Federal-state synergy in family medicine education.

During the 1960s national policy groups assessed the consequences of a four-decade decline in the nation's number of general practitioners. Various proposals were offered to make general practice a more attractive specialty. Most of the proposals have been institutionalized by means of a family practice specialty board, accredited family practice residency programs, and academic family practice units in medical schools. In retrospect, two events can be identified as critical factors in the successful launching of the family practice specialty: (1) the merging of the movement to make real the theoretical, normative concept of the primary care physician proposed in the academic literature with a reform movement within the clinically based, politically astute American Academy of General Practice and (2) the establishment of extramural funds for family practice, which helped it gain a crucial foothold within academic medical centers. The broad themes of the family practice movement, established in the 1960s and 1970s, continue to be appropriate themes for the 1980s and 1990s.

Cost-benefit analyses of California family practice residencies.

Several national commissions have recommended that family practice residency training be subsidized, but without stating how much support is needed. Financial studies of graduate medical education have used the methods of cost allocation or joint-products cost analysis. Previous cost-allocation studies indicate that one third of family practice residency costs are met by extramural subsidy. Cost reports of eight California public hospitals with a single family practice residency program were evaluated for the 1984-85 fiscal year. Discrepancies in the education costs reported to Medicare and those reported in state hospital disclosure reports demonstrate the arbitrary nature of the cost-allocation method. The Medicare medical education reimbursement was an average of $20,444 per resident. State and federal grants provided an average of $5,190 per resident. The Medicare payments and grants met an average of 35.7% of the education costs reported to Medicare. A joint-products cost analysis was used to estimate the pure cost of education in an 18-resident family practice residency. Replacing the residency with salaried physicians would have decreased the hospital's net return by $143,534. If neither grants nor Medicare education payments had been received, elimination of the program would have increased hospital net return by $428,083.

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.

Primary care physicians in underserved areas. Family physicians dominate.

Using the definitions of "medically underserved areas" developed by the California Health Manpower Policy Commission and data on physician location derived from a survey of California physicians applying for licensure or relicensure between 1984 and 1986, we examined the extent to which different kinds of primary care physicians located in underserved areas. Among physicians completing postgraduate medical education after 1974, board-certified family physicians were 3 times more likely to locate in medically underserved rural communities than were other primary care physicians. Non-board-certified family and general physicians were 1.6 times more likely than other non-board-certified primary care physicians to locate in rural underserved areas. Family and general practice physicians also showed a slightly greater likelihood than other primary care physicians of being located in urban underserved areas.