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Aust. J. Rural Health (2014) 22, 68–74
Original Research Financial costs for teaching in rural and urban Australian general practices: Is there a difference? Caroline O. Laurence, BA (Hons), MHSM, PhD,1,2 Maryanne Coombs, B Ed,3 Janice Bell, MBBS, BA, B Ed (Hons), FRACGP, Grad Dip Integ Med, Grad Cert CHIM, GAICD, A/FACHSM,3 and Linda Black, MAPs, DipAppPsych, BA (Pysch)1 1
Adelaide to Outback GP Training Program, North Adelaide, and 2Discipline of General Practice, University of Adelaide, Adelaide, South Australia, and 3Western Australian General Practice Education and Training, Bentley, Western Australia, Australia
Abstract Objective: To determine if the financial costs of teaching GP registrars differs between rural and urban practices. Design: Cost-benefit analysis of teaching activities in private GP for GP vocational training. Data were obtained from a survey of general practitioners in South Australia and Western Australia. Setting and participants: General practitioners and practices teaching in association with the Adelaide to Outback General Practice Training Program or the Western Australian General Practice Training. Main outcome measures: Net financial effect per week per practice. Results: At all the training levels, rural practices experienced a financial loss for teaching GP registrars, while urban practices made a small financial gain. The differences in net benefit between rural and urban teaching practices was significant at the GPT2/PRRT2 (−$515 per week 95% CI −$1578, −$266) and GPT3/PRRT3 training levels (−$396 per week, 95% CI (−$2568, −$175). The variables contributing greatest to the difference were the higher infrastructure costs for a rural practice and higher income to the practice from the GP registrars in urban practices. Conclusion: There were significant differences in the financial costs and benefits for a teaching rural practice compared with an urban teaching practice. With infrastructure costs which include accommodation, being a key contributor to the difference found, it might be time to review the level of incentives paid to practices in this area. If not addressed, this cost difference might be a disincentive for rural practices to participate in teaching. Correspondence: Dr Caroline Laurence, University of Adelaide, North Terrace, South Australia, 5005, Australia. Email: [email protected] Accepted for publication 21 November 2013. © 2014 National Rural Health Alliance Inc.
KEY WORDS: financial cost, GP vocational training, rural practice.
Introduction We know that there are differences between urban and rural GP in Australia. They differ in terms of patient utilisation,4 conditions managed,5,6 consultation length,7 prescribing rates,6,8 referral rates,9 skills required,10 characteristics,5 workload,11 use of IT12 and learning needs.13 In terms of education and training, the special training requirements for rural practice have resulted in specific pathways such as rural training within the Australian General Practice Training Program (AGPT) at the vocational training level and at the medical student level with the establishment of rural clinical schools and long-term placements in rural practice. There is some research that compare student views of rural practice,14 GP registrars’ views of rural placements15 and the impact of precepting medical students on rural supervisors’ consultations.16,17 However, to our knowledge there has been no research which compares the financial costs of teaching between urban and rural practices. The aim of this study was to determine if the financial cost associated with teaching GP registrars differs between urban and rural practices.
Methods Data on the time associated with teaching activities at the GP vocational training level were obtained from a questionnaire-based survey of South Australian and Western Australian GP supervisors who taught GP registrars within their private general practice. The survey was undertaken in 2007 in South Australia (SA) and 2010 in Western Australia (WA). Details of the survey method are provided elsewhere.2 Briefly, the Adelaide to Outback GP Training Program (AOGP)18 and Western doi: 10.1111/ajr.12085
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FINANCIAL COSTS OF TEACHING
What is already known on this subject: • GP provides a quality experiential learning environment for trainees across the training continuum, and the demand for GP clinical placements is increasing.1 • There are known benefits to practices from their participation in teaching such as the variety and enjoyment it provides to Supervisors, the recruitment potential and the quality it adds to patient care.1,2 • The financial cost of teaching varies between different levels of trainees, with a net cost to practices for teaching medical students and a small gain for teaching at prevocational and vocational training levels.3
Australian General Practitioner Education and Training (WAGPET)19 surveyed 469 general practitioners in 176 urban, outer metropolitan, rural and remote practices located in their training regions. The questionnaire had two parts: Part 1 sought information about the practice as a teaching environment, and Part 2 focused on individual teaching delivered by each GP. Part 1 was sent to the main GP supervisor in each practice and Part 2 to all GPs who taught in the practice. A response rate of 63% (297/469) was achieved from GP supervisors (Part 1 and Part 2) and 76% (134/176) from practices (Part 1). Of the 297 responding supervisors, 147 (49.5%) participated in teaching at one or more level of GP vocational training, and their results are included in this analysis. A practice was defined as rural or urban using their postcode and the Australian Standard Geographical Classification,20 Major cities (RA1) was defined as urban, and inner regional, outer regional, remote and very remote (RA2–5) as being rural. The GP supervisor refers to the general practitioner who undertakes the primary teaching role in a practice (hereafter referred to as supervisor). GP training has three levels of registrars which relate to their training term and are referred to as GP Term 1 to GP Term 3 (GPT1, GPT2 and GPT3) or Primary Rural and Remote Training if undertaking the Australian College of Rural and Remote Medicine training pathway (PRRT1 to PRRT3). The model of teaching that was evaluated, involved one-on-one teaching by a supervisor with a trainee within a practice. For example, a supervisor teaching a registrar at a GPT1 or PRRT1 level. The costing framework used in this analysis is reported in detail in a related study.3 The cost variables included were: direct teaching costs, which included preparation time for teaching and additional time teaching added to supervisor’s session (incorporating formal © 2014 National Rural Health Alliance Inc.
