Form 1 Appendix A THCGME Costing Instrument FINAL

General Instructions (detailed instructions provided in the instruction guide):
Refer to the instruction guide as you complete the THC Costing Instrument.
Use your best judgment on where to enter expenses. Please note: accounting and reporting practices may differ across THCs and continuity clinics.
• For guidance on General Instructions, see page 2 of the instruction guide.
• For guidance on Basic Information, see page 3 of the instruction guide.
• For additional guidance from the GW evaluation team, email thc_eval@gwu.edu

Basic Information
Teaching Health Center Graduate Medical Education Costing Instrument
Please Enter:
Name of Residency Program you are providing information on in this Costing Instrument:
THC Program Specialty:
Residency Accreditation:
Type of Sponsoring Institution for the Residency Program:
Were you previously accredited by AOA while a THC (Y/N)?
Number of continuity clinic(s):
Number of exam rooms in the continuity clinic(s):
Name(s) of the continuity clinic(s) that you are providing financial information on:
Licensure(s) for the continuity clinic(s) that you are providing financial information on (please specify if FQHC, rural health
clinic, etc., or multiple):
State(s) in which the continuity clinic(s) are located:
Reporting Period (most recent academic year):

July 1 2018 - June 30 2019

New or Expansion Program Under THC Grant:
Accredited Class Size per Year (if expansion, include THC and non-THC residents):
Contact Person:
Contact Person's E-mail:
Contact Person's Telephone:
Signatory:
Thank you for your assistance in completing this residency program Costing Instrument. The information gathered here will be important to inform your THCGME program officers to better
understand the costs of residency training programs and natural variations that occur between THC programs.

OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

1

Basic Info

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Clinic Patient Visits
The purpose of this worksheet is to report the total number of visits at the continuity clinic(s) and the distribution of those visits according to whether they are precepted or non-precepted. This distribution will serve as the basis for apportioning
clinic expenses and patient service revenues associated with the THC program.
• For guidance on Clinic Patient Visits, see page 5 of the instruction guide.
Ambulatory Visits in the Continuity Clinic(s)
Residency Faculty Precepted Visits

Non-Precepted Visits
Residency Faculty

PGY-1 Residents

PGY-2 Residents

PGY-3 Residents

PGY-4 Residents

Resident Total (All
PGYs)
0

Total visits provided in AY
2018-2019:
Of these visits, what
percentage were provided as
telehealth visits?

0

Page2 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Other Providers
All Other NonTeaching Provider
Visits

Total
Total Visits
0

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Continuity Clinic(s) Patient Revenue
The purpose of this worksheet is to collect information on the revenue generated by the continuity clinic(s) to determine the amount attributable to the residency program.
• For guidance on Continuity Clinic(s) Patient Revenue, see page 7 of the instruction guide.
Continuity Clinic(s) Patient Revenue
Continuity Clinic(s) Patient Revenue
Total Visits

Full Charges This Period

Payer
Total Medicaid
Total Medicare
Dual Eligible (Medicaid & Medicare)
Workman’s comp
Military Tri-Care
Other Public
Total Private
Self-Pay
Subtotals
Retroactive Settlements, Receipts, Paybacks:
Collections of Retroactive Payments
Penalty/Payback
Total Adjusted Revenue

$

-

$

-

Full Charges Per Visit

Net Revenue This Period

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

Net Revenue Per Visit

$

-

$

-

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

Amount Collected
This Period

$

-

$

-

Amount Collected Per Visit

$

Grants
Total Amount

.

FQHC Grant
Other Federal Grants:
Ryan White Part C HIV Early Intervention
Other Federal Grants
IHS/Tribal Funding
Medicare and Medicaid EHR Incentive Payments for
Eligible Providers
Non-Federal Grants Or Contracts:
State Government Grants and Contracts
State/Local Indigent Care Programs
Local Government Grants and Contracts
Total Grants

$

End Date of Grant

Is the grant likely to be renewed?
(Y/N)

Is the grant likely to be renewed?
(Y/N)

Notes

Notes

-

Residency Program Funding
Total Amount
THCGME Payment
Medicaid GME Payment
Other Residency Program Support Payment
Source
Source
Source
Source
Source
Sub-Total Residency Program Funding
Donations
Total Residency Program Funding

