Funding of residency programs: putrageous issues!

[supercut]

I'm not even sure how many of my fellow residents pay any attention to this, but I've learned some things that really piss me off.

First of all, the government (via medicare) pays each hospital that has residents a stipend per resident. This is to cover the extra costs associated with education. (for example, in the surgery world, cases move slower when there are residents involved, so less cases per day is less income)

The exact amount paid per resident is a secret (I challange any of you to try to find out the exact figure!) but in the neighborhood of $100,000 annually.

In my program, the funds are retained by the hospital and not given to the departments for whom the residents work. And I just learned that, since the department is not getting enough to fund all educational aspects, the department levys a "tax" on each attending who works with residents of 4% of their earnings! We are in danger of losing a couple of our best attendings (who are at another hospital in town that we spend some time at) becuase they haven't been paying the tax but now the deparment is demanding that they do.

Even though no one knows the exact amount the hospital is getting (and keeping) from medicare, estimates are that, if the department recieved the entire amount, it would be enough to fund the educational activites of the department without taxing the attendings.

For those of you who work at hospitals where the residents still do blood draws and patient transportation, doesn't it gall you that your hosptial is getting about $100,000 a year to fund your participation in these "educational" activites?

A couple years ago, one of our residents did a talk on GME funding. He had undertaken a project to try to find out the exact amount our hospital was getting from medicare and were is was going. Every offical he spoke to (at both our hospital and the ACGME) told him either they didn't know or couldn't release the information. Thats BS! Somebody knows, and doesn't want us to know.

I'm thinking its time we band together and demand an accounting of these funds. Any thoughts?

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[8744]

For those of you who work at hospitals where the residents still do blood draws and patient transportation, doesn't it gall you that your hosptial is getting about $100,000 a year to fund your participation in these "educational" activites?

I have never heard of a resdiency program where the residents transport patients. As for drawing blood and starting IVs, it is a good skill to learn and once you get the hang of it it doesn't take long at all. For the record though the only time I have ever drawn blood is when I ordered it "stat" and not on the usual phlebotomy schedule.

By the way, residents increase throughput in hospitals, not decrease it as you imply. When I was in Family Medicine last year our attending supervised five or six residents in clinic at any given time, each of whom saw between six and ten patients per half-day. The attending didn't necessarily see every patient and other than a usually brief precepting session if you look at the numbers, one attending supervising six low-paid residents who produced 100 billable patient encounters per day.

 

[8744]

And no, I am not crazy about residency pay either.

 

[f_w]

http://www.aamc.org/advocacy/library/gme/dgmebroc.pdf


It's only a secret if you are too ignorant to inform yourself.

 

[f_w]

Btw, it is your attending who has the most to gain from having residents. No academic surgeon comes to look at an aching kids belly at 2 in the morning, in PP that is the rule, not the exception.

 

[Faebinder]

Supercut has a point and Panda Bear is correct in his assessment but the problem is...


How do you prupose to stop this? Only something like a national residency union can stop something like that... otherwise.... a hospital will replace residents who objects....

 

[8744]

Supercut has a point and Panda Bear is correct in his assessment but the problem is...


How do you prupose to stop this? Only something like a national residency union can stop something like that... otherwise.... a hospital will replace residents who objects....

There is no stopping it. Since residency is not a permanent condition, even people who hate it have no real incentive to change things. I could get all irate, write my congressman, agitate, go to meetings, ad nauseum but on the small chance I accomplished anything by the time it was implemented I would be done with residency.

That's the same reason most people don't care about things like student government.

 

[southerndoc]

My hospital tells us what they receive per resident. The money is allocated to pay for additional faculty, support staff, etc. It's broken down what they pay for each. Yes, they do make a slight profit, but you would be surprised how much a residency costs.

 

[MacGyver]

http://www.aamc.org/advocacy/library/gme/dgmebroc.pdf


It's only a secret if you are too ignorant to inform yourself.

Its more complicated than that. Sure I know what he formula is and how to calculate it, but that doesnt do many any good if my hospital treats the "per resident amount" as a national security secret and wont reveal it.

Thats the bottom line. Most hospitals refuse to divulge the information you need in the formula to calculate the cost. Knowing teh formula is easy, getting the info from the hospital is the hard part.