What this study adds: • There are significant differences in the cost of teaching for a rural practice compared to an urban practice. • The greatest difference in the net financial effect between rural and urban practices is found at the GPT2 training level.
teaching and corridor teaching); administrative costs which included staff and GP administration time; and infrastructure costs which included room rental foregone (difference in income generated by a fully qualified GP and a GP registrar) and accommodation rental. The variables that comprised the benefits were subsidies and teaching allowances paid by the Regional Training Providers (RTPs) and the income generated for the practice from the GP registrar. Details on the variables used and their sources are provided in Table 1. The mean times and costs from the SA and WA study were combined and presented at 2010 prices for the relevant variables such as Australian Medical Association fees, Medicare Benefit Schedule fees, practice manager salaries and RTP subsidies.
Statistical analysis Probabilistic sensitivity analysis (PSA) was undertaken to estimate confidence intervals around the expected costs and benefits for rural and urban practices at the three training levels (GPT1/PRRT1, GPT2/PRRT2 to GPT3/PRRT3). The PSA involved defining probability distributions to represent the uncertainty around the true value of each input parameter for which confidence intervals were estimated. Given the nature of the parameters – bounded by zero and with a positive skew – log normal distributions were used to represent the uncertainty, with the distribution parameters being informed by the survey responses. A Monte Carlo simulation was then undertaken in which 1000 iterations of the model were evaluated. Each iteration involved the random sampling of parameter values from the defined probability distributions, which informed a distribution of the financial outcomes for each model of teaching. The 2.5th and 97.5th percentile values from the PSA informed the 95% confidence limits for each training model.
Results The characteristics of the practices that were involved in GP vocational training and who responded to the surveys are shown in Table 2.
Average across AOGP and WAGPET Mean number of
Rental subsidy (rural only)
Income to practice
Income retained by practice
patients seen per week
Mean hours per year
Teacher up-skilling subsidy
% of income generated by GP registrars
Australian Medical Association Fee schedule 2010
RACGP/ACRRM guidelines – GPET funding (GP registrars) + AOGP and WAGPET
RACGP/ACRRM guidelines – GPET funding (GP registrars) + AOGP and WAGPET)
RACGP/ACRRM guidelines – GPET funding (GP registrars) + AOGP and WAGPET
Practice subsidy
Average across AOGP and WAGPET
RACGP/ACRRM guidelines – GPET funding (GP registrars)
Income lost to practice for not using room for VR GP
Room rental foregone
Teaching allowance
Commercial rental rates (average SA/WA)
Accommodation (rural only)
Australian Medical Association fee schedule 2010
Australian Medical Association fee schedule 2010
AAPM annual salary survey 2009 (general practice)
Medicare Australia (MBS Nov 2010)
Australian Medical Association fee schedule 2010
Source of Unit cost data
GP supervisor questionnaire
Hourly rated based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64
35% − GPT3/PRRT3 registrar
40% − GPT2/PRRT2 registrar
43% − GPT1/PRRT1 registrar
GP registrars – Income per patient based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64
$139 per week
$1800 per annum
$9.76 per year for GPT3/PRRT3
$168 per year for GPT2/PRRT2
$337 per week for GPT1/PRRT1
$0 per week (GPT3/PRRT3)
$150 per week (GPT2/PRRT2)
$300 per week (GPT1/PRRT1)
$1087 per week (GPT3/PRRT3) – rural
$955 per week (GPT3/PRRT3) – urban
$1011 per week (GPT2/PRRT2) – rural
$728 per week (GPT2/PRRT2) – urban
$1058 per week GPT1/PRRT1) – rural
$921 per week GPT1/PRRT1) – urban
WAGPET/AOGP Steering Committees
AOGP/WAGPET
GP supervisor questionnaire
GP supervisor questionnaire
GP supervisor questionnaire
GP supervisor questionnaire
AOGP/WAGPET Steering Committees
WAGPET/AOGP
GP supervisor questionnaire
Hourly rated based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64
$235.50 per week
GP supervisor questionnaire
GP supervisor questionnaire
Hourly rated based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64 $60,122.50 + 20% on costs
Source of volume
Cost/benefit
AAPM, Australian Association of Practice Managers; ACRRM, Australian College of Rural and Remote Medicine; AOGP, Adelaide to Outback GP training program; GPET, General Practice Education and Training Ltd; GPT, general practice term; MBS, Medical Benefits Schedule; PRRT, primary rural and remote training; RACGP, Royal Australian College of General Practitioners; SA, South Australia; VR, Vocationally Registered; WA, Western Australia; WAGPET, Western Australian General Practitioner Education and Training.
Benefits
Infrastructure
Additional time added to a session due to teaching
Preparation time
Direct teaching activities
Staff administration
GP administration
Attendance at teacher up-skilling workshops
Administrative activities
Cost
Resource item used
Teacher up-skilling
Category of resources
Details of unit costs, costs and benefits and volume source used in analysis, 2010
Cost/benefit
TABLE 1:
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TABLE 2:
Characteristics of the practices involved in GP vocational training in WA and SA (n = 134)
Practice characteristic Teaching involvement
Practice location Practice size (no. of GPs)
Other types of teaching in the practices
Levels of teaching in the practices
Mean no. of years practice involved in teaching (range) Mean no. of GPs involved in teaching in each practice (range)
Urban (RA1)§ Rural and remote (RA2–5)§ Solo 2–3 4–5 6–10 >10 Mean no. of GPs in practice (range) Medical students Junior doctor – PGY1† Junior doctor – PGY2–3‡ GP registrar Medical student only Junior doctor only Registrar only Medical student + junior doctor Medical student + registrar Junior doctor + registrar Medical student + junior doctor + registrar
Mean
SD (range)
13.49 3.67
7.680 (1–40) 2.818 (1–16)
n
%
73 61 12 21 23 46 31 6.95 111 10 7 96 41 0 20 1 58 2 12
55 46 9 16 17 35 23 4.171 (1–18) 83.5 7.5 5.2 75.0 31 0 15 0.7 43 1.5 9
†PGY1, postgraduate year 1 or intern; ‡PGY2–3, postgraduate year 2 or 3; §Australian Geographic Standard Classification. Totals not exact due to rounding.
