Nurses making more than docs at UCSF County

[core0]

First, that cost analysis is inadequate, it once again accounts for direct revenue + cost + expense but does not account for what would it cost to have the resident replaced. A mid-level doing 60 hours a week would approximately cost $120k a year. I don't see that in any of the calculations and it is a valid substitution.

Second, I started to realize why studies like to show the loss and avoid talking about how much net money is made by the institution from residencies. If the studies do start to show that residencies are net profitable, the medicare reimburisement will start to argue that it wants to decrease GME funding cause residents are profitable as they are and they need to use that money elsewhere. You just can't win with medicare, it wants to cut down whether residents are good for the institution or bad (cost too much, lets keep their numbers down, they make more than enough for the institution, lets not give them as much.)

Yes but a mid-level would be able to bill Medicare and Medicaid for the services provided so there would be more income. Also in theory you would not need a residency office which is a good portion of the money. You could almost always make more money with mid-levels than a residency program (outside of those programs with a substantial no pay population). However the point of a residency program is not to make money, it is to educate residents (at least in theory).

David Carpenter, PA-C

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[Hernandez]

Alrighty, so I sat down. reread it and then had an MBA go over this with me as well. You're off base and misreading this just as I stated before.

Bottom line, it is unlikely that residency programs are cash cows swimming in extra money (at least based on the published data). They probably operate at a small net loss for the most part. If you can successfully cut the expenses you can probably make some money on a residency program. Expenses primarily consist of support staff and attendings.

You keep spouting about published data, yet I've not seen anything you've posted which support this claim. Please post an article which actually shows that residencies post any loss.

Total Program Expenses and Cost Per Resident, Including Uncontrolled Data*
# of Programs Median Value Mean Value Range SD
2003 total revenue/resident FTE 12 $257,644 $246,688 $178,700–$319,106 $49,170
2003 total expense/resident 12 $250,613 $285,352 $190,539–$429,674 $85,810
2003 total cost/resident 12 $33,276 $38,664 -$22,413–$232,948 $94,633

Unfortunately with SDN I can't get the table to work. But the mean cost (income - expense was $38k so yes it does show a loss on the residents (table 4a page 413).

Wrong. This article has so many holes and omissions it truly impossible to differentiate what they're stating. 1) They are using FTEs, yet they do not detail whether this is the traditional FTE based on 40 hour work weeks. 2) the incorporate the following into the "expenses" category.

Examples of these indirect expenses included some or
all of the following: human resources and personnel
management, information services, billing and collections,
general administrative support, transcription,
physical plant (rent or mortgage), expenses associated
with the physical plant (utilities, telephone, maintenance,
etc), capital equipment purchases, and benefits
or retirement packages for employees.​

This is disingenuous as a great deal of residents are utilizing these expenses but they were already in place. So do they actually increase the costs of these expenses? I doubt they have an effect on the utilities/phone/etc. The N for this study is extremely small.

Not only that, but revenue - expense does not equal the costs. There is some voodoo math going on here to justify these results.

"Evaluated at the means of teaching facilities, the marginal cost of a surgical resident is $252,361, of a psychiatric resident is $138,811, and of a medical resident is $90,525. The production function analysis finds a similar pattern, with residents in psychiatry generating more output than their wage, those in medicine having a small positive effect, and those in surgery generating negative outputs. Further, surgical residents reduce the productivity of staff physicians."

I would agree that this doesn't show loss, but if the marginal cost (and I am not sure if they are using it correctly here) is $252k for a surgery residency resident then even using 2003 data there is no way to make a "profit". If they are using marginal cost correctly every "unit" of surgery resident costs $252k more to produce (this would not fit supply and demand curves but we have already acknowledged that residency is purposely outside of supply and demand). This may be that the reduction of surgical efficiency is magnified as the residency program gets bigger.

While this is old data, what the article attempted to show was that hospitals (under a 1995 model) would make more money by producing more primary care physicians (which was all the rage in the 90's). As far as decreasing reimbursement, there is no corollary between reimbursement and costs for training. Costs have gone up significantly (look at costs in the FM paper above) while reimbursements have not. At some point in time it becomes cheaper (especially for community hospitals) to get rid of the residency.

