An incentive plan for professional fee collections at an indigent-care teaching hospital.

The authors describe the implementation and development of an incentive plan to improve professional fee collections at an indigent-care teaching hospital. They theorized that an incentive plan based on relative value unit (RVU) productivity would increase billings and collections of professional fees. Unique RVU targets were set for individual services based on the number of faculty full-time equivalents and average reported productivity for academic physicians by specialty. The incentive plan was based on the level of expected faculty billings, measured in RVUs, for each department. A "base + incentive" model was used, with the base budget being distributed monthly throughout the year, and the incentive held as a "withhold" to be paid at the year's end only if the billing target in RVUs was met. Additionally, a task force worked with physician billing office and the hospital to improve collections. In the first year after implementation of the system was in place, important increases were noted in total RVU productivity (30.5% over the previous year) and in collections (49.5% over the previous year). Sixteen of 23 departments exceeded their incentive targets, and it was possible to make distributions of professional fees to those departments, to be used within the hospital system to enhance clinical services. Moreover, the plan created an overall positive attitude toward billings and documentation of faculty activities. The authors believe that this kind of incentive plan will be increasingly important for academic faculty working in public hospital systems.     

The impact of the changing health care environment on the health and well-being of faculty at four medical schools.

PURPOSE: Increased pressure for clinical and research productivity and decreased control over the work environment have been reported to have adverse impacts on academic faculty in limited studies. The authors examined whether work-related stressors in academic medicine negatively affected the physical and mental health, as well as life and job satisfaction, of academic medical school faculty. METHOD: A 136-item self-administered anonymous questionnaire modified from a small 1984 study was distributed to 3,519 academic faculty at four U.S. medical schools following institutional review board approval at each school. Validated scales measuring depression, anxiety, work strain, and job and life satisfaction; a checklist of common physical and mental health symptoms; and questions about the impact of institutional financial stability, colleague attrition, and other work-related perceptions were used. Responses were analyzed by sex, academic rank, age, marital status, faculty discipline, and medical school. RESULTS: Responses were received from 1,951 full-time academic physicians and basic science faculty, a 54.3% response rate. Twenty percent of faculty, almost equal by sex, had significant levels of depressive symptoms, with higher levels in younger faculty. Perception of financial instability was associated with greater levels of work strain, depression, and anxiety. Significant numbers of faculty acknowledged that work-related strain negatively affected their mental health and job satisfaction, but not life satisfaction or physical health. Specialties were differentially affected. CONCLUSIONS: High levels of depression, anxiety, and job dissatisfaction-especially in younger faculty-raise concerns about the well-being of academic faculty and its impact on trainees and patient care. Increased awareness of these stressors should guide faculty support and development programs to ensure productive, stable faculty.     

Improving clinical productivity in the academic setting: a novel incentive plan based on utility theory.

PURPOSE: Academic internal medicine practices face growing challenges to financial viability due to high overhead, competing institutional missions, and suboptimal physician productivity. The authors describe the development of a clinical incentive plan for a group of academic subspecialty physicians at the Dana Clinic, an outpatient setting at Yale School of Medicine, and report on results of the first year's experience under the plan. METHOD: Utility theory was used to assess the risk profile of clinic faculty and identify incentive payments that would optimize faculty benefit or "utility" while minimizing departmental costs. Under the plan, physicians who reached a productivity target based on work Relative Value Units (wRVUs) between October 2003 and November 2004 had overhead costs covered and received a fixed payment to support salary; additional incentive payments were available for those exceeding the target. Physicians failing to reach the target were responsible for their own overhead costs and received no fixed payment. Physician productivity as measured by wRVU per full-time equivalent (FTE) was compared for the year prior to, and the year following, incentive plan introduction. RESULTS: Forty-seven members of eight academic sections were included in the analysis. Median productivity improved by 34%, with 42 of 47 physicians showing improvement. Significant improvements were also noted in collections (62%) and visit volume (23%), and shifts were observed in coding patterns. CONCLUSIONS: The unique threshold-based structure of the incentive plan, as determined through utility theory modeling, as well as permitting physicians to choose how to achieve the wRVU target were key features of its success, resulting in improved productivity without increasing practice resources or faculty salaries.     

