Study finds that residents improve access to care, provide value across payers
"Residents provide a significant amount of care to patients with orthopaedic injuries and musculoskeletal conditions," noted J. Benjamin Jackson, MD. When the attending is not present, much of that care goes unbilled. Currently, resident education is funded by Medicare and the host institution. "The Balanced Budget Act of 1996 froze funding for graduate medical education (GME), so any new resident openings have been funded by individual hospitals. Given the current economic situation in health care, we may see further cuts, so we wanted to demonstrate how much work residents. Ultimately, does the Medicare get value for its investment? Are other payers getting a free ride?

"When I was a resident, I analyzed all the consults I had done over a 2-year period, and we published the findings in The Journal of Graduate Medical Education [September 2014]," he continued. "One of the weaknesses of that initial research was that it was only one resident at one institution, so we decided to follow up with a prospective study in which we analyzed consults by residents from four institutions across the country over a 90-day period."

Monetary value
Dr. Jackson and his colleagues retrospectively reviewed patient charts for demographics, admission data, orthopaedic injuries, and any procedures performed by the resident. They converted ICD-9 Current Procedural Terminology (CPT) codes into work relative value units (wRVUs) using the 2014 Medicare CPT to wRVU Crosswalk. Only procedures that would typically be performed in the emergency department or on the inpatient floor by the resident without attending supervision (such as closed reductions, skeletal traction, and laceration repair) were used to calculate procedural CPT values. The monetary value of resident work on call was calculated by multiplying wRVUs by the 2014 Medicare rate of $35.8228/RVU.

From a total of 360 resident call shifts, 356 call sheets (98.8 percent) were available when the data were collected. The researchers identified 2,692 total patient consults, with an average of 7.47 consults per night per institution. Evaluation and management (E/M) codes generated 5,633.21 wRVUs with a calculated dollar amount of $201,797.36. Procedural codes generated an additional 6,073.03 wRVUs with a calculated dollar amount of $217,552.94. The researchers counted a total of 11,706.24 wRVUs generated over 360 call nights, for an average of 32.52 RVUs per night. The total dollar amount generated was $419,350.29 ($1,164.86 per call). Based on Medicare rates, they projected an average annual dollar value of resident call work per institution of $425,173.90.

"Our findings show that residents provide a significant amount of care across payers to patients with orthopaedic injuries and musculoskeletal conditions," said Dr. Jackson. "Based on that, we would argue that it is important to at least maintain, if not increase, the level of support for resident positions across the country."

Dr. Jackson and his team noted that GME funding is provided in the following two forms:

• Direct medical education (DME) payments, which help cover the direct costs of GME, such as stipends and benefits for residents and faculty
• Indirect medical education (IME) payments, which cover expenses associated with the treatment of severely ill patients and additional costs related to teaching residents

Driving policy
"Our institution estimates Medicare DME support per resident at approximately $40,000 per year, with total funding of $130,000 per resident," explained James Davies, MD, who presented data from the study at the 2017 AAOS Annual Meeting. "Residency education occurs while residents are performing clinical work and providing care for patients. Some of this professional services work is not billed by attending surgeons, who may not be physically present when the care is delivered. Work performed during call by orthopaedic residents is frequently not billed."

"We were a little surprised to see how often resident services are not billed," agreed Dr. Jackson, "just because an attending physician may not be present for the initial consult. So, private insurers receive a lot of benefit from resident availability, yet they don't fund resident positions directly, like Medicare does. Resident salaries are essentially supported either by Medicare or by the institution, but they provide services across all payers."

Dr. Jackson points out that the study data reflect only work performed by residents who were on call during nights and weekends, and do not include other duties such as rounding, assisting in surgery, or seeing patients in the clinic.

"Our data support the level of Medicare funding received, as the value of on-call work is significantly higher than the DME funding paid to hospitals for orthopaedic residents," said Dr. Davies. "It appears that Medicare gets its money's worth from orthopaedic residents from clinical call work alone, in addition to supporting the education of the next generation of surgeons."

"Residents help improve access to care," concluded Dr. Jackson. "When hospital administrators see how much care residents provide, it's much easier to make a case for adding a new resident position. I hope that more data like this, from orthopaedics as well as other specialties, can help drive policy in Washington."

Coauthors with Drs. Jackson and Davies include Miranda Bice, MD; Gregory Grabowski, MD; Scott A. Vincent, MD; Kevin D. Phelps, MD; Chris A. Cornett, MD; Brian P. Scannell, MD; and Alan Stotts, MD.

Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at ppollack@aaos.org

Reference
Jackson JB 3rd, Huntington WP, Frick SL: Assessing the value of work done by an orthopedic resident during call. J Grad Med Educ 2014;6(3):567-570. doi: 10.4300/JGME-D-13-00370.1. http://www.jgme.org/doi/abs/10.4300/JGME-D-13-00370.1