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Model for prioritization of Graduate Medical Education funding at a university setting – Engagement of GME committee with the Clinical Enterprise
The American Journal of Surgery xxx (2017) 1e8
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Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise Chandrakanth Are a, *, Melissa Suh a, Lauren Carpenter a, Hugh Stoddard b, Vicki Hamm c, Matthew DeVries d, Whitney Goldner e, Kimberly Jarzynka f, Jennifer Parker g, Jean Simonson h, Geoffrey Talmon i, Chad Vokoun j, Jeffrey Gold k, David Mercer a, Michael Wadman l a
Department of Surgery, University of Nebraska Medical Center, Omaha, NE, 68198, USA Emory University School of Medicine, Atlanta, GA, 30322, USA c Office of Graduate Medical Education, University of Nebraska Medical Center, Omaha, NE, 68198, USA d Department of Radiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA e Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA f Department of Family Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA g Department of Internal Medicine- Pediatrics, University of Nebraska Medical Center, Omaha, NE, 68198, USA h Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA i Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA j Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA k University of Nebraska Medical Center, Omaha, NE, 68198, USA l Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA b
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Article history: Received 21 April 2017 Received in revised form 16 June 2017 Accepted 2 July 2017
Background: Funding for graduate medical education (GME) is becoming scarce and is likely to worsen. There is a higher degree of accountability and return on investment demanded from public funds dedicated to GME. Academic centers (AC) partnered with clinical enterprises (CE) are finding it increasingly difficult to retain sustainable funding streams for GME activities. Methods: To develop and implement a novel algorithmic funding model at one AC in symbiotic partnership with the CE for all 50 GME programs with nearly 500 residents. Results: A new GME Finance and Workforce Committee was convened which was tasked with developing the novel algorithmic financial model to prioritize GME funding. Early outcomes measures that were monitored consisted of: satisfaction of all stakeholders and financial savings. Conclusions: The model was presented to all the stakeholders and was well received and approved. Early signs, demonstrated AC and CE satisfaction with the model, financial savings and increased efficiency. This GME funding model may serve as a template for other academic centers with tailored modifications to suit their local needs, demands and constraints. © 2017 Published by Elsevier Inc.
Keywords: Graduate Medical Education Funding Novel funding model
1. Introduction Greater value in graduate medical education (GME) means a better targeting of public GME money and more effective training models1: Twenty-first report of Council On Graduate Medical Education
* Corresponding author. E-mail address: [email protected] (C. Are).
(COGME).1 The 21st report1 from the COGME was released in August 2013, titled: “Improving Value in Graduate Medical Education”.1 This theme is now emphasized by virtually every entity involved in GME, ranging from the public to the government and the education community. Enhancing the value from GME financing is essential in the current environment of decreasing funding. The Patient Protection and Affordable Care Act's (PPACA) encouragement of Accountable Care Organizations (ACO's) has catalyzed the
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consolidation of health care entities across the country. Academic health centers (AC's) and Clinical Enterprises (CE's) which have functioned somewhat independently until now are embarking on consolidating their administrative and financial operations. In this environment, Graduate Medical Education Committee's (GMEC's) across the country are being forced to take a critical look at the current budget and funding mechanisms for GME activities. The Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education issued a report (July 29th 2014) on GME funding that highlights issues such as lack of transparency and accountability with the current system and makes recommendations for a new GME funding model.2 To align GME program outcomes with the workforce needs and training content demanded by all entities, institutions must consider and develop innovative funding mechanisms that account for these priorities.3 The aim of this descriptive study is to present the novel algorithmic funding model developed in 2014 by our AC in partnership with the CE and present some early outcome data. The new model revamped the funding structure for GME activities of all 50 programs with nearly 500 residents. 2. Methods The structure of our campus for GME consisted of three separate financial entities: The University of Nebraska Medical Center (UNMC), The Nebraska Medical Center (TNMC) and the University of Nebraska Medical Center Physicians (UNMCP). These three entities came together as one clinical enterprise, Nebraska Medicine (CE) to be prepared for the evolving health care environment and to combine all operations including the financial sectors. Since the CE sponsors the GME programs, the CE decided to revamp funding for all GME activities and delegated that responsibility to the GMEC through a charter. In response, the GMEC convened a new GME Finance and Workforce Committee (GMEFWC) that consisted of 11 members and included: the Associate Dean for GME, Assistant Dean for GME, the GME Administrator, 8 program directors representing hospitalbased, medical, and surgical programs, and the Associate Dean for Administration and Finance for the College of Medicine who served as a liaison to the CE. After committee formation, regulatory guidelines which needed to be followed while building the funding algorithm were reviewed. Two reports provided the foundation for this: a) the 21st report of the COGME, to provide information for long range structural planning and b) individual program requirements outlined by the residency review committee's (RRC's) of the Accreditation Council of Graduate Medical Education (ACGME). These reports provided the information necessary for development of program specific criteria for determining funding. As available, approved specialty society guidelines were referred to for non-accredited programs, as well as for programs accredited by bodies other than the ACGME (example: Oral Maxillofacial Surgery). The committee developed a hierarchy for 50 training programs sponsored by our CE (Fig. 1) that provided us with a structured approach to determining the relative importance of each training program for distribution of funds. Programs were divided into “high priority versus non-high priority” (designated as “core” or “non-core”) based on the COGME report,1 which recommended increases in GME funding towards “core” specialties (Recommendation 2.1). Programs were then categorized by their ACGME accreditation status to account for the differences in the regulatory requirements and workloads between ACGME accredited and nonACGME accredited programs. Lastly, based on the relative contributions to the AC and CE, programs were subjectively categorized
Fig. 1. Developing a hierarchy of training programs based on their national importance, ACGME accreditation status and relative contributions to the academic and clinical mission of the academic center.