This setup is insane. The federal government should publish every year what each residency program got in both DGME and IGME payments. The hospitals refuse to release the information.

 

[MacGyver]

BTW, residents make a hospital MORE profitable and MORE efficient, not less.

You guys have bought the hospital line hook and sinker. Of course they are going to lie about how residents incur all kinds of bogus costs and slow everybody down. They lie to the federal government so they can use this excuse as a bogeyman to extort more money.

Ask yourself this: imagine for one moment that your hospital lost all its residents and had to cover all the patients with the same number of attendings they ahve right now (no new hires or PAs). The hospital line is that they would be MORE efficient because the attendings wouldnt have to teach and therefore they would be able to treat all the patients more efficiently. Thats a load of bull****. Without residents, the hospitals would have to hire more attendings, PAs, and NPs which would cost them a HELL OF A LOT MORE than getting free money from teh fed govt to the tune of 100k per year per resident.

Hospitals are making a KILLING off these GME payments. They use it to subsidize operations of the hospital that are losing money (i.e. treating indigent patients). Only a fool believes that it really costs 100k per resident per year to train them and mitigate the "inefficiencies" introduced by residents.

Open your eyes people. The money that hospitals receive from GME has very little to do with training and EVERYTHING to do with subsidizing the uninsured population.

 

[dockdock]

Solution: universal healthcare.

 

[f_w]

This setup is insane. The federal government should publish every year what each residency program got in both DGME and IGME payments. The hospitals refuse to release the information.

When I did my residency, there was an annual report from the state health department that listed the payment to every hospital in the state.

Ask yourself this: imagine for one moment that your hospital lost all its residents and had to cover all the patients with the same number of attendings they ahve right now (no new hires or PAs).

Don't know where you work, but hospitals don't hire attendings around here.

I work at a community hospital these days. We have 1 resident who rotates here to operate with one of the surgeons, but he doesn't take call or does any of the service type work residents tend to do. A lot of the work residents are there to do only exists because a place is a teaching institution. An admission H+P at our place is typically printed out of the PMDs office computer (the 'H' part), the 'P' is done within 24 hrs of admission after the doc rounds on the patient. There are no 2 hr morning rounds or other idle losses of lifetime, patients are seen before the docs go to their office in the morning and after they leave in the afternoon. A brief note is dictated and that is about it.
Also, outside of teaching institutions, nursing tends to have a different function. Because there is not a plethora of interns and residents to monitor patients for changes in status, the RNs will call up the docs and act on phone orders.

Hospitals are making a KILLING off these GME payments.

Ok, so lets see: The hospital gets 100k/FTE (80-120 for the most part)
- salary for the resident is around 45k
- benefits+malpractice 25k
leaves about 30k per FTE in 'killing'.

And yes, teaching hospitals have longer length of stay and higher cost for consumables than non-teaching institutions.
While it is true that hospitals get more out of a residency than they put in (that is why they have residencies in the first place), but in the overall hospital budget GME profits are small fry.

The money that hospitals receive from GME has very little to do with training and EVERYTHING to do with subsidizing the uninsured population.

It has something to do with subsidizing hospitals, whether they do a significant amount of indingent care or not.

 

[8744]

Solution: universal healthcare.

Jesus. Then we'd make crappy pay after residency as well.

 

[shorrin]

btw,

NLRB ruled that residents in any non-govt. hosp (state, VA) can form a union. in 1998 nlrb ruled that residents are first and foremost employees and have a right to unionize, secure benefits, sick pay etc.

 

[docB]

There are a number of misconceptions about how private hospitals function being thrown around here. These misconceptions are clouding the debate over the residency $. Private hospitals don’t pay doctors. Private practice docs make their money by billing their patients. In fact docs pay the hospitals a credentialing fee every year (in my area $200-300) for the privilege of seeing their patients in the hospital. So by having residents, that the hospital does have to compensate, they automatically increase payroll expenditures over the non-academic hospital. Remember that “compensation” isn’t just salary. Its pay, benefits, meals, scrubs, coats, parking, etc. Other direct expenses include facilities like call rooms and office space, upkeep of those facilities, payment of support people. The teaching attendings often get stipends to augment their billing. You can argue that the residents make through put faster. That’s possible. But take it from the attending at the hospital that just started a new residency program this year, the hospital will be lucky to break even for the foreseeable future.