Some how I doubt you are using the term "marginal cost" correctly. This term has absolutely NOTHING to do with Losses, simply how much it costs to produce a surgeon. Factor in that they did not delineate whether this was on a yearly basis or not, I highly doubt they are. But let's look at it on the basis of of the average number of years of residency. IM is 3, Psych is 3, Surgery is what 5? Even beyond that, it makes complete sense that surgery costs more as there is much more expendable material involved in their training. but again, this does not say a thing about "loss" only costs.

Yes but how do you control expenses - salaries for support staff for the residency and for attending. Not exactly the way you want to go. As far as loss, the amount of income for a program is relatively fixed and the expense is higher for a smaller program so this generates a loss. This paper would seem toconfirm this (at least for family practice).

I've read this article twice and have no clue where how you are crossing your eyes to imagine the conclusions you're spouting off. This article only draws the conclusion any intelligent person should already be aware of. If medicare/caid is the primary source for funding these spots, then the Government needs to be cognizant that inflation and other costs will increase and require a proportional increase in funding.

However, none of these articles address the inherent cost savings of having a resident on staff instead of paying for a mid-level.

http://www.stfm.org/fmhub/fm2003/November/Gonzalez.pdf

But even if your diatribe about "losing money" is correct (which I do not believe you've proven), you fail to realize the further positive economic impact. from one of the references from one of your own articles

The economic impacts of Oklahoma's Family Medicine residency programs.

Lapolla M, Brandt EN, Barker A, Ryan L.

Oklahoma State University, 2819 S. Cincinnati Ave., Tulsa, OK 74114, USA.

The enactment of Medicare and Medicaid created a new demand for medical services in Oklahoma, particularly in rural areas. The state of Oklahoma responded by creating The Oklahoma Physician Manpower Training Commission in 1975. The overall purpose of the Commission was to increase the number of primary care physicians and influence distribution into non-metro areas. This analysis concerns the public policy value of this ongoing program. The PMTC has provided resident stipend funding to each of Oklahoma's publicly funded Family Medicine residency programs. Since 1975, the PMTC has provided over 139 million dollars in resident stipend funding and support; and there have been 749 program graduates with 431 practicing in Oklahoma. This model calculates that the Oklahoma-based physicians have created a cumulative 3.7 billion dollars of economic impact on the state; and conservatively estimates that only 10% of the practice decisions/locations were influenced by the PMTC. This creates an estimated return of 370 million dollars on an "investment" of 139 million dollars. Additionally the model demonstrates that the current cohort of physicians is annually responsible for 15,530 jobs and an associated payroll of 428 million dollars.​

 

[MacGyver]

If you are looking for analysis here is some. This particular study shows a net loss per resident:
http://www.stfm.org/fmhub/fm2006/June/Judith408.pdf

Here is a study from 95. At that time programs made a little money from FM and took huge losses from surgery:
http://gateway.nlm.nih.gov/MeetingAbstracts/102215440.html

Also note that resident costs decrease as the program is larger as evidenced here:
http://archinte.ama-assn.org/cgi/content/abstract/161/5/760

Bottom line this is a very complex process that is not easily fixable in the current economic climate.

David Carpenter, PA-C

Sorry but those studies are bull****. Let me take a quote from teh first article:

Examples of these indirect expenses included some or
all of the following: human resources and personnel
management, information services, billing and collections,
general administrative support, transcription,
physical plant (rent or mortgage), expenses associated
with the physical plant (utilities, telephone, maintenance,
etc), capital equipment purchases, and benefits
or retirement packages for employees.

Uhhh, NONE of those expenses has anything to do with residents. So this study is attributing costs to residents that dont exist. Its totally dishonest, implying that resident funding is supposed to cover the entire cost of operation of the hospital.

Retirement and benefit
packages averaged 19.6% of total expenses across
all personnel,

Since when do residents get RETIREMENT packages? What the **** does this have to do with resident training? Answer: absolutely nothing, which is why this is a bull**** study.