as “Valuable” versus “Essential”. The designation of “Valuable or Essential” was defined based on: the local requirements, met or unmet needs, and obligations of the AC, CE, the state and the geographic region. Adding a trainee in a specialty where the needs are already met may be valuable to adjust the workload but is not essential by other criteria. But adding trainees in a specialty where there is a shortage in the state/region or adding trainees in programs that have national/international reputation was considered essential. For example, funding for adding trainees in specialties that have a shortage in the state where the CE is located, such as family medicine, general surgery or psychiatry would be considered essential. On the other hand adding a fellow in a highly specialized field with minimal needs for the state might be valuable to the faculty but was not considered essential. Next, a hierarchy of the funding requirements for all the GME activities was developed. Requirements were categorized, by order of importance into: a) educational, b) salary support and c) other needs. Education, the core responsibility of the GME, was placed above all other needs. The “other” category consisted of administrative aspects of the programs that could not be classified in the categories of “education” or “salary support”. Educational needs were further categorized, based on the ACGME requirements, into three categories: a) RRC core requirements, b) RRC outcomes requirements and c) RRC detail requirements (Fig. 2). RRC Core requirements are statements that define the structure, resource, or process elements that are essential to every graduate medical education program. RRC Detail requirements are similar statements, but for programs in substantial compliance there is flexibility to utilize alternative or innovative approaches to meet Core requirements. The committee decided that funding educational strategies for core processes and outcome measures should be granted without debate, as they are mandated by the ACGME. In contrast, funding for any of the detail measures was to be considered carefully, as programs in good standing are allowed flexibility with the detail processes. The committee's attention then turned to salary support for program directors (PDs), associate/assistant program directors (APDs), program coordinators (PCs) and residents and which types of support was considered very important (Fig. 3). Prior to the development of this model, salary support for PDs and APDs was highly variable and did not take into consideration objective factors, such as program accreditation, size, workload, location, etc. In order to standardize the process, promote fairness, and improve transparency, the committee, by consensus, developed a formula
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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cost per resident can be can be reduced when implemented in a program with larger number of residents when compared to a smaller program. After reviewing all the operational expenses for programs of all sizes over the last 2e3 years, allotting $ 500 (for >20 trainees) and $ 1000 (for <20 trainees) per resident annually was deemed to be sufficient to satisfy the needs for all programs. In addition to the above operational expenses, a concerted effort was made to provide funding to support and stimulate research and scholarly activities for trainees. These efforts included:
Fig. 2. Distribution of funds based on educational needs to satisfy the RRC “core”, “outcome” and “detail measures” as outlined by ACGME.
that would apply to all programs. The formula, delineated in Table 1, accounted for the RRC specifications and the number of trainees in determining the amount of protected time and funding. The “other” requirements were addressed by providing a fixed amount based on the number of residents. After reviewing each program's operating costs for the previous year and noting some similarities, these costs were standardized for all programs. Larger programs with >20 residents were able to build in cost savings through economies of scale, whereas smaller programs had greater expenditures per resident. For example, the initial costs of initiating a new Patient Safety and Quality Improvement curriculum will cost the same for larger or smaller programs. But after initiation, the
a). Funding for each resident ($ 1500 for each resident) to attend one national meeting annually to present their research. Additional funds were factored to support academically successful residents to attend more than one meeting if required b). Funding for programs such as general surgery to permit residents to take time off from clinical years to undertake laboratory research c). Funding for conducting research in patient safety, quality and cost control aspects of health care delivery d). Funding to recruit research coordinators that can aid in research activities related to ACGME competencies, Clinical Learning Environment Review (CLER) requirements e). Funding to organize patient safety and quality conferences locally to stimulate research into these important aspects of patient care f). Funding to permit program directors and program coordinators to attend their annual specialty meeting as well as their respective annual program director's meeting. g). Funding to permit residents to attend conferences such as The National Surgical Quality Improvement Program Annual meeting that focus on patient safety and quality. Lastly, the committee developed an algorithmic approach, Fig. 4, to efficiently assess requests for new funding. Funding requests
Fig. 3. Distribution of funds based on salary support for program directors, program coordinators and residents.
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Table 1 Salary support for Program coordinators, Associate/Assistant Program Directors, Program coordinators and Assistant Program coordinators. ACGME accredited Program Director
1). For programs with clear specifications from RRC- the numerical value of protected time is approved 2). For programs with no clear specifications or no specifications: At least 1 resident ¼ 20% protected time For each additional resident ¼ increase by 1% to maximum of 50% protected time For programs with more than 20 residents ¼ 50% protected time Associate/Assistant 1). For programs with clear specifications from RRC of the Program Director number and amount of stated protected time was approved 2). For programs with no clear specifications: Provision for Associate/Assistant if more than 20 residents Protected time ¼ 10% Program 1). For programs with clear specifications from RRC- the number Coordinator of PC and support was approved 2). For programs with no clear specifications: Retain current structure for current year to adjust In the future ¼ 0.3 FTE þ0.03 FTE per trainee Assistant Program 1). For programs with clear specifications from RRC- the number Coordinator of PC and support was approved 2). For programs with no clear specifications or no specifications ¼ based on number of residents
typically range from supporting a new educational activity to expanding the pool of residents. The framework allows for scoring requests based on the ranking of program, ACGME accreditation status and the proposed need. For example, an ACGME approved
Non-ACGME accredited For fellowships or residencies with at least 1 trainee ¼ 10% For each additional trainee ¼ increase by 1% For programs that do not fill their positions ¼ decrease to 5%
Since most of these programs are Fellowships and consist of small number of trainees (1e3) - no funding was provided
Since most of these programs consist of small number of trainees (1e3), it was encouraged to build synergies combining 2e3 programs under one PC
Since most of these programs are Fellowships and consist of small number of trainees (1e3) - no funding was provided
high priority program with a funding request for an essential educational need that satisfies a core process will receive a high score and be viewed very favorably. In contrast, a request from nonhigh priority, non-ACGME accredited but valuable program for
Fig. 4. Model for assessing the importance of requests for new funds to enable the decision to approve or disapprove the funding request.
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“other” needs will receive a low score and is less likely to be funded. Some examples of decisions reached by using this algorithmic approach are highlighted in Table 2. This has been our first attempt at our campus to streamline the GME activity financing across the CE. Our learning curve is steep and might be very long, depending on how the ACGME environment evolves. Several guidelines were agreed upon to ensure efficient functioning of the committee. Some of the guidelines include: a. To ensure fairness in appropriation of the funds and maintain transparency in our decisions b. The interests of the public and the CE were placed above those of the program. c. Funds allocated for one GME activity are meant to be used exclusively for that purpose. d. Provisions were made to factor in the acceptable rate of inflation for salaries and expenses. e. Although objective formulae were used when possible, judgements based on values and priorities were important as well. The best approach we found was to start with an objective assessment and complete the decision-making process by adding value-based judgements as well. f. The Designated Institutional Official, who is the Associate Dean for Graduate Medical Education, was empowered with the authority on final decisions with any appeals or due process that were directed to the Dean of the College of Medicine. Feasibility: The indirect and direct costs associated with developing this new funding model are highlighted below: a. Time commitment: The GMEFWC convened six meetings (2e3 h in duration) between February and May 2014 which was followed by two additional meetings in June and in September of 2014. Scheduled meetings are held four times a year in addition to ad hoc meetings to address any unexpected issues. Since most of the committee members were part of GMEC and understood the importance of this effort, we were able to secure the time commitment from members and their supervisors. b. Costs: This includes cost incurred for developing the financial model and not the actual final budget (not included for nondisclosure reasons). ▪ Direct: The direct costs were minimal and included only materials needed for the meetings. ▪ Indirect: This included the time and effort of all the committee members, PD's, PC's and administrators of each program. PD's, PC's and administrator's time was needed to present their respective budgets to the GMEFWC in a standardized format developed by the committee. None of these activities were provided with any financial compensation.
