I feel sorry for all the residents who will be laid off when these cuts go through.......Link: http://www.medcitynews.com/2011/02/.../2011/04/obama-plan-visibly-upsetting-to.html
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Obama Cutting All GME For Children's Hospitals
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Link doesn't work. 😕
http://www.medcitynews.com/2011/02/...hildrens-hospitals-graduate-education-funding
two different links smashed together
two different links smashed together
Don't know how whether this is standard, but every children's hospital I have seen has looked like it has plenty of money (nice facilities with cool landscaping, custom murals, expensive playground equipment) probably due to the fact that it is easier to raise charity money for kids than for indigent adults. Not that losing extra money is good for any hospital, but I would venture they would be able to continue to have residency programs if they really wanted to.
Lets assume that all pediatrics GME money disappeared overnight.
The hospital has 3 options:
1) Hire midlevels to replace residents at 80k per position with 9-5 type hours.
2) Hire residents to work at 40k per position with the current 80 hour limits.
3) Hire neither midlevels nor residents and force all the attendings to provide 24/7 coverage in the hospital.
Its a no-brainer. Even if residents cost 40k (compared to $0 before) thats still a lot of savings over hiring a midlevel or an attending.
The one caveat though is electives and research time. If the hospital is paying for the residents out of their own pocket, you can say goodbye to protected research time or any kind of electives. They'll expect you to work in the hospital wards 9 months of the year with very little time for outpatient activities or cush electives.
The hospital has 3 options:
1) Hire midlevels to replace residents at 80k per position with 9-5 type hours.
2) Hire residents to work at 40k per position with the current 80 hour limits.
3) Hire neither midlevels nor residents and force all the attendings to provide 24/7 coverage in the hospital.
Its a no-brainer. Even if residents cost 40k (compared to $0 before) thats still a lot of savings over hiring a midlevel or an attending.
The one caveat though is electives and research time. If the hospital is paying for the residents out of their own pocket, you can say goodbye to protected research time or any kind of electives. They'll expect you to work in the hospital wards 9 months of the year with very little time for outpatient activities or cush electives.
The problem is that your math isn't accurate, because you are making a wrong assumption of what a resident costs. It's $40k just in SALARY, but then you have (1) additional insurance costs above and beyond either of the other two categories because you are insuring someone with an MD behind their name but without the experience necessary to have reasonable premiums, and (2) the expenses incurred in training and in running a residency program, and (3) the fact that often residents, since they are learning, actually slow down the attendings and midlevels during the early years, rather than pull their own weight. You can't just hire them as rank and file employees and say, go do your work, unsupervised, without any teaching. There are ACGME rules that require you to satisfy certain things with your residents, not just work them. So, there's a reason the government gives each hospital something like $100k per each resident -- it actually costs close to that to actually run a residency program, and so you need that kind of money to entice programs to run them. So if it's a choice between $100k cost of a resident, who by the way is gone in 3 years, or $80k cost of a midlevel you can potentially retain for decades after they become useful, then yeah, it is a no-brainer. But not the no-brainer you were suggesting.
Question: What is 2+2?
Answer: What do you want it to be?
It MIGHT be true that paying a midlevel is slightly cheaper than having a resident on duty but it's not $100,000 per year cheaper. The medical establishment has conned the congress into thinking that every resident is a gross drain on the system.
I would be willing to bet that if the congress completely wiped out the $9,000,000,000 in residency funding, there would be an insignificant drop off in the number of residency spots in the US. If you look at the last five years of residency growth, we have seen a 7% growth in residency spots in the US without any added Medicare funding. Physicians need to be trained. The health care system can not function without them. Various studies have shown that having residents improves the outcomes at institutions. We are going to see a tremendous shortage of physicians in the next 15 years. Physicians will get trained.
I have repeatedly seen on this message board a desire, among people who have been accepted to medical school, to see no more med schools. I have seen residents who hope to heaven that residency spots get cut back. It ain't gonna happen.
Answer: What do you want it to be?
It MIGHT be true that paying a midlevel is slightly cheaper than having a resident on duty but it's not $100,000 per year cheaper. The medical establishment has conned the congress into thinking that every resident is a gross drain on the system.
