation between the citation and other variables. RESULTS Pediatrics ranked 8th in scientific production during the period 2009-2018. In citations per journal it ranks 17th, and the average citations per article approaches 27, occupying, in this case, the 18th position. Below Pediatrics are Emergency Medicine, Rehabilitation, and Primary Health Care. There are no citations for 12.47% of the articles. The average impact factor places the area in 18th place and its h index was 197, reaching 14th position, and standing above seven other areas. The percentage of works carried out with international collaboration was 17.71%, above Primary Health Care (12.88%), Oncology (16.37%), and Emergency Medicine (17.03%). Among the Spanish journals, Anales de Pediatría was the fourth most productive journal, and occupied an intermediate position in terms of the number of citations. CONCLUSIONS The indicators of citation and impact of the Pediatrics area tend to be above areas such as Emergency Medicine, Primary Health Care, Dentistry, Oral Surgery & Medicine, and Rehabilitation. Professional practice outside large hospitals, together with poor funding, as well as the low number of clinical trials due to the ethical requirements imposed on studies with children, may be the causes that result in moderate citation and impact indicators.
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Affiliation(s)
- Adolfo Alonso-Arroyo
- Departamento de Historia de la Ciencia y Documentación, Universitat de València, Valencia, España; UISYS, Unidad Mixta de Investigación, Universitat de València-CSIC, Valencia, España
| | - Javier González de Dios
- Departamento de Pediatría, Universidad Miguel Hernández, Alicante, España; Servicio de Pediatría, Hospital General Universitario de Alicante, Alicante, España; ISABIAL-Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - Cristina Calvo
- Servicio de Pediatría, Enfermedades Infecciosas y Tropicales, Fundación IdiPaz, Hospital Universitario La Paz, Madrid, España; Universidad Alfonso X el Sabio, Madrid, España; RETIC SAMID Carlos III, Madrid, España; Red de Ensayos Clínicos en Pediatría (RECLIP), España; Red de Investigación Translacional en Infectología Pediátrica (RITIP), España; Plataforma de Investigación INVEST-AEP, España
| | - Ángeles Calduch-Losa
- Departamento Estadística e Investigación Operativa Aplicadas y Calidad, Universitat Politècnica de València, Valencia, España
| | - Rafael Aleixandre-Benavent
- UISYS, Unidad Mixta de Investigación, Universitat de València-CSIC, Valencia, España; Instituto de Gestión de la Innovación y del Conocimiento-Ingenio (CSIC-Universitat Politècnica de València), Valencia, España.
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Weiss P, Mauer E, Gerber LM, Boyer D, Abramson EL. Funding sources and effects of limited funding in pediatric pulmonology fellowship programs. Pediatr Pulmonol 2020; 55:221-225. [PMID: 31578809 DOI: 10.1002/ppul.24536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/19/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND The pediatric pulmonology workforce is at risk. Access to pediatric pulmonologists to meet patient needs is limited and recruitment of new trainees to replace the aging, retiring physician population may be inadequate. Furthermore, sources of funding for graduate medical education are insecure. However, no prior studies have identified the funding sources of pediatric pulmonology fellowships or the effects of funding constraints. METHODS We conducted a national survey of pediatric pulmonology training directors (PPTD) in the United States between 1 November, 2016 and 9 February, 2017 to examine the sources of funding for pediatric pulmonary fellows and the effect of funding limitations. RESULTS We obtained data from 48 PPTD, representing 89% of pediatric pulmonology programs (N = 54). Limitations in funding restricted program size in 31% of programs. A significant number of programs had no funding to cover educational resources such as advanced degrees (38%), courses (23%), society membership (25%), and journals and books (15%). Twenty seven percent of PPTD perceived their program as financially insecure for academic year 2019 and beyond. CONCLUSIONS Insufficient funding has limited the size of pediatric pulmonology programs and access to important educational resources. It is critical to ensure that there is adequate funding for pediatric pulmonology fellowship programs, as insecurity further endangers the pediatric pulmonology workforce and future provision of care for children with respiratory diseases.
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Affiliation(s)
- Pnina Weiss
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Elizabeth Mauer
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Linda M Gerber
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Debra Boyer
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Erika L Abramson
- Departments of Pediatrics and Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
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Tendulkar RD, Royce TJ, Olivier KR, Fields EC, Golden DW, Vapiwala N. Educators' Perspectives on the Association of Residents in Radiation Oncology Survey of Residents' Concerns. Pract Radiat Oncol 2019; 10:215-219. [PMID: 31790825 DOI: 10.1016/j.prro.2019.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/17/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rahul D Tendulkar
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio.
