CORNELL UNIVERSITY LIBRARY BUSINESS R 745.H65°'"°""""'""">"-lbrary DATE DUE !Kcw'"IJt ^^T^^rTi ^M BO" y i:ezi '9 BU T^ iMi 1 ^■b ^j^^im^Bi 1 . Hiiiu )im CAVLORO PRINTCOINU S A XI Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924017657184 MEDICAL PRACTICE PLANS AT U.S. MEDICAL SCHOOLS A REVIEW OF CURRENT CHARACTERISTICS AND TRENDS VOLUME I INTERIM FINAL REPORT Association of American Medical Colleges One Dupont Circle, N.W., Washington, D.C. 20036 U.S. Department of Health, Education and Welfare Public Health Service Health Resources Administration Bureau of Health Manpower Contract No. 231-76-0011 Additional copies of this report (Volume I and Volume II) have been printed by AAMC to allow distribution to individuals and institutions with an interest in medical practice plans. Orders for additional copies should be addressed to: Association of American Medical Colleges One Dupont Circle, N.W. , Suite 200 Attention: Membership and Subscriptions Washington, D.C. 20036 $5.00 each voliome Remittance or institutional purchase order must accompnay order. © Association of American Medical Colleges, 1977 The Government retains the right to use, dupli cate or disclose the contents of this report and to have or permit others to do so, MEDICAL PRACTICE PLANS AT U.S. MEDICAL SCHOOLS A Review of Current Characteristics and Trends William C. Hilles Sharon K. Pagan VOLUME I interim final report This Interim Final Report is in partial fulfillment of work to be performed and is subject to modification. Division of Operational Studies ASSOCIATION OF AMERICAN MEDICAL COLLEGES March 1977 The work upon which this pyblioation is based was supported in part by the Bureau of Health Manpower, department of Health, Education and Welfare pursuant to contract number 231-76-0011. However, any conclusions and/ or recommendations expressed herein do not necessajrily represent the views of the supporting agency. TABLE OF CONTENTS VOLUME I Page List of Illustrations 1 Advisory Committee 3 Executive Summary 5 Introduction 9 Historical Background 9 Recent Developments 11 Other Work on Medical Practice Plans 11 Scope and Objectives 13 Methodology 15 Collection of Plans 15 Profile Matrix 15 Practice Plan Typology and Grouping 16 Income Flow Diagrams 16 Use of Other Data 16 Results and Discussion 17 Plan Characteristics 17 Typology of Medical Practice Plans 21 Examples of Practice Plan Income Flow 22 Trends 41 Conclusions 47 Footnotes 49 Report Bibliography 51 Appendices 53 Appendix A - Checklist-Institutional 55 Plan(s) for Medical Practice, 1976 (working form) Appendix B - Medical Practice Plan 57 Profile Matrix, 1976 (working form) TABLE OF CONTENTS (cont'd) Appendices (cont'd) et. al.) Page Appendix C - Sample letter and form 59 to medical school dean requesting authorization to use data Annotated Bibliography of Medical Practice Plans 61 VOLUME II Medical Practice Plan Profile Matrix Glossary Medical Practice Plan Profile Matrices Completed Organization - Public Schools - Private Schools 5 11 Membership - Public Schools - Private Schools 15 21 Governance - Public Schools - Private Schools 25 31 Administration - Public Schools - Private Schools 35 41 Practice Setting/Plan Income - Public Schools - Private Schools 45 51 Fees (Schedule Determination , - Public Schools - Private Schools 55 61 11 TABLE OF CONTENTS (cont'd) Medical Practice Plan Profile Matrices Completed (cont'd) Page Fees (Billing System for Ambulatory Patients, et. al. ) Fees (Collection et.al. ) Compensation (Relationships between Faculty Utilization & Sources of Compensation, et. al. ) Compensation (Insurance & Retirement Benefits) Compensation (Malpractice Liability Coverage) Public Schools 65 Private Schools 71 Public Schools Private Schools Public Schools Private Schools Public Schools Private Schools Public Schools Private Schools 75 81 85 91 95 101 105 111 111 LIST OF ILLUSTRATIONS Page Table 1 - Medical Practice Plan Typology 23 Table 2 - Growth of Expenditures from 42 Medical Service Funds Practice Plan Income Flow Diagrams 25 Diagram 1 - Type A, 26-27 Private Medical School Diagram 2 - Type A, 28-29 Public Medical School Diagram 3 - Type B, 30-31 Private Medical School Diagram 4 - Type B, 32-33 Public Medical School Diagram 5 - Type B, 34-35 Public Medical School Diagram 6 - Type C, 36-37 Private Medical School Diagram 7 - Type C, 38-39 Public Medical School - 1 - Advisory Committee AAMC Study of Medical Practice Plans Clyde T. Hardy, Jr. (Associate Dean, Patient Services, Bowman Gray School of Medicine) CHAIRMAN Alice Cushing, M.D. (Assistant Chairman, Department of Pediatrics, University of New Mexico School of Medicine) Richard A. Grossi (Financial Director of the Medical Groups, University of Connecticut Health Center) V. Wayne Kennedy (Assistant Vice Chancellor for Health Sciences and Associate Dean, University of California School of Medicine at San Diego) Lawrence E. Martin (Associate Director, Massachusetts General Hospital) Carl L. Nelson, M.D. (Chairman, Department of Orthopaedic Surgery, University of Arkansas School of Medicine) Carole J. Stapleton (Coordinator Clinical Excellence Task Forces, Mount Sinai School of Medicine and Hospital) Edward J. Stemmler, M.D. (Dean, University of Pennsyl- vania School of Medicine) Observer ; Ronald D. Jydstrup (Project Advisor, Institutional Resources Branch, DOM Bureau of Health Manpower) AAMC Staff Support ; William C. Hilles (Associate Director, Division of Operational Studies; Project Director) Sharon K. Fagan (Staff Associate, Division of Operational Studies) Richard Knapp, Ph.D. (Director, Department of Teaching Hospitals) - 3 - EXECUTIVE SUMMARY The Study of Medical Practice Plans describes the structural and operational characteristics of over sixty plans in U.S. medical schools. These plans were found to include a documented description of the way the respec- tive clinical faculties conduct their patient care acti- vities. The study further establishes a typology based on plan structure and classifies the plans accordingly. Significant trends are observed and reported. The study's objective was to undertake a nationwide review of all medical school practice arrangements, and to describe their primary features. Thus, the effort was intended to result in current, comprehensive knowledge of the subject. Medical schools developing a plan for the first time, or preparing to alter their existing plan, would have the outcome of this study as a ready reference work. Using AAMC's collection of articles, monographs, and written descriptions of practice plans, supplemented by telephone, written or direct inquiry of the schools where information was lacking, the following products were generated: (1) An annotated bibliography on the subject of practice plans. (2) Profile matrices, for public and private institu- tions, displaying plan features relating to structure and governance, mechanics of adminis- tration, compensation patterns, income flow and disposition. (3) A rationale for categorizing practice plans, and the actual classification of all plans reviewed. (4) A set of flow diagrams, illustrating for each basic type of plan (representing at least one public and one private institution) the source and distribution of all practice plan income. Since compensation is the most significant object of expense from plan income, the devia- tion of the various components of compensation is highlighted. - 5 - (5) A discussion of the study's findings and trends since the 1950 's. The study's findings were determined from review of the completed profile matrices. Following is a recap of the more striking disclosures: • More than half of all the medical schools in the country have a written practice plan which applies universally throughout the institution; a dozen or so have separately incorporated plans. • Over three-fourths of the plans have either been initially implemented or significantly revised since 1970. • In all but a handful of plans membership is re- quired for clinical practitioners who are full- time faculty. • Fewer than a dozen institutions do not have a structured, broadly representative governing Dody provided exclusively for their