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Background and Objectives: Precepting methods have significant impact on the financial viability of family medicine residency programs. Following an adverse event, four University of Minnesota Family Medicine residency clinics moved from using Medicare's Primary Care Exception (PCE) and licensure precepting (LP) to a "universal precepting" method in which preceptors see every patient face to face. Variation in the implementation of universal precepting created a natural experiment of its financial impact., Methods: Universal precepting was implemented in October 2013 across four residency programs. Billing codes were measured 1 year before and 2.5 years after implementation by clinic and residency year., Results: There were significant financial differences between clinics based on original precepting method and implementation quality of universal precepting. The clinic moving from PCE to universal precepting with excellent implementation increased higher-level billing (99214) by 8%-10%. Clinics moving from LP demonstrated wide variation ranging from an 18% increase to a 13% decrease, consistent with the implementation quality., Conclusions: Clinics transitioning from PCE to universal precepting can see a significant increase in 99214 billing. Clinics transitioning from LP to universal precepting are at significant financial risk if poorly implemented, but may see increased 99214 billing with effective implementation. This suggests that both implementation quality and original precepting method impact 99214 billing rates when transitioning to universal precepting.

Objective: To determine if a clinic system to assess and vaccinate preschool-age children at every clinic visit can improve vaccination rates., Design: A nonequivalent control group design contrasting an intervention clinic with a comparison clinic., Setting: Two urban St Paul, Minn, clinics. The intervention clinic is a family practice residency clinic, and the comparison, clinic is a community health center clinic., Patients: Primarily a low socioeconomic status white population., Interventions: A clinic-wide system to identify and vaccinate children at all clinic visits. Appointment personnel, medical assistants, and physicians all had roles in the intervention protocol., Main Outcome Measures: Percentage of children at the 2 clinics who were up-to-date for a primary vaccine series at age 24 months and also at the end of the study collection periods, preintervention and postintervention., Results: The intervention clinic improved the percentage of children up-to-date for a primary vaccine series at age 24 months from 42% to 56% (P = .02), while the percentage at the comparison clinic did not change significantly (P = .81). Similarly, the intervention clinic improved the percentage of children up-to-date for age at the end of the study periods from 49% preintervention to 63% postintervention (P = .02), while the percentage at the comparison clinic did not improve significantly (P = .45). The system was especially useful for children with few visits to the intervention clinic., Conclusions: Although the intervention clinic resulted in a substantial improvement in vaccination rates for preschool-age children, rates remained well below national goals. A combination of clinic, community, and national initiatives may be needed to ensure appropriate vaccination rates for this challenging patient population.