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Kenneth R Olivier
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneapolis
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel W Golden
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Neha Vapiwala
- Department of Radiation Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Mason PK. Financing graduate medical education: challenges for training the next generation of electrophysiologists. J Interv Card Electrophysiol 2019; 56:143-150. [DOI: 10.1007/s10840-018-0406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022]
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Gani F, Ejaz A, Dillhoff M, He J, Weiss M, Wolfgang CL, Cloyd J, Tsung A, Johnston FM, Pawlik TM. A national assessment of the utilization, quality and cost of laparoscopic liver resection. HPB (Oxford) 2019; 21:1327-1335. [PMID: 30850188 DOI: 10.1016/j.hpb.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/12/2018] [Accepted: 02/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite recent enthusiasm for the use of laparoscopic liver resection, data evaluating costs associated with laparoscopic liver resections are lacking. We sought to examine the use of laparoscopic liver surgery, and investigate variations in cost among hospitals performing these procedures. METHODS A nationally representative sample of 12,560 patients who underwent a liver resection in 2012 was identified. Multivariable analyses were performed to compare outcomes associated with liver resection. RESULTS Among the 12,560 patients who underwent liver resection, 685 (5.4%) underwent a laparoscopic liver resection. The proportion of liver resections performed laparoscopically varied among hospitals ranging from 4.6% to 20.0%; the median volume of laparoscopic liver resections was 10 operations/year. Although laparoscopic surgery was associated with lower postoperative morbidity (aOR = 0.60, 95%CI: 0.36-0.99) and shorter lengths of stay [(LOS) aIRR = 0.83, 95%CI: 0.70-0.97], it was not associated with inpatient mortality (p = 0.971) or hospital costs (p = 0.863). Costs associated with laparoscopic liver resection varied ranging from $5,907 (95%CI: $5,140-$6,674) to $67,178 (95%CI: $66,271-$68,083). The observed variations between hospitals were due to differences in morbidity (coefficient: $20,415, 95%CI: $16,000-$24,830) and LOS (coefficient: $24,690, 95%CI: $21,688-$27,692). CONCLUSIONS Although laparoscopic liver resection was associated with improved short-term perioperative clinical outcomes, utilization of laparoscopic liver resection remains low.
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Affiliation(s)
- Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aslam Ejaz
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jordan Cloyd
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA.
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Weiss P, Myers AL, McGann KA, Mason KE, Kesselheim JC, Fleming G, Barron C, Klasner A, Heyman MB, Weiss DL, Mauer E, Gerber LM, Abramson EL. Funding Sources and Perceived Financial Insecurity in Pediatric Subspecialty Fellowship Programs. Acad Pediatr 2019; 19:815-821. [PMID: 31200029 DOI: 10.1016/j.acap.2019.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 05/24/2019] [Accepted: 06/01/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Shortages of pediatric subspecialists exist in many fields with insufficient recruitment of new fellows. The current system of funding graduate medical education is inadequate. We examined funding sources for trainee salary and educational expenses in pediatric fellowship programs, effects of funding constraints, and program characteristics associated with financial insecurity as reported by fellowship program directors (FPD). METHODS We conducted a national survey of FPD between November 1, 2016 and February 9, 2017. We used multivariable logistic regression to examine the association between perceived financial insecurity, program characteristics, and funding sources for fellow salary. RESULTS We obtained data from 519 FPD, representing 14 different pediatric subspecialties. FPD reported that funding limitations restricted program size and educational resources in 22% and 36% of programs, respectively. Nineteen percent of FPD perceived funding of their program to be insecure. Programs with 7 or more fellows (OR .50 [95% CI .27-.90], P = .03) or hospital or graduate medical education/Children's Hospital graduate medical education funding (OR .58 [95% CI .35-.96], P = .04) were less likely to be perceived as insecure. Conversely, programs with extramural (OR 1.74 [95% CI 1.07-2.81], P = .03) or division funding (OR 1.70 [95% CI 1.02-2.82], P = .04) or in subspecialties with more than 25% unfilled positions or programs (OR 1.86 [95% CI 1.11-3.09], P = .02) were more likely to be perceived as insecure. CONCLUSIONS Perceived financial insecurity of fellowship programs was strongly associated with program size, funding source, and unfilled positions, limiting recruitment and resources. Stable funding of fellowship programs is critical to maintain an adequate pediatric subspecialty workforce.
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Affiliation(s)
- Pnina Weiss
- Yale University School of Medicine (P Weiss), New Haven, Conn.
| | - Angela L Myers
- Children's Mercy Kansas City (AL Myers), Kansas City, Mo
| | | | - Katherine E Mason
- The Warren Alpert Medical School at Brown University (KE Mason and C Barron), Providence, RI
| | | | - Geoffrey Fleming
- Vanderbilt University School of Medicine (G Fleming), Nashville, Tenn
| | - Christine Barron
- The Warren Alpert Medical School at Brown University (KE Mason and C Barron), Providence, RI
| | - Ann Klasner
- University of Alabama at Birmingham (A Klasner), Birmingham, Ala
| | - Melvin B Heyman
- University of California at San Francisco (MB Heyman), San Francisco, Calif
| | | | - Elizabeth Mauer
- Weill Cornell Medicine (E Mauer, LM Gerber, and EL Abramson), New York, NY
| | - Linda M Gerber
- Weill Cornell Medicine (E Mauer, LM Gerber, and EL Abramson), New York, NY
| | - Erika L Abramson
- Weill Cornell Medicine (E Mauer, LM Gerber, and EL Abramson), New York, NY
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Khullar D, Frakt AB, Burke LG. Advancing the Academic Medical Center Value Debate: Are Teaching Hospitals Worth It? JAMA 2019; 322:205-206. [PMID: 31206128 DOI: 10.1001/jama.2019.8306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Dhruv Khullar
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Austin B Frakt
- Partnered Evidence-Based Policy Resource Center, Veterans Health Administration, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Laura G Burke
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Bates JE, Amdur RJ, Lee WR. The High Number of Unfilled Positions in the 2019 Radiation Oncology Residency Match: Temporary Variation or Indicator of Important Change? Pract Radiat Oncol 2019; 9:300-302. [PMID: 31100471 DOI: 10.1016/j.prro.2019.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Affiliation(s)
- James E Bates
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida, Gainesville, Florida.