 

[Miami_med]

Yes but a mid-level would be able to bill Medicare and Medicaid for the services provided so there would be more income. Also in theory you would not need a residency office which is a good portion of the money. You could almost always make more money with mid-levels than a residency program (outside of those programs with a substantial no pay population). However the point of a residency program is not to make money, it is to educate residents (at least in theory).

David Carpenter, PA-C

There's the crux of it. The PA can bill Medicare or Medicaid, while the resident, even if he has more training, can't bill at all. He can't even bill the same. The whole mess falls back on the government controlling reimbursement (much like all of the rest of the mess in medicine).

 

[core0]

Uhhh, NONE of those expenses has anything to do with residents. So this study is attributing costs to residents that dont exist. Its totally dishonest, implying that resident funding is supposed to cover the entire cost of operation of the hospital.

The hospital receives two sources of funding. GME funds that pay for the resident salaries and benefits and IME funds to pay for the indirect costs of residents. So the costs quoted are the for those portion of the costs (ie HR etc. that are attributable to residents.


Since when do residents get RETIREMENT packages? What the **** does this have to do with resident training? Answer: absolutely nothing, which is why this is a bull**** study.

Some hospitals offer 403b's etc. I believe they are required to offer health insurance so that would be the benefits. From a private practice standpoint 20% of salary as benefits is pretty poor (I would guess that the health insurance isn't all that good).

Both of these are necessary parts of looking at the cost of residencies. The main problem with residencies from a hospital perspective is that the costs of the IME have not come up with the hospital costs.

David Carpenter, PA-C

 

[core0]

There's the crux of it. The PA can bill Medicare or Medicaid, while the resident, even if he has more training, can't bill at all. He can't even bill the same. The whole mess falls back on the government controlling reimbursement (much like all of the rest of the mess in medicine).

In theory the reason that residents can't bill for services preformed is that they are accepting money from medicare to pay for the residents. An interesting analysis would be to bill for residents like you do for PAs. You either cobill at 100% or bill at 85% of the physician rate. I would guess that the hospitals with lots of paying patients would do very well, hospitals with a lot of medicare or no pays would do poorly. It would also lead to different ways to abuse residents. From a PA perspective a lot of what we do is about production. This may not be the best way to train physicians.

David Carpenter, PA-C

 

[MacGyver]

Some hospitals offer 403b's etc. I believe they are required to offer health insurance so that would be the benefits. From a private practice standpoint 20% of salary as benefits is pretty poor (I would guess that the health insurance isn't all that good).

Both of these are necessary parts of looking at the cost of residencies. The main problem with residencies from a hospital perspective is that the costs of the IME have not come up with the hospital costs.

David Carpenter, PA-C

Uhh, read this list again dude:

1) human resources and personnel
management

2) information services

3) billing and collections

4) general administrative support

5) transcription

6) physical plant (rent or mortgage)

7) expenses associated with the physical plant (utilities, telephone, maintenance

8) capital equipment purchases

9) benefits or retirement packages for employees.

the fact of the matter is that residents account for an exceedingly tiny percentage of those areas. There's no way in hell you can tell me that residents are responsible for the "physical plant fees" of a hospital. Thats a bunch of bull**** and you know it.

This is a ploy by hospital management to incorrectly assign Medicare resident revenues to non-resident costs.

Hospitals have 3 costs of residents:

1) Health insurance
2) Malpractice coverage
3) Salary

Here's another nice little BS section from the first study:

Meanwhile, expenses continue to increase. Most
prominent are individual salary increases, but there
was also an upward trend in the number of staff and
faculty supporting the program. Network directors in
discussion attributed this trend in part to the increased
regulatory environment and the implementation of
resident duty hours limitations. Additionally, overall
operational expenses are increasing at a faster rate than
associated net revenues. This deficit emphasizes the
importance of other revenue sources to support family
medicine training programs, as increasing visits alone
is for many programs a downward spiral in the current
reimbursement climate.

In other words they are attributing ALL the increases in staff to residents. Thats obviously BS logic. Their table shows increases in RNs, lab techs, and ancillary support stafff that has NOTHING to do with residents. The only "increased staff" that are related to residents are PAs/NPs to cover the new 80 hour work week regs.