plans; in more than half of all the plans reviewed, the dean is a member of this body. • Close to 60% of the plans have full-time, discrete plan managers. • Over 40% of the institutions whose plans are included in this study provided data as to source of direct payment for patient services. • Sixty percent of the plans centrally bill and collect above the departmental, or individual level; fewer than a dozen plans utilize an out- side service bureau. • In only rare instances is any patient-generated income excluded from a plan's purview. Fewer than a dozen plans do not have a system of employment agreements or contracts between the plan participant and the institution. Close to two-thirds of the plans include a personal incentive component of compensation. - 6 - • Malpractice insurance is usually institutionally financed either by the plan or parent institution; over a dozen have implemented self insurance programs and over thirty-five are considering the arrangement. A number of significant trends are readily apparent when comparing the findings of this study with two mile- stone studies conducted since mid-century, and when reviewing financial data provided to the AAMC by the medical schools annually. Income generated by practice plans as used by the schools to support their general operations has increased dramatically, not only in dollar amounts but also in the proportion of this source to regular operating revenue. Further trends discussed in this report relate to such matters as the increasing incidence of geographic vs. strict full-time faculty appointments; the growing prevalence of centralized and discrete management, including fee handling; and the preference for monetary rather than time controls over practice activity. - 7 - INTRODUCTION In recent years, more and more U.S. medical schools have developed formal policies and procedures governing the manner in which faculty physicians provide services to patients, reimbursement is secured, and the resulting funds are utilized. For a niamber of reasons, the development of these medical practice plans is continuing, and there is a great need for information to assist medical school administrators who are developing new plans or altering existing plans. It is also important to secure a better understanding of the current organization of medical practice in the academic setting, for the benefit of those at all levels in public and private sectors who need to assess the potential impact on academic medicine of proposed changes in the health care delivery system. For these reasons the Association of American Medical Colleges with support from the Bureau of Health Manpower, began a formal, two-year study of medical practice plans in January 1, 1976. This is the report of the first year of this study, describing general characteristics of plans and trends in plan development, based on a nationwide review. The second year of the study will include an in-depth examination of at least one institution representative of each of the more commonly used types of plans. Historical Background Sweeping changes have occurred since mid-century in the way medical care is delivered and paid for. These changes have had profound effects at the interface between patient service and education in U.S. medical schools and centers. A brief review of these historical developments will aid one in understanding why medical practice plans were developed and the forms they take. Until mid-century, medical schools depended more heavily on volunteer and part-time paid faculty for teaching in clinical subjects. The nucleus of full-time teaching clinicians was small, if it existed at all. The schools relied extensively upon indigent patients admitted to the wards of their teaching hospitals for clinical instruction. The clinical faculty payroll was relatively small, and there was no payment for most of the patient service. - 9 - A niomber of social and economic forces led to increases in the niimber of full-time clinical faculty. As a result of the Flexner Report, medical schools had moved towards closer ties with their universities and had begun to emulate other parts of the institution that had full-time faculties. The increasing demands for medical care placed heavy burdens on the voluntary clinical faculty and they could no longer devote the necessary time and energy to teaching as they had in the past. The response of the medical schools to federal initiatives to increase the level of biomedical research led to an expansion of full-time faculty with the proper preparation and time to undertake investigative work. The growth of undergraduate and graduate medical education enrollments and the acceleration of specialization required larger clinical faculties for which the medical schools found increasing difficulty in providing support from university resources. At the same time the clinical faculty size was increasing, the demand for quality care as a public right led to a rather sudden recognition of a governmental role in paying for such care. The Social Security Amendments of 1965 provided health insurance for the aged and disabled (Medicare) and grants to the states for medical assistance to the economically disadvantaged (Medicaid) . Together with the rise in private medical insurance. Medicare and Medicaid changed the system of financing medical care of the indigent, putting them essentially on the same, fee-for-service basis as other patients. As a result, the private and semiprivate services of the teaching hospitals have largely been integrated into the teaching programs, and greater direct faculty involvement in the care of these patients is required. Thus, the patient service activities of the greatly increased numbers of clinical faculty members must be financed, and third-party reimbursement for physician fees are available for this purpose. To maintain control of faculty compensation, however, and to maintain a balance of faculty activities, medical schools have felt a need to centralize and control this income and its utilization. To meet these needs, medical practice plans have been developed at a rapid rate. - 10 - Recent Developments During the past three or four years national interest in medical practice plans has intensified. Witness to this is the fact that more than two-thirds of the plans reviewed in this study began or have undergone major revision since 1972. Some of the impetus for this heightened interest has been the growing availability of third-party reimbursement for patient service provided by medical school faculty. But a more important factor has been the changing picture with respect to medical school financial resources. Although the degree of shift varies from school to school, there has been a diminution of the growth of federal support to the medical schools, forcing a concurrent demand for funds from unrestricted sources. Reduced proportional federal support for biomedical research has been particularly striking. Fortunately, much of the slack has been covered from discretion- ary resources. Prominent among such sources has been income from medical practice plans, which provides vital support for medical school faculty compensation. In order to keep the salaries of medical school faculty members competitive with the earnings generated by their counterparts in private practice, schools have written and rewritten practice plans to reflect more liberal personal incentives. As federal, state and local governments increased appro- priations to the health services sector, so grew the demand for greater accountability for costs incurred by providers. Medical schools, in particular, have been under close scrutiny in this regard, and in some quarters have found it to their advantage to encourage group practice on the part of their faculty. The result has often been a more rational and efficient use of health resources so that a better return can be achieved for time spent in practice, in dollars, in quality of care, and in faculty and patient satisfaction. Against this background, the Association embarked on this study to review the current state of the art of medical practice plans. Other