The influence of a family practice residency on the costs of inpatient diagnostic testing

A retrospective review of hospital records for 333 patients admitted to a large community teaching hospital by family physicians and family practice residents was performed to determine whether teaching programs in family practice led to a significant increase in the cost of care to patients. Three patient populations were identified for comparison: patients admitted by private family physicians when residents were not involved in patient care, patients admitted by the same family physicians while they served as attending physicians on the family practice service and allowed residents to participate in the care of their patients, and patients admitted by residents from the patient population at the Family Practice Center. After taking into account differences in case mix, an analysis of laboratory charges, radiology use, frequency of procedures, and use of consultants showed that the three groups were not different. Family practice residents managed their own patients as cost effectively as physicians in private practice, which suggests that experience alone is not necessary to develop methods of cost-efficient care. When these two groups were combined into a teaching unit, with few exceptions this efficiency was maintained. These results imply that the introduction of family practice residents into patient care does not invariably increase expenses to the patient.     

Medical education and the retention of rural physicians.

OBJECTIVE. This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN. Design is a prospective cohort study. PARTICIPANTS. Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION. In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS. Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS. These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.     

Family practice residencies in community health centers--an approach to cost and access concerns.

An inadequate number of trained primary care clinicians limits access to care at Community Health Centers. If family practice residents working in these centers can provide care to patients at a cost that is comparable to the center''s hiring its own physicians, then expansion of Family Practice Residency Programs into community centers can address both cost and access concerns. A cost-benefit analysis of the Family Practice Residency Program at the Fresno, CA, community center was performed; the community center is affiliated with the University of California at San Francisco. Costs included (a) residents'' salaries, (b) supervision of the family practice residents, (c) family practice program costs for educational activities apart from supervision at the community center, and (d) administrative costs attributable to family practice residents in the community center. Benefits were based on the number of patients that residents saw in the community center. Using this approach, a cost of $7,700 per resident per year was calculated. This cost is modest compared with the cost of training residents in inpatient settings. The added costs attributable to training residents in community health centers can be shared with agencies that are concerned with medical education, providing physicians to underserved communities, and increasing the supply of primary care physicians. Redirecting graduate medical education funding from hospitals to selected ambulatory care training centers of excellence would facilitate placing residents in community centers. This change would have the dual advantage of addressing the current imbalance between training in ambulatory care and hospital sites and increasing the capacity of community health centers to meet the health care needs of underserved populations.     

Practice objectives and goals; a survey of family practice residents.

This study shows that the majority of family practice residents initially become aware of individual community needs for family physicians in either medical school or early in residency training, but the final decision in regard to the selection of a specific community for private practice is not generally made until late in the third year of residency training. When the final decision as to practice location is established, the family practice resident and his family have regarded at least six different factors as significant. Most family practice residents will enter private practice as members of a group practice, rather than as solo practitioners. There is a direct relationship between the population of the family practice resident's home community and the size of the communities being considered for private practice. The most influential recruiting technique is personal contact by the physicians and citizens of the community, whereas the least effective method of recruiting is through printed material distributed through mail service.     

建立专科医师流动层 促进医院整体医疗质量提高

2002年以来,采用“培训合约制”的方式向社会招收培训医师,在3年培训结束后实行二次就业,一部分医师流动到其它县市医院工作,从而在医院形成一个住院医师的流动层。至2008年12月,医院已先后接纳228名培训医师进行培训,这些培训医师成为承担临床一线医疗任务的主要力量。在现有医院医师编制无法改变的情况下,通过建立专科医师流动层的方式,扩大医院住院医师队伍,可以在一定程度上改变目前大型公立医院医师群体“倒金字塔”的畸形状况,充实扩大相对固定的住院医师群体,成为医院整体医疗质量提高的重要保证。经过这一严格培训过程的专科医师求职到其它不同级别医院工作,对基层医疗单位医疗质量的提高也发挥非常积极的作用。     

Hysterectomy: variations in rates across small areas and across physicians' practices.

This analysis focuses on the practice of hysterectomy across 33 hospital catchment areas of one Canadian province, using claims data from the Manitoba health insurance system. Hysterectomy rates varied five-fold across hospital areas. The availability of hospitals and physicians was unrelated to area rates, and there appeared to be no access barriers in the low-rate areas. High-rate areas were characterized by women who visited large numbers of different physicians and by having larger proportions of French, Polish, and Italian residents (ethnic groups which are largely Catholic in Manitoba). Although women residents of high rate areas made somewhat more visits for gynecologic problems and had many more D&Cs (dilation and curretage of the uterus), it is concluded that this may be due as much to the practice style of physicians treating patients from these areas as to gynecologic need. Residents of high and medium-high rate areas are more likely to have hysterectomy-prone surgeons as their primary physicians. Such physicians appear both more likely to "label" their patients' conditions as gynecologic in origin and more likely to advise surgical intervention (both D&C and hysterectomy) once such conditions are diagnosed. Thus, a combination of patient and physician characteristics may explain much of the variation in small area hysterectomy rates, rather than narrowly defined medical need.     