Staffing Models in the FMC
Overall staffing per 10,000 outpatient visits in the
FMCs remained almost unchanged, but the composition
of those staff has changed (Table 7). Programs
averaged more administrators, billers, receptionists,
medical records, and nursing personnel, offset by fewer
"other" staff (social work, pharmacy, others). Excluding
the "other" category, which varied widely among
programs, overall core staffing per 10,000 patient visits
averaged 15.3% less than the Medical Group Management
Association (MGMA) average.

Here's yet another example of this study's idiocy. They attribute the entire staff of these outpatient clinics to resident needs. Thats obviously BS. There's no way that residents are responsibile for extra increases in nursing or pharmacy staff for example. Again, this study has a tremendously flawed premise from the beginning: it assumes that resident Medicare payments are supposed to cover the cost of the entire operation of the hospital. Thats obviously a load of crap.

Malpractice costs were significantly different among
the UWFMN programs between 2000 and 2003. In
2000, all programs shared an arrangement for malpractice
coverage with a single malpractice carrier; this
arrangement collapsed in 2002, and the programs had
to arrange for coverage individually. Most were able
to obtain this through their sponsoring institutions,
but a small number needed to contract independently.
The costs of these new contracts varied from $7,378 to
$780,000, with a mean of $82,588

This is yet another BS comparison. They are using the malpractice costs for the entire hospital and attributing them to resident usage.

Compensation expense increased 24.2% from 2000
to 2003. Programs reported a 6.7% increase in the
number of employees during this period, and a 16.5%
increase in number of faculty. Retirement and benefit
packages averaged 19.6% of total expenses across
all personnel, unchanged from 2000. Percent of total
compensation relative to total expenses, at 76.8%, did
not change significantly

More BS. This study assumes that all faculty increases and all staff increases in a hospital are due to resident requirements. Furthermore, that 6.7% increase in employees they are referring to is the aggregate increase in employees for the ENTIRE HOSPITAL, not residents. Yet they attribute ALL of those increased employee costs as well as new faculty costs to resident education. Pure BS.

The average GME + IME payment for each resident is $222,000. Any hospital who loses money based on that compensation is run by fools. Dont piss on my back and tell me its raining. All this crap coming from hospitals about them "losing money" on residents is pure propaganda designed to intimidate the federal government into giving them more $$$$

 

[djavid]

This is a little off topic but Miami_med,

I feel the problem is not that govt. has too much control over medicine.

I feel the problem is they control too little and control too much and can't make up their mind which way they want to go. This leads to gross neglegance.

If they want to control it then I say get on with it. If they want to make it private then I say just do it already. You can't have it both ways.

There's the crux of it. The PA can bill Medicare or Medicaid, while the resident, even if he has more training, can't bill at all. He can't even bill the same. The whole mess falls back on the government controlling reimbursement (much like all of the rest of the mess in medicine).

 

[core0]

Uhh, read this list again dude:



the fact of the matter is that residents account for an exceedingly tiny percentage of those areas. There's no way in hell you can tell me that residents are responsible for the "physical plant fees" of a hospital. Thats a bunch of bull**** and you know it.

This is a ploy by hospital management to incorrectly assign Medicare resident revenues to non-resident costs.

Hospitals have 3 costs of residents:

1) Health insurance
2) Malpractice coverage
3) Salary

The residents may take up a tiny percentage of the costs but they are real.Go to a residency office. There are people there. They take up space, draw salaries, use electricity. Someone has to pay for this. For any medical practice there are 4-5 people for any provider. You may need a few less for residents but it is still a very real cost.

On the other hand please tell your residency director that you consider his salary and any other salaries superflous and see how far that gets you.

Here's another nice little BS section from the first study:

In other words they are attributing ALL the increases in staff to residents. Thats obviously BS logic. Their table shows increases in RNs, lab techs, and ancillary support stafff that has NOTHING to do with residents. The only "increased staff" that are related to residents are PAs/NPs to cover the new 80 hour work week regs.

So you completely ignore the part about more staff needed to comply with increased reporting? It says nothing about ancillary staff. There is also increased staff which may be NP/PA or may be additional faculty.