End Date of Grant

$

-

$

-

Notes

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

Page3 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

-

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Faculty Salary and Benefits
The purpose of this worksheet is to collect expense information on faculty who support THC residency training. The table below collects information on full-time equivalent (FTE) allocations for residency
training to understand the cost of training a THC resident.
• Add rows if you have additional faculty by double clicking a Faculty cell, entering the respective faculty position name, and then the corresponding information.
• For guidance on Faculty Salary and Benefits, see page 10 of the instruction guide.
Residency Faculty FTE Allocations

Faculty Salaries and Benefits
Example - Core Faculty

Specialty
Internal Medicine

Total FTE
1.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Program Director
Associate Program Director
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Part time faculty
Part time faculty
Part time faculty
Part time faculty
Other Faculty
Total

Non-Precepted
Visits
0.10

0.00

Resident
Precepted Visits Inpatient Service
0.20
0.10

0.00

0.00

Residency
Related Clinic
Admin
0.05

0.00

Salary and Benefit Allocations
Non-Residency
Related Clinic
Admin
0.05

0.00

Residency
Program
Administration
0.50

Notes

0.00

Non-Teaching Providers FTE and Salaries

Total Non-Teaching Provider FTE
Total Salaries and Benefits

$

-

Page4 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Non-Precepted
Actual Salary
Actual Benefits
Visits
$
165,000 $
39,600 $
20,460
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
- $
- $
-

Precepted Visits
$
40,920
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-

Resident
Inpatient Service
$
20,460
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-

Residency
Related Clinic
Admin
$
10,230
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-

Non-Residency
Related Clinic
Admin
$
10,230
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-

Residency
Program
Administration
$
102,300
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Residency Program Precepting Agreements
The purpose of this worksheet is to account for contracted specialists other than faculty who are paid by the THC program to provide educational experiences for THC residents. This includes specialists who are
paid for by stipends or other remuneration but who are not salaried.
• For guidance on Residency Program Precepting Agreements, see page 12 of the instruction guide.

Preceptorships
Assistant Program Director
Medical Student Clerkship Director
Simulation Lead
Clinic Director
Behavioral Health
Community Preceptors
Critical Care
Emergency Medicine
Family Medicine
General Adult Medicine/Internal Medicine
General Pediatrics
General Surgery
Geriatrics
Gynecology
Hospitalist
Neurology
OB/GYN
Obstetrics
Psychiatry
Radiology
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Additional Preceptorships
Total

Total Amount of Agreements
Paid by the Residency
Program

Notes

$

-

Page5 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Name of Program:
THC Program Specialty:

Reporting Period:

July 1 2018 - June 30 2019

Resident Salaries and Benefits
The purpose of this worksheet is to identify the expenses associated with residents’ salaries and benefits for the reporting academic period.
• Add rows if you have more than 7 residents for any given PGY by double clicking a PGY cell, entering the respective PGY year and then the corresponding information.
• For guidance on Resident Salaries and Benefits, see page 13 of the instruction guide.
Year of Residency
PGY-1
PGY-1
PGY-1
PGY-1
PGY-1
PGY-1
PGY-1
PGY-2
PGY-2
PGY-2
PGY-2
PGY-2
PGY-2
PGY-2
PGY-3
PGY-3
PGY-3
PGY-3
PGY-3
PGY-3
PGY-3
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
Total

Total FTE

Actual Salary

$

Total

Actual Benefits

- $

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
- $

-

Page6 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Residency Program Administrative Expenses and In-Kind Donations
The purpose of this worksheet is to identify the full range of administrative expenses associated with educational and academic activities. Do not report expenses associated with administration in the continuity clinic(s) here. Report expenses associated with administration in the
continuity clinic(s) on the Clinic Admin worksheet.
• For guidance on Residency Program Administrative Expenses and In-Kind Donations, see page 14 of the instruction guide.

Residency Program Administrative Personnel
Residency Program Administrative Personnel paid by the THC
Admin Support Salaries

Total FTE

Program Coordinator
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Total

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 $

Residency Program Administrative Expenses
Residency Program Administrative Expenses paid by the THC
Total Residency Square Footage

Overhead
Question

$

Actual Benefits

-

$

-

Residency Program Administrative Expenses Provided In-Kind to the THC
Total Residency Square Footage

