Understanding the costs of ambulatory care training.

While patient care has been shifting to the ambulatory setting, the education of health care professionals has remained essentially hospital-based. One factor discouraging the movement of training into community-based ambulatory settings is the lack of understanding of what the costs of such training are and how these costs might be offset. The authors describe a model for ambulatory care training that makes it easier to generalize about to quantify its educational costs. Since ambulatory care training does not exist in a vacuum separate from inpatient education, the model is compatible with the way hospital-based education costs are derived. Thus, the model's elements can be integrated with comparable hospital-based training cost elements in a straightforward way to allow a total-costing approach. The model is built around two major sets of variables affecting cost. The first comprises three types of costs--direct, indirect, and infrastructure--and the second consists of factors related to the training site and factors related to the educational activities of the training. The model is constructed to show the various major ways these two sets of variables can influence training costs. With direct Medicare funding for some ambulatory-setting-based education pending, and with other regulatory and market dynamics already in play, it is important that educators, managers, and policymakers understand how costs, the characteristics of the training, and the characteristics of the setting interact. This model should assist them. Without generalizable cost estimates, realistic reimbursement policies and financial incentives cannot be formulated, either in the broad public policy context or in simple direct negotiations between sites and sponsors.