The cost of primary care resident training outside of hospital settings came close to an original estimate, now supporters have to show that it’s worth the money.

July 11—Federal funding for a popular medical education program is about to expire, but supporters are hopeful that a recent study, which identified the program’s actual costs and revenues, will provide the evidence Congress needs to sustain it.

“One thing we always get on the Hill is ‘What is the actual cost?’” Cristine Serrano, executive director for American Association of Teaching Health Centers in Washington, said in an interview. “We’ve been saying ‘It’s about $150,000.’ Now, it’s been confirmed, so this really will change the conversation.”

Researchers at George Washington University’s (GWU) Milken Institute of Public Health studied data from the 2013-2014 academic year at 26 Teaching Health Centers (THCs) and calculated that, for 2017, the median cost for training a resident in a THC would be $157,602. (For new programs, it was $169,339. For expansion programs, the median cost would be $144,999.)

“What is significant is that it establishes the cost of doing business,” co-author Fitzhugh Mullan, MD, a professor of health policy and pediatrics at GWU, said in an interview. “If a clinic wants to get into the resident-training business, they now know what it will cost.”

The Teaching Health Center Graduate Medical Education program, which trains primary care and dental residents in community settings, was created as a five-year initiative under the Affordable Care Act (ACA) and funded by a $230 million appropriation. It provided $150,000 per resident, per year. In 2015, Congress extended the program and appropriated $60 million per year and lowered the program’s support to $95,000 per resident. This funding will end in September 2017.

For the 2015-2016 academic year, there were 59 THCs training 690 residents in six primary-care specialties in 27 states and the District of Columbia, according to the New England Journal of Medicine study. Of these, 42 are new programs created by the ACA and 17 were expansions of existing programs.

“I’m very hopeful the findings will provide enough evidence for the authorizers and appropriators to put the program back on a sustainable course,” Mullan said.

Revenue from Residents

The study also broke new ground by looking revenues residents generated.

“That has never been part of the national conversation--but it was part of this study,” Mullan said. “The idea that a resident is a revenue producer is fairly obvious on its face, but no one has measured it.”

The residents at the 26 THCs studied by Mullan and colleagues saw patients during 203,924 ambulatory and 65,849 inpatient visits in the 2013-2014 academic year. The median revenue-generation level across all programs was $46,535 per resident—but with wide variation. The median at new programs (without senior residents) was $31,503 and $111,267 at expansion programs. Medicaid accounted for about two-thirds of revenues.

Revenue and visits increased as residents gained experience and required less supervision. The number of ambulatory visits averaged 302 for residents in their first year of training, 589 for second-year residents, and 945 for the third-year residents.

There are 125,319 medical residents training in 10,073 programs in the new 2016-2017 academic year, according to the Accreditation Council for Graduate Medical Education. Medicare is the largest source of GME funding, spending about $9.7 billion in 2012, according to the Institute of Medicine (IOM). Medicaid provided about $3.9 billion and the Department of Veterans Affairs (VA) contributed $1.4 billion.

“This program is the proverbial drop in the bucket, but it’s very challenged by the throttling back of funding from $150,000 to $95,000 per resident,” Mullan said.

‘Devil’s Choice’

Some programs have closed or reduced the number of residents they train. Most face what Mullan described as a “devil’s choice” because, if they decide to go forward with the reduced level of federal funding, then Congress may determine that a funding increase back to the original level is not needed.

Serrano agreed, and noted that so many programs have cut back.

“Because programs shut down, there’s more money in the pot,” Serrano said. “It’s a difficult dance and it has Congress asking ‘Are you just crying wolf or are you really going to shut down?’”

One institution in that position was Northwestern University Feinberg School of Medicine where Serrano worked from 2011 to 2015. With its community partner, Norwegian American Hospital, Feinberg has trained eight residents a year at the Erie Family Health Center in Chicago’s Humboldt Park neighborhood, which has a large Puerto Rican population.

Two years ago, when federal funding was in doubt, it cut back to only six residents. It has since gone back to eight. Deborah Clements, MD, chair of the family and community medicine department for Feinberg, said in an interview that the school would not accept new THC residents unless it could guarantee that it would have money on hand to support them through a three-year program.

Of the 32 physicians who have graduated from the program, Clements said 80% continue to serve “vulnerable populations” at Federally Qualified Health Centers or community clinics.

In addition to medical training, Clements said they’ve demonstrated leadership and advocacy skills testifying on the value of THCs before Congress and have “generated new knowledge” by presenting research findings at national conferences.

She said the immersed-in-the-community training they receive allows residents “to focus on things outside the clinic walls” such as the social determinants of health including access to healthy food and safe places to exercise.

Mullan praised the program at the Erie Health Center program for doing “fabulous, creative work,” but noted how it represents the struggle to get THC funding “regularized.”

In California, Serrano said THC supporters were heartened by legislators appropriating $100,000 million to support GME efforts. This included $17 million over six years to support existing THC residencies.

In Montana, Mullan praised the new internal medicine residency program operated by the Billings Clinic as a “creative bootstrap” operation. Billings has operated its program outside of the THC umbrella supported by $4.3 million in Hemsley Charitable Trust grants, which will help support residents who train at two rural clinics while also conducting rural health services research.

“But you don’t want to wait for a charity program here or saint there,” Mullan said. “You need public funding.”

Bold in Billings

The Billings program is now in its third year and that has its director, Robert Ficalora, MD, excited because a true picture of its costs and revenues will be able to be calculated now that it will have senior residents seeing patients.

“Even though we’ll only have a third more residents, they’ll be seeing twice as many patients,” Ficalora said. “We have seniors now, so we can throw a few bucks into the pot.”

The program started with an initial class of eight residents and now has 25.

“The United States went a long time without a new internal medicine residency program,” Ficalora said. He added that it’s gone a long time without the research its new residents will be doing. There has only been one scholarly article done on internal medicine GME in a rural setting, and it was written by a Billings physician in 1992, according Ficalora.

To boldly go where no one has gone before is a theme of the Billings program, Ficalora said. As a symbol of this mission, Ficalora wears a Star Trek tie when welcoming new residents every July 1.

“Nobody knew what this program would be like--the idea and the mission was to put residents in a rural training environment,” Ficalora said. “We have so many people with so little access to care.”

The approach is working, two residents have already signed contracts to stay with Billings when they are done with their training, Ficalora said.

Andis Robeznieks is a freelance writer based in Chicago. Follow Andis on Twitter at @AndisRobeznieks.

Publication Date: Monday, July 11, 2016