The downstream financial effects of a nursing home practice on an academic medical center

OBJECTIVE: To determine the financial impact of a nursing home practice on an academic medical center. DESIGN: Retrospective cohort design. SETTING: Middle-sized Midwestern community with fee-for-service Medicare population. SAMPLE: One hundred seventy-six nursing home residents followed by faculty and residents of a medical school department of family and community medicine. MEASUREMENTS: Billings and collections for professional and hospital services delivered by the academic medical center during fiscal year 1998. RESULTS: One hundred forty-four patient-years of service resulted in over 1 million dollars in billed charges. For every 1 dollar billed by family medicine, consulting physicians billed 2 dollars and the hospital billed 10 dollars. This amounted to over 4000 dollars per patient per year in reimbursement. This practice generated a wide variety of clinical problems (37 different diagnosis-related groups (DRGs) for the 61 admissions to the hospital). CONCLUSIONS: There is a significant downstream financial effect of a nursing home practice on an academic health center. For this and other reasons, this practice may be worthy of institutional support.     

Bronchial Epithelial Mucin in Rats Infected With Mycoplasma pulmonis

After 80 years, US training for clinical specialties is essentially hospital-based supervised practice. Needs for specialists are barely met, particularly since one third of residents are foreign citizens. Training must be more efficient, shorter, and relevant to community practice. Numbers of trainees in preventive medicine are entirely inadequate. Residencies have grown rapidly, but comprise only 1% of programs and positions. Younger physicians are recruited through community impact on health care, students, and teachers. These preventive medicine residents function outside hospitals, work fewer hours, are paid more than clinical residents, and obtain an academic year’s graduate education. They work fewer hours, but receive less pay than clinicians. The nation must examine the concept of training physicians for nonclinical preventive medicine functions and, if training continues, must develop methods of making training and career more attractive.     

Full clinical departments of family practice: their relationship to hospital privileges in university hospitals

All 52 family practice residency programs that hospitalize patients at a university hospital were surveyed to determine how many have full clinical departments of family practice and what effect having a full clinical department has on hospital privileges. A full clinical department is defined as one in which all hospital privileges for family physicians are reviewed and recommended by the family practice department without need for review by other specialties, even when the requested privileges overlap with another specialty. Responses were received from 100 percent of the surveyed hospitals. At 16 hospitals (30.8 percent) there is a full clinical department of family practice. When these hospitals were compared with the 36 (69.2 percent) at which there is no full clinical department, it was found that in every area of patient care, hospital privileges for family physicians are more extensive at hospitals with full clinical departments. The American Academy of Family Physicians is currently promoting the formation of full clinical departments of family practice as a method for improving hospital privileges for its members. The results of this study suggest that promoting the formation of full clinical departments will be an effective intervention.     

Physician Staffing of Small Rural Hospital Emergency Departments: Rapid Change and Escalating Cost

We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage. Twelve other hospitals (32%) hired visiting emergency department physicians to cover only weekends or evenings. The remaining 10 rural emergency departments (27%) were staffed entirely by external contract physicians. Thus, 86 percent of rural hospitals contracted for emergency department coverage, and 59 percent obtained some or all of this service from nonlocal physicians. Most of the 32 hospitals with some form of contracted services have changed to this emergency department coverage in the last few years. The cost of these services is high, particularly for the smallest hospitals that have fewer than eight emergency department visits per day and pay physician wages of nearly $100 per patient visit. Emergency staffing responsibility has shifted from local practitioners to the hospital administrators because of rural physician scarcity and a desire to improve quality and convenience. The cost of these changes may further undermine the economic viability of the smaller rural hospitals.     

Dilemma of black community hospitals

This feature of Urban Health covers a wide range of topics related to metropolitan hospitals, both public and private. This month's column discusses a hospital setting with which relatively few practicing physicians are well acquainted--the Black community hospital. More than 500 such hospitals were established in years following the Civil War, but their numbers have dwindled steadily in recent decades to the point where today only a handful survive. A recasting of missions and a thrust into the middle class population are among strategies needed to halt the demise of these institutions, says the author.     

Moonlighting policy and practice in family practice residencies

Moonlighting by residents is a controversial, but little-studied topic. A survey on moonlighting policy and practice was sent to all family practice residency program directors, and an 87 percent response rate obtained. Moonlighting is permitted by 97 percent of nonmilitary programs and is generally thought of by program directors as a positive educational experience. It is practiced by over two thirds of the second- and third-year residents in programs that monitor moonlighting. These residents spend an average of 28 hours each month moonlighting. The most commonly used moonlighting sites are hospital emergency rooms, followed by coverage for private practice physicians. Seventy percent of programs require approval for extracurricular work activity. Only 23 percent of residencies limit moonlighting for all residents, but 47 percent have had occasion to deny moonlighting privileges to individual residents.     