For urban practices, there was a net financial gain from their involvement in teaching ranging from $12 per week for GPT1/PRRT1 to $30 per week for GPT3/ PRRT3 (Table 3). The greatest net benefit came from teaching GPT2 level registrars at $508 per week. In contrast, at all levels of training, rural practices experienced a net loss from teaching: a loss of $26 per week for GPT1/PRRT1; $7 per week for GPT2/PRRT2; and $366 per week for GPT3/PRRT3. Costs that contributed to the differences found were infrastructure costs which were greater in rural practices compared with urban practices. In terms of benefits, the income generated for the practice by GP registrars was less in rural practices for all levels of training. The differences in net benefits between a rural and urban teaching practice were significant at the GPT2/ PRRT2 (−$515 per week, 95% CI −$1578, −$266 and GPT3/PRRT3 training levels (−$396 per week, 95% CI (−$2568, −$175) (Table 3).
Discussion We have determined that there is a difference in the financial cost of teaching at the vocational training level © 2014 National Rural Health Alliance Inc.
for urban and rural practices. For rural practices, we found that for all levels of GP registrars, the financial benefits gained from teaching do not outweigh the costs, while for urban practices there was a financial gain from teaching GP registrars at all levels. The differences in net benefit between rural and urban practices were significant at the more senior training levels (GT2/PRRT2 and GPT3/PRRT3). The breakdown of financial costs and benefits indicate that the infrastructure costs and the income to practice contribute to differences in net benefits between rural and urban practices, although these are not large in monetary terms. The direct costs of teaching such as formal and informal teaching were similar across the two settings as were administrative costs. However, rural practices needed to provide accommodation for the GP registrars who are placed in their practice for between six and 12 months. While there are subsidies provided by RTPs, these seem inadequate to contribute to quite significant costs. In addition, the rental rates for properties in rural areas can vary significant from one rural location to another. For example, in some rural mining towns in Western Australia, weekly rental rates can be more than $2000 per week.21
$236
$2436 ($2360, $4726)
Accommodation
Total costs
$35
$300
$337
$2410 ($2339, $3341)
Teacher up skilling payment
Teaching allowance
Practice subsidy
Total benefits
$1271
$12 (−$303, $1105)
$2436 ($2360, $4726)
−$26 (−$203, $1640)
Total costs
Net benefit
−$266
−$38 (−$727, $135)
$124 (−$725, $259)
$86 (−$30, $725)
$86 (−$30, $725)
$0
$0
$0
$139
−$54
$124 (−$725, $259)
$236
$137
$372
$2
$15
$779
−$7 (−$996, $159)
$2146 ($2044, $3143)
$2139 ($2056, $2459)
$2139 ($2056, $2459)
$169
$150
$35
$139
$1646
$2146 ($2044, $3143)
$236
$1011
$1246
$49
$72
GPT, general practice term; PRRT, primary rural and remote training; SA, South Australia; WA, Western Australia.
$2313 ($2230, $5428)
$2410 ($2339, $3341)
$2325 ($2291, $5456)
$2325 ($2291, $5456)
$337
$300
$35
$0
$1653
$2313 ($2230, $5428)
$0
$921
$921
$59
$62
Total benefits
Cost benefits
$1599
$139
Income to practice
Rental subsidy (rural only)
Benefits
$1293
$1058
Room rental foregone
$61
Teaching up skilling
Infrastructure
$1005
$77
Direct teaching activities
n = 36 (95% CIs)
Rural
n = 40 (95% CIs)
n = 63 (95% CIs) (95% CIs)
Urban
Rural
Difference
GPT2/PRRT2
GPT1/PRRT1
$508 (−$2127, $640)
$1691 ($1611, $4761)
$2199 ($2125, $2880)
$2199 ($2125, $2880)
$169
$150
$35
$0
$1846
$1691 ($1611, $4761)
$0
$728
$728
$58
$66
$839
n = 59 (95% CIs)
Urban
Costs and benefits for urban and rural practices for teaching GP Registrars in WA and SA, 2010 prices
Administrative activities
Costs
TABLE 3:
−$515 (−$1578, −$266)
$455 (−$1578, $540)
−$366 (−$1152, −$173)
$2119 ($2037, $33341)
$1754 ($1705, $2493)
$1754 ($1705, $2493)
−$60 (−$160, $1252) −$60 (−$160, $1252)
$10
$0
$35
$139
$1570
$2119 ($2037, $33341)
$236
$1087
$0
$0
$0
$139
−$200
$455 (−$1578, $540)
$235
$283
$1322
$52
−$10 $518
$30
$715
n = 34 (95% CIs)
Rural
$6
−$60
(95% CIs)
Difference
GPT3/PRTT3
$30 (−$2107, $166)
$1633 ($1570, 4728)
$1663 ($1605, $2880)
$1663 ($1605, $2880)
$10
$0
$35
$0
$1619
$1633 ($1570, $4728)
$0
$955
$955
$66
$43
$569
n = 62 (95% CIs)
Urban
(−$2568, −$175)
−$396
$487 (−$2568, $580)
$91 ($7, $2055)
$91 ($7, $2055)
$0
$0
$0
$139
−$49
$487 (−$2568, $580)
$236
$132
$367
−$14
−$13
$147
(95% CIs)
Difference
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The income contributed to the practice from rural registrars was lower than their urban counterparts and reflected a lower number of patients seen by this group. However, what is not captured in this variable was the income generated from hospital and after hours work, which forms a significant component of rural GP.10,11 A study on the viability of rural practice indicated that on average, 10% of a rural general practitioner’s income was generated from hospital activity,22 and so the income to practice in this study could be underestimated by 10%. The cost-benefit ratio was recalculated after applying an additional 10% income to the rural practices, and a net loss for rural practices was still found at the GPT2/PRRT2 and GPT3/PRRT3 level, although at the GPT1/PRRT1 rural practices now had a net benefit. What is not known is if additional teaching activities are also associated with the hospital work which would counteract this rise in benefits. In designing the questionnaire, it was attempted to capture rural Supervisor time spent on on-call supervision of a Registrar, a feature of rural practice, but there was an enormous variation in time reported by supervisors