First off, the ACGME teaching requirement is minimal. Yes, the attending has to round, but thats true regardless. Medicare funding residents at 100k is more than enough to cover costs. I went to residency at a non-university, for-profit hospital system and they expanded residents every year I was there. There's no way they would have done that if the Medicare 100k per year wasnt covering costs. The hospital had a choice and could have gotten rid of the residency program completely and hired midlevels instead. But they didnt. If the Medicare 100k wasnt enough to cover salary, benefits, malpractice, inefficiencies, overhead, etc then they wouldnt keep getting more residents every year. If any hospital in the country had a good reason to replace residents w/ midlevels, this was it.
So lets assume that it costs 100k for a resident. Midlevels are still more expensive because residents work longer hours so you have to hire 1.5 midlevels for every resident.
Resident at 100k vs 1.5 midlevels at 80k = 120k.
Thats assuming that midlevels incur ZERO malpractice cost which we know is not true.
First, midlevels don't really incur the same kind of medmal insurance costs because they aren't physicians, and don't technically practice medicine. Other than the DNP, they are working exclusively under the direction of an attending, and it's his insurance coverage that applies. No idea how the new DNP is covered.
Second, you emphasize that the residents are working 80 hours/week vs midlevels working lesser hours. But I think the bigger point is that residents don't stay longterm. The EARLY years for residents are not productive years. The learning curve is steep, and they are inefficient and lack the skills to generate much value. You may work 80 hours/week, but honestly someone who actually knew what they were doing could get the same thing done in 50. Folks appreciate this in their 3rd year of residency, when they find it so frustrating that the interns take so long to get stuff done.
Third, the key point is that residents don't stay on. You can keep a midlevel for decades if you keep them happy. A resident is there for 3 years. So if you have an employee who isn't productive or efficient until a couple of years into it, and once they become pretty good they leave, what kind of a value is that? Not much.
Fourth, I wasn't saying that residents don't make sense at $100k. I was saying that the assumption that residents "cost" $40k was wrong. They cost considerably more than that, which is why the government has to sweeten the pot to $100k to make it worth it for programs to incur the costs involved with residents. At $100k it's a good deal for hospitals. And sure, if they can get another $100k for each resident, then more is better, which is why the places you describe have kept adding to their programs. But
if funding gets cut (which is what this thread is about), then midlevels become a better deal. Which is what I was saying is the actual "no brainer" here.
Fifth, I don't know what you got in terms of "teaching" and to what extent your program was in ACGME compliance, but saying that the teaching requirement is minimal and basically consists of rounding simply isn't accurate. These days there's pretty significant numbers of lecture hours, grand rounds and M&M conferences and other obligations imposed on each residency by ACGME. Many places have additional "obligations" imposed by subspecialty governing bodies, the hospital etc. And on top of that, attendings are expected to teach not only on rounds but in other contexts, as are the more senior residents, etc. I'd estimate for example that currently as a resident we get probably 3 hours of each 10 hour day of actual teaching from attendings (both formal and informal). It's a lot of hours of each day that could be spent by both the residents and attendings doing money generating things. The PAs and NPs don't get this kind of attention.
