ACGIM Chiefs Alert
VOLUME 2, ISSUE 1: JANUARY 29, 2003
PRESIDENT’S PERSPECTIVE
“HISTORY BECKONS, ACGIM RESPONDS!”
by Mark Linzer, MD
On February 1st, ACGIM will, for the first time, take a place at the table of the Association of Subspecialty Professors (ASP) by joining in their leadership retreat to discuss the role of GIM in ASP. Later in February, ACGIM representatives will travel to California to join the Association of Professors of Medicine (APM) Winter Meetings. We will have a one-hour meeting with the leaders of the APM (department chairs) to discuss issues of importance to academic GIM.
And so I am soliciting your ideas and concerns. For the ASP meeting, Mark Multach will join me from University of Miami. Our agenda will include announcing the approved proposal that brings ACGIM and SGIM into ASP, initiating the topic of the name change (any ideas are welcome!), as well as brainstorming about the new generalist-sub-specialist committee that I will potentially chair, thus placing me on the ASP Executive Committee in addition to their Council. In particular, what topics would you like to see the GIM-SSIM committee take on as part of its charge? And are any of you interested in joining me on the committee (which is to be balanced with respect to generalists and specialists)?
For the APM meetings, we will clarify the role and format of the annual APM-ACGIM meetings, then launch into the "hot topics" for this year. Currently, we are considering raising the topics of funding the resident’s clinic, role of hospitalists in GIM sections and departments of medicine, and the domain of GIM and how this relates to the overall departmental mission. How do these topics sound to you and do you have any other burning issues you'd like us to bring to the chairs' attention? For this meeting, Bob Centor and I will be joined by Martin Shapiro and David Karlson, President and Executive Director of SGIM.
For history not to repeat itself (i.e. for these new connections between generalists and specialists and chairs to provide both potential and substance, as prior affiliations have failed to demonstrate), we will need to think carefully about what we want to accomplish and how to do it. I welcome your thoughts (email to mxl@medicine.wisc.edu) and support as we move into these new opportunities together!
DIVISION CHIEFS DISCUSS FINANCIAL EFFECTS OF
RESIDENT CLINIC TRAINING
By Robert M. Centor, MD
Editor, ACGIM Chiefs’ Alert
Last month we asked division chiefs to share the financial effects of resident clinic training. We received 22 responses, summarized below. Full text of responses are available at .
RESPONSE SUMMARY
1 division makes money in the residents' clinic.
1 division is not involved in the residents' clinic.
5 divisions lose money.
1 division cannot tell (faculty and resident clinics are joined and cannot account just the residents).
14 divisions are 'subsidized' - 6 by the hospital and 8 by the Department.
Departmental subsidies seemed to come at state institutions - teaching moneys were used to '”make the division whole.” This probably represents a biased sample. If you did not reply to the initial question, please send Bob Centor a reply at this time. We believe this information is very important as we have discussions with APM (the chairs) and for each division chief who negotiates with hospitals or departments.
FINANCIAL EFFECTS OF RESIDENT CLINIC TRAINING
1. Bob, we are reimbursed by the hospital for the amount of time that our faculty spends precepting the residents' clinic. The reimbursement supports the salary effort devoted to the clinic. Clinical receipts from the clinic flow directly to the hospital. In theory, this arrangement should break even for the Division, but doesn't because we are not reimbursed for the time outside of clinic to edit and sign residents' dictations or the time required to prepare for teaching sessions that occur before the start of clinic. Nonetheless, the reimbursement we receive exceeds what we would receive if we lived off of receipts from the clinic, which has a very adverse payer mix. Gary Rosenthal (U of Iowa)
2. My division runs the clinic at break even. The department allocates funds to 'make us whole'. Since most of our patients are truly indigent or Medicare/Medicaid, our collections would not pay for our faculty time. (UAB)
3. At Ohio State currently the division breaks even as the hospital picks up the difference. Prior to 2 years ago, the division lost money (annual loss $367,000 for resident's clinic) and the department did not specifically cover those losses, stating that is was our duty to support the department and that was our way of supporting it. Due to overall divisional losses we were picked up entirely by the hospital for clinical services at that point 2 years ago. Now the hospital pays the overhead, collects the fees, and pays the division a dollar per RVU amount, the same for resident's clinic as for faculty practices. Bob Murden Division Director, General Medicine The Ohio State University
4. The residents' clinic at LSU is held at the medical center of Louisiana (Charity hospital). Although we bill and collect for our faculty supervision, the collections in no way come near salary support needed to staff the clinic. We are "subsidized" to staff the clinic from residency supervision funds that the department receives from charity hospital.