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3. Results The model was presented to all the stakeholders including the GME community, clinical departments and the Board of the CE. The model was well received and approved by all stakeholders in 2014. Although the model is still in its early stages, we have already witnessed several significant benefits which included: a) The majority of PD's noted a positive influence of this new funding model because the protected time arising from the dedicated salary support has made it possible for them to focus more of their efforts on the training program. b). There has been streamlined facilitation of departments to restructure the FTE (clinical and academic) requirements of PD's and APD's due to the dedicated salary support. c). The Next Accreditation System (NAS)4 has placed an increased emphasis on the role of core faculty which has increased their work load significantly. This work includes mandatory scholarly activity, ACGME survey participation, involvement in faculty development and creation of a Clinical Competency Committee to assess residents' performance based on the milestones. Adequate support needs to be provided to core faculty that enables them to satisfy these requirements while simultaneously contributing to the educational and clinical goals of the CE. In this model we were able to secure funding for core faculty activities. Standardized core faculty salary support was calculated as 0.10 FTE of an AAMC Associate Professor salary at the 50th percentile for each core faculty member. Recognizing the variations in department needs under the NAS, the salary support was distributed to each department as a lump sum, with distribution to be determined by the department chair in consultation with the PD. d). The ability to consolidate PCs across different programs (in the same department) and combine split FTE's into one FTE. In the past, individual small programs had their own PC who would also perform other non-GME related administrative tasks. It was felt by the committee that consolidating these into one FTE position that exclusively performed GME work would not only improve efficiency but also results in financial savings. In addition, the PC would be a specialist in GMErelated administration rather than a general administrator for the department. e) Through this new model additional funds were made available for initiatives to pursue activities that enhance patient safety and quality of care. f) The model's hierarchy has been extremely helpful in efficiently reaching decisions on requests for new funds. g) The ability to critically assess the relative value of ACGME accredited versus non-ACGME accredited programs and their funding requests.
Table 2 Examples of funding decisions reached based on model depicted in Fig. 4. Program
Reason for funding request
Score
Priority
Final decision
Medicine/Pediatrics Geriatrics Pulmonary/Critical Care Medicine Internal Medicine Adult Infectious disease Hematopathology ENT Uveitis Sports vision
Increase in 4 trainee positions Increase in 2 trainee positions Increase in 3 trainee positions Increase in 3 trainee positions Increase in 1 trainee position every other year Increase in 1 trainee position Request to re-arrange locations of resident rotations that would affect resident salary support Start a new fellowship Start a new fellowship
8 8 8 8 6 6 6 2 2
High High High High Medium Medium Medium Low Low
Approved Approved Approved Approved Approved Approved Denied Denied Denied
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h). Resident travel to meetings has been streamlined due to uniform availability of funding for all programs although it is too early to document an increase in meeting attendance. We expect that as we gain experience, we will continue to be able to target our resources more effectively, increase our financial savings and improve administrative efficiency.
e).
4. Discussion The authors feel that the described financial model is novel for the following reasons: a). Prior to initiation of the financial model, funding for the more than 50 programs was obtained from a diverse set of sources: Clinical Enterprise, College of Medicine, Department discretionary funds, outside affiliate hospitals, industry support, individual private donors and other entities. These funding sources were not uniform and there was no guarantee of sustainability of the funding streams. In addition, individual training programs and their respective Departments were responsible for reaching out to these diverse funding sources and this incurred a significant amount of effort which did not always guarantee secured funding. This additional burden of work distracted the program directors from the educational and administrative duties of directing a program. In our novel model, we have secured streams of funding which has reduced the unnecessary workload of the residency directors, department chairs and program coordinators. This has helped the program directors to focus their efforts exclusively on directing their respective programs and relieved the Chairpersons of constantly having to ensure GME funding from year to year. b). Prior to the initiation of our novel financial model, there was no consistency in how support was provided for PD's, APD's and PC's. The financial support was not based on any structured approach and thereby was not reflective of the workload involved. We noted that some programs had support disproportionate to the number of trainees whereas some large programs did not have adequate support at all. To promote fairness in funding for GME was one of our core principles. As a result, in our new model, funding for GME was based on the amount of workload involved, which was based on some factors such as the number of trainees and ACGME accreditation status. c). Prior to the initiation of the financial model, there was a significant lack of transparency in funding for all the GME programs. Individual programs had variable (not always productive) perceptions about how other programs on campus were funded. This combined with the equally significant variability did not engender cohesiveness in the GME community. The transparency in our new funding model (based on a simple algorithmic approach) has dispelled incorrect perceptions, increased satisfaction and promoted cohesiveness in the GME community. In addition, the new level of transparency helps us to address the concern of lack of transparency voiced by the IOM about GME funding. d). Prior to the initiation of our financial model, the final authority in determining funding for any GME activity rested with the Clinical Enterprise. In a radical change from the established practice at our institution and across most of the nation, the CE divested all responsibility of re-structuring funding for all GME activities to the GME office. This was undertaken with the assumption that the GME office is best suited to understand its own needs and address them. This in
f).
g).
h).
i).
j).