I would be willing to bet that if the congress completely wiped out the $9,000,000,000 in residency funding, there would be an insignificant drop off in the number of residency spots in the US. If you look at the last five years of residency growth, we have seen a 7% growth in residency spots in the US without any added Medicare funding. Physicians need to be trained. The health care system can not function without them. Various studies have shown that having residents improves the outcomes at institutions. We are going to see a tremendous shortage of physicians in the next 15 years. Physicians will get trained.
I have repeatedly seen on this message board a desire, among people who have been accepted to medical school, to see no more med schools. I have seen residents who hope to heaven that residency spots get cut back. It ain't gonna happen.
I don't see residency spots getting cut back, nor do I see them increasing in the near term. However med schools have been dramatically increasing, so I suspect there will be a big crunch for the offshore schools as US graduates start to approximate US residency slots. I question your 7% residency spot growth without Medicare funding stat -- do you have a reference?
At any rate, I think it pretty ludicrous that someone think that the salary of a resident is the only cost involved. In fact a residency program is an expensive venture. From the $100k a program gets for a resident, half goes to salary and state employee benefits. Probably another $20k to insurance costs, another couple of grand to book funds and educational expenses, and the rest to administrative costs of running the residency program, which generally has several full time employees. Not to mention that the faculty is expected to take time out of their schedule to teach, which cuts down on their daily profitability. The "profit" of a resident comes from whatever business the residents generate in their later years. The negative is that they slow down things during their early years. Since residency for most programs is only 3-4 years, I would suggest that residents are a cost in the first year or two and become profitable in the latter year or two, right before they leave. A PA is asked to do less, and probably becomes profitable much earlier. But more importantly, they don't leave after year 3. So the "investment" you make in teaching them is not wasted the same way it typically is in a resident, who takes that skillset elsewhere. So yeah, I'd say residents don't make business sense, and only exist because the $100k a program gets plus whatever they can get at the end of the residency makes it slightly worth it. If a program is adding residents without funding, then they have managed to generate an economy of scale better than the typical residency program. They still would be better off with a good PA, but there are non-financial reasons an academic center might want to sustain a certain level of residents even beyond the funding.
Please see Table 3 of the Linked PDF:
http://www.nrmp.org/data/2011Adv Data Tbl.pdf
After subtracting prelim and transitional spots from the total, In 2007 there are 20,521 spots and in 2011 there are 22,127. That constitutes an increase of 7.8% in five years. Throw on another 1,850 spots in the DO Match and another 600 or so from the San Francisco match and you get to 24,575. This fall's MS1 total in the US was 18,600 MS1s and 5,200 OMS1s. With the usual 5% attrition rate there will be about 22,600 US grads looking for spots in 2014. If we see 1% growth per year in residency spots over the next four years we will see about 25,600 spots in 2014. This will leave about 3,000 spots for FMGs and Caribbean students.
No one says that the salary is the only cost involved. How could someone say that when residents only get paid about $52,000 per year and medicare pays the institution about $100,000 per year per resident. My point is that the contributions that residents make is undervalued by the hospitals so that they can sing the blues to Congress.
My bad, I though you were suggesting a 7% slot growth per year over 5 years, not total. 1-2% a year change is pretty negligible. Not enough to say folks are adding these folks because of their amazing financial benefit. Just the opposite, actually. In fact I know of a few places that added a resident despite it being a financial hit simply because they had someone good they wanted to keep and because the change of ACGME duty hour rules made it difficult to staff their shifts with the number of residents they already had. I wouldn't be surprised if lots of places were making this kind of decision based on desire to maintain an academic program despite the profitability not being as great. I also wouldn't lump allo and osteo into the same grouping here, as osteo hospitals have their own motivations for making sure their rapidly increasing enrollment finds residencies -- as a smaller player in the medicine game, they can't afford to have folks coming out of med school and not finding jobs, so even if it costs them more they "need" to pony up.