德国家庭医生执业路径及服务模式

德国“家庭医生”包含全科医生、家庭内科医生和儿科医生三类医师。除门诊开业外,家庭医生执业场所可延伸至医院,医院通过加强私人诊所与医院之间的良好互动从而发展整合医疗。家庭医师协会作为家庭医生职业群体代理,在福利报酬等方面与政府医保支付机构进行谈判。“家庭医生服务模式”下,疾病保险基金通过改进与家庭医生的服务购买协议,从而达到激励患者和服务提供方主动依从“守门人”制度的效果。     

Private medical services in the Italian public hospitals: the case for improving HRM

This study explores how Italian public hospitals can use private medical activities run by their employed physicians as a human resources management (HRM) tool. It is based on field research in two acute-care hospitals and a review of Italian literature and laws. The Italian National Health Service (NHS) allows employed physicians to run private, patient-funded activities ("private beds", surgical operations, hospital outpatient clinics, etc.). Basic regulation is set at the national level, but it can be greatly improved at the hospital level. Private activities, if poorly managed, can damage efficiency, equity, quality of care, and public trust in the NHS. On the other hand, hospitals can also use them as leverage to improve HRM, with special attention to three issues: (1) professional evaluation, development, and training; (2) compensation policies; (3) competition for, and retention of, professionals in short supply. The two case studies presented here show great differences between the two hospitals in terms of regulation and organizational solutions that have been adopted to deal with such activities. However, in both hospitals, private activities do not seem to benefit HRM. Private activities are not systematically considered in compensation policies. Moreover, private revenues are strongly concentrated in a few physicians. Hospitals use very little of the information provided by the private activities to improve knowledge management, career development, or training planning. Finally, hospitals do not use private activities management as a tool for competing in the labor market for health professionals who are in short supply.     

Hospital-sponsored primary care: I. Organizational and financial effects

Findings are presented from a seven-year (1976-83) evaluation of the Community Hospital Program (CHP), a national demonstration program sponsored by the Robert Wood Johnson Foundation to assist 54 community hospitals in improving the organization of access to primary care. Upon grant expiration, 66 per cent of hospital-sponsored group practices continued under some form of hospital sponsorship; over 90 per cent developed or were planning to develop spin-off programs; and new physicians were recruited and retained in the community. About 9 per cent of hospital admissions were accounted for by group physicians and grantee hospitals experienced a greater annual increase in their market share of admissions than competing hospitals in the area. While only three of the groups generated sufficient revenue to cover expenses during the grant period, 21 additional groups broke even during the first post-grant year. Productivity and cost per visit compared favorably with most other forms of care. Hospitalization rates from the hospital-sponsored practices were somewhat lower than those for other forms of care. Medical director leadership and involvement and the organization design of the practice were among several key factors associated with higher performing practices. The ability of such joint hospital-physician ventures to meet the needs of the poor and elderly in a time of Medicare and Medicaid cutbacks is discussed along with suggestions for targeting future initiatives in primary care.     

Why Rural Residents Migrate for Family Physician Care

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.     

Hospital–Community Partnerships: Facilitating Communication for Population Health on Columbus’ South Side

Previous studies have focused on the role anchor institutions play in community development. However, less attention has been directed to how hospitals can effectively partner with community-organizations and residents as part of population health efforts. This article examines community views of one initiative developed by a major American children’s hospital in partnership with local community organizations. The data for this study come from 35 in-depth interviews with local residents from the neighborhood adjacent to the hospital and two interviews with hospital administrators. Our findings suggest that the contexts in which hospitals and other non-profit corporations operate pose unique challenges to effective communication. In particular, hospitals and community organizations may think differently about the merits and nature of open communication. Especially when acting as anchor institutions working beyond their formal medical expertise, hospitals may struggle to communicate the scope and goals of their non-medical work in the community.     

Trust between managers and physicians in community hospitals: the effects of power over hospital decisions

Trust is a key element of effective work relationships between managers and physicians. Despite its importance, little is known about the factors that promote trust between these two professional groups. We examine whether manager and physician power over hospital decisions fosters manager-physician trust. We expect that with more power, managers and physicians will have greater control to enforce decisions that benefit the interests of both groups. Subsequently, they may gain confidence that their interests are supported and have more trust for each other. We test proposed hypotheses with data collected in a national study of chief executive officers and physician leaders in community hospitals in 1993. Findings indicate that power of managers and physicians over hospital decisions is related to manager-physician trust. Consistent with our expectations, physicians perceive greater trust between the two groups when they hold more power in four separate decision-making areas. Our hypotheses, however, are only partially supported in the manager sample. The relationship between power and trust holds in only one decision area: cost/quality management. Our findings have important implications for physician integration in hospitals. A direct implication is that physicians should be given the opportunity to influence hospital decisions. New initiatives, such as task force committees with open membership or open forums on hospital management, allow physicians a more substantial involvement in decisions. Such initiatives will give physicians more "voice" in hospital decision making, thus creating opportunities for physicians to express their interests and play a more active role in the pursuit of the hospital's mission and objectives.