Work on Medical Practice Plans The Association of American Medical Colleges has maintained an interest in the evolution of medical practice plans for many years. Two decades ago this began with a comprehensive, detailed - 11 - ■ I study by the late Augustus Carroll of the policies and practices relating to the patient care activities of the faculty at nineteen medical schools^ Since then, the Association has collected intermittently in varying detail information on the administration of faculty compensation and on the derivation of income through plans for medical practice. In addition, medical school business officers both nationally and regionally have participated in and profited from discussion and work- shops on the subject of practice plans. Prior to Carroll's research in the late 1950 's, there had been little reference in the literature to medical practice plans, either as a described arrange- ment or as a source of medical school income. Drs. John Deitrick and Robert Berson however, did publish a book in 1953 which discussed in detail the financing of medical schools as well as faculty appointment practices.2 The two authors do provide good historical background for the setting in which formal practice plans began to appear. During the 1960 's, Clyde T. Hardy, Jr. of the Bowman Gray School of Medicine became interested in documenting the characteristics of practice plans nation- wide. In 1967 in cooperation with the AAMC he surveyed 84 institutional members of the Association, and received 72 replies. The results were published by the AAMC^^ An additional source has been used in this study of practice plans and sheds considerable light on the growth of income to the medical schools from this source. Since 1956-57, the AAMC has gathered annual data from its constituents on their expenditures and sources of support for meeting them. Income from medical service plans has been reported along with other financial data each year in the Journal of the American Medical Association 's medical education issue. Other materials used in this study are referenced as footnotes where appropriate and appear in the Biblio- graphy. - 12 - SCOPE AND OBJECTIVES There are currently 111 established M.D. degree- granting accredited medical schools. Participation in Phase I of the Study was encouraged by open invitation from the AAMC. Limits on the time available to synthesize and doc\ament plan descriptions precluded inclusion of more than the 67 institutions represented in this report. Another group of 32 schools have either implemented or are developing guidelines for implementation of a medical practice plan. Twelve schools of medicine do not have an acknowledged practice plan that is institutional in scope. It has been the general objective of this two-year study to identify and describe the key characteristics of the plans found to be functioning nationwide. The descriptive analysis which follows addresses structure and governance, mechanics of administration, compensation patterns, income flow and disposition. Additional objectives have included (1) a review of national trends with respect to practice plans; (2) the development of a rationale for typing plans and for grouping them accordingly; and (3) an in-depth examination of at least one institution representative of each of the more commonly used types of plans, such examination to be conducted on site to review any problems of implementation and operation and to determine how it is evaluated by the school's faculty and staff. This latter objective will be undertaken during the second year of the study. The end result of this two-year study will be an updated and broadened knowledge of the subject of medical practice plans. Medical schools planning to develop a new plan for the first time, or preparing to alter their present plan, will have the outcome of this study as a ready reference work. - 13 - METHODOLOGY Collection of Plans Over the years the AAMC has collected intermittently and in varying detail information on the administration of faculty compensation through plans for medical practice. First, steps were taken to determine through contacts with the schools whether the plans the Association had in its files were current; where they were found to be no longer valid, updated versions were gathered for analysis. Profile Matrix A comprehensive set of matrices displaying a number of characteristics for each plan was generated for this study. This was developed in the following fashion: (1) Drawing from written plans sent to the Associa- tion by the medical schools, project staff developed an internal checklist (See Appendix A) to record consistently the major character- istics of practice plans. Topics under which questions were posed included: plan organization, membership requirements, governance, administra- tion, practice setting, fee determination and collection, compensation and income distribution patterns, malpractice liability insurance, plan objectives and implementation procedures. Some of the data on the checklist were completed by staff with information on hand; when data were not immediately available, it was gathered by telephone or by site visit. (2) An abbreviated instrument was developed in matrix fashion (See Appendix B) to display what was judged to be the more salient features of practice plans. The completed checklists were used as source documents for filling out the preliminary matrices . (3) Both checklist and the preliminary matrices were then sent to the deans of all medical schools under review to validate the analysis and to gain approval to use the data in the study (See Appendix C) . (4) The final matrices were completed for each responding school, and constitute a major section - 15 - of this report. Very few schools wished their identity known on the matrices; therefore, the institutional entries have been letter-coded, but with a regional designation. They are further disaggregated by private and public status. Practice Plan Typology and Grouping From information displayed on the checklist and profile matrices, a typology was developed for grouping plans with similar features. Earlier work in typing practice plans (i.e. Rand Corporation, Institute of Medicine) was reviewed but rejected for the reasons detailed later in this report. The AAMC typology, in brief, reasons that plan structure should be the criteria for classification. A spectrum can be drawn where centralized, more formally structured plans appear at one end, while the more decentralized, less structured, plans appear at the other extreme. Using the typological framework, plans were assigned to one of three categories, further broken down by private and public ownership. Income Flow Diagrams Following the assignment of plans to the appropriate category, at least two plans (one public, one private) were selected for further review as to income generation and disposition. A dynamics model, or flow diagram , was drawn for each selected plan. Each diagram depicts gross plan income. The models further illustrate sequentially the distribution and use of the revenue by object of expense. Special attention is paid to the various components of faculty compensation (i.e. base salary, fringe benefits, salary supplements and/or incentive payments) and the sources of these increments. A brief description appears opposite each flow diagram. Use of Other Data As each institutional plan was reviewed, the study's staff drew upon other AAMC data relating to the particular institution and its practice arrangements. Such data already in Association files included accreditation reports, faculty salary questionnaires, and various correspondence with the schools on the subject. The use of these materials served to provide insight into aspects not otherwise obvious in the written plan. - 16 - RESULTS AND DISCUSSION Plan Characteristics In the following sections, characteristics of medical practice plans in operation at U.S. medical schools are described. A typology is developed, and examples of each type are presented. Finally, a discussion of trends in practice plan development is presented. The following