I still think your prior point of what's a "no brainer" has it backwards. Residents only become profitable at the end of their tenure right before they leave, and cost more than midlevels both in terms of expenses and in terms of training time (attending time) in the early years. Since midlevels are actually cheaper in this respect -- they get asked to do less and it's acceptable for them be trained less, and since they potentially stay beyond a 3 year residency term, it's actually a no brainer to go the midlevel route if dollars are your driving force. If you are trying to be an academic teaching facility, then there may be other reasons for running a residency program, but I think financially these are not the optimal employee choice. Residents are "overvalued" because they aren't making you money until they get fully trained and once they are trained they leave. Midlevels are the "undervalued" group in the equation because they stay on past the first couple of years. Which is why the government needs to subsidize residents to get hospitals to have them at all.
Have you seen proof of that? Evidence Based Politics has shown no data confirming any death.
When the duty hours were cut they added residents for coverage. Why didn't the hospitals add mid-levels?
If hospitals don't train residents where are they going to get physicians in fifteen years? The latest AAMC projection is that this country will be about 135,000 physicians short in 2025. Some hospital administrators are taking the long view that training physicians increases the institutions' net revenues over the long haul. They aren't just concerned with the next 15 minutes.
The reason I cite the DO spots is that they create slack in the system. To the extent that osteopathic doctors take osteopathic residency spots more spots are left for IMGs and FMGs. 🙂
The problem with this question is that "they" is two different people. All hospitals are not in the same mindset. The private hospitals who opt for midlevels instead of residents simply assume they will get physicians in 15 years from the academic centers that train them. The academic centers keep restocking residents, despite the cost, because there is come cache to being a teaching hospital and academic center of excellence. It attracts better attendings, more grants/donations, and keeps the program in the limelight. So yeah, if the duty hour changes require them to eat the cost of one more resident, they probably still do it. That's your 1% growth right there, despite it not being the better deal. But there is a breaking point for this, and if the $100k per resident gets cut enough, this will cease to be an adequate answer for even them.
Again, this kind of projection does not factor in new forms of midlevels such as the DNP. The current administration sure is.
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.
Back to the topic at hand....
Cutting the entire GME budget is not going to happen.
How this came down is some stupid junior congressman in his first term in office didnt understand what the "GME funding" was. He assumed it was somebody's pork barrel project without even bothering to research it. He sees a quick and easy 300 million budget cut that will supposedly make him look good to the fiscal conservatives so he slashes it.
Once Congress finds out exactly what this "childrens GME" thing is, it will get put back in the budget. I would stake my life on that. The question is, will it get cut by a certain percentage?
Cutting the entire GME budget is not going to happen.
How this came down is some stupid junior congressman in his first term in office didnt understand what the "GME funding" was. He assumed it was somebody's pork barrel project without even bothering to research it. He sees a quick and easy 300 million budget cut that will supposedly make him look good to the fiscal conservatives so he slashes it.
Once Congress finds out exactly what this "childrens GME" thing is, it will get put back in the budget. I would stake my life on that. The question is, will it get cut by a certain percentage?
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.
Just because a midlevel may be more productive than a junior resident does not mean that you would be able to get away with replacing them one to one (thinking that they would get the work done faster). Part of the issue is coverage. A resident works nights, weekends, long shifts, whatever is needed. A PA isn't going to fulfill all of those things (well maybe if you paid then an enormous amount). So you would need more than one to cover all those hours unless you leave certain hours unstaffed (or work things out with home call, but again, you would have to pay extra for that). I think a hospital that already has residents who experiences a funding cut would be more likely to find a way to keep the residents (they could lower salaries and benefits, divert some donations, etc), rather than scramble to fundamentally change the way they run and find a bunch of midlevels to staff everything that needs staffing. Not saying one way is cheaper than another, but that it would be simpler, which seems to be the way hospitals do things.
Unfortunately hospitals could get the midlevels for the days and move the majority of the resident hours to the off hours. There's not really any rules that say the bulk of the resident's 80 hour weeks cannot be composed exclusively of nights and weekends.
Yet no hospital does this, not even the hospitals that are for-profit, non-academic and have zero reason for preferring residents over midlevels except for $$$$ reasons.