Total Amount
Education/Didactic Costs:
Resident Education Stipends
Resident Required Training
Simulation Center Costs
Education Supplies
Medical/Dental School or OPTI fees
General Educational Allowance
Licensing/Certification Fees:
Licensing Examination Fees
In-Service Examination Fees
Board Certification Fees
Board Preparation Costs
Resident Licensing Fees
State Medical Licenses
Resident Training Licenses
DEA Licenses
DATA-2000 Waivers
Other Licensing Fees
Program Fees and Costs:
Accreditation Fees
NRMP/Match Participation Fees
Recruitment Costs
Graduation Costs
Faculty/Staff Development
Travel
Away Rotation Housing
General Liability Insurance
Academic Malpractice Insurance
Legal and Accounting
Consortium Expenses (if applicable)
Rent/Occupancy
Supplies:
Mobile Communications Devices
Laptops/Tablets
Telemedicine or Tele-education
IT Costs
White Coats/Uniforms
Printing and Postage
Office Supplies
Other:
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total

Residency Program Administrative Personnel Provided In-Kind to the THC

Actual Salary

Residency Program
Cost
$
$
$
$
$
$
$
$
$
-

Admin Support Salaries
Program Coordinator
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Total

Total FTE

Actual Salary
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 $

Actual Benefits

-

$

-

Residency Program
Cost
$
$
$
$
$
$
$
$
$
-

Notes:

Total Amount
Education/Didactic Costs:
Resident Education Stipends
Resident Required Training
Simulation Center Costs
Education Supplies
Medical/Dental School or OPTI fees
General Educational Allowance
Licensing/Certification Fees:
Licensing Examination Fees
In-Service Examination Fees
Board Certification Fees
Board Preparation Costs
Resident Licensing Fees
State Medical Licenses
Resident Training Licenses
DEA Licenses
DATA-2000 Waivers
Other Licensing Fees
Program Fees and Costs:
Accreditation Fees
NRMP/Match Participation Fees
Recruitment Costs
Graduation Costs
Faculty/Staff Development
Travel
Away Rotation Housing
General Liability Insurance
Academic Malpractice Insurance
Legal and Accounting
Consortium Expenses (if applicable)
Rent/Occupancy
Supplies:
Mobile Communications Devices
Laptops/Tablets
Telemedicine or Tele-education
IT Costs
White Coats/Uniforms
Printing and Postage
Office Supplies
Other:
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
- Total

$

-

Response

Is there an administrative overhead component
charged to your residency program? How is the
administrative overhead charge determined? For
example, if your sponsoring organization or
institution assigns a 5% overhead to your THC grant
for administrative purposes include those costs
here.

Page7 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Clinic Administrative Expenses
For this worksheet, we will collect information on all administrative expenses attributable to the resident continuity clinic(s) and separated from all other costs related to the residency program. The definition of a continuity clinic will align with ACGME requirements: a
continuity clinic is a setting in which residents develop a continuous, long-term therapeutic relationship with a panel of patients, with the resident serving as the primary physician for this panel.
• For guidance on Clinic Administrative Expenses, see page 19 of the instruction guide.
Resident Continuity Clinic(s) Adminstrative Expenses
Total Amount
Administrative Personnel Salaries/Benefits
Purchased Admin Services
Office Supplies
Recruitment
Staff Development
Travel
IT Infrastructure
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Clinic Admin Expenses
Overhead
Administrative Overhead
Finance and Accounting Overhead
Physical Plant
IT Overhead
Other Expense Type
Other Expense Type
Other Expense Type
Total Overhead

$

Notes

Total Amount

$

Notes

-

Page8 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Clinical Operations Expenses
The purpose of this worksheet is to collect information on the total operational expenses of the continuity clinic(s) in relation to the continuity clinic(s) visits and revenue.
• For guidance on Clinical Operations Expenses, see page 21 of the instruction guide.
Clinic Square Footage
Total Amount
Square Footage
Clinic Operations Expenses
Type of Expense
Clinical Support Personnel Salaries/Benefits
Purchased Medical/Dental Services
Medical/Dental Supplies
Medical/Dental Equipment
Licensing Fees
Malpractice Insurance
EHR licenses/Maintenance
Uniforms
Occupancy
Depreciation
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total

Total Amount

$

Notes

-

Page9 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Inpatient Revenue and Expenses

The purpose of this worksheet is to determine the costs incurred by a THC when its residents train in a hospital, and any associated payments made by the hospital back to the THC for
inpatient care services performed by the THC residents. Please do not repeat information in this worksheet elsewhere in the THC Costing Instrument.
• For guidance on Inpatient Revenue and Expenses, see page 23 of the instruction guide.
Inpatient Resident Service(s) Revenue