Research issues in forensic pathology: a survey of academic institutions employing forensic pathologists

In an effort to characterize research efforts in forensic pathology, a questionnaire was sent to a representative of each of the 14 academic medical centers that employ full-time faculty forensic pathologists. Responses were received from all 14 (100%) of the institutions queried, representing a total of 39 forensic pathology faculty positions; 21 positions were tenure track and 18 positions were clinical or other tracks. Of the 39 positions, 25 positions (64%) at 10 institutions required some degree of research or scholarly output. Of the 25 forensic pathologists with a research imperative, only 3 (12%) were principal investigators or co-investigators on funded forensic pathology-based projects. The major limitation cited by respondents on the performance of forensic pathology research was the lack of protected time from service responsibilities. Fellowship training in forensic pathology was available at 6 of the 14 respondent institutions. Of these institutions, 4 (67%) had a research requirement for trainees, and 4 (67%) provided research training. In conclusion, very few US medical schools currently employ full-time faculty forensic pathologists. Of these, only a small number of institutions prioritize research by these faculty members. Scant federal funds are available to support research in forensic pathology. Few forensic pathology fellowship programs provide research training. To achieve a robust research agenda in forensic pathology that is sufficient to support the needs of the criminal justice and public health systems will require a paradigm shift in the medicolegal death investigative system and investment by federal agencies.     

The continued evolution of faculty appointment and tenure policies at U.S. medical schools.

For the past several decades, financial uncertainty, changes in health care delivery and reimbursement, and changing workforce needs have prompted medical schools to continually refine their appointment and tenure policies. Studies during the past 30 years have examined the nature of these faculty appointment and tenure policies in U.S. medical schools, and in this article the authors present data from a 2005 survey on faculty personnel policies to extend this analysis.For both basic science and clinical faculty in U.S. medical schools, the authors describe tenure systems, trends in the number and percentage of full-time faculty on tenure-eligible tracks, the financial guarantee of tenure, and probationary period lengths. They review the status of flexible policies and highlight two current faculty policy changes that many institutions have made or are actively contemplating: the recognition of interdisciplinary and team science, and a broadening view of scholarship.Results show that although tenure systems remain well established in medical schools, the proportion of faculty on tenured or tenure-eligible tracks has continued to decline over time. Changes in the financial guarantee associated with tenure have transformed the fundamental concept of tenure at many medical schools, and the percentage of schools that have lengthened the probationary period for tenure-track faculty has steadily increased during the past 25 years. Tenure-clock-stopping policies and part-time tenure policies continue to exist at medical schools, though results indicate low faculty use of the policies, suggesting a disconnect between policy and practice.     

Part-time residency training in internal medicine: analysis of a ten-year experience.

PURPOSE: To evaluate a ten-year experience (1983-1993) with a part-time residency curriculum. METHOD: In 1994, the authors analyzed the curriculum through interviews with graduates of a part-time residency track, surveys of faculty and graduates of a full-time residency program, and a quantitative comparison of faculty evaluations of those part-time and full-time residents. RESULTS: Both participants and full-time residents supported the part-time track and reported no adverse effect on the residency program as a whole. Analysis of faculty evaluations found that part-time residents scored significantly higher with respect to clinical skills (p = .0005) and humanistic skills (p = .0001), while there was no difference between the groups in leadership or teaching skills. CONCLUSIONS: This part-time residency curriculum provided a highly useful program track for a group of internal medicine residents with concomitant obligations, allowing them to complete their training in an uninterrupted fashion. The part-time structure did not adversely affect clinical competence and may have fostered humanistic attributes. The authors believe that this form of curriculum deserves wider consideration in residency training.     