Yet. Thus far funding for residents hasn't been cut. When it does, things may change. Your post is like saying "nobody puts up their umbrellas before it starts raining" -- Of course not. But that doesn't mean they won't when the downpour starts.
Doing that would take a terrible toll on the health of the residents.
Not so much health, but rather personal lifestyle. They would be working the same hrs/wk as before. It would just suck in general tho.
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I think it would run afoul of some ACGME or RRC rules in regards to having residents cover non-teaching services (its already problematic for programs who have residents admit patients to non-teaching services)
Who's to say that night time services cannot be teaching services? Hospitals have pretty free hands to decide this kind of stuff. To my knowledge there are no rules that prohibit hospitals from moving some of these functions to the off hours.
Possibly, but I think most of us feel that night coverage if not already there pushes closely for favoring service over education. ACGME asks residents to complete surveys about this stuff regularly, and I think they take it seriously if residents indicate that service is favored over education in their program. At least that seems to be how things work at my program.
On SDN, mid-levels including nurse practitioners only (or almost only...) work weekdays, are covered under the attending's malpractice insurance and are interchangeable with interns.
In the actual world in which I care for patients (and this is a pediatric-related thread...), nurse practitioners (NNPs) work nights and weekends, often times without anyone else in the hospital with them responsible for the care of newborn infants and/or with a very high level of autonomy putting them at risk for being involved in malpractice action (and I am aware of numerous such cases in which NNPs were named).
They are often if not usually covered under separate malpractice insurance from the doctors (we are covered by the med school or by the corporation that hires us as independent contractors, they are covered by the hospitals and sometimes obtain their own insurance) and function at a level most closely related to that of senior residents. They transport babies 24/7 often operating with their nearest physician "supervisor" a couple hundred miles away and so have real need to be experts at intubation and other procedures for newborns including emergency evacuation of pneumothaces, and UAC/UVC placement, and as such are not interchangeable with our beginning residents who don't have those skills reliably. Even second year residents are generally in the current way of things not well experienced at these like our NNPs are.
GME funding is almost certainly not going to be lost for our pediatric hospitals. The role of trainees (residents and fellows) in the institutions is not largely exchangeable with "midlevels" and the effect of any funding cut, would, in my opinion, be more related to how the hospital saw itself as a teaching institution than any specific $$ issues involved. Some hospitals would see themselves as training the next generation of pediatricians, pediatric specialists (and caregiving/referral docs). Others would not, just as they do not currently see themselves that way.
In the actual world in which I care for patients (and this is a pediatric-related thread...), nurse practitioners (NNPs) work nights and weekends, often times without anyone else in the hospital with them responsible for the care of newborn infants and/or with a very high level of autonomy putting them at risk for being involved in malpractice action (and I am aware of numerous such cases in which NNPs were named).
They are often if not usually covered under separate malpractice insurance from the doctors (we are covered by the med school or by the corporation that hires us as independent contractors, they are covered by the hospitals and sometimes obtain their own insurance) and function at a level most closely related to that of senior residents. They transport babies 24/7 often operating with their nearest physician "supervisor" a couple hundred miles away and so have real need to be experts at intubation and other procedures for newborns including emergency evacuation of pneumothaces, and UAC/UVC placement, and as such are not interchangeable with our beginning residents who don't have those skills reliably. Even second year residents are generally in the current way of things not well experienced at these like our NNPs are.
GME funding is almost certainly not going to be lost for our pediatric hospitals. The role of trainees (residents and fellows) in the institutions is not largely exchangeable with "midlevels" and the effect of any funding cut, would, in my opinion, be more related to how the hospital saw itself as a teaching institution than any specific $$ issues involved. Some hospitals would see themselves as training the next generation of pediatricians, pediatric specialists (and caregiving/referral docs). Others would not, just as they do not currently see themselves that way.
exactly!!!!
never ever listen to those shortage "expectations". they are based on flawed information where those supporting the report sit and circle jerk to each other.
define "shortage"....
I do know that malpractice for residents in Pa is about $6000/year, I know because I paid for a month out of pocket.