5. The Wishard Community Health Centers collect around $200,000 per physician FTE per year, while the commercial managed care sites bring in a bit more than $320,000 per MD FTE. Residents practice in about a third of these sites, mostly in the Wishard Community Health Centers. We cannot separate the residents "clinics" from the faculty clinics because they practice side-by-side, each resident's patient is staffed by a faculty physician (usually one who is not seeing patients that day, i.e. an assigned teaching attending, paid for by IUMG-PC), and the patient is billed in the name of the faculty physician. Overall, last fiscal year IUMG-PC made a profit of $4.5 million. However, it also gets a subsidy from the hospital of $35,000 per physician. If one removed this subsidy, the practice broke even. The subsidy does not change depending on IUMG-PC's financial situation (and it actually went down to $30,000 this year). It is based on an a priori negotiation with the hospital. Hence, the practice makes or loses money based on its productivity, along with this fixed subsidy. Profits are dispersed to the physicians (as productivity-based year-end bonuses), the IU School of Medicine, and Wishard Hospital.
6. The cost in salary/fringe for division members who teach in the continuity practice is about $55,000. The dept pays us about $31,000. We charge only for Medicare under the primary care exception, bringing in about $10,000. Patients are indigent, with no coverage, Medicare or Medicaid. We do not break even - L. Randol Barker, MD
7. The question of "breaking even" depends on how the division's activities are accounted for. Does the question mean with downstream test revenue included? Bad debt and discounts? Inpatient revenue? Outpatient revenue? Combined? With reimbursement from a medical school or residency paying for faculty time? Grant support? Or does it just mean meeting a target set by the Dept for the division and the "breaking even" is accounted for at the Dept level? My division meets a target based on cost/RVU negotiated with the Dept of Medicine Chair for the year. There also is a target for patient encounters per workday.
My division meets the target nearly every year however many divisions in the Dept struggle while others have some excess that can be used to fund internal projects. The GI Division at Mayo wrote up the system in an article "A Novel Incentive System for Faculty in an Academic Medical Center” Brandt et al, Ann Intern Med. 2002; 137:738-743. If one looks at real dollars, I seriously doubt any division of general medicine outside of private practice truly breaks even. For the rest of us, the average loss nationally is about $100K/physician. Vinod Sahney PhD at Henry Ford says the loss is from the enriched benefits for employees at medical centers over the benefits given in private practice. My cynical side says institutions can manipulate the numbers for any general medicine group to induce whatever amount of guilt they feel is needed to keep GM in it's place. I am quite content with the Cost/RVU system but it will not work well outside a fee-for-service environment.
8. As I think you know, our budgets are determined at the Department level, not at the Divisions. I cannot answer you question with precision. However, I know that our Department's clinical practice (general medicine and all subspecialties) loses money at the site where the resident continuity clinic is held -- although things are getting better. Since essentially all of our patients are indigent and without private insurance, it's safe to conclude that general medicine loses money on the residents' clinic. The Department supports faculty salaries to teach in that setting, largely from State of Texas funding. - Andy Diehl
9. We would lose money in the residents' clinic, though I cannot break out resident billings from staff primary care billings. Overall the division breaks even given the other activities we do such as attending, medical directorships, etc. - Craig R. Garrett, MD (Hennepin)
10. RWJ - Outpatient resident clinic is mostly supervised outside of GIM. We have an indigent clinic that is supported by the dean and not my fiscal responsibility. I share faculty but do not pay that portion of time spent there. We do have two afternoons in which residents practice in the faculty site I run and pay for. The last time I examined this we determined that our loss was about 3 K per clinic even though the chair pays the room expense. Jeff
11. At MGH, the E&M fees for resident patients about cover overhead, and the preceptor the DOM covers salaries (which amount to about 70% of the “opportunity cost” compared to a faculty session primarily by the hospital and secondarily. The visit/RVU payment to most MGH primary care practices that include residents pays the same amount per visit regardless of collections, so there's basically equal work for equal pay regardless of how well-healed the clientele (we have community-based practices in communities across the economic spectrum). - Michael
12. At the University of Missouri-Columbia, the hospital covers the overhead and the attending physicians bill for their services. However, due to relative low volume, the time spent attending is not a remunerative as when the attending is working strictly clinical. The medical school is developing a mission-based budgeting plan, which should make allowances for this difference.