turn also improved the collaborative efforts between the CE and AC which is in synchrony with what the ACGME is promoting-a more collaborative relationship between the C suite (CEO's office) and D suite (Dean's office). Another novel aspect of our funding model is the clear delineation of the various lines of expenses needed to run a training program. This includes costs for: PD/APD support, PC support, core faculty support and operational expenses. This delineation helps us to assess the importance of each funding request depending on which funding line it belongs to. Funding for core faculty is a unique and novel aspect of our model. The NAS emphasizes the importance of core faculty with many added new responsibilities. The ability to provide this support relieves the core faculty from clinical duties and enhances their participation in ACGME/NAS/CLER activities. In addition, providing the support is enabling the program directors and chairpersons to expect a certain obligatory level of core faculty participation in key GME activities. The ACGME is placing an increasing degree of emphasis on scholarly activity. Several programs have received citations for the lack of scholarly activity. The novel feature of our model is that we have set aside specific amount of funds to promote scholarly activity for each resident. This also enables them to attend national/regional meetings. In addition, we were able to allocate funds for programs (example: general surgery) that provide opportunity for dedicated time for basic science research and thereby maintain the academic credentials of the department. The CLER places an enormous amount of emphasis on patient safety, quality and resident/fellow involvement in these activities. In our funding model, we were able to allocate funds specifically to enhance resident/fellow involvement in these initiatives. Another novel aspect of the funding model is the emphasis we placed on national trends as outlined by the COGME and IOM. The “high priority” specialties highlighted by the COGME report were placed in a separate category of higher importance. This is likely one of the early funding models that attempts to build synergies with current and emerging national trends as emphasized by recognized national bodies such as the COGME and IOM. A unique aspect of this funding model is the consideration given to addressing the workforce needs of our state. Funding requests for programs that train physicians in specialties of shortages were given high priority. As a result, our retention rate (keeping our GME trainees in our own state) is 56% which is higher than the national average of 44.9%.5 This ability to retain our own trainees in our state will be of help to our AC/CE and affiliated hospital partners across the state.
Our financial model is new and we are in our third full year of implementation. We feel that it is too early to expect major financial savings although we are witnessing some early signs of benefits. We are assessing our savings in two categories (similar to costs): direct and indirect savings. To help with this we have created a novel “Return on Investment” (ROI) report. (Table 3) This ROI report consist of 8 metrics and 21 variables. The 8 metrics include: Program status, Patient Safety and Quality Improvement, Educational activity, Scholarly activity, Community outreach, Workforce alignment, Program stewardship and Clinical cost impact. The 21 variables assessed in this novel ROI report provide a detailed analysis of the benefits derived as well as the cost savings (direct and indirect). For example, trainee contribution to patient care is noted to be associated with enhanced clinical productivity which adds to the revenue streams of the AC and CE. Some other
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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Table 3 GME “return on investment” Report.
examples of cost savings at this early stage include: consolidation of multiple PC's into one PC with GME expertise, discontinuation of several other activities such as serving alcohol at evening journal clubs etc. We have also realized cost saving by declining requests for funding for new program or program expansions based on our algorithm. The time saved by PD's/APD's/PC's and Chairpersons with not having to worry about funding has enabled them to focus more on their program as well as clinical productivity. The cost benefits we are witnessing at this early stage portends a highly likely scenario of further major cost savings (direct and indirect) in the future. In addition to the direct cost benefits, several other indirect cost benefits are being realized. For example in the Program status metric (Accreditation variable), nearly 98% of our programs are in good standing with continued accreditation. For the workforce alignment metric, our ability to retain nearly 56% of our trainees to stay in our own state and work in our primary and other affiliated hospitals is also considered a metric of success.5 The model was presented to all the stakeholders (GME community- PD's/APD's Department Chairpersons, CE) and was received well. Since its implementation, we have continued to receive consistently positive feedback from all stakeholders. The feedback emphasizes the value of the new funding model based on fairness, uniformity and transparency. Our stakeholders note the ease in dealing with GME office regarding funding issues as well as the safety net of funding for their GME activities. We have not conducted a survey of the stakeholders but may consider doing the same after a few more years of operation in the new funding model.
In the early phase of our new funding model, we do not feel that there are winners or losers. By streamlining the funding model based on a structured algorithm, promoting fairness, uniformity, and transparency, and by securing a safety net of funding stream we feel that everyone is a winner at this stage. There was no major redistribution of large funding streams at this stage but rather introduction of uniformity, fairness and transparency.
5. Conclusions AC's that partner with CE's are being forced to critically appraise funding for GME activities. At our AC, the GMEC was tasked by the CE to assess the current status and develop a financial model for the future of GME activities across the CE. A novel algorithmic financial model was developed by creating a GMEC Finance Working Committee in the financial year 2014 which has met the approval of all stakeholders. Although early in its application the new model has already resulted in financial savings and improved administrative efficiency. It is likely with additional experience we will realize greater benefits. We anticipate that our model could be employed, with appropriate modifications to suit their local environment, as a template by other academic centers or clinical enterprises.
Funding The authors report no external funding source for this study and declare they have no competing interest.
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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Author contributions 1. Collection of data: Hamm, Wadman 2. Development of financial model: Are, Hamm, DeVries, Goldner, Jarzynka, Parker, Simonson, Talmon, Vokoun, Wadman 3. Drafting and/or review of manuscript: All authors Acknowledgements The authors would like to thank Mr. Michael McGlade, Associate Dean for Administration and Finance with College of Medicine for his input and serving on the committee. The authors would also like to thank the senior leadership of the AC and CE for their support. References 1. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/ twentyfirstreport.pdf - Accessed 4 April 2014. 2. Graduate Medical Education that Meets the Nation's Health Needs. IOM; 2014. available at: http://www.iom.edu/Reports/2014/Graduate-Medical-EducationThat-Meets-the-Nations-Health-Needs.aspx. Accessed August 26, 2014. 3. Goodman DC, Robertson RG. Accelerating physician workforce transformation through competitive graduate medical education funding. Health Aff.
2013;32(11):1887e1892. 4. Next Accreditation System http://www.acgme.org/acgmeweb/tabid/435/ ProgramandInstitutionalAccreditation/NextAccreditationSystem.aspx, Accessed 25 September 2015. 5. Association of American Medical Colleges. State Physician Workforce Data Book; 2015. https://members.aamc.org/eweb/upload/2015StateDataBook%20(revised). pdf. Accessed August 6, 2017.