A qualitative study of the experiences of one group of African Americans in pursuit of a career in academic medicine

Recent reports demonstrate that medical school enrollment of minority students has continuously declined over the past several years and underrepresented minorities (URMs) continue to account for a disproportionately low percentage (less than 4%) of full-time academic faculty at medical schools in the United States. This article reports on a qualitative research project to examine the sociocultural experiences that influenced one group of minority physicians pursuing an academic medical career. Nine African American faculty, one resident, and one fellow from a Southern medical school of 574 full-time clinical and basic faculty completed 25 open-ended questions on a structured, qualitative interview plus background demographics. These nine faculty represented 82% (N = 11) of the total number of African American clinical and basic scientist faculty on campus at the end of the 1999 academic year. The narrative interviews describe key decision points, environmental and economic influences, and cultural experiences that affected faculty career choices and illustrate the real-life experiences of current minority faculty and scientists. These narratives contain significant messages for addressing policy on school campuses to improve the opportunities and likelihood of increasing the proportion of minority physicians and scientists.     

The present and future of appointment, tenure, and compensation policies for medical school clinical faculty.

The authors present data and information about appointment, tenure, and compensation policies to describe how medical schools are redefining the terms under which they relate to their full-time clinical faculties. First, the authors note the increasing differentiation of clinical faculty members into two groups, researchers and clinicians. The present-day competitive realities of both research and clinical enterprises have prompted this change and the principles of mission-based management are reinforcing it. Second, they document the long-term tendency of schools to appoint new clinical faculty members to contract-term (as opposed to tenure) appointments, as special non-tenure-eligible tracks for clinically oriented faculty proliferate. Third, they report on the policies of schools to limit the financial guarantees provided to clinical faculty members who are awarded tenure. For schools that have yet to address this issue, they discuss the various employment and pay arrangements that inform or confuse the question. Fourth, they describe historic problems with clinical faculty compensation arrangements and illustrate, with examples from ten schools, the characteristics of recently implemented performance- and risk-based compensation plans. While these trends in institutional policies and practices may initially concern faculty advocate groups, the authors argue that they may serve the long-term interests of those groups. The terms of relationships between medical schools and their clinical faculties are tied closely to the specifics of organizational structure, which are currently undergoing review and change. The challenge all schools face is to define these terms in ways that allow them to continue to attract high-quality clinical faculty while avoiding an insupportable financial liability.     

Implementing a comprehensive relative-value-based incentive plan in an academic family medicine department.

The authors describe the implementation and first three years (1997-1999) of a department-wide incentive plan of the Department of Family Medicine at the State University of New York at Buffalo School of Medicine and Biomedical Sciences. By using a consensus approach, a representative elected committee designed a clinical relative value unit (explained in detail) that could be translated to equally value and reward faculty efforts in patient care, education, and research and which allowed the department to avoid the imposition of a model that could have undervalued scholarship and teaching. By 1999, the plan's goal of eight patient-care-equivalent points per four-hour session had been exceeded for pure clinical care. Clearly, only a small financial incentive was necessary (in 1999, an incentive pool of 4% of providers' gross salary) to motivate the faculty to be more productive and to self-report their efforts. Long-term productivity for pure clinical care rose from 9.8 points per session in 1997 to 10.4 in 1999. Of the mean total of 3,980 points for the year 1999, the contribution from teaching was 1,146, or 29%, compared with 25% in 1997. For scholarship, the number of points was 775, or 20%, in 1999, compared with 11% in 1997. The authors describe modifications to the original plan (e.g., integration of quality measures) that the department's experience has fostered. Problems encountered included the lack of accurate and timely billing information from the associated teaching hospitals, the inherent problems of self-reported information, difficulties of gaining buy-in from the faculty, and inherent risks of a pay-for-performance approach. But the authors conclude that the plan is fulfilling its goal of effectively and fairly quantifying all areas of faculty effort, and is also helping the department to more effectively demonstrate clinical productivity in negotiations with teaching hospitals.     

Advancing health care education and practice through research: the University of Toronto, Donald R. Wilson Centre for Research in Education.