| | - W Robert Lee
- Department of Radiation Oncology, Duke University, Durham, North Carolina
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27
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Why Graduate Medical Education Funding Matters. J Am Coll Radiol 2018; 15:1517-1520. [DOI: 10.1016/j.jacr.2018.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/18/2018] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
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Stipelman CH, Poss B, Stetson LA, Boi L, Rogers M, Puzey C, Koduri S, Kaplan R, Lee VS, Clark EB. Financial Analysis of Pediatric Resident Physician Primary Care Longitudinal Outpatient Experience. Acad Pediatr 2018; 18:837-842. [PMID: 29777782 DOI: 10.1016/j.acap.2018.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To determine whether residency training represents a net positive or negative cost to academic medical centers, we analyzed the cost of a residency program and clinical productivity of residents and faculty in an outpatient primary care practice with or without residents. METHODS Patient volume and revenue data (Current Procedural Terminology codes) from an academic primary care general pediatric clinic were evaluated for faculty clinics (faculty only) and resident teaching clinics (longitudinal outpatient experience [LOE]) with 1 to 4 residents per faculty. A detailed cost per resident was determined using a departmental financial model that included salary, benefits, faculty and administrative staff effort, nonpersonnel costs, and institutional graduate medical education support. RESULTS The LOE clinics had a greater mean number of patient visits (11.6 vs 6.8) than faculty clinics per faculty member. In the LOE clinic, the number of patient visits per clinic was directly proportional to the number of residents per faculty. The cost for each resident was $250 per clinic ($112 per resident, $88 per medical assistant per resident, and $50 per room per resident). When factoring in clinic costs and faculty supervision time, the LOE clinics (average 3.5 residents with 1 supervising faculty) had greater average cost (+$687.00) and revenue (+$319.45) and lower operating margin (revenue minus cost, -$367.55) than the faculty clinics (1 faculty member). CONCLUSIONS Pediatric resident LOE clinics had a greater average number of patient visits and revenue per faculty member but higher costs and lower operating margins than faculty clinics.
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Affiliation(s)
- Carole H Stipelman
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah.
| | - Brad Poss
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah; University of Utah Health, Salt Lake City, Utah
| | | | - Luca Boi
- University of Utah Health, Salt Lake City, Utah
| | - Michael Rogers
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
| | - Caleb Puzey
- University of Utah Health, Salt Lake City, Utah
| | - Sri Koduri
- University of Utah Health, Salt Lake City, Utah
| | | | - Vivian S Lee
- Department of Radiology, University of Utah Health, Salt Lake City, Utah
| | - Edward B Clark
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah; University of Utah Health, Salt Lake City, Utah
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Chen Q, Bagante F, Merath K, Idrees J, Beal EW, Cloyd J, Dillhoff M, Schmidt C, Diaz A, White S, Pawlik TM. Hospital Teaching Status and Medicare Expenditures for Hepato-Pancreato-Biliary Surgery. World J Surg 2018; 42:2969-2979. [DOI: 10.1007/s00268-018-4566-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Rieselbach RE, Epperly T, Friedman A, Keahey D, McConnell E, Nichols K, Nycz G, Roberts J, Schmader K, Shin P, Shtasel D. A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:406-413. [PMID: 28930763 DOI: 10.1097/acm.0000000000001901] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.