List of abbreviations GME: Graduate medical education GMEC: Graduate medical education committee AC: Academic center CE: Clinical enterprise GMEWFC: Graduate medical education workforce and finance committee COGME: Council on graduate medical education PPACA: Patient protection and affordable care act ACO: Accountable care organization IOM: Institute of Medicine ACGME: Accreditation Council of Graduate Medical Education NAS: Next accreditation system PD: Program director APD: Associate/Assistant Program Director PC: Program Coordinator RRC: Residency review committee FTE: Full time equivalent
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Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise Chandrakanth Are a, *, Melissa Suh a, Lauren Carpenter a, Hugh Stoddard b, Vicki Hamm c, Matthew DeVries d, Whitney Goldner e, Kimberly Jarzynka f, Jennifer Parker g, Jean Simonson h, Geoffrey Talmon i, Chad Vokoun j, Jeffrey Gold k, David Mercer a, Michael Wadman l a
Department of Surgery, University of Nebraska Medical Center, Omaha, NE, 68198, USA Emory University School of Medicine, Atlanta, GA, 30322, USA c Office of Graduate Medical Education, University of Nebraska Medical Center, Omaha, NE, 68198, USA d Department of Radiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA e Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA f Department of Family Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA g Department of Internal Medicine- Pediatrics, University of Nebraska Medical Center, Omaha, NE, 68198, USA h Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA i Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA j Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA k University of Nebraska Medical Center, Omaha, NE, 68198, USA l Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA b
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a b s t r a c t
Article history: Received 21 April 2017 Received in revised form 16 June 2017 Accepted 2 July 2017
Background: Funding for graduate medical education (GME) is becoming scarce and is likely to worsen. There is a higher degree of accountability and return on investment demanded from public funds dedicated to GME. Academic centers (AC) partnered with clinical enterprises (CE) are finding it increasingly difficult to retain sustainable funding streams for GME activities. Methods: To develop and implement a novel algorithmic funding model at one AC in symbiotic partnership with the CE for all 50 GME programs with nearly 500 residents. Results: A new GME Finance and Workforce Committee was convened which was tasked with developing the novel algorithmic financial model to prioritize GME funding. Early outcomes measures that were monitored consisted of: satisfaction of all stakeholders and financial savings. Conclusions: The model was presented to all the stakeholders and was well received and approved. Early signs, demonstrated AC and CE satisfaction with the model, financial savings and increased efficiency. This GME funding model may serve as a template for other academic centers with tailored modifications to suit their local needs, demands and constraints. © 2017 Published by Elsevier Inc.
Keywords: Graduate Medical Education Funding Novel funding model
1. Introduction Greater value in graduate medical education (GME) means a better targeting of public GME money and more effective training models1: Twenty-first report of Council On Graduate Medical Education
* Corresponding author. E-mail address: [email protected] (C. Are).
(COGME).1 The 21st report1 from the COGME was released in August 2013, titled: “Improving Value in Graduate Medical Education”.1 This theme is now emphasized by virtually every entity involved in GME, ranging from the public to the government and the education community. Enhancing the value from GME financing is essential in the current environment of decreasing funding. The Patient Protection and Affordable Care Act's (PPACA) encouragement of Accountable Care Organizations (ACO's) has catalyzed the
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Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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consolidation of health care entities across the country. Academic health centers (AC's) and Clinical Enterprises (CE's) which have functioned somewhat independently until now are embarking on consolidating their administrative and financial operations. In this environment, Graduate Medical Education Committee's (GMEC's) across the country are being forced to take a critical look at the current budget and funding mechanisms for GME activities. The Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education issued a report (July 29th 2014) on GME funding that highlights issues such as lack of transparency and accountability with the current system and makes recommendations for a new GME funding model.2 To align GME program outcomes with the workforce needs and training content demanded by all entities, institutions must consider and develop innovative funding mechanisms that account for these priorities.3 The aim of this descriptive study is to present the novel algorithmic funding model developed in 2014 by our AC in partnership with the CE and present some early outcome data. The new model revamped the funding structure for GME activities of all 50 programs with nearly 500 residents. 2. Methods The structure of our campus for GME consisted of three separate financial entities: The University of Nebraska Medical Center (UNMC), The Nebraska Medical Center (TNMC) and the University of Nebraska Medical Center Physicians (UNMCP). These three entities came together as one clinical enterprise, Nebraska Medicine (CE) to be prepared for the evolving health care environment and to combine all operations including the financial sectors. Since the CE sponsors the GME programs, the CE decided to revamp funding for all GME activities and delegated that responsibility to the GMEC through a charter. In response, the GMEC convened a new GME Finance and Workforce Committee (GMEFWC) that consisted of 11 members and included: the Associate Dean for GME, Assistant Dean for GME, the GME Administrator, 8 program directors representing hospitalbased, medical, and surgical programs, and the Associate Dean for Administration and Finance for the College of Medicine who served as a liaison to the CE. After committee formation, regulatory guidelines which needed to be followed while building the funding algorithm were reviewed. Two reports provided the foundation for this: a) the 21st report of the COGME, to provide information for long range structural planning and b) individual program requirements outlined by the residency review committee's (RRC's) of the Accreditation Council of Graduate Medical Education (ACGME). These reports provided the information necessary for development of program specific criteria for determining funding. As available, approved specialty society guidelines were referred to for non-accredited programs, as well as for programs accredited by bodies other than the ACGME (example: Oral Maxillofacial Surgery). The committee developed a hierarchy for 50 training programs sponsored by our CE (Fig. 1) that provided us with a structured approach to determining the relative importance of each training program for distribution of funds. Programs were divided into “high priority versus non-high priority” (designated as “core” or “non-core”) based on the COGME report,1 which recommended increases in GME funding towards “core” specialties (Recommendation 2.1). Programs were then categorized by their ACGME accreditation status to account for the differences in the regulatory requirements and workloads between ACGME accredited and nonACGME accredited programs. Lastly, based on the relative contributions to the AC and CE, programs were subjectively categorized
Fig. 1. Developing a hierarchy of training programs based on their national importance, ACGME accreditation status and relative contributions to the academic and clinical mission of the academic center.