ranging from 0 to 40 hours. While this might be valid, it was also difficult to attribute a financial cost to this rural activity. The absence of this aspect of rural teaching might contribute to even higher teaching costs. On the other hand, this might not be such a key differentiation between rural and urban practices as urban GPs also have access to other sources of income outside their practices such as nursing home visits. Determining approaches to best capture these aspects of income to the practice requires further investigation. Over the last two decades there have been considerable incentives provided to general practitioners to move and work in rural and remote areas of Australia. At the vocational training level, we have seen the creation of the rural pathway, with incentive payments (GP Rural Incentives Program23) to those registrars enrolled in this pathway if they spend 18 months of their three years in a rural or remote location. At the medical school level, we have seen new schools established in regional areas and cohorts of students spending significant periods of their training in a rural location. However, these incentives and strategies are either focused on the Universities or the GP registrar. For teaching practices little differentiation is made between the subsidies for teaching in an urban or rural setting at a cost to rural practices. The results could jeopardise rural practice participation in GP training if the costs of teaching become too much. Moreover, recruiting new teaching practices in a rural area might be difficult if the financial burden is too great to offset the intangible benefits for teaching.2 A key limitation for this study is that for the rural practices, it only captures GP registrar activities that © 2014 National Rural Health Alliance Inc.
occur in the practice and does not include hospital work or nursing home visits that forms a component of their workload as well as another source of income to the practice. A second limitation might be the generalisability of the results. However, while data were collected from two of the 17 RTPs in Australia, they are representative of the RTPs who manage both rural and urban teaching practices, with WAGPET being the second largest RTP in terms of training places and the only provider in their state. AOGP had a similar proportion of training places to the other seven RTPs in this category. Moreover, RTPs have similar requirements for teaching, as set out in the standards for GP training, minimum standards of terms of conditions for registrars employed in teaching practices that sets out the conditions for pay, patient load and supervision levels and set levels of subsidies from GPET. Therefore, the results are likely to be generalisable to other RTPs, allowing for some contextual differences as found in this study in regards to rental costs.
Conclusion The results show that the many differences between rural and urban GP also extend to the financial costs and benefits associated with teaching GP registrars. This cost difference might be a disincentive for rural practices to participate in teaching. With infrastructure costs, which include accommodation, being a key contributor to the difference found, it might be time to review the level of incentives paid to practices.
Acknowledgements We thank the practices and supervisors who participated in this survey and the two Steering Groups who oversaw the studies in WA and SA.
References 1 Pearce R, Laurence C, Black L, Stocks N. The challenges of teaching in a general practice setting. The Medical Journal of Australia 2007; 187: 129–132. 2 Laurence C, Black L. Teaching capacity in general practice: results from a survey of practices and supervisors in South Australia. The Medical Journal of Australia 2009; 191: 102–104. 3 Laurence C, Black L, Karnon J, Briggs N. To teach or not to teach? A cost benefit analysis of teaching in private general practice. The Medical Journal of Australia 2010; 193: 608–613. 4 Harrison C, Britt H. General practice – workforce gaps now and in 2020. Australian Family Physician 2011; 40: 12–15. 5 Britt H, Miles D, Bridges-Webb C, Neary S, Charles J, Traynor V. A comparison of country and metropolitan
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general practice. The Medical Journal of Australia 1993; 159: S9–S64. Caldwell T, Jorm A, Knox S, Braddock D, Dear K, Britt H. General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia. The Australian and New Zealand Journal of Psychiatry 2004; 38: 774–780. Britt H, Valenti L, Miller G. Determinants of consultation length in Australian general practice. The Medical Journal of Australia 2005; 183: 68–71. Stocks N, Ryan P, Allan J, Williams S, Willson K. Gender, socioeconomic status, need or access? Differences in statin prescribing across urban, rural and remote Australia. The Australian Journal of Rural Health 2009; 17: 92–96. Gruen R, Know S, Britt H. Where there is no surgeon: the effect of specialist proximity on general practitioners’ referral rates. The Medical Journal of Australia 2002; 177: 111–115. Britt H, Miller G, Valenti L. ‘It’s Different in the Bush’: A Comparison of General Practice Activity in Metropolitan and Rural Areas of Australia 1998–2000. Canberra: Australian Institute of Health and Welfare, 2001. McGrail M, Humphreys J, Joyce C, Scott A, Kalb G. How do rural GPs’ workloads and work activities differ with community size compared with metropolitan practice? Australian Journal of Primary Health 2012; 18: 228– 233. Macgregor R, Hyland P, Harvie C. Do organisational characteristics explain the differences between drivers of ICT adoption in rural and urban general practices in Australia. Australasian Journal of Information Systems 2009; 16: 77–97. Allan J, Schaefer D. Do the learning needs of rural and urban general practitioners differ? The Australian Journal of Rural Health 2005; 13: 337–342. Eley D, Young L, Shrapnel M, Wilkinson D, Baker P, Hegney D. Medical students and rural general