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Affiliation(s)
- Richard E Rieselbach
- R.E. Rieselbach is professor emeritus of medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, and past president, Association of Program Directors in Internal Medicine. T. Epperly is president and chief executive officer, Family Medicine Residency of Idaho, clinical professor of family medicine, University of Washington School of Medicine, Seattle, Washington, and past president and board chair, American Academy of Family Physicians. A. Friedman is professor emeritus of pediatrics, past vice president, Health Sciences, and former dean, University of Minnesota Medical School, Minneapolis, Minnesota, and former board chair, American Board of Pediatrics. D. Keahey is chief advocacy and research officer, Physician Assistant Education Association, and adjunct associate professor, University of Utah School of Medicine, Utah Physician Assistant Program, Salt Lake City, Utah; ORCID: http://orcid.org/0000-0003-3107-3678. E. McConnell is associate professor, Duke University School of Nursing, clinical nurse specialist and nurse scientist, Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Durham, North Carolina, director, Center of Excellence in Geriatric Nursing Education, and codirector, Health Resources and Services Administration-funded Duke Geriatric Workforce Enhancement Program; ORCID: http://orcid.org/0000-0002-2896-8596. K. Nichols is professor of internal medicine and dean, Chicago College of Medicine, Downers Grove, Illinois, past president, American Osteopathic Association, and president, Institute of Medicine of Chicago; ORCID: http://orcid.org/0000-0002-4960-4118. G. Nycz is executive director, Family Health Center of Marshfield, Inc., Marshfield, Wisconsin; ORCID: http://orcid.org/0000-0001-6151-0336. J. Roberts is professor and former dean, School of Pharmacy, and director, Center for Interprofessional Practice and Education, University of Wisconsin-Madison, Madison, Wisconsin; ORCID: http://orcid.org/0000-0002-2309-7621. K. Schmader is professor of medicine and chief, Division of Geriatrics, Department of Medicine, Duke University Medical Center, director, Geriatric Research, Education and Clinical Center, and associate chief of staff, Geriatrics and Extended Care, Department of Veterans Affairs Medical Center, Durham, North Carolina. P. Shin is associate professor, Health Policy and Management, George Washington University, Washington, DC, and director, Geiger Gibson Program in Community Health, RCHN Community Health Foundation. D. Shtasel is founding director, Kraft Family National Center for Leadership and Training in Community Health, Massachusetts General Hospital Michele and Howard J. Kessler Chair in Public and Community Psychiatry, and associate professor of psychiatry, Harvard Medical School, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-8932-8066
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van Rossum TR, Scheele F, Sluiter HE, Bosman PJ, Rijksen L, Heyligers IC. Flexible competency based medical education: More time efficient, higher costs. MEDICAL TEACHER 2018; 40:315-317. [PMID: 29141485 DOI: 10.1080/0142159x.2017.1395404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The financing of postgraduate medical education (PGME) becomes an important topic. PGME is costly, and in most western countries is partly paid by public funding. One of the models that can help to reduce costs is time-variable PGME. Moving to true outcome-based education can lead to more efficient training programs while maintaining educational quality. We analyzed the financial effects of time-variable PGME by identifying the educational activities of PGME programs and comparing the costs and revenues of these activities in gynecology training as an example. This resulted in a revenue-cost balance of PGME activities in gynecology. As gynecology consists of both surgical and non-surgical parts, this specialty is a good starting point for a training cost analysis that can be used for a more general discussion. Shortening PGME programs without losing educational quality appears to be possible with time-variable structures. However, shortening is only safely possible on those areas in which residents have already obtained the desired level of competence. This means that time can be gained at the expense of those educational activities in which residents generate the highest revenues. We therefore conclude that shorter education with the help of time-variable training schemes leads to overall higher costs at the hospital level.
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Affiliation(s)
- Tiuri R van Rossum
- a School of Health Professions Education (SHE) , Maastricht University , Maastricht , The Netherlands
| | - Fedde Scheele
- b VU University and VU University Medical Center , Amsterdam , The Netherlands
- c OLVG Teaching Hospital , Amsterdam , The Netherlands
| | - Henk E Sluiter
- d Deventer Hospital , Deventer , The Netherlands
- e Department of Internal Medicine and Nephrology , Deventer Hospital , Deventer , The Netherlands
| | - Peter J Bosman
- f Independent Management Consultant , Bodegraven , The Netherlands
| | - Lotte Rijksen
- g The Dutch Association of Medical Specialists , Utrecht , The Netherlands
| | - Ide C Heyligers
- a School of Health Professions Education (SHE) , Maastricht University , Maastricht , The Netherlands
- h Zuyderland Medical Center , Heerlen , The Netherlands
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MacKinnon M, Murray S. Reframing Physician Burnout as an Organizational Problem: A Novel Pragmatic Approach to Physician Burnout. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2018; 42:123-128. [PMID: 28247366 DOI: 10.1007/s40596-017-0689-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/15/2017] [Indexed: 06/06/2023]
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Gonzalo JD, Thompson BM, Haidet P, Mann K, Wolpaw DR. A Constructive Reframing of Student Roles and Systems Learning in Medical Education Using a Communities of Practice Lens. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017. [PMID: 28640036 DOI: 10.1097/acm.0000000000001778] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Health systems are in the midst of a transformation that is being driven by a variety of forces. This has important implications for medical educators because clinical practice environments play a key role in learning and professional development, and evolving health systems are beginning to demand that providers have "systems-ready" knowledge, attitudes, and skills. Such implications provide a clear mandate for medical schools to modify their goals and prepare physicians to practice flexibly within teams and effectively contribute to the improvement of health care delivery. In this context, the concepts of value-added medical education, authentic student roles, and health systems science are emerging as increasingly important. In this Article, the authors use a lens informed by communities of practice theory to explore these three concepts, examining the implications that the communities of practice theory has in the constructive reframing of educational practices-particularly common student roles and experiences-and charting future directions for medical education that better align with the needs of the health care system. The authors apply several key features of the communities of practice theory to current experiential roles for students, then propose a new approach to students' clinical experiences-value-added clinical systems learning roles-that provides students with opportunities to make meaningful contributions to patient care while learning health systems science at the patient and population level. Finally, the authors discuss implications for professional role formation and anticipated challenges to the design and implementation of value-added clinical systems learning roles.