observations have been made using a set of matrices which record the more salient characteristics of medical practice plans. These matrices are presented separately for public and private institutions and can be found in Volume II. The development and growth of plans for medical practice at academic institutions has accelerated during the last sixteen-year period. Seventy percent of those plans currently in existence have been implemented since 1960, Very few plans now in operation have continued to function without major revision. Ninety percent of the public medical school plans described in this study have been revised since 1970. A large proportion, 75 percent, of private medical school plans have also been significantly modified. The AAMC Study of Medical Practice Plans includes descriptions of a variety of organizational structures. Most of the medical schools participating in this study report having a single practice plan that is fully institutional in scope. In most cases the location of a comprehensive centralized plan is within the school of medicine. Variation of clinical practice arrangements for academic departments or medical specialties is permitted by nearly one-third of the institutions in this report. In these instances, the departments are given considerable latitude in customizing a plan to their needs. Over 20 percent of the public medical schools have practice plans which are separately incorporated. Membership in a public medical school practice plan is required for full-time clinical faculty in almost every case (95%) . A little more flexibility in membership requirements seems to prevail at private medical schools (80%) , In approximately 10 percent of all practice plans, part-time and volunteer faculty are eligible to participate fully in the plan with some schools requiring the participation of - 17 - such faculty. More than one category of membership is available in 20 percent of the plans studied. Usually "other" types of plan membership are optional for faculty who are less than full-time at the medical school, A written description of the practice plan structure and its operational ground rules has been prepared and formally approved at most of the institutions included in this study. Plan policies are frequently determined by a group of individuals whose primary objective is the resolution of clinical practice-related issues. The composition of this body always includes faculty representatives from the clinical science disciplines. A common mixture of some clinicians elected at large in addition to each clinical science department chairman is frequently observed. Deans participate in these deliberations at 80 percent of the public medical schools and more than half the private institutions. Other university, state and hospital officials are involved with practice plan governance at the same rate, (65%) , for both public and private medical schools. Basic science faculty in private institutions are unlikely to be members of a practice plan policy-making body, but some official rep- resentation from the basic sciences is visible at one-quarter of the public medical schools. The administration of medical practice plans has been evolving into a full-time occupation. Seventy percent of the public medical schools and 43 percent of the private medical schools studied report that a full-time manager is responsible for plan operation. Nearly half of these administrators report directly to a health center or university official other than the medical school dean. When administrative staff of the medical school is involved part-time in the coordination of plan support services, the dean usually assumes greater responsibility for practice plan operation. This situation occurs more often in private medical schools than in public ones. Sites for the provision of services by plan participants vary little from one medical school to another. Most faculty physician offices are located within the school and its owned or affiliated hospitals. Occasionally office space is leased in a facility outside the institution. There is not much difference between public and private schools in the kinds of clinical activities included within the plan purview. Hospital inpatient services are under the plan umbrella in at least 90 percent of the cases studied. Eighty-three percent of the plans encompass hospital out- patient departments. Physician practice in ambulatory clinics outside the hospital is also included in 70 percent - 18 - of the plans. Seldom are any patient-related income generating activities by participants in a medical practice plan excluded from the plan. Several mechanisms for monitoring faculty practice activities are in effect at most medical schools, including employment agreements, required financial statements and central billing and fee collection procedures . The centralization of billing and collection services for patient fees has been located most often in the office of a full-time plan manager. Uniform procedures may also be adopted at decentralized points, e.g. departments, and only the methods of implementation vary. Initial disbursement of professional fees received is also frequently a function of the practice plan office. Indeed a definite pattern of centralized plan operation emerges based on the observation that 79 percent of the public medical school full-time plan managers and 60 percent of the full-time plan managers at private schools are responsible for a professional fee billing, collection and disbursement system. Few practice plans have effected for ambulatory patients a unified billing system which includes hospital charges. Approximately one-third of all plan billing systems provide for billing 100 percent of the fee schedule. A majority of those which do are centralized in a plan office. The average number of monthly statements sent on behalf of plan participants ranges from 4,400-40,000 at public medical schools and from 5,000-68,000 at private schools of medicine. Net collection rates for the two groups are remarkably similar, 70-97 percent by public medical school plans and 79-98 percent by private medical school plans. Analysis of plan income by source of direct payment for patient service is handicapped by the general unavailability of supporting data. Many more public medical school plans (63 percent vs. 39 percent of private medical school plans) are equipped to generate statistical indicators of patient service loads and collection experience. The Internal Revenue Service review and approval of the tax status for a medical practice plan can be either separate or included in the audit for the parent organization within which the plan operates. Forty-three percent of the plans in effect at public medical schools have received IRS approval; one in four practice plans at - 19 - private schools have been approved. Half of these reviews by the IRS have occured since 1970. A direct relationship between faculty involvement (percent of time spent in major areas of activity) and sources of faculty compensation has been identified at 40 percent of the public medical schools having a plan(s) for medical practice, Fifty-two percent of the private medical school plans evaluate this relationship, A common mechanism for relating faculty activities to sources of compensation is effort or time analysis, A less formal but frequently used alternative is the annual budget review by department chairmen and the medical school dean. Although plan participants usually receive an employment agreement upon appointment to the medical school faculty, separate components of compensation are not usually identified. A formula describing the derivation of base, supplement and incentive portions of compensation is often presented to faculty in conjunction with a letter of appointment. Sixty-three percent of the public medical school plans in operation provide an incentive component of compensation for participants , Seventy percent of the private medical school plans offer opportunity to earn incentive income. In most cases the amount of incentive income is affected by the level of medical practice activity. Salary ranges