as “Valuable” versus “Essential”. The designation of “Valuable or Essential” was defined based on: the local requirements, met or unmet needs, and obligations of the AC, CE, the state and the geographic region. Adding a trainee in a specialty where the needs are already met may be valuable to adjust the workload but is not essential by other criteria. But adding trainees in a specialty where there is a shortage in the state/region or adding trainees in programs that have national/international reputation was considered essential. For example, funding for adding trainees in specialties that have a shortage in the state where the CE is located, such as family medicine, general surgery or psychiatry would be considered essential. On the other hand adding a fellow in a highly specialized field with minimal needs for the state might be valuable to the faculty but was not considered essential. Next, a hierarchy of the funding requirements for all the GME activities was developed. Requirements were categorized, by order of importance into: a) educational, b) salary support and c) other needs. Education, the core responsibility of the GME, was placed above all other needs. The “other” category consisted of administrative aspects of the programs that could not be classified in the categories of “education” or “salary support”. Educational needs were further categorized, based on the ACGME requirements, into three categories: a) RRC core requirements, b) RRC outcomes requirements and c) RRC detail requirements (Fig. 2). RRC Core requirements are statements that define the structure, resource, or process elements that are essential to every graduate medical education program. RRC Detail requirements are similar statements, but for programs in substantial compliance there is flexibility to utilize alternative or innovative approaches to meet Core requirements. The committee decided that funding educational strategies for core processes and outcome measures should be granted without debate, as they are mandated by the ACGME. In contrast, funding for any of the detail measures was to be considered carefully, as programs in good standing are allowed flexibility with the detail processes. The committee's attention then turned to salary support for program directors (PDs), associate/assistant program directors (APDs), program coordinators (PCs) and residents and which types of support was considered very important (Fig. 3). Prior to the development of this model, salary support for PDs and APDs was highly variable and did not take into consideration objective factors, such as program accreditation, size, workload, location, etc. In order to standardize the process, promote fairness, and improve transparency, the committee, by consensus, developed a formula
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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cost per resident can be can be reduced when implemented in a program with larger number of residents when compared to a smaller program. After reviewing all the operational expenses for programs of all sizes over the last 2e3 years, allotting $ 500 (for >20 trainees) and $ 1000 (for <20 trainees) per resident annually was deemed to be sufficient to satisfy the needs for all programs. In addition to the above operational expenses, a concerted effort was made to provide funding to support and stimulate research and scholarly activities for trainees. These efforts included:
Fig. 2. Distribution of funds based on educational needs to satisfy the RRC “core”, “outcome” and “detail measures” as outlined by ACGME.
that would apply to all programs. The formula, delineated in Table 1, accounted for the RRC specifications and the number of trainees in determining the amount of protected time and funding. The “other” requirements were addressed by providing a fixed amount based on the number of residents. After reviewing each program's operating costs for the previous year and noting some similarities, these costs were standardized for all programs. Larger programs with >20 residents were able to build in cost savings through economies of scale, whereas smaller programs had greater expenditures per resident. For example, the initial costs of initiating a new Patient Safety and Quality Improvement curriculum will cost the same for larger or smaller programs. But after initiation, the
a). Funding for each resident ($ 1500 for each resident) to attend one national meeting annually to present their research. Additional funds were factored to support academically successful residents to attend more than one meeting if required b). Funding for programs such as general surgery to permit residents to take time off from clinical years to undertake laboratory research c). Funding for conducting research in patient safety, quality and cost control aspects of health care delivery d). Funding to recruit research coordinators that can aid in research activities related to ACGME competencies, Clinical Learning Environment Review (CLER) requirements e). Funding to organize patient safety and quality conferences locally to stimulate research into these important aspects of patient care f). Funding to permit program directors and program coordinators to attend their annual specialty meeting as well as their respective annual program director's meeting. g). Funding to permit residents to attend conferences such as The National Surgical Quality Improvement Program Annual meeting that focus on patient safety and quality. Lastly, the committee developed an algorithmic approach, Fig. 4, to efficiently assess requests for new funding. Funding requests
Fig. 3. Distribution of funds based on salary support for program directors, program coordinators and residents.
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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Table 1 Salary support for Program coordinators, Associate/Assistant Program Directors, Program coordinators and Assistant Program coordinators. ACGME accredited Program Director
1). For programs with clear specifications from RRC- the numerical value of protected time is approved 2). For programs with no clear specifications or no specifications: At least 1 resident ¼ 20% protected time For each additional resident ¼ increase by 1% to maximum of 50% protected time For programs with more than 20 residents ¼ 50% protected time Associate/Assistant 1). For programs with clear specifications from RRC of the Program Director number and amount of stated protected time was approved 2). For programs with no clear specifications: Provision for Associate/Assistant if more than 20 residents Protected time ¼ 10% Program 1). For programs with clear specifications from RRC- the number Coordinator of PC and support was approved 2). For programs with no clear specifications: Retain current structure for current year to adjust In the future ¼ 0.3 FTE þ0.03 FTE per trainee Assistant Program 1). For programs with clear specifications from RRC- the number Coordinator of PC and support was approved 2). For programs with no clear specifications or no specifications ¼ based on number of residents
typically range from supporting a new educational activity to expanding the pool of residents. The framework allows for scoring requests based on the ranking of program, ACGME accreditation status and the proposed need. For example, an ACGME approved
Non-ACGME accredited For fellowships or residencies with at least 1 trainee ¼ 10% For each additional trainee ¼ increase by 1% For programs that do not fill their positions ¼ decrease to 5%
Since most of these programs are Fellowships and consist of small number of trainees (1e3) - no funding was provided
Since most of these programs consist of small number of trainees (1e3), it was encouraged to build synergies combining 2e3 programs under one PC
Since most of these programs are Fellowships and consist of small number of trainees (1e3) - no funding was provided
high priority program with a funding request for an essential educational need that satisfies a core process will receive a high score and be viewed very favorably. In contrast, a request from nonhigh priority, non-ACGME accredited but valuable program for
Fig. 4. Model for assessing the importance of requests for new funds to enable the decision to approve or disapprove the funding request.
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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“other” needs will receive a low score and is less likely to be funded. Some examples of decisions reached by using this algorithmic approach are highlighted in Table 2. This has been our first attempt at our campus to streamline the GME activity financing across the CE. Our learning curve is steep and might be very long, depending on how the ACGME environment evolves. Several guidelines were agreed upon to ensure efficient functioning of the committee. Some of the guidelines include: a. To ensure fairness in appropriation of the funds and maintain transparency in our decisions b. The interests of the public and the CE were placed above those of the program. c. Funds allocated for one GME activity are meant to be used exclusively for that purpose. d. Provisions were made to factor in the acceptable rate of inflation for salaries and expenses. e. Although objective formulae were used when possible, judgements based on values and priorities were important as well. The best approach we found was to start with an objective assessment and complete the decision-making process by adding value-based judgements as well. f. The Designated Institutional Official, who is the Associate Dean for Graduate Medical Education, was empowered with the authority on final decisions with any appeals or due process that were directed to the Dean of the College of Medicine. Feasibility: The indirect and direct costs associated with developing this new funding model are highlighted below: a. Time commitment: The GMEFWC convened six meetings (2e3 h in duration) between February and May 2014 which was followed by two additional meetings in June and in September of 2014. Scheduled meetings are held four times a year in addition to ad hoc meetings to address any unexpected issues. Since most of the committee members were part of GMEC and understood the importance of this effort, we were able to secure the time commitment from members and their supervisors. b. Costs: This includes cost incurred for developing the financial model and not the actual final budget (not included for nondisclosure reasons). ▪ Direct: The direct costs were minimal and included only materials needed for the meetings. ▪ Indirect: This included the time and effort of all the committee members, PD's, PC's and administrators of each program. PD's, PC's and administrator's time was needed to present their respective budgets to the GMEFWC in a standardized format developed by the committee. None of these activities were provided with any financial compensation.