13. We do not have a separate residents' clinic or separate accounting. Our entire primary care program, however, operates in the red and we must make up from other sources. SDF
14. Our resident clinic is subsidized by the hospital. It is a money losing operation because the hospital runs the program. The department divorced itself from the clinic approximately 7 years ago and will never take it back. I have the responsibility to oversee and staff the operation. The clinic does not provide enough patients for the residents so have placed residents for continuity in our community practice sites. Geno Merli
15. At SIU School of Medicine, the clinics operate at a 45% overhead or a 55% profit margin. All resident billings go through the supervising attending. We have a very good payer mix and do not face the same problems that many institutions with a large indigent population face. We have no subsidy from the school, the state, or anyone else for the resident clinics. Our DGIM does not lose money and never has. - Bob Bussing
16. Each of the 3 primary care departments at UK (GIM, pediatrics and FP dept.) is supported with state funds ear-marked for "primary care resident education". We fund our primary care residency program director (who also serves as an associate residency director for the Department of Medicine residency program) at 20-25% FTE and divide the remaining funds evenly to each faculty for each resident clinic team they staff (usually 20 teams/year). This offsets our faculty costs for the resident clinics. The Medicine department runs the ambulatory clinics and pays for the costs of the resident clinic. The department considers the clinic as department overhead and a share of that expense is charged to each division based on each division's annual projected income and is paid on a flat monthly rate through each year (this includes only clinic staff and supplies - no rent - the space is owned by the Dean and funded with a Dean's tax). Since the rate we are charged is not based on utilization and our cost is less than what it would be if it were, we essentially get a "discount" that I can consider a partial education subsidy. Between those two funding sources, our resident clinics essentially break even.
17. At Wake Forest, we have two clinics: 1- a community clinic owned and run by the hospital which contracts for GIM to precept residents and back-up Physician Assistants, but does not bill Professional fees. We break even in this clinic - we only use as many FTEs (~3.6 FTEs) as we are contracted. 2- a hospital contract to precept residents and bill pro fees. We lose approximately $5000-8000 per faculty member/ clinic slot / year (depending on faculty salary, expenses etc.), implicitly recouping the loss from the Department (since the department covers our deficit at the end of the year). We are not explicitly budgeted for this loss.
18. Currently, the hospital pays the expenses and takes the receipts. It pays a stipend for the physician faculty who attend in the clinic. This will change soon and the practice plan/Department will assume responsibility for the resident clinic deficit. - Mary Nettleman
19. At East Carolina University we lose money with the residents’ clinic. We have a large Medicare/ Medicaid/ uninsured group of patients, and have inefficiencies in our system. No specific subsidy from the Dept. I am not thrilled to report that I don’t have a sense of how much money we lose every year.
20. In our hospital-based residents' primary care clinic, we see approximately 20,000 visits/year and have about 100 resident-providers. Our payer mix is approximately 30% Medicare, 25% uninsured and 45% Medicaid. We provide 3 GIM faculty per session as preceptors. We use chief residents and volunteer faculty as preceptors also. We recently began billing Medicare and Medicaid under the primary care exception rule, and our receipts for the first year were about $160,000. In addition, we receive Teaching and Administration support for precepting from our hospital: currently $362,500/year. (Mark Fagan Rhode Island Hospital)
21. Oregon - We have three internal medicine resident clinic sites located within three faculty practices. All the primary care practices are part of the "integrated primary care organization"--3 internal medicine, 4 pediatrics, 4 family medicine. Since our collection rates vary across sites (and are generally poor related to a high percentage of Medicaid, Medicare, and uninsured patients for both faculty and residents), we give faculty credit for their work on a "charge" basis (work RVUs) and average the "collection rate" across all sites to avoid unhealthy competition for commercially insured patients. Resident RVUs are pooled by site and divided among those who provided the supervision for the month. In general, the faculty supervises 3-4 residents (9-20 patients) per half-day. The faculty does just as well or better for a resident supervision half-day as they do in their own practice when measured by RVUs. We lose money in primary care and receive support from the hospital, not the Department, to make us whole. Faculty is paid on an incentive model and generally takes home 29-34% of charges, including the resident RVUs credited to them. Salaries are still below the MGMA and AAMC benchmarks when correlated to the RVU production level.