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Affiliation(s)
- Jed D Gonzalo
- J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania; ORCID: http://orcid.org/0000-0003-1253-2963. B.M. Thompson is professor of medicine and associate dean for learner assessment and program evaluation, Penn State College of Medicine, Hershey, Pennsylvania. P. Haidet is professor of medicine, humanities, and public health sciences and director of medical education research, Penn State College of Medicine, Hershey, Pennsylvania. K. Mann was professor emeritus, Division of Medical Education, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. D.R. Wolpaw is professor of medicine and humanities, senior consultant for education innovation, Regional Medical Campus, and director, Doctors Kienle Center for Humanistic Medicine, Penn State College of Medicine, Hershey, Pennsylvania
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Lichtenstein C, Cora-Bramble D, Ottolini M, Agrawal D. Is There a Return on a Children’s Hospital’s Investment in a Pediatric Residency’s Community Health Track? A Cost Analysis. J Community Health 2017; 43:372-377. [DOI: 10.1007/s10900-017-0433-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Financial, Resource Utilization and Mortality Impacts of Teaching Hospital Status on Pediatric Patients Admitted for Sepsis. Pediatr Infect Dis J 2017; 36:712-719. [PMID: 28033241 DOI: 10.1097/inf.0000000000001526] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the changing healthcare landscape in the United States, teaching hospitals face increasing pressure to provide medical education as well as cost-effective care. Our study investigated the financial, resource utilization and mortality impact of teaching hospital status on pediatric patients admitted with sepsis. METHODS We conducted a retrospective, weighted statistical analysis of hospitalized children with the diagnosis of sepsis. The Agency for Healthcare Research and Quality 2009 Kids' Inpatient Database provided the data for analysis. Diagnosis of sepsis and severity of illness levels were based on All Patient Refined Diagnosis-Related Groups of 720: Septicemia and Disseminated Infections. Teaching hospital status was based on presence of training programs. Statistical analysis was conducted using STATA 12.1 (Stata Corporation, College Station, TX). RESULTS Weighted analysis revealed 17,461 patients with sepsis-9982 in teaching and 7479 in nonteaching hospitals. When comparing all patients, length of stay (8.2 vs. 4.8, P < 0.001), number of procedures received (2.03 vs. 0.87, P < 0.001), mortality (4.7% vs. 1.6%, P < 0.001), costs per day ($2326 vs. $1736, P < 0.001) and total costs ($20,428 vs. $7960, P < 0.001) were higher in teaching hospitals. Even when stratified by severity classes, length of stay, number of procedures received and total costs were higher in teaching hospitals with no difference in mortality. CONCLUSIONS Our study suggested that teaching hospitals provide pediatric inpatient care for sepsis at greater costs and resource utilization without a clear improvement in overall mortality rates in comparison with nonteaching hospitals.
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Krinsky S, Ryan AM, Mijanovich T, Blustein J. Variation in Payment Rates under Medicare's Inpatient Prospective Payment System. Health Serv Res 2017; 52:676-696. [PMID: 27060973 PMCID: PMC5346495 DOI: 10.1111/1475-6773.12490] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. DATA SOURCES/STUDY SETTING Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. STUDY DESIGN We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. DATA COLLECTION/EXTRACTION METHODS Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. PRINCIPAL FINDINGS In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. CONCLUSIONS Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.
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Affiliation(s)
| | - Andrew M. Ryan
- University of Michigan School of Public Health and Institute for Healthcare Policy and InnovationAnn ArborMI
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Gonzalo JD, Baxley E, Borkan J, Dekhtyar M, Hawkins R, Lawson L, Starr SR, Skochelak S. Priority Areas and Potential Solutions for Successful Integration and Sustainment of Health Systems Science in Undergraduate Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:63-69. [PMID: 27254015 DOI: 10.1097/acm.0000000000001249] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Educators, policy makers, and health systems leaders are calling for significant reform of undergraduate medical education (UME) and graduate medical education (GME) programs to meet the evolving needs of the health care system. Nationally, several schools have initiated innovative curricula in both classroom and workplace learning experiences to promote education in health systems science (HSS), which includes topics such as value-based care, health system improvement, and population and public health. However, the successful implementation of HSS curricula across schools is challenged by issues of curriculum design, assessment, culture, and accreditation, among others. In this report of a working conference using thematic analysis of workshop recommendations and experiences from 11 U.S. medical schools, the authors describe seven priority areas for the successful integration and sustainment of HSS in educational programs, and associated challenges and potential solutions. In 2015, following regular HSS workgroup phone calls and an Accelerating Change in Medical Education consortium-wide meeting, the authors identified the priority areas: partner with licensing, certifying, and accrediting bodies; develop comprehensive, standardized, and integrated curricula; develop, standardize, and align assessments; improve the UME to GME transition; enhance teachers' knowledge and skills, and incentives for teachers; demonstrate value added to the health system; and address the hidden curriculum. These priority areas and their potential solutions can be used by individual schools and HSS education collaboratives to further outline and delineate the steps needed to create, deliver, study, and sustain effective HSS curricula with an eye toward integration with the basic and clinical sciences curricula.