If you are arguing that average NNPs are better at intubations and lines than average peds residents, I would agree with that.
But I would also say that experienced NNPs (20+ years experience) are better than average neonatology attendings at intubations and lines as well.
I could take a high school student with no formal training and put him in the NICU for a year. I'd give him 8-5 hours with no call and he gets all first attempts at intubations and lines for 12 months. After the end of that 12 months he'll be better than any peds resident or new NNP at both lines and intubations.
Training monkeys to do procedures is easy.
Hospitals have deeper pockets and thus generally can't opt for the minimum coverage for their employees, and their premiums will be much higher. To some extent you pay for that extent you are trying to protect. Your life won't be affected differently if you get sued for $10 million versus $100 million -- you aren't worth more than either cap. For a hospital there's a difference. There's also liability to the hospitals for negligent supervision, and so their liability risk is different than you insuring for yourself as an independent contractor. Also insurance varies based on specialty.
No. Do you think that CRNA's of 20 years experience are better at intubations, especially difficult ones, than anesthesia attendings? Or is it something special about neonatologists that make you think we are not at least as good as NNPs at them?
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The 2008 workforce study done by Edward Salsberg of AAMC's Center for Workforce Studies assumed a greater use of mid-levels. In fact it assumed that NPs & PAs would handle 25% of primary care in 2025. Here's the link:
https://www.aamc.org/download/82828/data/salsberg2008l.pdf
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I wasn't paying for myself as an independent contractor, but as if i was as a resident as I was a visit resident. I payed the hospital for the same map-prac that they get residents, cause I'm now a fellow here and the facesheet is the same.
I don't know enough specifics to comment on the deal you personally were involved in. All I can tell you is that many hospitals pay much higher premiums for residents, at least in some specialties.
They dont pay any set fee. They self-insure.
That was always my understanding. Both my residency and fellowship programs were a Self Insured Trust trainess. Maybe its different at smaller programs.
My residency program did not self insure.
Self insurance is an option, but from what I've seen from the legal side it's actually the minority approach for hospitals. It's a complex decision as to whether it makes sense to self insure, and depends a lot on what medmal awards are like in the jurisdiction in which the facility is located, the kind of practice involved, how risk averse the facility is, what the insurance premiums would be, how much you could make on the premium amounts if you invested them instead of created an expense, and so on. In the current recession, where most debt/equity instrument investments didn't do so hot, self insurance ended up being a bad gambit. If you are paying premiums to an outside facility, the cost is going to be higher. But even if you self insure, you are still creating a financial reserve equivalent to a premium for each resident.
I know that a bill authorizing an extension of federal support of GME at children's hospitals was introduced by Frank Pallone from New Jersey and Joe Pitts a Republican from Pennsylvania. Did this pass the house and has it gone through the Senate?
I understand that this affects GME at 56 children's hospitals. Could somebody please provide a link identifying the 56 hospitals?
Thanks
I understand that this affects GME at 56 children's hospitals. Could somebody please provide a link identifying the 56 hospitals?
Thanks
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1.Senate passed a similar bill
https://www.aamc.org/advocacy/washh...311houseapproveschgmereauthorizationbill.html
2.The 56 hospitals ate listed here
http://www.federalregister.gov/arti...ent-program-final-eligibility-and-funding#t-1
Last item below table of contents.
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The nice folks at AAMC sent me the actual 56 hospitals receiving CHGME. Here's the link:
http://granteefind.hrsa.gov/searchbyprogram.aspx?select=T23&index=29&year=2011
Sorry buddy....I compared about a dozen hospitals from another article that matched and it looked right.
Thanks for the correction.👍
So whats the status of this right now? Anyone know?
OK, so lets take a 3rd year pediatrics resident who completes a NICU fellowship.
Before he starts fellowship, we all agree the NNPs are going to be better at procedures on average, correct?
OK, so lets go thru the 3 years of fellowship. Are you now telling me that there's something magical about those 3 years that all of a sudden the NICU fellow is now superior to the NNPs at procedures? I call BS on that. Yes, they will have a better knowledge base, but the NNPs will still be superior at procedures.