22. We did away with the residents' clinic a few years ago and now train nearly all our residents in faculty offices. We lose money doing it, and the Department/Health System subsidizes
NEW RECRUITMENT LISTINGS:
ACADEMIC GENERAL INTERNIST/CLINICIAN-EDUCATOR: University of California, Davis ASSISTANT/ASSOCIATE PROFESSORS, PREVENTIVE MEDICINE: University of Alabama at Birmingham ASSOCIATE CHIEF, CLINICAL RESEARCH: GIM Section, Boston University School of Medicine PHYSICIAN-INVESTIGATORS: University of Iowa GENERAL INTERNAL MEDICINE FELLOWSHIP: Harvard Medical School For details, and more listings, go to http://www.acgim.net/positionopenings.htm.
ACGIM may post free listings by sending them to ACGIMChiefsAlertEditor@SGIM.org, attention Lorraine Tracton.
NEW -- Non-members may now post listings for a modest fee ($100 per 50 words) by sending them to the above email address.
PUBLISHING OPPORTUNITIES
- CALL FOR DISPARITIES IN HEALTH PAPERS The
Journal of General Internal Medicine is soliciting papers for a special issue on
disparities in health. Submissions for this issue should be sent to JGIM, attention
JudyAnn Bigby, following instructions for authors at
- JAMA IS RECRUITING ARTICLES FOR "SCIENTIFIC EVIDENCE AND CLINICAL APPLICATIONS" JAMA has started a new series entitled "Scientific Evidence and Clinical Applications," edited by Wendy Levinson. Dr. Levinson is recruiting articles on topics relevant to general internists, and, in her experience, “…this is a wonderful opportunity for a general internal medicine faculty member to pair up with a specialist and write two peer-reviewed articles for JAMA. Most that have been published so far have been written by young general internists.” Dr. Levinson is hoping that ACGIM members will think of individuals in their sections who would be interested in doing this. Interested people should email Dr. Levinson (wendy.levinson@utoronto.ca) and she will help them develop their articles. For samples, please refer to -
Fletcher RH, Fairfield KM "Vitamins for chronic disease prevention in adults: clinical applications." JAMA 2002 Jun19;287(23):3127-3129
Fletcher RH, Fairfield KM "Vitamins for chronic disease prevention in adults: scientific review." JAMA 2002 Jun19;298(23):3116-3126
Inuzucchi SE "Oral antihyperglycemic therapy for type 2 diabetes: scientific review." JAMA 2002 Jan16;287(3):360-372
Holmboe ES "Oral antihyperglycemic therapy for type 2 diabetes: clinical application." JAMA 2002 Jan16;287(3):373-376
Please feel free to contact Dr. Levinson if she can assist you or your faculty members in shaping an article for this series.
FUNDING OPPORTUNITY:
DEADLINE REMINDER: LINN GRANT APPLICATIONS ARE DUE FEBRUARY 1, 2003. SGIM’s Lawrence S. Linn grants are awarded to young investigators "to study or improve the quality of life for persons with AIDS or HIV infection." A maximum of $10,000 for each grant and a maximum of two grants will be funded each year. The awards, endowed by the Lawrence Linn Trust, will be presented at SGIM’s 26th Annual Meeting, April 30-May 3, 2003 in Vancouver, British Columbia. For the full RFP and Application Form go to http://www.sgim.org/lawrencelinn.cfm.