Notes
Amount Received from
Hospital

Revenue Category
Direct payments
Agreed upon payments
Medicare pass-through
State Medicaid
Call and coverage
Other
Other
Other
Total
Inpatient Resident Service(s) Expenses
Expense Category
Faculty costs
Staffing and support costs
Facility costs
Indirect costs
Overhead
In-kind
Other
Other
Other
Total

$

Notes

Amount Paid to Hospital

$

-

Page10 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Name of Program:
THC Program Specialty:
Reporting Period:

July 1 2018 - June 30 2019

Additional Information About Your THC and Continuity Clinic(s)
The purpose of this worksheet is to provide additional information about your continuity clinic(s) or health center that could affect THC financing, operations, and sustainability.
• For guidance on Additional Information About Your THC and Continuity Clinic(s), see page 25 of the instruction guide.
Question
1. What aspects of your THC residency program do you think are unique and innovative?
2. What are the biggest challenges related to funding/financial security for your residency
program?

3. What are the biggest challenges around resident staffing for your residency program?

4. What are the biggest challenges around faculty staffing for your residency program?

5. What are the biggest regulatory/reimbursement challenges for your residency program?
6. Did your routine ongoing expenses (e.g. faculty administrative costs, education costs, etc.)
increase as a result of now meeting ACGME accreditation standards?
7. Describe some of your most successful strategies to recruit THC residents who are likely to
practice in underserved and rural areas?
8. What lessons have you learned in your THC program that might be useful for new THCs?
9. Describe benefits to your continuity clinic(s) or health center associated with your residency
program? For example, has the THC program helped with staff recruitment and retention? Has it
created new staffing models for your organization? Has the volume or capacity at your continuity
clinic(s) or health center increased?

Response
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.

10. Describe the relationship between the supply of residents and the supply of advanced practice 1.
2.
clinicians in the continuity clinic(s)? How has staffing of advanced practice clinicians grown or
3.
decreased as a result of having THC residents?
1.
11. How does training residents affect your continuity clinic(s) or health center’s finances and
2.
administrative responsibilities?
3.
• Are more or fewer patients seen as a result of having residents in the clinic(s)?
• Are additional staff needed to support the residents?
• Has the physical infrastructure needed to be changed to accommodate classroom space,
computers, equipment, supplies or other program needs?
• Are there additional reporting requirements as a result of the residency program and the THC
program specifically?
12. Is your continuity clinic(s) or health center planning to expand, either physically or in the
number of patients you serve? If yes, can you describe your plans? Has there recently been an
expansion?
13. Does your continuity clinic(s) or health center participate in value-based purchasing,
alternative payment models, accountable care organizations, or other payment and delivery
reforms that affect overall financing and operations or changes to your Medicaid PPS rate? If yes,
explain.

1.
2.
3.
1.
2.
3.

1.
2.
3.
15. Describe any significant changes in your Medicaid PPS rate or ambulatory service rate at your 1.
continuity clinic(s) or health center that have occurred over the past five years? Note the impact of 2.
3.
these changes in revenues.
1.
16. What primary care initiatives are being implemented in your continuity clinic(s) or health
center and how are the residents integrated into and trained in these initiatives? For example, in 2.
3.
what ways are residents involved in patient centered medical homes, quality improvement,
leadership opportunities, and interdisciplinary/team-based care?
14. Describe any significant changes in the payer mix at your continuity clinic(s) or health center
that have occurred in the last five years? Note the impact of these changes in revenues.

Page11 OMB Number XXXX-XXXX and Expiration date X/XX/XXXX

Public Burden Statement: The purpose of this collection is to determine an appropriate THCGME Program payment for indirect medical
expenses (IME) as well as to update, as deemed appropriate, the per resident amount used to determine the Program’s payment for direct
medical expenses (DME). An evaluation will be conducted using a standardized THCGME Costing Instrument to gather data from all THCs
participating in the THCGME Program. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-XXXX and
it is valid until XX/XX/202X. This information collection is required to obtain a benefit as required by Section 5508 of the Affordable Care Act of
2010 amended section 340H of the Public Health Service Act to establish the Teaching Health Center Graduate Medical Education
(THCGME) Program in which the Secretary has the authority to determine an appropriate THCGME program payment. Public reporting
burden for this collection of information is estimated to average 10 hours per response, including the time for reviewing instructions, searching
existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane,
Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.