The vision of the Wilson Centre for Research in Education at the University of Toronto, Ontario, Canada, is "advancing health care education and practice through research." With a core staff of eight PhD researchers, five full-time administrative staff, 150 clinical faculty members, and over a dozen fellows and visiting professors from around the world, the Wilson Centre has become an international leader in health professional education research. Diversity of ideas and research methodologies, a culture of mutual support and mentorship, and strong support from both the university and a major teaching hospital have propelled the Wilson Centre. Challenges such as focusing research priorities, involving the clinical faculty more extensively, and defining productive international collaborations are among the current issues for academic planning.     

Evaluation of the action plan for Roma people in health area

By virtue of the national program for Romanies and participation in the Decade of Roma Inclusion 2005-2015, Croatia has chosen its strategic standpoint toward programs of social inclusion of Romanies in four priority areas: housing, education, employment and health. The objectives of the Roma Action Plan (AP) for 2005-2015 in the health area focus on: * ensuring equal availability of health services through information about personal rights and health insurance options; * child health improvement and care, as well as mortality reduction; * raising health awareness and care in terms of safe motherhood, family planning and reproductive health; * financial support to schooling of Roma people in health professions In order to monitor the implementation of AP and measure the availability of health care and condition, certain indicators of the number and coverage of Romanies are crucial for each of the above objectives: indicators for the Roma informed about personal rights resulting from the mandatory health insurance; for Romanies who have health insurance; for vaccinated Romani children, for Romani newborns born in maternity hospitals, for prenatal and pregnancy health care in Romani women, for Romanies included in family planning, for the mortality rate and causes of death in Romanies, and for the Roma receiving scholarships for education in health professions. Most of these indicators are only obtainable through special studies, while routinely monitored indicators simply do not satisfy quantitative needs. Another problem is Romanies not stating their ethnic denomination. Consequently, routine Roma mortality and cause of death statistics are unreliable. At the state level, no specific indicators of implementation could be obtained for any of the above health objectives, while some were obtainable for specific units of local and self-government (Baranja, Medimurje and Primorje-Goranska County). According to the research, more than 50% of Romanies in Croatia are situated in Medimurje, where they make up 3.4% of overall population, but also 53% of recipients of unemployment compensation. In Medimurje County, local and EU funds were used to undertake certain measures of protection from infectious diseases, alongside health education in combating ignorance and mistrust of Roma towards vaccination. Baranja used state budget funds to conduct preventive examinations of Romani women who have no health insurance, and to educate them in health measures of safe motherhood, family planning and infant health care. Although the AP includes a series of measures for improving Romanies' health, it cannot be implemented or its effects measured without clearly defined organizers of activities, resources assigned for implementation, and process and outcome indicators.     

Mission aligned management and allocation: a successfully implemented model of mission-based budgeting.

In response to declining funding support and increasing competition, medical schools have developed financial management models to assure that resource allocation supports core mission-related activities. The authors describe the development and implementation of such a model at the University of Wisconsin Medical School. The development occurred in three phases and included consensus building on the need for mission-based budgeting, extensive faculty involvement to create a credible model, and decisions about basic principles for the model. While each school may encounter different constraints and opportunities, the authors outline a series of generic issues that any medical school is likely to face when implementing a mission-based budgeting model. These issues include decisions about the amounts and sources of funds to be used in the budgeting process, whether funds should be allocated at the department or individual faculty level, the specific metrics for measuring academic activities, the relative amounts for research and teaching activities, and how to use the budget process to support new initiatives and strategic priorities. The University of Wisconsin Medical School's Mission Aligned Management and Allocation (MAMA) model was implemented in 1999. The authors discuss implementation issues, including timetable, formulas used to cap budget changes among departments during phase-in, outcome measures used to monitor the effect of the new budget model, and a process for school-wide budget oversight. Finally, they discuss outcomes tracked during two years of full implementation to assess the success of the new MAMA budget process.     

Crushing the commercial spirit in academic medicine: a crusade that failed.