UPCOMING EVENTS:
April 6 - 11, 2003: Harvard Presents: Program for Health Care Negotiation and Conflict Resolution Leadership: This one-week program is designed to give health care leaders the skills, analytic capabilities, and methods to manage and resolve the critical conflicts facing health care today. Participants learn methods of interest-based negotiation, multi-dimensional problem solving, and mediation specifically applied to health care scenarios. Program faculty instruct participants directly through one-on-one mentoring. Each participant receives a videotape of his or her mediation with constructive recommendations for improvement. Apply at http://www.hsph.harvard.edu/ccpe/programs/ANCR.shtml#register or call 617-384-8692 for more information.
READING SUGGESTIONS FROM THE ACGIM CHIEFS’
ALERT EDITOR
I have several articles to suggest this month.
- First, please note my review of “Follow This Path" below
- “The Word Doctor “ -- a nice article about the power of stories in medicine. The Word Doctor
- “What can internal medicine do to attract more medical students to careers in primary care?”-- from the ACP-ASIM Observer, this article does a good job of putting the decreased interest into perspective. What can internal medicine do to attract more medical students to careers in primary care?
Last year, in the SGIM Forum, I reviewed three books for leaders. As many of my friends know, my favorite is titled “First, Break All the Rules”. This book focuses on management more than leadership. It uses data collected by the Gallup organization, to provide framework for understanding high quality management.
The Gallup organization also publishes management articles on a website titled the Gallup Management Journal (gmj.gallup.com). I frequent this site to see new articles. I was excited to see that they had published a new book titled “Follow This Path”. This book extends the lessons of “First, Break All the Rules” at an organizational.
I offer this review and highlight the concepts that they champion.
I recommend reading “First, Break All the Rules” prior to reading this book (although this book certainly can stand on its own). The book’s principle theme is that great organizations tap into emotions and maximize the percentage of emotionally engaged employees. “Follow This Path” refers to the steps that help one take an organization towards greater success. I will summarize the path with gross simplifications.
The first step requires that one acknowledge that emotions play a major role in driving outcomes. When you think about your experience as a medical student, house officer or faculty member you may or may not have been emotionally engaged at all times. During those times that you are emotionally engaged you work harder and work more effectively. During those times when you do not feel emotional engagement you just go through the motions.
The second step in the path is recognizing that each employee has innate talents that allow for emotional engagement. These talents differ for each person. The key is to allow people to use their talents in a way that is emotionally satisfying. This book does include a review of 34 different talents that each of us may possess. Each of us succeeds in some talents greater than others. The Gallup organization’s authors have written a book titled “Now Discover Your Strengths” which goes into these talents in great depth. Being exposed to the idea that different people view the world and are comfortable in the world with different sets of talents is a very important concept.
The third step on our path is to understand that talent combinations lead to success. What the Gallup organization suggests is that you find out why truly successful workers are passionate about their work. What makes the great ward attending? What makes the great clinic attending? What makes the great researcher? Why are they passionate? That may help one find others who may succeed at that task.
The fourth step is to maximize the number of engaged employees. This refers to the questionnaire from First Break All the Rules. Engaged employees are happy with their work environment and feels supported.
The next step requires one to understand how to maximize the number of engaged employees. Understanding that having employees who are not engaged and not emotionally attached to your group in many ways decreases the productivity of the entire group follows this.
The path continues by discussing the role of emotional engagement by customers and how customers develop a passion for an organization. We have all seen this in medicine where patients do become emotionally attached to their primary care physician. This is very important to the institution. Those who minimize the importance of this relationship err in valuing the physician.
The ninth step involves understanding how to enhance customer engagement. Many academic centers forget that the primary care groups and physicians often sustain the emotional attachment to the institution.
While this book is predominantly concerned with improving profits in business, I quickly made connections with successful divisions of general internal medicine, successful practices and even successful ward teams. I recommend this book predominantly for those in leadership positions, whether division directors, program directors, clerkship directors or other administrative positions. Those who are considering leadership and management positions might want to read this book to see whether or not they have the talents and desire to work with people to try to maximize their emotional engagements to the organization. This book emphasized the importance of developing individual relationships with each team member. The great managers maximize overall production using emotion support.