Financial Considerations Associated With a Fourth Year of Residency Training in Family Medicine: Findings From the Length of Training Pilot Study.

BACKGROUND AND OBJECTIVES: The feasibility of funding an additional year of residency training is unknown, as are perspectives of residents regarding related financial considerations. We examined these issues in the Family Medicine Length of Training Pilot. METHODS: Between 2013 and 2019, we collected data on matched 3-year and 4-year programs using annual surveys, focus groups, and in-person and telephone interviews. We analyzed survey quantitative data using descriptive statistics, independent samples t test, Fisher's Exact Test and χ2. Qualitative analyses involved identifying emergent themes, defining them and presenting exemplars. RESULTS: Postgraduate year (PGY)-4 residents in 4-year programs were more likely to moonlight to supplement their resident salaries compared to PGY-3 residents in three-year programs (41.6% vs 23.0%; P=.002), though their student debt load was similar. We found no differences in enrollment in loan repayment programs or pretax income. Programs' descriptions of financing a fourth year as reported by the program director were limited and budget numbers could not be obtained. However, programs that required a fourth year typically reported extensive planning to determine how to fund the additional year. Programs with an optional fourth year were budget neutral because few residents chose to undertake an additional year of training. Resources needed for a required fourth year included resident salaries for the fourth year, one additional faculty, and one staff member to assist with more complex scheduling. Residents' concerns about financial issues varied widely. CONCLUSIONS: Adding a fourth year of training was financially feasible but details are local and programs could not be compared directly. For programs that had a required rather than optional fourth year much more financial planning was needed.

Report From the FMAHealth Practice Core Team: Achieving the Quadruple Aim Through Practice Transformation.

Family Medicine for America's Health (FMAHealth) is a strategic planning organization effort that was created out of the reevaluation of the first Future of Family Medicine project from 2004. This article is a summary of the key findings of the FMAHealth Practice Core Team. At the highest level, we find that family medicine practices have compelling intrinsic and extrinsic reasons to evolve to new models of care delivery. We have demonstrated that payment transformation is imperative to successful practice transformation and that comprehensive payment models that include attention to physician work within the social determinants of health and require fewer administrative burdens will be key to achieving the quadruple aim. To bridge payment reform and practice transformation will require better and fewer measures of physician effectiveness in order to allow the physician-patient dyad to thrive in these new models. Achieving these goals will require a sustained national effort involving not only the many family medicine membership organizations, but their collaborative work with others in the health care transformation industry who may not have been our traditional partners. Educational initiatives must be robust, available to all family physicians regardless of professional organization membership, and focused on meeting physicians and physician practice managers where they are with the goal of moving them toward a state of more advanced care delivery. This article outlines the work done by the FMAHealth Practice Team that supports the above assertions.

Simulation of air quality and operational cost to ventilate swine farrowing facilities in Midwest U.S. during winter.

We have developed a time-dependent simulation model to estimate in-room concentrations of multiple contaminants [ammonia (NH3), carbon dioxide (CO2), carbon monoxide (CO) and dust] as a function of increased ventilation with filtered recirculation for swine farrowing facilities. Energy and mass balance equations were used to simulate the indoor air quality (IAQ) and operational cost for a variety of ventilation conditions over a 3-month winter period for a facility located in the Midwest U.S., using simplified and real-time production parameters, comparing results to field data. A revised model was improved by minimizing the sum of squared errors (SSE) between modeled and measured NH3 and CO2. After optimizing NH3 and CO2, other IAQ results from the simulation were compared to field measurements using linear regression. For NH3, the coefficient of determination (R2) for simulation results and field measurements improved from 0.02 with the original model to 0.37 with the new model. For CO2, the R2 for simulation results and field measurements was 0.49 with the new model. When the makeup air was matched to hallway air CO2 concentrations (1,500 ppm), simulation results showed the smallest SSE. With the new model, the R2 for other contaminants were 0.34 for inhalable dust, 0.36 for respirable dust, and 0.26 for CO. Operation of the air cleaner decreased inhalable dust by 35% and respirable dust concentrations by 33%, while having no effect on NH3, CO2, in agreement with field data, and increasing operational cost by $860 (58%) for the three-month period.

A New Foundation for the Delivery and Financing of American Health Care.

BACKGROUND AND OBJECTIVES: For the past decade, primary care practices across America have worked to implement a practice model called the Patient-Centered Medical Home (PCMH) to revitalize practice, better support clinicians and patients, improve efficiency, and facilitate growth in primary care capacity. In spite of substantial progress, this work has not been matched by sufficient change in the payment system to allow these goals to be accomplished. Nevertheless, improving the quality and availability of primary care remains essential to achieving the goals of the Triple Aim (better health care, better population health, and containment of health care costs). For this to occur, the PCMH model of care must be further refined, and the payment system for primary care must be completely restructured. The need for these changes is urgent. In October 2014, the discipline of family medicine announced a comprehensive strategic plan called Family Medicine for America's Health (FMAHealth). FMAHealth proposes to expand the PCMH care model by fully integrating our nation's behavioral/mental health, public health, and primary care systems to create a new foundation for American health care. Accomplishing these ambitious goals will require a broad coalition of private and public interests across the health care disciplines as well as patients, communities, government, and businesses. These changes require additional infrastructure that existing financing systems do not adequately support, so comprehensive payment reform is essential for large-scale dissemination and sustainability of this model. The new payment model must reward value rather than volume of service and must provide a secure financial foundation for practices designed to care for patients and communities at affordable costs.

Five Key Leadership Actions Needed to Redesign Family Medicine Residencies.

BACKGROUND: New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership. OBJECTIVE: We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change. METHODS: The Preparing the Personal Physician for Practice (P4) project (2007-2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign. RESULTS: Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience. CONCLUSIONS: Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.