The struggle between academic values and the practice opportunities in clinical medicine has continued throughout the present century. The reformers who prevailed in bringing clinical teaching into the university as a full-time occupation were persuaded that only university ideals--academic rigor, high professionalism, and full-time service in teaching and research--could create the kind of environment in which clinical science and effective clinical teaching could flourish. Their victory was never complete, and much of America's clinical establishment resisted the change, arguing that it was not commercial gain but concerns over teaching medicine in a narrowly academic enclave that motivated them. For the first two thirds of the century, the commercial spirit in academic medicine, while never completely crushed, gave way to an academic ethos that honored academic recognition and research honors over making money. Events of the past 30 years have reawakened the commercial spirit with a vengeance. In the years since Medicare, managed care, and HMOs have become prominent, faculty practice has become a principal means of maintaining teaching hospitals, high professional salaries, and medical teaching. In the present crisis, the author believes, only an unprecedented, all-out effort on the part of medical faculties and their allies to separate out medical education from other health care concerns and secure strong support from government offers any long-range hope for success.     

The LeMoyne-Owen College��UTCHS Cooperative Educational Program: A Model for Minority Recruitment

A program of cooperative education between LeMoyne-Owen College and the University of Tennessee Center for the Health Sciences (UTCHS) was designed to attract students from the undergraduate institution to the various health professional schools at UTCHS. The program was initiated by a black faculty member at UTCHS. It involved a faculty exchange between the two institutions and the implementation of several changes in the pre-health science curriculum at the undergraduate institution. Other components of the program included: the gift of equipment and supplies to LeMoyne-Owen College by UTCHS; counseling of LeMoyne-Owen students by UTCHS faculty members; the generation of private funds by the faculty and staff at UTCHS for the support of LeMoyne-Owen students participating in the cooperative education program; and broad exposure of LeMoyne-Owen students to the laboratories and clinical facilities at UTCHS.     

Overcoming a perfect storm: an academic cardiology section's story of survival.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.     

How do academic health centers value and encourage clinical research?

To investigate whether there is a misalignment of the perceived values of and incentives for clinical research within U.S. academic health centers (AHCs), in 1999 the authors surveyed medical school deans, academic administrators, department chairs, and faculty members at 80 AHCs that are the members of the University HealthSystem Consortium, a not-for-profit consortium of AHCs. A total of 358 faculty from 58% of the institutions surveyed responded, with a mean of 3.76 responses/institution. There was general agreement that clinical research offers AHCs a considerable spectrum of benefits, including prestige, recruitment and retention of faculty, criteria for promotion of faculty, and financial support. Investigator-initiated research and government-funded research ranked highest in terms of their desirability compared with industry-sponsored and contract research. This preference was agreed upon across all categories of respondents and types of research (translational, clinical tests, and outcomes). Significant differences existed between the perceptions of deans/AHC administrators, who stated that they were increasing their emphasis on clinical investigation in the areas of research space (56% of responders), administrative support (81%), and patient recruitment (61%) and the perceptions of their departmental chairs/faculties in the same areas (34%, 52%, and 40%, respectively; p <.05). Faculty opinions documented few new investments in the actual infrastructure dedicated to clinical research. The authors conclude that their findings, which they consider reasonably representative, strongly suggest that the value of clinical research to AHCs is well understood. Their findings also identify important opportunities for AHCs to provide a wider range of incentives for the conduct of clinical research.     

Implementing a simpler approach to mission-based planning in a medical school.

Changes in the education, research, and health care environments have had a major impact on the way in which medical schools fulfill their missions, and mission-based management approaches have been suggested to link the financial information of mission costs and revenues with measures of mission activity and productivity. The authors describe a simpler system, termed Mission-Aligned Planning (MAP), and its development and implementation, during fiscal years 2002 and 2003, at the School of Medicine at the University of Texas Health Science Center at San Antonio, Texas. The MAP system merges financial measures and activity measures to allow a broad understanding of the mission activities, to facilitate strategic planning at the school and departmental levels. During the two fiscal years mentioned above, faculty of the school of medicine reported their annual hours spent in the four missions of teaching, research, clinical care, and administration and service in a survey designed by the faculty. A financial profit or loss in each mission was determined for each department by allocation of all departmental expenses and revenues to each mission. Faculty expenses (and related expenses) were allocated to the missions based on the percentage of faculty effort in each mission. This information was correlated with objective measures of mission activities. The assessment of activity allowed a better understanding of the real costs of mission activities by linking salary costs, assumed to be related to faculty time, to the missions. This was a basis for strategic planning and for allocation of institutional resources.     

