Blog: Enhancing Accountability in Graduate Medical Education by Calculating the Costs and Revenues of Community-based Primary Care Residency Training

Despite considerable federal investment, graduate medical education (GME) financing is neither transparent for estimating residency training costs nor accountable for effectively producing a physician workforce that matches the nation’s health care needs. Amid these ongoing challenges of transparency and accountability in GME financing, the Teaching Health Center Graduate Medical Education (THCGME) program—established in 2010 as part of the Affordable Care Act to support primary care training in community-based settings—provided an opportunity to systematically collect data on the cost of residency training in these sites.Our team—which includes researchers from the Department of Health Policy and Management at the George Washington University Milken Institute School of Public Health—developed a standardized methodology for quantifying the expenses and revenues associated with training primary care physicians in underserved community-based settings as part of a five-year evaluation of the THCGME program. We fielded the THCGME Costing Instrument with 43 residencies operating in academic year 2013-2014 and published our estimate of the cost of training residents in Teaching Health Centers, which was $157,602 per resident for fiscal year 2017, in the New England Journal of Medicine.Our recent paper, “Comprehensive Revenue and Expense Data Collection Methodology for Teaching Health Centers: A Model for Accountable Graduate Medical Education Financing,” published in the Journal of Graduate Medical Education presents our approach to reach our cost estimate. The paper describes how we constructed the tool to collect standardized comprehensive financial data on residency training. It also discusses what we learned about the feasibility of collecting comparable financial data from residencies in order to establish an evidence-based payment for graduate medical education in community-based primary care residencies.We found that Teaching Health Center residencies were able to provide data on educational outlays, patient service expenses and revenues from residents' ambulatory and inpatient care, and payer mix. The THCGME Costing Instrument provides a model for calculating evidence-based costs and revenues of community-based residency programs, and it enhances accountability by offering an approach that estimates residency costs and revenues in a range of settings. Additionally, the THCGME Costing Instrument may have utility for application in other residency training settings. Marsha Regenstein is the Principal Investigator of the independent evaluation of the Teaching Health Center Graduate Medical Education (THCGME) initiative. Dr. Regenstein is a Professor in the Department of Health Policy. She also directs the Department's Master of Science degree in Health Policy and is the DrPH Program Director for GWSPH.Mariellen Malloy Jewers is a Research Scientist in the Health Policy and Management Department in the Milken Institute School of Public Health at George Washington University where she manages the implementation of data collection and data management efforts for the Evaluation and Initial Assessment of HRSA Teaching Health Centers. Ms. Jewers is a PhD candidate at the Trachtenberg School of Public Policy and Public Administration and holds a Master's of International Affairs from Columbia University.