Self-Funding a Postprofessional Athletic Training Residency

Athletic Training Residencies

A PP-ATR's curriculum is a planned program of clinical and didactic education in a focused area of athletic training education using an evidence-based approach to provide advanced preparation for an athletic trainer.⁴ The curriculum is structured around 6 core competencies ensured to provide clinic and didactic experiences in each. The educational programing and timing of the clinical rotations are intended to optimize the resident's experience and accomplish the residency's goals and objectives.

The CAATE requires that a PP-ATR is a minimum of 12 consecutive months of continuous fulltime practice commitment and should be a specific area of focus of athletic training education.⁴ The core competencies are similar to those specified by the Institute of Medicine, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties.⁴ The 6 core competencies that the CAATE has identified that a PP-ATR must be designed to address are (1) patient-centered care, (2) interdisciplinary collaboration, (3) evidence-based practice, (4) quality improvement, (5) use of health care informatics, and (6) professionalism.⁴

The CAATE accreditation process is a 3-step progression that consists of a year-long self-study, submitting a self-study report, and a peer review process which includes an onsite visit. As a requirement of this accreditation, residents complete preresidency, midresidency, and postresidency formal evaluations specific to the PP-ATR core competencies as well as quarterly self-assessments. The preceptors also provide assessments of the residents and their abilities to meet the core competency objectives. These are intended to evaluate and provide constructive feedback to the residents, residency director, preceptors, and the program.

Current accredited PP-ATRs are found in adult and rehabilitation, clinical examination and diagnosis, and general medicine.⁵ The current accredited programs that focus on clinical examination and diagnosis (CE) are found within the physician practice setting.⁵ The athletic training education domain of CE states athletic trainers must possess strong clinical examination skills to accurately diagnose and effectively treat their patients.^4,6–8 Athletic trainers must also apply clinical reasoning skills throughout the physical examination process in order to select the appropriate assessment tests and formulate a differential diagnosis.^4,6–8 Thus, athletic trainers' knowledge and skills in musculoskeletal medicine make them unique professionals to assist in the physician practice. Using an athletic trainer's skillset, physicians are able to increase patient throughput by providing quality services to more patients in the same period of time, resulting in an increase in clinic revenue.^1,3,9–14 The use of athletic trainers in the orthopaedic clinic setting has grown exponentially over the last decade.^1–3,9–16 Educational programming offered in PP-ATR build upon the athletic trainers' foundational knowledge in CE, preparing them be effective clinicians when entering the workforce.

Funding

Funding a PP-ATR can be expensive, and with recent changes in health care, it is becoming increasingly difficult for health care entities to take on additional costs. The financial burden is becoming a larger hurdle for those intending to start medical residencies.¹⁷ OMeGA Medical Grants Association, a third-party administrator of fellowship grants, reports that nearly 50% of orthopaedic fellowships are funded by medical device technology companies; similarly, some PP-ATRs have received outside sponsorship from companies involved in health care to offset some of the cost of providing additional education experiences.¹⁷ With the creation of more residencies, these sponsorships have become increasing difficult to obtain and sustain. Relying solely on these sponsorship dollars can lead to financial difficulties and, in some cases, abandonment of the PP-ATR if funding ceases to be available.

Medicare reimburses teaching hospitals for a portion of the costs incurred during the education process.¹⁷ The amount that is reimbursed is based on the institution's Medicare patient load.¹⁷ This allows orthopaedic fellows and residents to practice the advanced skills being learned while being able to offset the cost of their education.¹⁷ Also, medical residents and fellows are covering their costs through patient care of emergency room patients during on-call periods. Similarly, a portion of physical therapy residents' time is spent seeing and billing for patient care that is not included in their educational programming. Though athletic trainers cannot be reimbursed through Medicare, it has been shown that athletic trainers can help generate revenue in the physician practice setting.¹² Postprofessional athletic training residency educational programing is intended to have athletic training residents gain on-the-job training providing patient care to advance their knowledge and skills. Though athletic training residents are not intended to provide additional workforce, it is envisioned that they will have the knowledge and skills to be fully integrated into their professional setting in the final months of their training. This integration into a clinic may allow for an athletic training resident to indirectly generate revenue.

As an example of how this would work for a PP-ATR focused in clinical evaluation and diagnosis, the first trimester of a PP-ATR is intended to develop a foundation of knowledge, skills, and abilities. This foundation is designed to address the core competencies of patient-centered care, use of health care informatics, and interdisciplinary collaboration. Though all the competencies are addressed throughout the entire residency, certain stages allow for further development of specific competencies. The second trimester is focused on fine tuning and implementing those skills learned in the first trimester. This time is intended to enhance the competencies of evidence-based practice and quality improvement. During the final trimester, the athletic training resident is fully integrated into the clinic staff of their physician preceptor rotations and is further developing the competency of professionalism. With the full integration of the athletic training resident, it allows for the clinic staff to operate more efficiently with an additional trained practitioner. By having an additional member on the existing staff, an increase in patient throughput is expected which would result in increased patient access. It has been shown that adding athletic trainers in the physician practice setting of an orthopaedic practice can result in a 15%–30% increase in patient throughput.^{3,11–13,18–20} This accounts for an increase, in some cases, of 6–8 patients per day.¹⁸ Hajart et al¹² demonstrated that this increased efficiency created by the addition of athletic trainers to a clinical practice setting can equate to about $123 000 in generated clinic revenue based on Medicare collection rates for evaluation and management codes. Hajart et al¹² also outlines how increased patient visits can create further downstream revenue. Downstream revenue is considered revenue from any additional ancillary services throughout the patient encounter. This can include but is not limited to additional radiographic imaging studies, surgery, durable medical equipment, and physical therapy. These increases in efficiency support the fact that having an athletic training resident can result in a financial benefit to the clinical practice by providing financial support for the positions. As athletic training residents progress in their knowledge of CE and have a greater comprehension of the domains, in the final trimester of their program, they are able to function as an additional advanced clinical practitioner in the physician practice. There is no evidence to state the athletic training resident is incapable during the first 4 months and only in the last. However, our experience shows that, during the first 4 months of training, athletic training residents may not have the same effect on a clinic as during the final 4 months. The increased efficiency during the final 4 months would be enough to offset the cost of the athletic training resident. The total revenue generated from additional patient visits during the final 4 months can be estimated by using one-third of the $123 000 reported in Hajart et al,¹² which would equate to $36 900. This additional revenue creation based on charged evaluation and management codes alone would be similar enough to the costs of the athletic training resident's salary and benefits. Additional ancillary downstream revenue would only increase the value the athletic training resident provides to the institution or hospital system.