for full-time faculty positions held by plan participants are specified by 50 percent of the public institutions (either medical school or parent) and 43 percent of those privately supported. Fringe benefits which are usually available to practice plan participants include disability insurance, health insurance, life insurance, tax sheltered annuities and other plans for retirement. Clearly a majority of these benefits are provided by the institution. The benefits most frequently supplemented by practice plans are as follows: disability insurance by 30 percent of the public school plans and 22 percent of the private ones; life insurance by 28 percent of the public school plans and 17 percent of the private school plans; retirement plans by 45 percent of public school plans and 22 percent at the private school plans. Although medical practice plans are only occasionally exclusive providers of customary fringe benefits, they have become responsible for payment of malpractice liability insurance premiums at 53 percent of the public medical schools and 26 percent of the private schools of medicine included in this study. Public schools of medicine also cite departments (25% of the cases) and parent universities - 20 - (20% of the cases) as sources of premium payment. Private medical schools report that hospitals (30% of the cases) and individuals (30% of the cases) are alternative premium payment sources. Frequently coverage is purchased by more than one agent. In 40 percent of all cases the university holds a blanket policy. Individuals are the policy holders in almost 30 percent of the study schools. Practice plans and hospitals account for the remainder of the policy holders. Rapid escalation of premiums for malpractice liability coverage by commercial carriers has motivated 53 percent of the public medical schools and 65 percent of the private institutions to consider self-insurance schemes. An additional 20 percent of the public schools of medicine and 22 percent of the private schools have recently implemented some type of mechanism to insure themselves for malpractice liability. In these instances, the plan or the institution usually pays the premiiims . In general the evolution of a plan(s) for medical practice is a combination of many changes in the external and internal environment. Typology of Medical Practice Plans Some attempts have been made over the years to classify medical practice plans according to a logical typology. This has posed real problems since plans have become very complex arrangements, often uniquely patterned to fit the local needs of a particular institution. The characteristics of practice plans as set forth in the institutions' written documents cover a wide variety of policy and procedural areas — governance, restrictions (or lack thereof) as to practice setting, membership requirements, administrative and reporting procedures, fee determination, billing and collecting practices, compensation patterns, income distribution, and general expenditure-approving authorities. To classify plans consistently into a neat grouping which considers all these attributes is difficult or even impossible. A. P. Williams of the Rand Corporation attempted to classify practice plans following a review of the arrangements at a sample of ten medical centers.* He found no two plans the same, but presented three prototypic plans based on the salient features of financial incentives for the individual physician, control by the dean and department head over physician compensa- tion, and the basis for allocation of an individual's earnings to funds under the control of the department head and the dean. * A. P. Williams, "The Resource Allocation Process in Academic Health Centers", in preparation. - 21 - The three types presented by Williams were: Plan A, a departmental group with negotiated salary; Plan B, a departmental group with incentive; and Plan C, a private practice "income tax". The survey performed for the present study found plans similar in many respects to each of Plan A, Plan B and Plan C of Williams, but others were different from any one of the three. The three plans of Williams do not in fact include all existing combinations of the salient characteristics he identified. Careful study of his draft report shows that he intended the three diagrams to be illustrative examples rather than a comprehensive typology. There would be a typology only if one focused on the distinguishing features of negotiated salary , incentive , and private practice " income tax" , because only in this way would the classification be exhaustive. With data from sixty-seven centers rather than ten, it was even more difficult to find patterns, and the typology presented in this report is rather general, focusing on the organizational and certain operational characteristics of the plans rather than on control per se . With this more general approach, the attributes selected do tend to cluster together. A spectrum can be constructed which shows a centralized, more formal plan structure at one end, and a decentralized, less structured arrangement at the other. This axis is illustrated below: Centralized ^ Intermediate ^ Decentralized (formal) Plans (informal) Plans There are at least four aspects of a plan's organization and operations which can generally be identified with the three positions on this spectrum. These are considered on the accompanying illustration (See Table 1) . 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Each is described as a model which diagrams the flow of income generated through the plan, and sequentially displays expenditures by object category. Particular attention is paid to the compensation expense item and the source of the various components of this item. A brief description appears on each diagram's facing page. Generally, each block on the diagrams depicts practice plan distributions in the aggregate, namely for all faculty under the plan whether it be a schoolwide, departmental or sectional arrangement. Often, when the components of compensation are considered, however, the focus is on the individual and his/her earnings. No rigorous attempt was made to standardize nomenclature in many of the blocks. The terminology used to describe a distribution point, or fund repository, was taken directly from the respective school ' s plan description without reinterpretation . - 24 - INCOME FLOW DIAGRAMS - 25 - Practice Plan Income Flow Diagram #1 (Type A) (Private Medical School, South) This centralized practice plan covers all full-time clinical faculty physicians. Practice earnings are generated both at a new University Hospital and at several affiliated hospitals. All income derived from professional activities must go into the plan, including practice earnings, honorariums, and royalties. The physician is paid a total salary from the medical school. This salary is negotiated with the clinical department chairman and dean who decide the mix of sources (grants, institution, and professional earnings) appropriate for the individual physician. The professional earnings component for each physician is influenced by the amount of revenues he generated in the preceding year. Fifty percent of patient-related income and 15 percent of other professional earnings go to the medical school which uses it to cover the cost of practice expense, which includes nurses, auxiliary personnel, records, billing, appointments, central records, etc. Any earnings over a physician's projected contribution to his total salary are taxed, but are then distributed as an incentive. The physician gets 90 percent of the first $10,000, 70 percent of the next $10,000, and 65 percent after that. The remaining portion is divided between the dean's fund (25%) and department or section reserve funds (75%) . Expenditures from the dean's fund are made at his discretion for new or operating school programs. The department reserve fund, administered by the department chairman and two elected faculty representatives, is used to defray a variety of departmental expenses. This fund is also used to make up deficits in salaries for those physicians who do not