Here's yet another example of this study's idiocy. They attribute the entire staff of these outpatient clinics to resident needs. Thats obviously BS. There's no way that residents are responsibile for extra increases in nursing or pharmacy staff for example. Again, this study has a tremendously flawed premise from the beginning: it assumes that resident Medicare payments are supposed to cover the cost of the entire operation of the hospital. Thats obviously a load of crap.

Once again you either failed to read the study or fail to grasp the significance. If you look at the residency staff as a primarily inpatient workforce any changes to a program with increased outpatient requirements necessarily decrease that workforce. Also since that particular study looks at family medicine it is completely appropriate to look at the costs of running the outpatient clinic since it is part of the resident education process.


This is yet another BS comparison. They are using the malpractice costs for the entire hospital and attributing them to resident usage.



More BS. This study assumes that all faculty increases and all staff increases in a hospital are due to resident requirements. Furthermore, that 6.7% increase in employees they are referring to is the aggregate increase in employees for the ENTIRE HOSPITAL, not residents. Yet they attribute ALL of those increased employee costs as well as new faculty costs to resident education. Pure BS.

The average GME + IME payment for each resident is $222,000. Any hospital who loses money based on that compensation is run by fools. Dont piss on my back and tell me its raining. All this crap coming from hospitals about them "losing money" on residents is pure propaganda designed to intimidate the federal government into giving them more $$$$

I guess you read a different report than I did. The increase in the report was the increase in program size (FTE's).

As far as cost I am curious where you came up with $220,000? The only source I can find is from the ACGME from 2002:
"For FY 2002, the average per-resident payment for both Direct Medical
Education and Indirect Medical Education is estimated at $72,000."
https://www.acgme.org/acWebsite/positionPapers/pp_FedReport202.pdf

I seriously doubt the amount has tripled in the last five years. I would be interested in seeing your source for this.

David Carpenter, PA-C

 

[MacGyver]

The 200k is for total revenues from both IME, DME and patient sources. Its listed in the flawed study you keep citing.

Outpatient clinics: this flawed study assumes that 100% of hte cost of the clinic is born by resident training. Basically teh implicit assumption is that without residents these clinics would not exist and therefore 100% of the cost of operation is assigned to "resident training." Thats obviously a load of crap.

Take a look at Table 7. It uses an average of 30 support staff workers at Family Medicine practices. It includes the cost of ALL 30 OF THESE SUPPORT WORKERS into the "resident cost" calculation, implying that residents are responsible fro 100% of the workload of these people. Please explain to me why 100% of the billing support staff cost is assigned to resident tasks.

Take a look at Table 5 and htis little gem listed underneath:

“Core faculty” was defined as those faculty employed by the program
at the main residency and satellites run by the main program; it excluded
faculty at satellite programs operated by other entities (such as community
health centers), rural tracks, fellowships, and research and teaching functions
outside of the residency program.

This study is attributing 100% of the costs of these "core faculty" to residents when in fact they make up very little of the cost for training purposes.

You still havent addressed the other flaws of this study. Tell me again why "power plant maintenance" is supposed to be covered by resident revenues.

There are a bunch of BS imaginary costs that are being attributed to residents in this study that simply dont exist.

 

[Miami_med]

In theory the reason that residents can't bill for services preformed is that they are accepting money from medicare to pay for the residents. An interesting analysis would be to bill for residents like you do for PAs. You either cobill at 100% or bill at 85% of the physician rate. I would guess that the hospitals with lots of paying patients would do very well, hospitals with a lot of medicare or no pays would do poorly. It would also lead to different ways to abuse residents. From a PA perspective a lot of what we do is about production. This may not be the best way to train physicians.

David Carpenter, PA-C

There's still really no incentive to train residents, and giving hospitals a lump sum and saying "train them," is obviously going to lead to some abuse. In a system where residents could bill, perhaps it would atleast slant incentive towards productive activities, while simultaneously diminishing incentive to use residents as cheap labor, as they come with an hourly wage below the LPNs on the service. If we really wanted to be technical, and keep Medicare in some way specially involved (which I'm not advocating), we could just let residents bill, while giving hospitals certain educational incentives. It would be ripe for abuse, but no more so than the current system.