The astute among you will point out that if that’s the case a private, for profit hospital shouldn’t take on a residency. Good point but the real values of the residency to the hospital are prestige, the ability to attract referrals from doctors who can have their patients cared for by the residents and eventually (this is a big one) the hope that the residency grads will stay in the area and treat their patients in the hospital that trained them.

 

[Lefty]

You can't compare private practice to teaching hospitals straight across the boards. The private practice hospitals in the area around our hospital send as many of the uninsured patients that they can to our hospital and also the more difficult, complex, high risk medical problems to our hospital--from high risk OB to high risk infectious disease. You can't tell me the private practice docs would be able to see all the high risk patients a surgery or medicine team sees at our hospital and manage their problems before he goes to his office in the morning. They use residents for that in the teaching hospital.

Another point to consider was briefly mentioned by a previous post. The RNs in private practice are a different breed. They have come to rely on residents to do a lot of the work they might normally do in a PP hospital in all the teaching hospitals I have been at.

Residents pick up an enormous amount of the workload for the hospital. And for the previous poster who said that he'd never transported a patient and that IVs and blood draws were good skills to have--obviously hasn't been at a VA hospital before. At our VA the residents are the only ones who can do transport for any ICU or telemetry patients. Plus, the nurses aren't allowed to draw blood (yes, RNs). If the IV team can find/make an excuse not to draw a patient's blood in the morning it's the residents who have to do it.

 

[8744]

...At our VA the residents are the only ones who can do transport for any ICU or telemetry patients....

Presumably this is because they might code on the way to radiology or wherever. I have to add that when I was at the VA, I wasn't transporting the patient per se but following while the patient care techs pushed the bed down the halls.

I don't consider this kind of thing scut work. It's just like carrying the Code Pager except you're pre-emptively positioned with the unstable patient.

 

[docB]

You can't compare private practice to teaching hospitals straight across the boards. The private practice hospitals in the area around our hospital send as many of the uninsured patients that they can to our hospital and also the more difficult, complex, high risk medical problems to our hospital--from high risk OB to high risk infectious disease.

Again you are assuming a lot. First off a private hospital can't just transfer all the uninsured and/or complex cases to the teaching hospital. It's illegal under EMTALA and the transferring facility won't risk it and the receiving facility won't stand for it. When you're the resident on the receiving end of the transfers it does seem like everything is being dumped on you but it's more complex than that. If the pateints are coming your way they have provide a reason that you are a higher level of care or they have to get an attending and the hospital to agree to accept it

You can't tell me the private practice docs would be able to see all the high risk patients a surgery or medicine team sees at our hospital and manage their problems before he goes to his office in the morning. They use residents for that in the teaching hospital.

We have hospitalists who carry huge services. Privates carry fewer and when they do get more complex they consult as needed. This is all done by attendings. And remember that the attendings are not paid by the hospital. Attendings are cheaper to the hospital than residents.

Another point to consider was briefly mentioned by a previous post. The RNs in private practice are a different breed. They have come to rely on residents to do a lot of the work they might normally do in a PP hospital in all the teaching hospitals I have been at.

In private practice the RNs do the scut. In academia the residents do the scut. That could be considered a benefit to the hospital if they view that as a perk for the nurses or if they staff fewer nurses. Are they paying more or less to have the residents do the scut vs. the RNs? It's probably a wash.

Residents pick up an enormous amount of the workload for the hospital. And for the previous poster who said that he'd never transported a patient and that IVs and blood draws were good skills to have--obviously hasn't been at a VA hospital before. At our VA the residents are the only ones who can do transport for any ICU or telemetry patients. Plus, the nurses aren't allowed to draw blood (yes, RNs). If the IV team can find/make an excuse not to draw a patient's blood in the morning it's the residents who have to do it.

Again there are cheaper ways to get the scut accomplished than having residents.

Everyone wants to be valuable. But residents are trainees. Your real value will appear when you're out. If you removed the residents from the teaching hospitals they would implode but that's because the systems there have evolved to depend on the residents. Private hospitals do the same job without residents. We aren't imploding but we are having lots of adjustment disorders getting used to our residents in my private hospital. Residents just are not a huge cash cow.

 

[f_w]

docB, you beat me to it.