earn their projected amount, i.e. physician base salaries. Excess accumulation above 150% of total professional and fringe benefits costs paid to clinical faculty from Practice Plan sources are shifted to "Practice Plan General Fund" and used to develop clinical departments participating in the Plan. This account is administered by the Plan's Executive Committee and Medical Center Administration. - 26 - Practice Plan Income Flow Diagram #1 (Type A) (Private Medical School, South) Gross income from patient care and other professional earnings 50% Patient income 15% Other :ik_ Net available income I Other school funds -^ COMPENSATION Base salary & fringe benefits Portion paid by Plan dollars (including benefits) Incentive component 90% of 1st $10,000 70% of 2nd $10,000 65% above $20,000 Plan practice expenses Billing & collecting Malpractice insurance Support staff Miscellaneous clinic administrative costs 3verage- -M .25%^ Dean's Fund Reserve Account Practice Plan General Fund to develop clinical depts . -75%-> Department reserve fund T -Excess accumulation Base salary support (if required) Fringe benefits, e.g. Society dues, journals, travel Program expansion House staff support Practice Plan Income Flow Diagram #2 (Type A) (Public Medical School, Midwest) The Plan at this public medical school typifies one where there is considerable central control and involvement at the school level. The Dean has strong administrative responsibility- All full-time faculty licensed to practice in the State and actually conducting patient care activities are required to participate in the Plan; non-physician faculty and part-time physician faculty may be nominated and appointed to Plan membership with the Dean's approval. Whether generated on-or-off -campus, all "professional income" of full-time faculty is considered Plan income when they are acting "in their capacity as Plan members". Where such activities result in pay for patient care or regularized administrative or consulting activities related significantly to but not directly involved in the provision of patient care, such income is included under the Plan. Annually each Plan member signs a "ceiling agreement" which includes a recommended base salary, usually derived from sources other than Plan revenue, and a clinical supplement. The latter is held within a range with a "ceiling limit" and derived from net available income. The combination of base and supplement is approved each year by the Dean and high authorities. Gross income from patient care activities is reduced first by an assessment to cover the costs of operating the Plan. Included are not only administrative expenses, e.g. billing and collecting, but also professional expenses, e.g. professional liability insurance, facilities overhead, technical staff. Such expenditures are recovered monthly. The net residual is distributed in the following proportions: 1) normally at least 80% and no more than 90% to support the clinical supplement (where the net exceeds the individual's "ceiling limit" the excess is available for "program support" and with authorization may also be used to provide clinical supplementation up to the "ceiling" for those whose activities would minimize their earning potential) ; 2) normally at least 10% and no more than 20% to "program support^'. Program support can be used broadly for educational, research and service programs of the school, and where appropriate by their departments and sections. By prior agreement this accumu- lation is sub-allocated to a fund for use by the Dean (in consultation with Provost and the Plan's advisory committee), and to the respective department. A major use of both the departments' and the Dean's funds is to support clinical supplementation where required. - 28 - Practice Plan Income Flow Diagram #2 (Type A) (Public Medical School, Midwest) Gross income from patient care activities _4l Net available income Other school funds COMPENSATION Base salary & fringe benefits Clinical supplement (to ceiling limit) e- Plan operating costs Billing and collecting General administration, e.g. legal fees Practice costs, e.g. facilities, equipment, staff salaries Professional liability insurance 90% 20- 10% (when ceiling limit reached) Program support (broad-based) Jik_ Dean' s Fund Departmental funds Program costs and support Clinical supplement Local plan costs Dept. program support Clinical supplement - 29 Practice Plan Income Flow Diagram #3 (Type B) (Private Medical School, Northeast) The Practice Plan at this small urban private medical school was implemented in June, 1976. Previously, there had been no plan; each clinical faculty member was entitled to his own practice earnings in addition to his University salary. The new Plan embraces a multidisciplinary associa- tion of single specialty groups each representative of a clinical department of the medical school. Each of the groups is free to choose the form of organization most suited to its needs. Membership includes: 1) All regular and "grandfathered" geographic full-time clinical faculty appointed at the time of the Plan's implementation; 2) strict full-time clinical faculty who elect to join; 3) part-time clinical faculty who elect to join and who do not maintain offices for practice outside the Health Sciences Center. All gross income generated by the regular GFT clinical faculty is recorded in individual practitioner accounts following a departmentalized billing and collection process. "Grandfathered" members are assessed in accordance with guidelines developed and imposed by the Plans governing body. All patient income generated by SFT Plan members is deposited into a College of Medicine Fund to be disbursed at the Dean's discretion. The first call on gross income generated by regular GFT and "grandfathered" faculty is support for Plan administra- tion. This includes hospital overhead charges, annually negotiated on the basis of space utilization; computer service bureau costs prorated to the service units on a per statement basis; professional liability insurance; and other staff and non-personnel administrative costs. The next expense of the Plan is a minimum 10% contribution by each service unit to the College of Medicine Fund, to be used at the Dean's discretion. The residual is to be divided between the respective department and the earning practitioner in accordance with a departmental plan. Departments are encouraged to base their component on the practice activity of individuals, assuring that individuals who do not wish to practice are not forced to contribute to the departmental fund. - 30 - Practice Plan Income Flow Diagram #3 (Type B) (Private Medical School, Northeast) Gross income from professional fees generated by regular GFT Plan members Income resulting from assessments of "grandfathered" Plan members* Plan adminis- ^ trative costs :ii_ Net available income (each service unit) Billing & collecting (departmental) Hospital facility overhead Professional liability insurance Support staff Supplies, etc. Patient income gen- erated by SFT faculty COMPENSATION Base salary & fringe benefits .Clinical supplement^ 10%'' College of Medicine Fund (Dean's discretion) Department Fund: Contributions based on departmentally determined guidelines * "Grandfathered" Plan members are geographic full-time clinical faculty who at the time of the Plan's implementation had "proven financial, professional, or legal obligations outside the University setting" (prior to July 1, 1975). "Grandfathering" ordinarily applies to ambulatory care only. 31 Practice Plan Income Flow Diagram #4 (Type B) (Public Medical School, Northeast) This practice plan provides a central administrative framework while preserving considerable departmental autonomy in determining the most effective distribution of its plan revenue. Practice takes place at a wide variety of affiliated hospitals and unaffiliated facilities. All full- time and part-time clinical faculty licensed to practice in the State are required to be members of the plan. A voting participant is one who spends 50% or more at the College Hos- pital or affiliates. All patient-related income is deposited