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Affiliation(s)
- Jed D Gonzalo
- J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania. E. Baxley is senior associate dean of academic affairs, Brody School of Medicine at East Carolina University, Greenville, North Carolina. J. Borkan is chair and professor of family medicine and assistant dean for primary care-population health program planning, Alpert Medical School of Brown University, Providence, Rhode Island. M. Dekhtyar is research associate, Medical Education Outcomes, American Medical Association, Chicago, Illinois. R. Hawkins is vice president, Medical Education Outcomes, American Medical Association, Chicago, Illinois. L. Lawson is assistant dean for curriculum, assessment, and clinical academic affairs and assistant professor of emergency medicine, Brody School of Medicine at East Carolina University, Greenville, North Carolina. S.R. Starr is assistant professor of pediatric and adolescent medicine and director of science of health care delivery education, Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minnesota. S. Skochelak is group vice president of medical education, American Medical Association, Chicago, Illinois
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Martin M, Salzberg L. Resident characteristics to evaluate during recruitment and interview: a Delphi study. EDUCATION FOR PRIMARY CARE 2016; 28:81-85. [PMID: 27966391 DOI: 10.1080/14739879.2016.1266696] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES The recruitment and interview process for medical residency programmes is a time- and resource-intensive effort. There is very little research to guide programmes when evaluating residency candidates. This study represents one step in identifying candidate characteristics to assess during the recruitment and interview process. METHODS Sixteen expert interviewers from 14 family medicine residency programmes in North Carolina participated in a three-round Delphi study to build consensus around a ranked list of successful resident candidate characteristics. An interrater reliability analysis produced average pair-wise agreement and Krippendorff's Alpha coefficients. RESULTS Clinical skills, medical knowledge, interpersonal and communication skills, critical thinking, and professional and ethical behaviour were the highest ranked characteristics. Average pair-wise agreement for rounds two and three were 6.30 and 11.04%, respectively. CONCLUSIONS Residency programmes may benefit from using an empirically studied list of characteristics to evaluate candidate applications and interviews. Future research should include national surveys of expert interviewers from a variety of residency programmes and a longitudinal study to correlate interview evaluations using the ranked list with measures of residency success.
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Affiliation(s)
- Matthew Martin
- a Duke/Southern Regional Area Health Education Centre (AHEC) Family Medicine Residency Programme , Fayetteville , NC , USA
| | - Lenard Salzberg
- a Duke/Southern Regional Area Health Education Centre (AHEC) Family Medicine Residency Programme , Fayetteville , NC , USA
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Falit BP, Pan HY, Smith BD, Alexander BM, Zietman AL. The Radiation Oncology Job Market: The Economics and Policy of Workforce Regulation. Int J Radiat Oncol Biol Phys 2016; 96:501-10. [DOI: 10.1016/j.ijrobp.2016.05.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/10/2016] [Accepted: 05/25/2016] [Indexed: 11/29/2022]
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Gonzalo JD, Haidet P, Blatt B, Wolpaw DR. Exploring challenges in implementing a health systems science curriculum: a qualitative analysis of student perceptions. MEDICAL EDUCATION 2016; 50:523-31. [PMID: 27072441 DOI: 10.1111/medu.12957] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/30/2015] [Accepted: 10/19/2015] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Although a critical component of educational reform involves the inclusion of knowledge of and skills in health systems science (HSS) (including population health, health system improvement and high-value care) many undergraduate medical education programmes focus primarily on traditional basic and clinical sciences. In this study, we investigated students' perceptions of the barriers to, challenges involved in and benefits of the implementation of a HSS curriculum. METHODS In 2014, we conducted 12 focus groups with 50 medical students across all years of medical school. Group interviews were audio-recorded and transcribed verbatim. We used thematic analysis to explore students' perceptions of a planned HSS curriculum, which was to include both a classroom-based course and an experiential component. We then identified themes and challenges from the students' perspective and agreed upon results and quotations. RESULTS Students identified four barrier-related themes, including (i) medical-board licensing examinations foster a view of basic science as 'core', (ii) systems concepts are important but not essential, (iii) students lack sufficient knowledge and skills to perform systems roles and (iv) the culture of medical education and clinical systems does not support systems education. Students also identified several perceived benefits of a systems curriculum, including acquisition of new knowledge and skills, enhanced understanding of patients' perspectives and improved learning through experiential roles. The major unifying challenge related to students' competing priorities; one to perform well in examinations and match into preferred residencies, and another to develop systems-based skills. CONCLUSIONS Students' intrinsic desire to be the best physician possible is at odds with board examinations and desired residency placements. As a result, HSS is viewed as peripheral and non-essential, greatly limiting student engagement. New perspectives are needed to effectively address this challenge.
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Affiliation(s)
- Jed D Gonzalo
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Paul Haidet
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Barbara Blatt
- Office of Medical Education, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Daniel R Wolpaw
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Gonzalo JD, Graaf D, Johannes B, Blatt B, Wolpaw DR. Adding Value to the Health Care System: Identifying Value-Added Systems Roles for Medical Students. Am J Med Qual 2016; 32:261-270. [DOI: 10.1177/1062860616645401] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To catalyze learning in Health Systems Science and add value to health systems, education programs are seeking to incorporate students into systems roles, which are not well described. The authors sought to identify authentic roles for students within a range of clinical sites and explore site leaders’ perceptions of the value of students performing these roles. From 2013 to 2015, site visits and interviews with leadership from an array of clinical sites (n = 30) were conducted. Thematic analysis was used to identify tasks and benefits of integrating students into interprofessional care teams. Types of systems roles included direct patient benefit activities, including monitoring patient progress with care plans and facilitating access to resources, and clinic benefit activities, including facilitating coordination and improving clinical processes. Perceived benefits included improved value of the clinical mission and enhanced student education. These results elucidate a framework for student roles that enhance learning and add value to health systems.
