By 2032, it is estimated that the US will experience a shortage of 21,000 to 55,000 primary care physicians (PCPs). To help address the shortage, many community-based institutions are looking to graduate medical education (GME) residency training to increase class size and/or add new programs.
Historically, a significant percentage of primary care residency training has occurred through large academic health systems that offered ambulatory training in hospital-operated clinics. These programs are frequently challenged to meet ambulatory training requirements for resident training and are seldom designed with PCP training in mind; rather, they typically focus on feeding their high-end fellowships. The primary care resident’s ambulatory training experience in major academic institutions often results in new physicians being unprepared for the rigors of private practice. Structuring ambulatory training to meet ACGME requirements, drive optimal volume levels, and establish appropriate scheduling and preceptor-resident ratios is critical to operating a high-performing GME clinic and producing well-rounded PCPs. This operating outcome is essential for community-based training programs.
In addition to the challenges associated with effective residency program training, teaching clinics can be costly to operate and generally represent the highest-cost component of residency training. Effective program management in the ambulatory setting is critical in order to optimize the educational experience, improve financial performance, and ensure resident preparedness in independent private practice. The challenge is to manage clinic performance based on the key metrics and attributes unique to the academic ambulatory environment.
Effective Management of Primary Care Teaching Clinics
Managing teaching clinics is far more complicated than managing traditional private practices due to characteristics that are unique to the primary care teaching setting. Traditional medical practice management metrics, such as gross charges, gross and net revenue, work RVUs, and collection rates, are relevant to teaching clinics, but additional tools and approaches are required for effective management. Key academic attributes are developed by combining integrated technologies with performance evaluation that is aligned with ACGME training requirements. By managing and measuring performance to ACGME academic requirements, the clinic can compartmentalize unique teaching attributes in the following ways:
- Determination of Faculty Effort: Historically, the management of faculty effort is documented in vague faculty contracts and random, arbitrarily administered time studies. Isolate and differentiate the time spent in private practice, teaching clinics, and other responsibilities such as inpatient service or call coverage. With the use of faculty and resident schedules, scheduling/billing information, and medical records data, faculty time and effort can be accurately tracked, imputed, and subsequently managed.
- Establishment of Optimal Scheduling Parameters: Optimization of the CMS primary care exception (PCE) can greatly increase clinic productivity. Under the PCE, residents can provide care without direct supervision for moderate-to-low-level encounters. Scheduling to effectively apply the PCE is necessary to optimize performance, and while the exception enables faculty members to precept up to four residents at a time, a best practice resident-to-faculty ratio is 3:1.
- Predictive Faculty and Resident Scheduling: In the outpatient/ambulatory setting, resident scheduling occurs in two half-day sessions. Managing this structure is critical in a teaching clinic. It is essential that faculty and residents are scheduled to meet optimal resident-to-faculty ratios and adhere to the schedule. Such predictive scheduling and management will optimize the productivity of each session and meet training requirements.
- Determination and Optimization of Available Clinical Space: Resident clinics are sometimes located in space that is not sufficient to optimize the potential of the CMS PCE. If ideal productivity volumes are to be achieved, it is essential to have an appropriate number of clinic exam and procedure rooms based on appropriate resident and faculty schedules.
- Real-Time Monitoring of Acuity Levels: Evaluation and management (E&M) coding is often a challenge in teaching clinics. Faculty are required to be physically present in the room with patients (and document accordingly) when a level 4 or 5 patient encounter is billed. Many resident clinics may default to level 3 or below to reduce potential audit risk or to allow residents to see the patient without the need for the attending physician to be present in the exam room. Active management through education and regular monitoring often results in shifting the E&M curve to more appropriate and realistic levels while achieving regulatory compliance.
- Tracking of Resident Clinical Requirements: Many primary care specialties have specific visit and procedural targets required by the ACGME (family medicine: 1,650 visits over three years; internal medicine: 130 half-day sessions over three years; OB/GYN: 120 half-day sessions over four years). This is often manually tracked and managed. Integrating the various systems (e.g., billing, scheduling, medical records) can provide automated documentation of resident volumes and expeditiously compile the specific services or procedures required to monitor program quality.
Effective management of primary care residency programs, particularly clinic operations, is critical to allow hospitals to develop and expand new residency programs and to produce practice-ready graduates. Although many of the concepts and variables introduced above are generally well known and regarded in the academic community, performance management oriented to the metrics specific to teaching environments is generally not a focus of clinic operations. When the operating parameters unique to the teaching setting are acknowledged and managed, the productivity potential of the CMS PCE dramatically increases.
A superior outpatient teaching experience can include operational efficiencies while simultaneously complying with the accreditation requirements set forth by the ACGME and enhancing program quality. Structuring clinic operations based on these variables will improve economics and provide a vehicle for program expansion to improve access to the medically underserved community. This will enable underserved communities to address the physician shortage with qualified, efficient, practice-prepared physicians.
Published July 21, 2020