into the Plan. A minimal guaranteed salary is negotiated annually between the individual , trie Department Chairman, and the Dean. This salary has two components: 1) an academic base which follows a schedule according to academic rank, and 2) a clinical salary component part or all of which may be provided from practice plan revenues according to departmental distribution formulae. Such formulae must be approved by the School's Board of Trustees. In no case, however, may the maximum allowable total compensation, excluding fringe benefits but including the clinical supplement, exceed twice the maximum academic base salary for a given rank. An assessment is applied at the outset to gross revenue to support plan overhead. Such items as cost of billing and collecting, legal fees, medical support, and facility maintenance are covered by this charge. The next lien against the Plan's revenue is a progressive tax for the Dean's Fund. This is on the basis of departmental collections (net of overhead) at the following rate: 5% of the first $150,000, 10% of the second $150,000, and 15% of the net above $300,000. Although each department has its own distribution formula, there is an overriding obligation to assist each departmental practitioner to reach his/her allowable maximum salary. Invariably there is a percentage retained for the Chairman's discretion and/or his department's use prior to reaching an "overage" point. When departmental distributions have been satisfied, a balance, or "overage" may occur. This is allocated: 60% retained by department, 30% to the Dean's Fund, 10% to a School reserve fund. A great amount of latitude exists in the expenditure of departmentally retained funds as long as University procedures and policies are followed. - 32 - Practice Plan Income Flow Diagram #4 (Type B) (Public Medical School, Northeast) Gross income from patient care activities Plan -^ overhead Net available income Other School funds Billing & collecting Legal & accounting fees Other Plan administration Medical support services Facility maintenance COMPENSATION Base salary Fringe benefits Clinical supplement Portion paid by Plan dollars e" Negotiated guaranteed annual minimum Dean's Fund accrued from departmental contributions according to following scale: 5% of 1st $150,000 10% of 2nd $150,000 15% above $300,000 •H u rH rd Q) 0) fO d CO rH O (U -H Oj iH -O X (d j:5 0) M o o S -H w -d CN "O &1 CJ (U m c p s -H h w e • >H (U o o o J ^ S Oj-rH U-l 0) > m tf u CQ dJ < (U w EH 3 •H 0) rH 0^ n) X C m H H •H m -P o (0 j:; U V x; Q) Cfl ■p & & O H (0 M mh o o No. o Medi 00 n 00 CM 00 n o n CN CN in 00 cr> 00 o U 0) >^ r^ iH 00 in in 1 1 IX) t^ 1 1 O r~ 1 in VD vo r^ (TN cn Medical Practice Plans (cont'd) Is there explicit recognition of variation in salary ranges for different medical specialties? 1) . 2) .No Yes Which fringe benefits are institutionally provided to practice plan participants? 1) 2) 3) 4) 5) 6) 7) 8) 9) Disability insurance Group health insurance Major medical insurance Life insurance General liability insurance Reti rement Tax sheltered annuity Deferred compensation plan Other: (specify) Are any institutionally provided fringe benefits supplemented by the practice plan? 1) No 2) Yes If Yes, which fringe benefits are supplemented: 1) Disability insurance 2) Group health insurance 3) Major medical insurance 4) Life insurance A23- Compensation, 1976 Medical Practice Plans (cont'd) 5) General liability insurance 6) Retirement 7) Tax sheltered annuity 8) Deferred compensation plan 9) Other: (specify) Does the Plan provide specific fringe benefits not provided by the institution? 1) 2) No Yes If Yes, which benefits are made available to participants? 1) Disability insurance Group health insurance Major medical insurance Life insurance General liability Retirement 2) 3) 4) 5) 6) 7) 8) 9) Tax sheltered annuity Deferred compensation plan Other: (specify) A24- Compensation, 1976 Medical Practice Plans (cont'd) I What is the source of malpractice insurance coverage for Plan participants? 1) University policy 2) Medical school policy 3) Hospital policy 4) Practice Plan policy 5) Departmental policy 6) Individual/Personal policy 7) Other: (specify) Who pays the premiums for malpractice insurance for Plan participants? 1) _ Uni versi ty 2) _ Medical school 3) _ Hospital 4) _ Practice Plan 5) _ Department 6) _ Individual 7) _ Other: (specify) K. Has your medical school considered or decided to self insure for malpractice liability? 1) No 2) Yes If Yes, self insurance has been 1) Under consideration 2) Implemented in (year) Income Distribution, 1976 Medical Practices Plan Respondent Tel ephone Income Distribution A. Indicate the distribution points for practice plan revenue by percentage allocation: Gross Residual 1 Residual 2 Plan operation Physician compensation Group (department) Research and development by dept, Medical school (general funds) Medical center University Academic enrichment (dean) Research and development Plan trust Other: ^ (specify) B. Do the Practice plan guidelines include a provision for adjustment in the percentage of income distributed to various points? 1) 2) _No Yes If Yes, describe the basis on which the distribution scheme could be renegotiated: - A26 Income Distribution Medical Practice Plans (con't) C. What mechanisms exist for limiting patient care activity? 1 ) None 2) Income ceilings - describe: 3) Time limitation - describe: 4) Limit on the number of private patients 5) Other: D. (specify) Does the Plan restrict the purposes for which expenditures can be made from Plan income? 1) 2) No Yes If Yes, which expenditures, exclusive of salary support, can be authorized by the Plan: 1) 2) 3) 4) 5) 6) 7) 8) 9) House Staff support Medical reference service Medical illustrations Fel 1 owships Licenses Permits (narcotics, etc.) Continuing education (includes professional society "dues, journals, travel, etc.) Faculty retreats Visiting professor and lecturer honoraria - A27 - Income Distribution Medical Practice Plans (con't) 10) 11) 12) Equipment Support personnel Other: (specify) E. Expenditures usually approved by departmental authority are as follows: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) _House Staff support _Medical reference service _Medical illustrations _Fel 1 owships _Licenses _Permits (narcotics, etc.) _Continuing education (includes professional society dues, journals, travel, etc.) Faculty retreats Visiting professor and lecturer honoraria Equipment _Support personnel Other: (specify) - A28 Objectives, 1976 Medical Practice Plans Respondent Tel ephone Objectives Which of the following objectives were finally adopted at the time of plan ratification or amendment? 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Attract and retain capable medical educators _Acl £: u3 ■a: 1^ a: llj o^ D If— -> D. o ■K C o 4J •■- ■ f- on o s- -C ■t->TT> C (0 (O o Qs: s rtj CT =c 4-> c - ■!-> O- .c (U +-> O c c o 1— 1 s: i- 0) -C ■l-> o "io -!-> in c c ^ (U o o J- rO 1— 1 to T- O- S- 1— •a: s- 3 rvi ■(-) o T3 t— * 3 >i 01 S- ■— +-> 2: +-> dl ra S- o •1 — •1 — CL ■!-> to 13 o ■!-> 31 +j U) • c JC t-H o CO > 1 1 ■o 13 Ol Ll. e: ■K .• — s 0) Wl r— ^^ O- c •1 — (O -!-> Cl- 3 io !Z o OJ •r— +J O) 3 c +J •r- •1— OO C/1 c t—t c o z s- ^ r— h- o to o •.- > ■1- .c *-> h- 4-> to u D. 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O O 4-> c o o i-i O I ■a: o l-H D_ E c >)■'- o o a-w— Q- o E=c r— dJ OJ a. ntf E 3 •PXJ : to i~< W) ■*-> 0) c rd Q. o N E= •r- •I- O -P 1 — O « •r» ^ 4JM- OJ^ o □£ >» in 4J +J 0) O p— o •a XJ (U •■- .