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Affiliation(s)
| | - Deanna Graaf
- Penn State College of Medicine, Hershey, Pennsylvania
| | | | - Barbara Blatt
- Penn State College of Medicine, Hershey, Pennsylvania
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Financing Graduate Medical Education to Meet the Needs of Children and the Future Pediatrician Workforce. Pediatrics 2016; 137:peds.2016-0211. [PMID: 27020794 DOI: 10.1542/peds.2016-0211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The American Academy of Pediatrics (AAP) believes that an appropriately financed graduate medical education (GME) system is critical to ensuring that sufficient numbers of trained pediatricians are available to provide optimal health care to all children. A shortage of pediatric medical subspecialists and pediatric surgical specialists currently exists in the United States, and this shortage is likely to intensify because of the growing numbers of children with chronic health problems and special health care needs. It is equally important to maintain the supply of primary care pediatricians. The AAP, therefore, recommends that children's hospital GME positions funded by the Health Resources and Services Administration be increased to address this escalating demand for pediatric health services. The AAP also recommends that GME funding for pediatric physician training provide full financial support for all years of training necessary to meet program requirements. In addition, all other entities that gain from GME training should participate in its funding in a manner that does not influence curriculum, requirements, or outcomes. Furthermore, the AAP supports funding for training innovations that improve the health of children. Finally, the AAP recommends that all institutional recipients of GME funding allocate these funds directly to the settings where training occurs in a transparent manner.
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The Nation׳s Physician Workforce and Future Challenges. Am J Med Sci 2016; 351:11-9. [DOI: 10.1016/j.amjms.2015.10.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/14/2015] [Indexed: 11/22/2022]
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Clinkscales JD, Fesmire FM, Hennings JR, Severance HW, Seaberg DC, Patil N. The Effect of Emergency Medicine Residents on Clinical Efficiency and Staffing Requirements. Acad Emerg Med 2016; 23:78-82. [PMID: 26714030 DOI: 10.1111/acem.12834] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/25/2015] [Accepted: 05/06/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The effect of emergency medicine (EM) residents on the clinical efficiency of attending physicians is controversial. The authors hypothesized that implementing a new EM residency program would result in an increase in relative value units (RVUs) generated per hour by attending physicians and decrease staffing requirements. METHODS This was a retrospective observational analysis of an emergency department before, during, and after the establishment of a new EM residency program. We analyzed the change in RVUs billed, patients seen, and hours worked by attending physicians, midlevel providers (MLPs), and residents, and addressed potential confounding factors. RESULTS The clinical efficiency of attending physicians increased by 70%, or 4.98 RVUs/hour (from 7.12 [SD ± 1.4] RVUs/hour to 12.1 [SD ± 2.2] RVUs/hour, p < 0.001) with the implementation of an EM residency program. Overall, net department RVU generation rose by 32%, even as attending physician coverage decreased by 6.3% (p < 0.05), and MLP coverage dropped by 60% (p < 0.05). We estimated that the implementation of the residency saved 4,860 hours of attending physician coverage and 5,828 hours of MLP coverage per year. This represents an estimated $1,741,265 in annual staffing savings, comparable to the residency program's annual operating cost of $1,821,108. CONCLUSIONS The implementation of an EM residency program had a positive effect on the clinical efficiency of attending physicians and decreased staffing requirements.
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Affiliation(s)
- Jeffrey D. Clinkscales
- Department of Emergency Medicine; Erlanger Institute for Clinical Research; University of Tennessee College of Medicine Chattanooga; Erlanger Health System; Chattanooga TN
| | - Francis M. Fesmire
- Department of Emergency Medicine; Erlanger Institute for Clinical Research; University of Tennessee College of Medicine Chattanooga; Erlanger Health System; Chattanooga TN
| | - Jacob R. Hennings
- Department of Emergency Medicine; Erlanger Institute for Clinical Research; University of Tennessee College of Medicine Chattanooga; Erlanger Health System; Chattanooga TN
| | - Harry W. Severance
- Department of Emergency Medicine; Erlanger Institute for Clinical Research; University of Tennessee College of Medicine Chattanooga; Erlanger Health System; Chattanooga TN
| | - David C. Seaberg
- Department of Emergency Medicine; Erlanger Institute for Clinical Research; University of Tennessee College of Medicine Chattanooga; Erlanger Health System; Chattanooga TN
| | - Nirav Patil
- Department of Quality Management; Greenville Health System; Greenville SC
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Stoller J, Pratt S, Stanek S, Zelenock G, Nazzal M. Financial Contribution of Residents When Billing as "Junior Associates" in the "Surgical Firm". JOURNAL OF SURGICAL EDUCATION 2016; 73:85-94. [PMID: 26684417 DOI: 10.1016/j.jsurg.2015.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/26/2015] [Accepted: 06/18/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE There is an increasing number of proposals to change the way Graduate Medical Education is funded. This study attempts to estimate the potential financial contribution of surgical residents using an alternative funding mechanism similar to that used by law firms, which would allow surgery departments to bill for resident activity as "junior associates." METHODS Following 24 residents over a period of 12 weeks, we were able to estimate the annual revenue that they generated from operating room procedures, independent consultations, patient management, and minor procedures using Medicare reimbursement rates. The appropriate first assistant modifier was used to calculate the operating room procedure fees, but full price was used to calculate the revenue for minor procedures, patient management, and consultations done independently. We adjusted for vacation time and academic activities. RESULTS Including postgraduate year 1 residents, the estimated yearly revenue generated per resident in first assistant operative services was $33,305.67. For minor procedures, patient management, and independent consultations, the estimated yearly revenue per resident was $37,350.66. The total estimated financial contribution per resident per year was $70,656.33. Excluding postgraduate year 1 residents, as most states require completion of the intern year before full licensure, the estimated yearly revenue generated per resident in first assistant operative services was $38,914.56. For minor procedures, patient management, and independent consultations, the estimated yearly revenue per resident was $55,957.33. The total estimated financial contribution per resident per year was $94,871.89. CONCLUSIONS Residents provide a significant service to hospitals. If resident activity was compensated at the level of supervised "junior associates" of a surgery department, more than 75% of the direct educational costs of training could be offset. Furthermore, we believe this value is underestimated. Given the foreseeable changes in Graduate Medical Education funding, it is imperative that alternative approaches for funding be explored.