 

[Miami_med]

This is a little off topic but Miami_med,

I feel the problem is not that govt. has too much control over medicine.

I feel the problem is they control too little and control too much and can't make up their mind which way they want to go. This leads to gross neglegance.

If they want to control it then I say get on with it. If they want to make it private then I say just do it already. You can't have it both ways.

I've actually said that before. I just happen to believe that the government taking something over is the surest way to have a disaster within a couple of decades. However, I agree that the current system is based on the most ridiculous false logic, attributing both god-like skill and Christ-like self sacrifice as expectations to physicians while simultaneously expecting them to bear legal and financial responsibility for their practices according to market principles and malpractice law is absurd. As an example, having EMTALA while not giving doctors legal immunity. I just think that responsibility all around is a good thing, and I advocate the capitalist model.

 

[dutchman]

I've actually said that before. I just happen to believe that the government taking something over is the surest way to have a disaster within a couple of decades. However, I agree that the current system is based on the most ridiculous false logic, attributing both god-like skill and Christ-like self sacrifice as expectations to physicians while simultaneously expecting them to bear legal and financial responsibility for their practices according to market principles and malpractice law is absurd. As an example, having EMTALA while not giving doctors legal immunity. I just think that responsibility all around is a good thing, and I advocate the capitalist model.

Great point.

 

[NotAProgDirector]

I really shouldn't get into this discussion.

Ah well, here goes:

A. What are the costs of training residents?

Hospitals have 3 costs of residents:

1) Health insurance
2) Malpractice coverage
3) Salary

This is not complete. Additional direct costs include:
1. Portions of the PD and APD's salaries/benefits.
2. Program administrator salaries/benefits.
3. ACGME fees, Match fees, ERAS fees, ITE fees, etc.
4. Recruiting costs, including all those dinners.
5. GME office costs (shared between all the residency programs)
6. Infrastructure costs -- computers for residents, pagers, scrubs, etc.

However, there are many INDIRECT cost savings associated with a residency program, noted below.

B. How much money do programs gain from training residents?

Programs get resident income from two sources -- directly from Medicare as DME and IME, and by billing patient services directly to insurers.

The amount of money programs get from Medicare is quite variable. An old but informative article about this is here. As this is an NEJM article, you may need a subscription to see it. I have attached the relevant table to this message. Ignore the first column -- this is the amount of money a residency program "would" get if other payers paid like Medicare does. They don't, so what programs actually get per resident is in the last column. The study is obviously dated, but overall the amount of money from GME has decreased since the passage of the BBA of 1997, not increased.

Yet, this is not the whole story. This study only looks at DME. DME flows directly to the sponsor of the residency program (could be a medical school, hospital, or other health care organization). IME flows directly to hospitals where residents deliver care. There is a very complex and insane formula for how much IME a hospital gets. In general, the total IME spending is double the DME spending, so you can multiply the number in the last column by 3 and get a reasonable estimate of how much money hospitals get for training residents. You can see that a small number of programs, many in NYC, make a tremendous amount. Most other programs do not.

Hospitals also obtain income by billing for resident services. This is not true additional income -- inpatient services are all billed by faculty, and residents who see patients in the outpatient setting are supervised by a faculty member who usually sees less patients -- at our institution, our calculations show that a faculty member seeing patients on their own generates the same $$ as one who works with 3.5 residents (mixture of PGY levels). I should add that this is not true for fellows, who often see patients semi-autonomously and hence can add to billing.

So, for most programs, the amount of DIRECT money received for teaching residents is about equal to the DIRECT costs of training residents. Over time, the DIRECT costs of training residents have increased, and the DME/IME have decreased, such that now it is usually a break even or small loss for programs.

C. What about indirect costs?

Although the direct costs of resident training is usually equal to or more than the direct income obtained, there is a tremendous costs savings to the system in general. This is simply because many hospitals rely on residents for their night coverage. Replacing residents with other resources is extremely expensive -- many NP/PA's are unwilling to work at night, or do not have the clinical skills to do so. Faculty coverage at night, either with moonlighters or hospitalists, is enormously expensive and does not generate any additional income for the system in general. Hence, in any discussion of the financial impact of residents, the cost of replacing the service that those residents provide needs to be considered. However, when hosiptals look at their residency programs, these "cost savings" are invisible.