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3. Results The model was presented to all the stakeholders including the GME community, clinical departments and the Board of the CE. The model was well received and approved by all stakeholders in 2014. Although the model is still in its early stages, we have already witnessed several significant benefits which included: a) The majority of PD's noted a positive influence of this new funding model because the protected time arising from the dedicated salary support has made it possible for them to focus more of their efforts on the training program. b). There has been streamlined facilitation of departments to restructure the FTE (clinical and academic) requirements of PD's and APD's due to the dedicated salary support. c). The Next Accreditation System (NAS)4 has placed an increased emphasis on the role of core faculty which has increased their work load significantly. This work includes mandatory scholarly activity, ACGME survey participation, involvement in faculty development and creation of a Clinical Competency Committee to assess residents' performance based on the milestones. Adequate support needs to be provided to core faculty that enables them to satisfy these requirements while simultaneously contributing to the educational and clinical goals of the CE. In this model we were able to secure funding for core faculty activities. Standardized core faculty salary support was calculated as 0.10 FTE of an AAMC Associate Professor salary at the 50th percentile for each core faculty member. Recognizing the variations in department needs under the NAS, the salary support was distributed to each department as a lump sum, with distribution to be determined by the department chair in consultation with the PD. d). The ability to consolidate PCs across different programs (in the same department) and combine split FTE's into one FTE. In the past, individual small programs had their own PC who would also perform other non-GME related administrative tasks. It was felt by the committee that consolidating these into one FTE position that exclusively performed GME work would not only improve efficiency but also results in financial savings. In addition, the PC would be a specialist in GMErelated administration rather than a general administrator for the department. e) Through this new model additional funds were made available for initiatives to pursue activities that enhance patient safety and quality of care. f) The model's hierarchy has been extremely helpful in efficiently reaching decisions on requests for new funds. g) The ability to critically assess the relative value of ACGME accredited versus non-ACGME accredited programs and their funding requests.
Table 2 Examples of funding decisions reached based on model depicted in Fig. 4. Program
Reason for funding request
Score
Priority
Final decision
Medicine/Pediatrics Geriatrics Pulmonary/Critical Care Medicine Internal Medicine Adult Infectious disease Hematopathology ENT Uveitis Sports vision
Increase in 4 trainee positions Increase in 2 trainee positions Increase in 3 trainee positions Increase in 3 trainee positions Increase in 1 trainee position every other year Increase in 1 trainee position Request to re-arrange locations of resident rotations that would affect resident salary support Start a new fellowship Start a new fellowship
8 8 8 8 6 6 6 2 2
High High High High Medium Medium Medium Low Low
Approved Approved Approved Approved Approved Approved Denied Denied Denied
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h). Resident travel to meetings has been streamlined due to uniform availability of funding for all programs although it is too early to document an increase in meeting attendance. We expect that as we gain experience, we will continue to be able to target our resources more effectively, increase our financial savings and improve administrative efficiency.
e).
4. Discussion The authors feel that the described financial model is novel for the following reasons: a). Prior to initiation of the financial model, funding for the more than 50 programs was obtained from a diverse set of sources: Clinical Enterprise, College of Medicine, Department discretionary funds, outside affiliate hospitals, industry support, individual private donors and other entities. These funding sources were not uniform and there was no guarantee of sustainability of the funding streams. In addition, individual training programs and their respective Departments were responsible for reaching out to these diverse funding sources and this incurred a significant amount of effort which did not always guarantee secured funding. This additional burden of work distracted the program directors from the educational and administrative duties of directing a program. In our novel model, we have secured streams of funding which has reduced the unnecessary workload of the residency directors, department chairs and program coordinators. This has helped the program directors to focus their efforts exclusively on directing their respective programs and relieved the Chairpersons of constantly having to ensure GME funding from year to year. b). Prior to the initiation of our novel financial model, there was no consistency in how support was provided for PD's, APD's and PC's. The financial support was not based on any structured approach and thereby was not reflective of the workload involved. We noted that some programs had support disproportionate to the number of trainees whereas some large programs did not have adequate support at all. To promote fairness in funding for GME was one of our core principles. As a result, in our new model, funding for GME was based on the amount of workload involved, which was based on some factors such as the number of trainees and ACGME accreditation status. c). Prior to the initiation of the financial model, there was a significant lack of transparency in funding for all the GME programs. Individual programs had variable (not always productive) perceptions about how other programs on campus were funded. This combined with the equally significant variability did not engender cohesiveness in the GME community. The transparency in our new funding model (based on a simple algorithmic approach) has dispelled incorrect perceptions, increased satisfaction and promoted cohesiveness in the GME community. In addition, the new level of transparency helps us to address the concern of lack of transparency voiced by the IOM about GME funding. d). Prior to the initiation of our financial model, the final authority in determining funding for any GME activity rested with the Clinical Enterprise. In a radical change from the established practice at our institution and across most of the nation, the CE divested all responsibility of re-structuring funding for all GME activities to the GME office. This was undertaken with the assumption that the GME office is best suited to understand its own needs and address them. This in
f).
g).
h).
i).
j).
