understanding the costs and benefits of outpatient teaching gimgel session faculty development...
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Understanding the Costs and Benefits of Outpatient Teaching
GIMGEL Session
Faculty Development Project
James R. Boex, MBA
What Are We Going to Accomplish Today?
• understand the cost context of ambulatory training;
• learn how educational activities affect ambulatory sites’ operating costs;
• apply a cost model for ambulatory training to your own site;
• understand an approach to identifying the benefits of clinical training; and
• consider how this model for identifying benefits might apply to your own setting.
Understanding the Value Added to Clinical Care by Educational Activities*
HOW CAN WE MEASURE VALUE?
Any assessment of value must include both costs and benefits
in current jargon, “benefits” = “value added”
UNDERSTANDING COSTS IN CLINICALEDUCATION REQUIRES MANY AREAS
OF INVESTIGATION
cost measurement
trainee mix types of trainingactivities
quality oftraining how training affects
clinical productivity(activity analysis)
Understanding the Costs of Ambulatory Care Training*
Conceptual Costs Model
costs ATTRIBUTABLE to education
costs ALLOCATABLE to education
costs ASSOCIATEDwith education
direct costs
indirectcosts
educationinfrastructur
e
costs
*Academic Medicine, September 1998
Understanding the Costs of Ambulatory Training*
Definitions & Examples
• Direct Costs (strong relationship to cause): resident stipends, dedicated faculty time, etc.
• Indirect Costs (weaker relationship to cause): heat & light, space costs, estimated faculty time, etc
• Infrastructure Costs (weakest relationship to cause): more tests, assumed lower productivity, etc.
*Academic Medicine, September 1988
Measuring the Costs of Primary Care Education in the Ambulatory Setting*
The Cost of Education in Ambulatory Sites is
Approximately the Same as in Hospitals
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
$1400000
$1600000
non-teaching site teaching site
infrastructure
direct & indirect
operating costs
24%12%
*Academic Medicine, May 2000
Assessing Ambulatory Primary Care Education - Costs, Methods and Quality:
Education Adds to CostsClinical Productivity Costs
ambulatory clinicians supervising principally PGY-2 and PGY-3 residents saw fewer patients than when not teaching
and half of the ambulatory clinicians reported that
teachingextended their 4-hr work sessions by an
average of 45 minutes per session
Measuring the Costs of Primary Care Education in
the Ambulatory Setting* Who Pays the Costs of Ambulatory Training?
0%
20%
40%
60%
80%
100%
sponsors sites teachers
doesn't paypays
*Academic Medicine, May 2000
Measuring the Costs of Primary Care Education in the Ambulatory Setting*
More Centers Are Teaching Than Believed
0%
25%
50%
75%
100%
BCRR MGMA
non-teachteaching
If 33% - 50% of ambulatory care sites thought not to be teachingare in fact teaching, what are the implications of this for schools
or programs when negotiating with sites?
*Academic Medicine, May 2000
Measuring the Costs of Primary Care Education in the Ambulatory Setting*
Ambulatory Costs and BBA Medicare Payments
Medicare
DME analog
MedicareIME
analog
Medicare GME*
Ambulatory Sites
35%
65%
68%
32%
infrastructure
direct
indirect
*Academic Medicine, May 2000
Measuring the Costs of Primary Care Education in the Ambulatory Setting*
Medicare GME Payments for Non-Hospital TrainingThe Balanced Budget Act allows the Secretary of HHS
to pay GME costs to ambulatory sites based on their attributable and allocatable costs
*Academic Medicine, May 2000
Measuring the Costs of Primary Care Education in the Ambulatory Setting*
Medicare GME Payments for Non-Hospital Training
A POTENTIALLY IMPORANT INCENTIVE:the BBA also allows residency programs to count residents
in ambulatory sites toward their IMEA payments IF the program and the site can agree in writing on the
site’s costs and payments
*Academic Medicine, May 2000
Understanding the Value Added to Clinical Care by Educational Activities*
IF VALUE IS IN THE EYE OF THE BEHOLDER, WHOSE PERSPECTIVES ARE
IMPORTANT? payers patients clinicians/teachers clinical care organizations learners communities educational organizations
*Academic Medicine, October 1999
Understanding the Value Added to Clinical Care by Educational Activities*
PAYERS’ VIEWS OF AREAS OF POTENTIAL VALUE ADDED BY
EDUCATION TO CLINICAL CARE influence future practitioners improved clinician recruitment & retention higher quality clinical care the direct labor of trainees improved clinician work satisfaction
*Academic Medicine, October 1999
Understanding the Value Added to Clinical Care by Educational Activities*
THE VALUE COMPASSfrom clinical to education
EducationEducationClinicalClinical
CostCost
FunctionalFunctional
SatisfactionSatisfaction
*Academic Medicine, October 1999
Understanding the Value Added to Clinical Care by Educational Activities*
Defining the Compass Points Clinical - signs & symptoms, test results, specific measures of
health status, educational status, or analogous situation
Functional - how well can the _________ do what it needs to do?
Satisfaction - how does the _________ react to the situation being assessed?
Cost - what are the financial and other costs that accrue to the ___________ in the situation being assessed?
*Academic Medicine, October 1999
OPERATIONALIZING THE EDUCATIONAL VALUE
COMPASS
EducationClinical
Cost
Functional
Satisfaction
teaching organizations
learners
the community
clinical care organizations
clinician/teachers
patientsin research and in your setting
SUMMING UP:WHAT HAVE WE DISCUSSED?
the costs of teaching are approximately the same in ambulatory sites as in hospitals, but the types of cost differ
Medicare makes substantial funds available for GME and provides an incentive for these to be shared between hospitals and ambulatory sites;
all involved gain benefits as well as pay costs when education takes place in ambulatory and other clinical settings
both gains and costs can be measured and should be taken into account as partnerships are developed
for more information, contact:
James R. Boex, MBADirector, Office of Health Services Organization & Research
Northeastern Ohio Universities College of Medicine
(330) 325-6165jrb@neoucom.edu
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