The Next Generation- Clinical & Research News - For and about the Physicians and Researchers of Brigham and Women's HospitalThe Next Generation- Clinical & Research News - For and about the Physicians and Researchers of Brigham and Women's Hospital

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The Next Generation

Clinical & Research News is pleased to introduce this new feature, a column written by our residents and fellows about issues that matter to them. If you would like to submit a column to The Next Generation, please email BWHClinicalandResearchNews@partners.org

Determining the Value of Care Provided by Residents

By David I. Rosenthal, MD
BWH Internal Medicine, PGY3

As a resident, I am constantly striving to provide the best care I possibly can, but I have no idea if what I am providing is actually valuable care for my patients.

As leaders and payers of our health care system increasingly focus on providing value, defined as the outcomes achieved over the cost to achieve them, academic medical centers find themselves in a unique position trying to balance clinical care efficiencies with other important missions of research and teaching. Politically, the issue of value in clinical care is incredibly timely as President Obama's recent FY'2013 budget proposal includes signficant cuts to Indirect Medical Education payments in an effort to better align graduate medical education payments with patient care costs.

David Rosenthal

Even though resident physicians' monthly paychecks come from our parent organizations, many don't realize that these salaries are subsidized by the Medicare program, which in 2010 contributed $9.5 billion in Graduate and Indirect Medical Education (GME and IME) to teaching hospitals nationwide to support the training of about 100,000 residents. For every 10 residents per 100 beds, a teaching hospital receives a 5.5 percent add-on adjustment to its Medicare payment rate for hospital care.[1] For the Brigham, as a 793-bed teaching affiliate of Harvard Medical School with about 679 BWH residents (and more integrated residencies with MGH), that represents a significant add-on adjustment for all hospital care provided to Medicare patients. This substantial add-on payment has, in the past, been justified by understanding that care delivered in teaching hospitals is often less efficient. Pointedly, with the recent FY'2013 budget proposal, there is a renewed focus on our training inefficiencies. The following is the language used in the OMB proposal:

"Medicare compensates teaching hospitals for the indirect costs stemming from inefficiencies created from residents "learning by doing." The Medicare Payment Advisory Commission (MedPAC) has determined that these Indirect Medical Education (IME) add-on payments are significantly greater than the additional patient care costs that teaching hospitals experience, and the Fiscal Commission, among others, recommended reducing the IME adjustment.This proposal would reduce the IME adjustment by 10 percent beginning in  2013, and save approximately $9 billion over 10 years."[2]


Interestingly, rather than proposing explicit cuts in IME dollars, the Medicare Payment Advisory Commission (MedPac) in their 2010 recommendation paper[3], recommended a move to a performance-based incentive program with IME payments to institutions contingent on reaching "desired educational outcomes and standards." At the time, reactions to this "pay-for-performance" idea were mixed from the ACGME, AMA and AAMC.[4] It is still very unclear what the ultimate outcome will be regarding budget decisions around IME funding; however, it is clear that future Medicare dollars provided to teaching hospitals will come under a fair amount of scrutiny and may require new metrics and reporting capabilities.


To anticipate such a climate, members of the BWH Department of Medicine are currently looking into the possibility of a proposed Residency Dashboard, based on the current Balanced Scorecard model developed by the Center for Clinical Excellence to better account for patients cared for by residents and to help define educational outcomes and standards that might be incorporated into a future reporting system. Such a system should help to keep track of the patients cared for by residents, and more importantly, help in understanding how we have provided them with valuable care. In a time of tightening government dollars, we all must find ways to prove our return on investment.


On a personal level, I hope that such a system will provide me with more outcome measurements about my own residency experience, and perhaps foster personalized, tailored learning opportunities.


[1]Iglehart JK. The uncertain future of Medicare and graduate medical education. New Engl J Med2011;365(14):1340-1345.

[2]http://www.whitehouse.gov/sites/default/files/omb/budget/fy2012/assets/jointcommitteereport.pdf

[3] Graduate medical education financing: Focusing on educational priorities (Chapter 4, June 2010 MedPac report)

[4] Iglehart JK. Health reform, primary care, and graduate medical education. N Engl J Med2010;363:584-590