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practitioners: congruent views on the reality of recruitment into rural medicine. The Australian Journal of Rural Health 2007; 15: 12–20. Elliott T, Bromley T, Chur-Hansen A, Laurence C. Expectations and experiences associated with rural GP placements. Rural and Remote Health 2009; 9: 1264 (online). Walters L, Worley P, Prideaux D, Lange K. Do consultations in rural general practice take more time when practitioners are precepting medical students? Medical Education 2008; 42: 69–73. Walters L, Worley P, Prideaux D, Rolfe H, Keaney C. The impact of medical students on rural general practitioner perceptors. Rural and Remote Health 2005; 5: 403 (online). Adelaide to Outback GP Training Program. Adelaide to Outback GP training program. Adelaide, 2013. [Cited 3 Sep 2013]. Available from URL: http://www .adelaidetooutback.com.au/ Western Australian General Practice Education and Training. WAGPET Perth, 2012. [Cited 3 Sep 2013]. Available from URL: http://wagpet.com.au/ Australian Bureau of Statistics. ASGC Remoteness Classification: Purpose and Use. Census Paper 03/01. Canberra: ABS, 2003. Property Observer. Pilbara mining rents: the seven most expensive WA boom towns. 2011. [Cited 3 Sep 2013]. Available from URL: http://www.propertyobserver.com .au/residential/pilbara-mining-rents-the-seven-most -expensive-wa-boom-towns/2011113052624 Rural Doctors Association of Australia. Viable Models of Rural and Remote Practice. Stage 1 and Stage 2 Report. Canberra: Rural Doctors Association of Australia, 2003. Department of Health and Ageing. General Practice Rural Incentives Program (GPRIP). [Cited 22 Feb 2013]. Available from URL: http://www.ruralhealthaustralia.gov .au/internet/rha/publishing.nsf/Content/General_Practice _Rural_Incentives_Program
© 2014 National Rural Health Alliance Inc.
Aust. J. Rural Health (2014) 22, 68–74
Original Research Financial costs for teaching in rural and urban Australian general practices: Is there a difference? Caroline O. Laurence, BA (Hons), MHSM, PhD,1,2 Maryanne Coombs, B Ed,3 Janice Bell, MBBS, BA, B Ed (Hons), FRACGP, Grad Dip Integ Med, Grad Cert CHIM, GAICD, A/FACHSM,3 and Linda Black, MAPs, DipAppPsych, BA (Pysch)1 1
Adelaide to Outback GP Training Program, North Adelaide, and 2Discipline of General Practice, University of Adelaide, Adelaide, South Australia, and 3Western Australian General Practice Education and Training, Bentley, Western Australia, Australia
Abstract Objective: To determine if the financial costs of teaching GP registrars differs between rural and urban practices. Design: Cost-benefit analysis of teaching activities in private GP for GP vocational training. Data were obtained from a survey of general practitioners in South Australia and Western Australia. Setting and participants: General practitioners and practices teaching in association with the Adelaide to Outback General Practice Training Program or the Western Australian General Practice Training. Main outcome measures: Net financial effect per week per practice. Results: At all the training levels, rural practices experienced a financial loss for teaching GP registrars, while urban practices made a small financial gain. The differences in net benefit between rural and urban teaching practices was significant at the GPT2/PRRT2 (−$515 per week 95% CI −$1578, −$266) and GPT3/PRRT3 training levels (−$396 per week, 95% CI (−$2568, −$175). The variables contributing greatest to the difference were the higher infrastructure costs for a rural practice and higher income to the practice from the GP registrars in urban practices. Conclusion: There were significant differences in the financial costs and benefits for a teaching rural practice compared with an urban teaching practice. With infrastructure costs which include accommodation, being a key contributor to the difference found, it might be time to review the level of incentives paid to practices in this area. If not addressed, this cost difference might be a disincentive for rural practices to participate in teaching. Correspondence: Dr Caroline Laurence, University of Adelaide, North Terrace, South Australia, 5005, Australia. Email: [email protected] Accepted for publication 21 November 2013. © 2014 National Rural Health Alliance Inc.
KEY WORDS: financial cost, GP vocational training, rural practice.
Introduction We know that there are differences between urban and rural GP in Australia. They differ in terms of patient utilisation,4 conditions managed,5,6 consultation length,7 prescribing rates,6,8 referral rates,9 skills required,10 characteristics,5 workload,11 use of IT12 and learning needs.13 In terms of education and training, the special training requirements for rural practice have resulted in specific pathways such as rural training within the Australian General Practice Training Program (AGPT) at the vocational training level and at the medical student level with the establishment of rural clinical schools and long-term placements in rural practice. There is some research that compare student views of rural practice,14 GP registrars’ views of rural placements15 and the impact of precepting medical students on rural supervisors’ consultations.16,17 However, to our knowledge there has been no research which compares the financial costs of teaching between urban and rural practices. The aim of this study was to determine if the financial cost associated with teaching GP registrars differs between urban and rural practices.