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Affiliation(s)
- Jeremy Stoller
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Sarah Pratt
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Stephen Stanek
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Gerald Zelenock
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Munier Nazzal
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio.
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Affiliation(s)
- John C. Burkhardt
- Corresponding author: John C. Burkhardt, MD, MA, University of Michigan Health System, Department of Emergency Medicine, 1500 E Medical Center Drive, Ann Arbor, MI 48109-5303, 734.232.6008,
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49
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What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data. Clin Orthop Relat Res 2015; 473:3337-47. [PMID: 26239239 PMCID: PMC4586190 DOI: 10.1007/s11999-015-4445-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 06/30/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited. QUESTIONS/PURPOSES We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained? METHODS We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors. RESULTS There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,377-30,323]) compared with the Midwest, South, and West (USD 20,614, [USD 18,592-22.968]; USD 21,584, [USD 19,663-23,941]; USD 22,421, [USD 20,317-25,860]; p < 0.001) and for teaching compared with nonteaching hospitals (USD 23,152 [USD 20,426-27,127] versus USD 21,336 [USD 19,352-23,846]; p < 0.001). Patient characteristics explained approximately 15% of the variance in hospital payments, hospital characteristics (teaching status, geographic region) explained 30% of variance, and approximately 55% of variance was not explained by either factor. CONCLUSIONS There is much unexplained variation in episode-of-care payments at the hospital-level, suggesting opportunities for enhanced efficiency. Further research is needed to ensure an appropriate balance between such efficiencies and access to care. LEVEL OF EVIDENCE Level II, economic analysis.
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50
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Kogan JR, Conforti LN, Bernabeo E, Iobst W, Holmboe E. How faculty members experience workplace-based assessment rater training: a qualitative study. MEDICAL EDUCATION 2015; 49:692-708. [PMID: 26077217 DOI: 10.1111/medu.12733] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 11/13/2014] [Accepted: 02/11/2015] [Indexed: 05/09/2023]
Abstract
CONTEXT Direct observation of clinical skills is a common approach in workplace-based assessment (WBA). Despite widespread use of the mini-clinical evaluation exercise (mini-CEX), faculty development efforts are typically required to improve assessment quality. Little consensus exists regarding the most effective training methods, and few studies explore faculty members' reactions to rater training. OBJECTIVES This study was conducted to qualitatively explore the experiences of faculty staff with two rater training approaches - performance dimension training (PDT) and a modified approach to frame of reference training (FoRT) - to elucidate how such faculty development can be optimally designed. METHODS In a qualitative study of a multifaceted intervention using complex intervention principles, 45 out-patient resident faculty preceptors from 26 US internal medicine residency programmes participated in a rater training faculty development programme. All participants were interviewed individually and in focus groups during and after the programme to elicit how the training influenced their approach to assessment. A constructivist grounded theory approach was used to analyse the data. RESULTS Many participants perceived that rater training positively influenced their approach to direct observation and feedback, their ability to use entrustment as the standard for assessment, and their own clinical skills. However, barriers to implementation and change included: (i) a preference for holistic assessment over frameworks; (ii) challenges in defining competence; (iii) difficulty in changing one's approach to assessment, and (iv) concerns about institutional culture and buy-in. CONCLUSIONS Rater training using PDT and a modified approach to FoRT can provide faculty staff with assessment skills that are congruent with principles of criterion-referenced assessment and entrustment, and foundational principles of competency-based education, while providing them with opportunities to reflect on their own clinical skills. However, multiple challenges to incorporating new forms of training exist. Ongoing efforts to improve WBA are needed to address institutional and cultural contexts, and systems of care delivery.
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Affiliation(s)
- Jennifer R Kogan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa N Conforti
- Milestones Development and Evaluation, Accreditation Council of Graduate Medical Education, Chicago, Illinois, USA
| | - Elizabeth Bernabeo
- Evaluation Research and Development, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - William Iobst
- Academic and Clinical Affairs, Commonwealth Medical College, Scranton, Pennsylvania, USA
| | - Eric Holmboe
- Milestones Development and Evaluation, Accreditation Council of Graduate Medical Education, Chicago, Illinois, USA
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