Understanding the Costs and Benefits of Outpatient Teaching

1. Understanding the Costs and Benefits of Outpatient Teaching GIMGEL Session Faculty Development Project James R. Boex, MBA

2. 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 howthis model for identifying benefits might apply to your own setting.

3. 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”

4. trainee mix types of training activities quality of training how training affects clinical productivity (activity analysis) cost measurement UNDERSTANDING COSTS IN CLINICALEDUCATION REQUIRES MANY AREASOF INVESTIGATION

5. education infrastructure costs ASSOCIATED with education costs indirect costs costs ALLOCATABLE to education direct costs costs ATTRIBUTABLE to education Understanding the Costs of Ambulatory Care Training*Conceptual Costs Model *Academic Medicine, September 1998

6. 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

7. 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 12% 24% *Academic Medicine, May 2000

8. Assessing Ambulatory Primary Care Education - Costs, Methods and Quality:Education Adds to Costs Clinical 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 teaching extended their 4-hr work sessions by an average of 45 minutes per session

9. Measuring the Costs of Primary Care Education in the Ambulatory Setting*Who Pays the Costs of Ambulatory Training? *Academic Medicine, May 2000

10. Measuring the Costs of Primary Care Education in the Ambulatory Setting*More Centers Are Teaching Than Believed If 33% - 50% of ambulatory care sites thought not to be teaching are in fact teaching, what are the implications of this for schools or programs when negotiating with sites? *Academic Medicine, May 2000

11. Medicare GME* Ambulatory Sites Medicare IME analog 35% 68% infrastructure indirect Medicare DME analog 65% 32% direct Measuring the Costs of Primary Care Education in the Ambulatory Setting*Ambulatory Costs and BBA Medicare Payments *Academic Medicine, May 2000

12. Measuring the Costs of Primary Care Education in the Ambulatory Setting*Medicare GME Payments for Non-Hospital Training The 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

13. 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

14. 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

15. 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

16. Functional Education Clinical Satisfaction Cost Understanding the Value Added to Clinical Care by Educational Activities*THE VALUE COMPASS from clinical to education *Academic Medicine, October 1999

17. 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

18. Functional clinical care organizations teaching organizations Education Clinical Satisfaction learners clinician/teachers Cost the community patients OPERATIONALIZING THE EDUCATIONAL VALUE COMPASS in research and in your setting

19. SUMMING UP:WHAT HAVE WE DISCUSSED? • the costs of teaching areapproximately the samein ambulatorysites as in hospitals, but thetypes of cost differ • Medicare makessubstantial fundsavailable for GME and provides an incentive for these to beshared between hospitals andambulatory sites; • all involvedgain benefits as well as pay costswhen education takes place in ambulatory and other clinical settings • both gains and costscan be measured and should be taken intoaccountas partnerships are developed

20. for more information, contact: James R. Boex, MBA Director, Office of Health Services Organization & Research Northeastern Ohio Universities College of Medicine (330) 325-6165 jrb@neoucom.edu