— c r— O T3 fd -I- OJ c +-> -a O =J -r- •r- +J > +J-r- O S2£ i- 01 APPENDIX Sample Letter and Form to Medical School Dean Requesting Authorization to Use Data - 59 - association of american November 23, 1976 Dear Dean: On October 4, 19 76 a memorandum from AAMC President, John A.D. Cooper, requested your support for our current Study of Medical Practice Plans. This project signifies a long standing interest by medical school deans in practice plan organization and administration. To facilitate develop- ment of a mechanism for keeping our information current, AAMC staff has designed two documents on which they record plan descriptions. A blank copy of a draft form of the profile matrix was sent to your attention with Dr. Cooper's memorandum #76-40. Attached for your review are copies of both the revised profile matrix and the checklist on which the profile is based. Each form shows information descriptive of the practice plan at your school. A glossary has been prepared by staff to assist in interpreting the terms used to describe practice plan characteristics and is also attached. Details relating to the practice plan(s) at your insti- tution have been obtained through personal contact with medical school staff, site visit observations and perusal of written plan descriptions. The composite profile derived from these sources is displayed on the matrix to which we have previously referred. We are now seeking validation and approval of this profile matrix to satisfy two goals: 1) Our immediate and short-term goal is to include this concise description of your practice plan in the final study report to be distributed to all medical school deans as well as to the sponsor. - CI - Page Two 2) Our long-term goal is to establish a flexible system for exchanging practice plan information and encouraging open discussions of topical concerns. Your willingness to be involved in each phase of this AAMC Study considerably improves our chances for future advancement toward our long-term goal. Please indicate on the attached sheet your preference for type of participation in the AAMC Study of Medical Practice Plans. I will be available upon request to talk with you about our Study and your participation in it. Our project deadline ( December 15 ) is fast approaching, and we need your response as quickly as possible. Sincerely, William C. Hilles Associate Director Division of Operational Studies WCH Attachments - C2 - DEAN'S PREFERENCE MEDICAL PRACTICE PLAN STUDY INCLUSION 1976 Please check your preference (s) for inclusion in the current AAMC Study: !• Include the profile matrix for this institution in the final report of Phase I. 2. Do not identify by name. 3. Identification by name is permitted. 4. The profile matrix may be used by AAMC staff for analysis. 5. Do not include the profile matrix for this institution in the final report of Phase I. Dean Date Institution Telephone Please return this sheet with an APPROVED copy of the completed profile matrix for your institution to: Ms. Sharon K. Fagan Staff Associate Division of Operational Studies Suite 200, No. 1 Dupont Circle, N.W. Washington, D.C. 20036 202-466-4687 - C3 - Annotated Bibliography of Medical Practice Plans - 61 - ANNOTATED BIBLIOGRAPHY OF MEDICAL PRACTICE PLANS SPECIAL REPORT Association of American Medical Colleges One Dupont Circle, N.W Washington, D.C. 20036 U.S. Department of Health, Education, and Welfare Public Health Service Health Resources Administration Bureau of Healtti Manpower Contract No. 231-76-OOI1 JUNE 1976 CONTENTS FACULTY PRACTICE INCOME 1 ORGANIZATION AND OPERATION OF INSTITUTIONALLY-RELATED GROUP PRACTICE 2 CASE STUDIES OF INSTITUTIONALLY-RELATED GROUP PRACTICE 4 SOCIOECONOMIC AND POLITICAL ISSUES ? - 1 - Faaulty Practice Income American Group Practice Association. Income Distribution: An Abstract and Analysis . Alexandria, Virginia: American Group Practice Association, 1974. Traces the considerations in developing an income dis- tribution plan for a group practice. Includes sample excerpts from clinic policies which directly pertain to methods for determining physician income. Bromberg, J. Patient-Generated Medical School Income. (Datagrams) Journal of Medical Education , 49:201-5, 1974. Summarizes and compares the operating income sources for four-year accredited medical schools with emphasis on patient-generated revenue. Discusses the growing significance of this source of support for regular operations of medical schools. Harvey, J.D. An Institutional Approach in the Funding of Full-Time Clinical Faculty Salaries. Journal of Medical Education , 49:219-28, 1974. Describes the funding of fixed salaries of strict full- time clinical faculty at an affiliated teaching hospital of Johns Hopkins University School of Medicine. Dis- cusses the creation of an internal environment that is conducive to relating percentage of faculty effort expended with strict apportion of sources of faculty salary. Addresses the issue of third-party reimburse- ment for professional medical and surgical care by faculty in theory and in practice. Anlyan, W.G. Discussion of Faculty Practice Income. Clinical Research , 21:917-18, December 1973. Stresses the importance of balancing a delicate system for providing patient care, research and teaching. Addresses the need for responsible controls that are useful and supportive to a variety of participants in the system. - 2 - Maloney, J.V., Jr. Discussion of Faculty Practice Income. Clinical Research , 21:918-20, December 1973. Challenges the medical education establishment to identify the parameters in the system, describe their interrelationships mathematically and select objectives, Suggests that manipulation of the parameters, using eco- nomic incentive, will move the system to assure the meeting of objectives. Petersdorf, R.G. Faculty Practice Income - Implications for Faculty Morale and Performance. Clinical Research , 21:911-17, December 1973. Debates the strengths and weaknesses of two major types of compensation arrangements for clinical faculty. Pre- dicts the effect of each type on physician behavior relating to patient care activities. Hardy, C.T. Look Who's Thriving on Fee-For-Service. Medical Economics , 48:120, November 22, 1971. Analyzes the growth of schoolwide medical group practices in terms of income volume and distribution. AAMC Division of Operational Studies. Medical Service Plan Income. (Datagrams) Journal of Medical Education , 45:375, 1970. Displays aggregate volume of income derived from medical school faculty service activities. Shows the dollar pro- portion of income from that source expended for faculty salaries. Organization and Operation of Institutionally -Related Group Practice Springall, W.H. Group Practice in the University Teaching Environment. Hospital Administration , 16:44-58, Spring 1971. 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X X X X X X X X tj j: X X X X X X X X X X X X E w ■u 4J ■u 4J 4J ■4J 4-1 4-1 >1 m CD CO CO CO CD CD to n) rt CO CO n) 4-1 CO CO CO td tn (U Q) OJ Oi en cu tu CI) eu Ul 1^ JS J3 J3 X. ss b. tn o o: ^ fh n o ?, -■H 3 a) (m E u 51 o ■P M m H > 1) •H g 0. o H a w 2 ^ ! e~s &^ +j 0) 10 n) n) cd n) n) o n) n) ta r^ n) to c m 0. rH r~\ (1) m ■H C rH I—) rH rH rH rH ^ rH H rH ■M O •H •H ■H •H •H •rl •H ■H •H -H E nj 0) -H -a -H D 10 6-S fr^ O M O cfl CO n) rt n) 00 n) nJ n) rH n) (0 u t for y Sou colle E U > > > > > > > > > > z 1 ■H 0) n) n) rt CO rt m ra ^U rt CO M c a to 'D Ul (D to E 6^ fr-; 4H &4 -;r 'Si E a) to -H 4J (N rH >1 4J ■o <: Cl4 irect P Serv (Percen U i-H 0) 0) o ■■H C J= 10 \ 3 U) 0) 4-1 o 4J o 4-J o 4-1 O 4-1 o S-S 4-1 o 4J o 4J o B-S 4J o 4-1 o D H Vi O H 0) 0) x; 3 P r-l O m 2 g; z z; z 00 z z z z z Ul (U -p X CM o 4-1 c ti > fO m OJ ^ X X X CM a (1) e 0) rH ■H •H u w o •H P 1 Ul •P r-H 10 D o n3 -H O 3 >, C « X X X X X X X X rH z p< tC XI P -H b E -H M a -p u Eh 10 a a CI Ul Q o. X l«! X X X X X X X o> >, C a: o rH W XI rH • p w m CD O a ro Ul Q, C X X X X X X X X X X X Cr| rsl u >H 0) u tn p X tNl M 4H o Eh tJ> X X CO -H ■o ■p < 0) i-H m o 0< > Ul a u o i-H 10 01 X X X P O -rH a: O o 0) u X X X X VO 01 4-» E en a 01 X X X X X X X X r^ -H f-\ cn a: •a x: X X X X X X X X O CM E w i-1 4J 4-1 4-1 u 03 0] 01 10 a) 4J td 4-1 tfl 4H 01 en 0) 01 0) 0) 01 i-q x: JS 43 X3 x: (U J= XI x: s XI a) o O o 4J 4-1 4-1 4J 4J s 4J 4-1 4-1 s 4-1 & O M 3 3 d 3 T3 d 3 ^ ■B u XI rH K o O o o o •H o O o •rl o •H CO ai CJ "Z en M CO en a CO en z s z S 4J m w 1 1 o 1 1 !- 1 en 1 H 1 1 > ^ ^ 1 >* O EH en 4« ' 53 X fd rt H H &4 O •4-> 0) ^ c to o iH •H 4-1 (d x: C o CO-H en W g M B o Pm (1) -H +J rH OJ X5 Q d PM (1) nH ■O a; ^ o CO - 55 - w o hi 1) M £ h o n C(l K Ih •~i m y, () < -H i-i •n Ck (1) f; w C) o H •H H •H t) XI g 3 0. 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