Methods Data on the time associated with teaching activities at the GP vocational training level were obtained from a questionnaire-based survey of South Australian and Western Australian GP supervisors who taught GP registrars within their private general practice. The survey was undertaken in 2007 in South Australia (SA) and 2010 in Western Australia (WA). Details of the survey method are provided elsewhere.2 Briefly, the Adelaide to Outback GP Training Program (AOGP)18 and Western doi: 10.1111/ajr.12085
69
FINANCIAL COSTS OF TEACHING
What is already known on this subject: • GP provides a quality experiential learning environment for trainees across the training continuum, and the demand for GP clinical placements is increasing.1 • There are known benefits to practices from their participation in teaching such as the variety and enjoyment it provides to Supervisors, the recruitment potential and the quality it adds to patient care.1,2 • The financial cost of teaching varies between different levels of trainees, with a net cost to practices for teaching medical students and a small gain for teaching at prevocational and vocational training levels.3
Australian General Practitioner Education and Training (WAGPET)19 surveyed 469 general practitioners in 176 urban, outer metropolitan, rural and remote practices located in their training regions. The questionnaire had two parts: Part 1 sought information about the practice as a teaching environment, and Part 2 focused on individual teaching delivered by each GP. Part 1 was sent to the main GP supervisor in each practice and Part 2 to all GPs who taught in the practice. A response rate of 63% (297/469) was achieved from GP supervisors (Part 1 and Part 2) and 76% (134/176) from practices (Part 1). Of the 297 responding supervisors, 147 (49.5%) participated in teaching at one or more level of GP vocational training, and their results are included in this analysis. A practice was defined as rural or urban using their postcode and the Australian Standard Geographical Classification,20 Major cities (RA1) was defined as urban, and inner regional, outer regional, remote and very remote (RA2–5) as being rural. The GP supervisor refers to the general practitioner who undertakes the primary teaching role in a practice (hereafter referred to as supervisor). GP training has three levels of registrars which relate to their training term and are referred to as GP Term 1 to GP Term 3 (GPT1, GPT2 and GPT3) or Primary Rural and Remote Training if undertaking the Australian College of Rural and Remote Medicine training pathway (PRRT1 to PRRT3). The model of teaching that was evaluated, involved one-on-one teaching by a supervisor with a trainee within a practice. For example, a supervisor teaching a registrar at a GPT1 or PRRT1 level. The costing framework used in this analysis is reported in detail in a related study.3 The cost variables included were: direct teaching costs, which included preparation time for teaching and additional time teaching added to supervisor’s session (incorporating formal © 2014 National Rural Health Alliance Inc.
What this study adds: • There are significant differences in the cost of teaching for a rural practice compared to an urban practice. • The greatest difference in the net financial effect between rural and urban practices is found at the GPT2 training level.
teaching and corridor teaching); administrative costs which included staff and GP administration time; and infrastructure costs which included room rental foregone (difference in income generated by a fully qualified GP and a GP registrar) and accommodation rental. The variables that comprised the benefits were subsidies and teaching allowances paid by the Regional Training Providers (RTPs) and the income generated for the practice from the GP registrar. Details on the variables used and their sources are provided in Table 1. The mean times and costs from the SA and WA study were combined and presented at 2010 prices for the relevant variables such as Australian Medical Association fees, Medicare Benefit Schedule fees, practice manager salaries and RTP subsidies.
Statistical analysis Probabilistic sensitivity analysis (PSA) was undertaken to estimate confidence intervals around the expected costs and benefits for rural and urban practices at the three training levels (GPT1/PRRT1, GPT2/PRRT2 to GPT3/PRRT3). The PSA involved defining probability distributions to represent the uncertainty around the true value of each input parameter for which confidence intervals were estimated. Given the nature of the parameters – bounded by zero and with a positive skew – log normal distributions were used to represent the uncertainty, with the distribution parameters being informed by the survey responses. A Monte Carlo simulation was then undertaken in which 1000 iterations of the model were evaluated. Each iteration involved the random sampling of parameter values from the defined probability distributions, which informed a distribution of the financial outcomes for each model of teaching. The 2.5th and 97.5th percentile values from the PSA informed the 95% confidence limits for each training model.
Results The characteristics of the practices that were involved in GP vocational training and who responded to the surveys are shown in Table 2.
Average across AOGP and WAGPET Mean number of
Rental subsidy (rural only)
Income to practice
Income retained by practice
patients seen per week
Mean hours per year
Teacher up-skilling subsidy
% of income generated by GP registrars
Australian Medical Association Fee schedule 2010
RACGP/ACRRM guidelines – GPET funding (GP registrars) + AOGP and WAGPET
RACGP/ACRRM guidelines – GPET funding (GP registrars) + AOGP and WAGPET)
RACGP/ACRRM guidelines – GPET funding (GP registrars) + AOGP and WAGPET
Practice subsidy
Average across AOGP and WAGPET
RACGP/ACRRM guidelines – GPET funding (GP registrars)
Income lost to practice for not using room for VR GP
Room rental foregone
Teaching allowance
Commercial rental rates (average SA/WA)
Accommodation (rural only)
Australian Medical Association fee schedule 2010
Australian Medical Association fee schedule 2010
AAPM annual salary survey 2009 (general practice)
Medicare Australia (MBS Nov 2010)
Australian Medical Association fee schedule 2010
Source of Unit cost data
GP supervisor questionnaire
Hourly rated based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64
35% − GPT3/PRRT3 registrar
40% − GPT2/PRRT2 registrar
43% − GPT1/PRRT1 registrar
GP registrars – Income per patient based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64
$139 per week
$1800 per annum
$9.76 per year for GPT3/PRRT3
$168 per year for GPT2/PRRT2
$337 per week for GPT1/PRRT1
$0 per week (GPT3/PRRT3)
$150 per week (GPT2/PRRT2)
$300 per week (GPT1/PRRT1)
$1087 per week (GPT3/PRRT3) – rural
$955 per week (GPT3/PRRT3) – urban
$1011 per week (GPT2/PRRT2) – rural
$728 per week (GPT2/PRRT2) – urban
$1058 per week GPT1/PRRT1) – rural
$921 per week GPT1/PRRT1) – urban
WAGPET/AOGP Steering Committees
AOGP/WAGPET
GP supervisor questionnaire
GP supervisor questionnaire
GP supervisor questionnaire
GP supervisor questionnaire
AOGP/WAGPET Steering Committees
WAGPET/AOGP
GP supervisor questionnaire
Hourly rated based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64
$235.50 per week
GP supervisor questionnaire
GP supervisor questionnaire
Hourly rated based on 4 Level B items − 2 × MBS fee $34.40 + 100% bulk billing item ($6.65 urban location or $10.05 rural location) + 2 × AMA fee $64 $60,122.50 + 20% on costs
Source of volume
Cost/benefit
AAPM, Australian Association of Practice Managers; ACRRM, Australian College of Rural and Remote Medicine; AOGP, Adelaide to Outback GP training program; GPET, General Practice Education and Training Ltd; GPT, general practice term; MBS, Medical Benefits Schedule; PRRT, primary rural and remote training; RACGP, Royal Australian College of General Practitioners; SA, South Australia; VR, Vocationally Registered; WA, Western Australia; WAGPET, Western Australian General Practitioner Education and Training.