Sixteen years' experience with a required third-year family medicine clerkship at Jefferson Medical College.

Jefferson Medical College has developed a program to successfully meet the goal of teaching ambulatory care to all medical students, by providing each of its 223 third-year students with a required six-week clerkship in family medicine. The structured clerkship takes place at one of seven residency-based family practice centers, is supplemented by a formal curriculum, and is based on the active clinical involvement of caring for patients under full-time family medicine faculty supervision. This clerkship has been in existence for 16 years, and has added over 400,000 student-patient encounters to the clinical education of over 3,500 students. Student evaluations of the clerkship have rated it the highest of the six required core clerkships at Jefferson. In addition, over 16% of Jefferson graduates have entered family medicine residency training programs, a rate higher than that of any other school in the northeastern United States, and significantly higher than the average for all U.S. medical schools (12%). Jefferson's experience suggests that ambulatory care can be taught as a core component of the clinical education of all medical students. To be successful, however, strong institutional support, a structured curriculum, an adequate number of patients, a dedicated faculty, a sufficient number of training sites, an appropriate evaluation process, and significant financial support are all necessary.     

Educating future physicians for a minority population: a French-language stream at the University of Ottawa.

The Faculty of Medicine at the University of Ottawa has recently developed a French-language undergraduate medical education stream in order to train physicians for the francophone minority population of the province of Ontario. This new program was planned with the following societal requirements in mind: the need to receive health care in one's mother tongue, the need to have physicians who know the community, and the expectation of receiving good medical care in an ambulatory setting. A systematic educational planning model was used in order to develop three educational innovations in response to these needs and expectations: a communication skills laboratory; early student exposure to the ambulatory, primary care setting for development of clinical skills; and clerkship rotations in a francophone community hospital. Program developers provided ongoing faculty development activities in order to prepare francophone faculty for their new roles. They also considered student participation in program development an essential element of its success. The program has positive outcomes both within and outside the Faculty of Medicine. These include an enrichment effect on the English-language stream, an increased interest in medical education, student satisfaction with their community hospital clerkship rotations, and the recognition of the educational program as a national resource for francophone minority groups. Medical schools that serve minority population groups may benefit from the experience gained at the University of Ottawa.     

Job satisfaction and workplace characteristics of primary and specialty care physicians at a bimodal medical school.

PURPOSE: A few medical schools are highly successful in obtaining research funding and producing primary care physicians. The authors compared the job satisfaction of primary and specialty care faculty at one of these bimodal schools. METHODS: In 1998, all full-time physician-faculty (n = 408) in 15 clinical departments at the University of Iowa College of Medicine (a bimodal medical school) were sent a questionnaire based on the Price-Mueller model of job satisfaction. Faculty rated their global job satisfaction and perceptions about 18 workplace characteristics, stressors, and supports. Responses of primary and specialty care physicians were compared in these domains. RESULTS: A total of 71% of surveyed faculty (n = 341) returned usable questionnaires. Primary and specialty care faculty reported similar levels of job satisfaction (p =.20), and similar percentages (51% versus 54%, p =.63) reported overall satisfaction with their jobs at the medical school. However, primary care faculty perceived less opportunity to advance (p <.01), greater professional-role ambiguity (p =.02), less collegiality (p =.02), and less ability to make full use of their clinical skills (p =.01). Primary and specialty care faculty reported similar intentions of leaving the medical school within the coming year (p =.41). CONCLUSIONS: Primary and specialty care physicians at one bimodal medical school reported similar levels of job satisfaction. However, the primary care physicians rated several important job-related domains lower than did their specialty care colleagues, most notably the opportunity to advance within the medical school.