D. So will residents get paid more in the future?

This is a difficult question. I have stated, multiple times in the forum, that I think that residents deserve a higher salary than is currently offered (or perhaps loan forgiveness, which is essentially the same thing). Residency is not a free market, and probably shouldn't be one. There are many people out there willing to be a resident for free -- a true free market could actually decrease salaries.

In addition, virtually all programs have started some sort of uncovered service to address increased census and workload, duty hour restrictions, team caps, etc. As programs start these uncovered services, which by the IM-RRC rules must be uncovered 24/7, the cost savings associated with residency programs is disappearing. As programs start other overnight coverage plans, residency programs are potentially going to become true money losers. It will not surprise me at all if we see many programs start to shrink their residency programs in the next few years, especially when further GME funding cuts are necessary to pay for the exploding costs of Medicare Part D. Hospitals are now "capped" for the total number of residents in training -- if you go over your cap, you get no additional funding. In addition, CMS is looking closely at what residents do, and some payors are refusing to reimburse for resident time spent in conference, research projects, etc. Hospitals will be tempted to decrease the size of "loser" programs (like IM) and increase the size of money "winner" programs (such as ortho) -- more ortho residents = more active OR time (in general) = more joint replacements = more $$ (at least for now, although the rules will change).

 

[MacGyver]

If you want to argue that the costs of training residents has increased recently, thats fine I wont argue that.

What I'm arguing is that residency programs LOSE MONEY for the hospital.

Thats a load of BS.

If it were true, then all these small community hospital programs that have FMGs by the truckload would have closed down a long time ago.

Yet oddly enough, thats not happening. New York alone has over 200 small community based hospitals with no university affiliation that are nothing but FMG factories. Medicare pays FMG residents even less than AMGs, yet none of these programs have closed down.

 

[exPCM]

--

 

[Faebinder]

If you want to argue that the costs of training residents has increased recently, thats fine I wont argue that.

What I'm arguing is that residency programs LOSE MONEY for the hospital.

Thats a load of BS.

If it were true, then all these small community hospital programs that have FMGs by the truckload would have closed down a long time ago.

Yet oddly enough, thats not happening. New York alone has over 200 small community based hospitals with no university affiliation that are nothing but FMG factories. Medicare pays FMG residents even less than AMGs, yet none of these programs have closed down.

APD didn't argue that, I think you both agree on that part. We are definitely seeing a shift of residency spots from FM to other specialties. FM dropped the highest number of spots ever last year. 103... even my regression expected a drop of 70 PGY1 positions last year. 103 was a lot. Yet the overall number of PGY1 went up slightly, pretty much implying that those slots are being replaced elsewhere.

 

[NotAProgDirector]

If you want to argue that the costs of training residents has increased recently, thats fine I wont argue that.

What I'm arguing is that residency programs LOSE MONEY for the hospital.

Thats a load of BS.

If it were true, then all these small community hospital programs that have FMGs by the truckload would have closed down a long time ago.

Yet oddly enough, thats not happening. New York alone has over 200 small community based hospitals with no university affiliation that are nothing but FMG factories.

We agree completely here. If you include the indirect costs of hiring resident replacements, it clearly is a positive. If you only count direct costs, its probably a loser. Obviously, you need to include all costs if you want to be realistic. Studies that suggest residencies lose money ignore indirect costs, which is ridiculous.

Medicare pays FMG residents even less than AMGs, yet none of these programs have closed down.

This is not true to my knowledge. Medicare reimburses AMG's and IMG's equivalently. Individual programs set resident salaries, which are based on many factors (cost of living, etc).

 

[Apollyon]

New York alone has over 200 small community based hospitals with no university affiliation that are nothing but FMG factories.

New York State or New York City? NYC has ~100 hospitals total (all comers).

 

[MacGyver]

New York State or New York City? NYC has ~100 hospitals total (all comers).

New York state