Benefits
Infrastructure
Additional time added to a session due to teaching
Preparation time
Direct teaching activities
Staff administration
GP administration
Attendance at teacher up-skilling workshops
Administrative activities
Cost
Resource item used
Teacher up-skilling
Category of resources
Details of unit costs, costs and benefits and volume source used in analysis, 2010
Cost/benefit
TABLE 1:
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TABLE 2:
Characteristics of the practices involved in GP vocational training in WA and SA (n = 134)
Practice characteristic Teaching involvement
Practice location Practice size (no. of GPs)
Other types of teaching in the practices
Levels of teaching in the practices
Mean no. of years practice involved in teaching (range) Mean no. of GPs involved in teaching in each practice (range)
Urban (RA1)§ Rural and remote (RA2–5)§ Solo 2–3 4–5 6–10 >10 Mean no. of GPs in practice (range) Medical students Junior doctor – PGY1† Junior doctor – PGY2–3‡ GP registrar Medical student only Junior doctor only Registrar only Medical student + junior doctor Medical student + registrar Junior doctor + registrar Medical student + junior doctor + registrar
Mean
SD (range)
13.49 3.67
7.680 (1–40) 2.818 (1–16)
n
%
73 61 12 21 23 46 31 6.95 111 10 7 96 41 0 20 1 58 2 12
55 46 9 16 17 35 23 4.171 (1–18) 83.5 7.5 5.2 75.0 31 0 15 0.7 43 1.5 9
†PGY1, postgraduate year 1 or intern; ‡PGY2–3, postgraduate year 2 or 3; §Australian Geographic Standard Classification. Totals not exact due to rounding.
For urban practices, there was a net financial gain from their involvement in teaching ranging from $12 per week for GPT1/PRRT1 to $30 per week for GPT3/ PRRT3 (Table 3). The greatest net benefit came from teaching GPT2 level registrars at $508 per week. In contrast, at all levels of training, rural practices experienced a net loss from teaching: a loss of $26 per week for GPT1/PRRT1; $7 per week for GPT2/PRRT2; and $366 per week for GPT3/PRRT3. Costs that contributed to the differences found were infrastructure costs which were greater in rural practices compared with urban practices. In terms of benefits, the income generated for the practice by GP registrars was less in rural practices for all levels of training. The differences in net benefits between a rural and urban teaching practice were significant at the GPT2/ PRRT2 (−$515 per week, 95% CI −$1578, −$266 and GPT3/PRRT3 training levels (−$396 per week, 95% CI (−$2568, −$175) (Table 3).
Discussion We have determined that there is a difference in the financial cost of teaching at the vocational training level © 2014 National Rural Health Alliance Inc.
for urban and rural practices. For rural practices, we found that for all levels of GP registrars, the financial benefits gained from teaching do not outweigh the costs, while for urban practices there was a financial gain from teaching GP registrars at all levels. The differences in net benefit between rural and urban practices were significant at the more senior training levels (GT2/PRRT2 and GPT3/PRRT3). The breakdown of financial costs and benefits indicate that the infrastructure costs and the income to practice contribute to differences in net benefits between rural and urban practices, although these are not large in monetary terms. The direct costs of teaching such as formal and informal teaching were similar across the two settings as were administrative costs. However, rural practices needed to provide accommodation for the GP registrars who are placed in their practice for between six and 12 months. While there are subsidies provided by RTPs, these seem inadequate to contribute to quite significant costs. In addition, the rental rates for properties in rural areas can vary significant from one rural location to another. For example, in some rural mining towns in Western Australia, weekly rental rates can be more than $2000 per week.21
$236
$2436 ($2360, $4726)
Accommodation
Total costs
$35
$300
$337
$2410 ($2339, $3341)
Teacher up skilling payment
Teaching allowance
Practice subsidy
Total benefits
$1271
$12 (−$303, $1105)
$2436 ($2360, $4726)
−$26 (−$203, $1640)
Total costs
Net benefit
−$266
−$38 (−$727, $135)
$124 (−$725, $259)
$86 (−$30, $725)
$86 (−$30, $725)
$0
$0
$0
$139
−$54
$124 (−$725, $259)
$236
$137
$372
$2
$15
$779
−$7 (−$996, $159)
$2146 ($2044, $3143)
$2139 ($2056, $2459)
$2139 ($2056, $2459)
$169
$150
$35
$139
$1646
$2146 ($2044, $3143)
$236
$1011
$1246
$49
$72
GPT, general practice term; PRRT, primary rural and remote training; SA, South Australia; WA, Western Australia.
