Graduate Education in Primary Care: An Economic Analysis

To determine the financial requirements of an established primary-care educational program for house officers, we studied two prepaid and two fee-for-service Harvard Primary Care Program affiliated practices. Program-wide, each resident saw an average of 112 patients per month, with patient service costs of $2,580. With teaching and administrative expenses included, total monthly costs averaged $3,120 and $3,270 per trainee for prepaid and fee-for-service practices respectively. In fee-for-service practices, resident billings for patient services averaged $2,790, yielding revenues of $2,510 per month, which offset 77 per cent of total program costs. At current reimbursement rates, covering full program costs in the fee-for-service practices would require an increase of more than 40 per cent in resident-provided patient-care volume. By reducing time available for broad ambulatory experiences, such an increase would necessitate substantial program restructuring and limit opportunities for innovation in the Harvard Primary Care Program. (N Engl J Med 297:638–643, 1977) The Harvard Primary Care Program was established to provide postgraduate education in primary-care internal medicine, with quality patient care by residents at participating practices and opportunities for research in primary care. The Program includes physicians in residency tracks at five Harvardaffiliated general hospitals and a health-maintenance organization (HMO). Currently, a primary-care resident's year is divided into six months of outpatient (ambulatory) training, which includes direct general-internal-medicine patient care, ambulatory subspecialty clinical experience, didactic and preceptor sessions and six months of inpatient training, during which activities of the resident are identical in function and finance to those of “standard-track” internal-medicine residents.