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 how this 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. UNDERSTANDING COSTS IN CLINICAL EDUCATION REQUIRES MANY AREAS OF INVESTIGATION cost measurement trainee mix types of training activities quality of training how training affects clinical productivity (activity analysis )

5. Understanding the Costs of Ambulatory Care Training* Conceptual Costs Model costs ATTRIBUTABLE to education costs ALLOCATABLE to education costs ASSOCIATED with education direct costs indirect costs education infrastructure costs * 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 24% 12% *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. Measuring the Costs of Primary Care Education in the Ambulatory Setting* Ambulatory Costs and BBA Medicare Payments Medicare DME analog Medicare IME analog Medicare GME*Ambulatory Sites 35% 65% 68% 32% infrastructure direct indirect * 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 sites 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? npayers npatients nclinicians/teachers nclinical care organizations nlearners ncommunities neducational 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 ninfluence future practitioners nimproved clinician recruitment & retention nhigher quality clinical care nthe direct labor of trainees nimproved clinician work satisfaction *Academic Medicine, October 1999

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

17. Understanding the Value Added to Clinical Care by Educational Activities* Defining the Compass Points nClinical - signs & symptoms, test results, specific measures of health status, educational status, or analogous situation nFunctional - how well can the _________ do what it needs to do? nSatisfaction - how does the _________ react to the situation being assessed? nCost - what are the financial and other costs that accrue to the ___________ in the situation being assessed? *Academic Medicine, October 1999

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

19. SUMMING UP: WHAT HAVE WE DISCUSSED? nthe costs of teaching are approximately the same in ambulatory sites as in hospitals, but the types of cost differ nMedicare makes substantial funds available for GME and provides an incentive for these to be shared between hospitals and ambulatory sites; nall involved gain benefits as well as pay costs when education takes place in ambulatory and other clinical settings nboth gains and costs can be measured and should be taken into account as 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