$2313 ($2230, $5428)
$2410 ($2339, $3341)
$2325 ($2291, $5456)
$2325 ($2291, $5456)
$337
$300
$35
$0
$1653
$2313 ($2230, $5428)
$0
$921
$921
$59
$62
Total benefits
Cost benefits
$1599
$139
Income to practice
Rental subsidy (rural only)
Benefits
$1293
$1058
Room rental foregone
$61
Teaching up skilling
Infrastructure
$1005
$77
Direct teaching activities
n = 36 (95% CIs)
Rural
n = 40 (95% CIs)
n = 63 (95% CIs) (95% CIs)
Urban
Rural
Difference
GPT2/PRRT2
GPT1/PRRT1
$508 (−$2127, $640)
$1691 ($1611, $4761)
$2199 ($2125, $2880)
$2199 ($2125, $2880)
$169
$150
$35
$0
$1846
$1691 ($1611, $4761)
$0
$728
$728
$58
$66
$839
n = 59 (95% CIs)
Urban
Costs and benefits for urban and rural practices for teaching GP Registrars in WA and SA, 2010 prices
Administrative activities
Costs
TABLE 3:
−$515 (−$1578, −$266)
$455 (−$1578, $540)
−$366 (−$1152, −$173)
$2119 ($2037, $33341)
$1754 ($1705, $2493)
$1754 ($1705, $2493)
−$60 (−$160, $1252) −$60 (−$160, $1252)
$10
$0
$35
$139
$1570
$2119 ($2037, $33341)
$236
$1087
$0
$0
$0
$139
−$200
$455 (−$1578, $540)
$235
$283
$1322
$52
−$10 $518
$30
$715
n = 34 (95% CIs)
Rural
$6
−$60
(95% CIs)
Difference
GPT3/PRTT3
$30 (−$2107, $166)
$1633 ($1570, 4728)
$1663 ($1605, $2880)
$1663 ($1605, $2880)
$10
$0
$35
$0
$1619
$1633 ($1570, $4728)
$0
$955
$955
$66
$43
$569
n = 62 (95% CIs)
Urban
(−$2568, −$175)
−$396
$487 (−$2568, $580)
$91 ($7, $2055)
$91 ($7, $2055)
$0
$0
$0
$139
−$49
$487 (−$2568, $580)
$236
$132
$367
−$14
−$13
$147
(95% CIs)
Difference
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The income contributed to the practice from rural registrars was lower than their urban counterparts and reflected a lower number of patients seen by this group. However, what is not captured in this variable was the income generated from hospital and after hours work, which forms a significant component of rural GP.10,11 A study on the viability of rural practice indicated that on average, 10% of a rural general practitioner’s income was generated from hospital activity,22 and so the income to practice in this study could be underestimated by 10%. The cost-benefit ratio was recalculated after applying an additional 10% income to the rural practices, and a net loss for rural practices was still found at the GPT2/PRRT2 and GPT3/PRRT3 level, although at the GPT1/PRRT1 rural practices now had a net benefit. What is not known is if additional teaching activities are also associated with the hospital work which would counteract this rise in benefits. In designing the questionnaire, it was attempted to capture rural Supervisor time spent on on-call supervision of a Registrar, a feature of rural practice, but there was an enormous variation in time reported by supervisors ranging from 0 to 40 hours. While this might be valid, it was also difficult to attribute a financial cost to this rural activity. The absence of this aspect of rural teaching might contribute to even higher teaching costs. On the other hand, this might not be such a key differentiation between rural and urban practices as urban GPs also have access to other sources of income outside their practices such as nursing home visits. Determining approaches to best capture these aspects of income to the practice requires further investigation. Over the last two decades there have been considerable incentives provided to general practitioners to move and work in rural and remote areas of Australia. At the vocational training level, we have seen the creation of the rural pathway, with incentive payments (GP Rural Incentives Program23) to those registrars enrolled in this pathway if they spend 18 months of their three years in a rural or remote location. At the medical school level, we have seen new schools established in regional areas and cohorts of students spending significant periods of their training in a rural location. However, these incentives and strategies are either focused on the Universities or the GP registrar. For teaching practices little differentiation is made between the subsidies for teaching in an urban or rural setting at a cost to rural practices. The results could jeopardise rural practice participation in GP training if the costs of teaching become too much. Moreover, recruiting new teaching practices in a rural area might be difficult if the financial burden is too great to offset the intangible benefits for teaching.2 A key limitation for this study is that for the rural practices, it only captures GP registrar activities that © 2014 National Rural Health Alliance Inc.
occur in the practice and does not include hospital work or nursing home visits that forms a component of their workload as well as another source of income to the practice. A second limitation might be the generalisability of the results. However, while data were collected from two of the 17 RTPs in Australia, they are representative of the RTPs who manage both rural and urban teaching practices, with WAGPET being the second largest RTP in terms of training places and the only provider in their state. AOGP had a similar proportion of training places to the other seven RTPs in this category. Moreover, RTPs have similar requirements for teaching, as set out in the standards for GP training, minimum standards of terms of conditions for registrars employed in teaching practices that sets out the conditions for pay, patient load and supervision levels and set levels of subsidies from GPET. Therefore, the results are likely to be generalisable to other RTPs, allowing for some contextual differences as found in this study in regards to rental costs.
Conclusion The results show that the many differences between rural and urban GP also extend to the financial costs and benefits associated with teaching GP registrars. This cost difference might be a disincentive for rural practices to participate in teaching. With infrastructure costs, which include accommodation, being a key contributor to the difference found, it might be time to review the level of incentives paid to practices.
Acknowledgements We thank the practices and supervisors who participated in this survey and the two Steering Groups who oversaw the studies in WA and SA.
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