turn also improved the collaborative efforts between the CE and AC which is in synchrony with what the ACGME is promoting-a more collaborative relationship between the C suite (CEO's office) and D suite (Dean's office). Another novel aspect of our funding model is the clear delineation of the various lines of expenses needed to run a training program. This includes costs for: PD/APD support, PC support, core faculty support and operational expenses. This delineation helps us to assess the importance of each funding request depending on which funding line it belongs to. Funding for core faculty is a unique and novel aspect of our model. The NAS emphasizes the importance of core faculty with many added new responsibilities. The ability to provide this support relieves the core faculty from clinical duties and enhances their participation in ACGME/NAS/CLER activities. In addition, providing the support is enabling the program directors and chairpersons to expect a certain obligatory level of core faculty participation in key GME activities. The ACGME is placing an increasing degree of emphasis on scholarly activity. Several programs have received citations for the lack of scholarly activity. The novel feature of our model is that we have set aside specific amount of funds to promote scholarly activity for each resident. This also enables them to attend national/regional meetings. In addition, we were able to allocate funds for programs (example: general surgery) that provide opportunity for dedicated time for basic science research and thereby maintain the academic credentials of the department. The CLER places an enormous amount of emphasis on patient safety, quality and resident/fellow involvement in these activities. In our funding model, we were able to allocate funds specifically to enhance resident/fellow involvement in these initiatives. Another novel aspect of the funding model is the emphasis we placed on national trends as outlined by the COGME and IOM. The “high priority” specialties highlighted by the COGME report were placed in a separate category of higher importance. This is likely one of the early funding models that attempts to build synergies with current and emerging national trends as emphasized by recognized national bodies such as the COGME and IOM. A unique aspect of this funding model is the consideration given to addressing the workforce needs of our state. Funding requests for programs that train physicians in specialties of shortages were given high priority. As a result, our retention rate (keeping our GME trainees in our own state) is 56% which is higher than the national average of 44.9%.5 This ability to retain our own trainees in our state will be of help to our AC/CE and affiliated hospital partners across the state.
Our financial model is new and we are in our third full year of implementation. We feel that it is too early to expect major financial savings although we are witnessing some early signs of benefits. We are assessing our savings in two categories (similar to costs): direct and indirect savings. To help with this we have created a novel “Return on Investment” (ROI) report. (Table 3) This ROI report consist of 8 metrics and 21 variables. The 8 metrics include: Program status, Patient Safety and Quality Improvement, Educational activity, Scholarly activity, Community outreach, Workforce alignment, Program stewardship and Clinical cost impact. The 21 variables assessed in this novel ROI report provide a detailed analysis of the benefits derived as well as the cost savings (direct and indirect). For example, trainee contribution to patient care is noted to be associated with enhanced clinical productivity which adds to the revenue streams of the AC and CE. Some other
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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Table 3 GME “return on investment” Report.
examples of cost savings at this early stage include: consolidation of multiple PC's into one PC with GME expertise, discontinuation of several other activities such as serving alcohol at evening journal clubs etc. We have also realized cost saving by declining requests for funding for new program or program expansions based on our algorithm. The time saved by PD's/APD's/PC's and Chairpersons with not having to worry about funding has enabled them to focus more on their program as well as clinical productivity. The cost benefits we are witnessing at this early stage portends a highly likely scenario of further major cost savings (direct and indirect) in the future. In addition to the direct cost benefits, several other indirect cost benefits are being realized. For example in the Program status metric (Accreditation variable), nearly 98% of our programs are in good standing with continued accreditation. For the workforce alignment metric, our ability to retain nearly 56% of our trainees to stay in our own state and work in our primary and other affiliated hospitals is also considered a metric of success.5 The model was presented to all the stakeholders (GME community- PD's/APD's Department Chairpersons, CE) and was received well. Since its implementation, we have continued to receive consistently positive feedback from all stakeholders. The feedback emphasizes the value of the new funding model based on fairness, uniformity and transparency. Our stakeholders note the ease in dealing with GME office regarding funding issues as well as the safety net of funding for their GME activities. We have not conducted a survey of the stakeholders but may consider doing the same after a few more years of operation in the new funding model.
In the early phase of our new funding model, we do not feel that there are winners or losers. By streamlining the funding model based on a structured algorithm, promoting fairness, uniformity, and transparency, and by securing a safety net of funding stream we feel that everyone is a winner at this stage. There was no major redistribution of large funding streams at this stage but rather introduction of uniformity, fairness and transparency.
5. Conclusions AC's that partner with CE's are being forced to critically appraise funding for GME activities. At our AC, the GMEC was tasked by the CE to assess the current status and develop a financial model for the future of GME activities across the CE. A novel algorithmic financial model was developed by creating a GMEC Finance Working Committee in the financial year 2014 which has met the approval of all stakeholders. Although early in its application the new model has already resulted in financial savings and improved administrative efficiency. It is likely with additional experience we will realize greater benefits. We anticipate that our model could be employed, with appropriate modifications to suit their local environment, as a template by other academic centers or clinical enterprises.
Funding The authors report no external funding source for this study and declare they have no competing interest.
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010
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Author contributions 1. Collection of data: Hamm, Wadman 2. Development of financial model: Are, Hamm, DeVries, Goldner, Jarzynka, Parker, Simonson, Talmon, Vokoun, Wadman 3. Drafting and/or review of manuscript: All authors Acknowledgements The authors would like to thank Mr. Michael McGlade, Associate Dean for Administration and Finance with College of Medicine for his input and serving on the committee. The authors would also like to thank the senior leadership of the AC and CE for their support. References 1. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/ twentyfirstreport.pdf - Accessed 4 April 2014. 2. Graduate Medical Education that Meets the Nation's Health Needs. IOM; 2014. available at: http://www.iom.edu/Reports/2014/Graduate-Medical-EducationThat-Meets-the-Nations-Health-Needs.aspx. Accessed August 26, 2014. 3. Goodman DC, Robertson RG. Accelerating physician workforce transformation through competitive graduate medical education funding. Health Aff.
2013;32(11):1887e1892. 4. Next Accreditation System http://www.acgme.org/acgmeweb/tabid/435/ ProgramandInstitutionalAccreditation/NextAccreditationSystem.aspx, Accessed 25 September 2015. 5. Association of American Medical Colleges. State Physician Workforce Data Book; 2015. https://members.aamc.org/eweb/upload/2015StateDataBook%20(revised). pdf. Accessed August 6, 2017.
List of abbreviations GME: Graduate medical education GMEC: Graduate medical education committee AC: Academic center CE: Clinical enterprise GMEWFC: Graduate medical education workforce and finance committee COGME: Council on graduate medical education PPACA: Patient protection and affordable care act ACO: Accountable care organization IOM: Institute of Medicine ACGME: Accreditation Council of Graduate Medical Education NAS: Next accreditation system PD: Program director APD: Associate/Assistant Program Director PC: Program Coordinator RRC: Residency review committee FTE: Full time equivalent
Please cite this article in press as: Are C, et al., Model for prioritization of Graduate Medical Education funding at a university setting e Engagement of GME committee with the Clinical Enterprise, The American Journal of Surgery (2017), http://dx.doi.org/10.1016/ j.amjsurg.2017.07.010