Charles P. Clayton
As required by the Patient Protection and Affordable Care Act (ACA; PL 111-148), the Centers for Medicare & Medicaid Services (CMS) proposed regulations concerning Medicare support for graduate medical education (GME) Wednesday, June 30, 2010. The proposal includes a process for redistributing unused residency positions as well as plans for implementing new statutory rules that require Medicare to pay more fairly for some GME activities in non-hospital settings.
With regard to the general distribution of unused GME positions, ACA generally requires CMS to take 65% of a hospital’s unused Medicare funded GME positions and redistribute them according to priorities established by Congress. To receive positions, a hospital must demonstrate a likelihood of filling the new positions within three years and must use 75% of the new positions for primary care training (internal medicine, family medicine, geriatrics, pediatrics, preventive medicine, or osteopathic general practice) or general surgery while maintaining the hospital’s current load of primary care positions. Priority for redistributed positions will be given to hospitals in states with current resident-to-population ratios in the lowest quartile and the 10 states, districts, or territories with the highest percentage of total population living in health professional shortage areas. Depending on demand from institutions in these two groupings, there may or may not be additional unused positions for redistribution to other states. The Association of American Medical Colleges estimated the number of unused positions for redistribution at 900 positions before CMS released the proposed rule; the number may vary from this early estimate.
According to the CMS proposal, the states, districts, or territories noted in the sidebar to this article qualify under the aforementioned criteria. Priority for receipt of redistributed slots is also assigned to hospitals in rural areas and hospitals that have a rural training track.
The ability of hospitals applying for new positions to demonstrate a likelihood of filling positions is the first criterion CMS will use in screening applications. CMS will then apply the priorities listed above, with applications in more than one category receiving a higher standing. To help sort applications within priority categories, CMS is proposing six evaluation criteria that will create a score for the application. Higher scores will increase the chances of obtaining new positions within any category. The most important proposed evaluation criteria include:
- Whether the hospital has a Medicare utilization rate of 60% or more.
- Whether the hospital will use the positions to create or add fellows to a geriatrics training program.
- Whether the hospital can demonstrate that residents added in pediatrics or internal medicine will likely stay in primary care practice, including through the presence of a primary care track.
- Whether 100% of the new positions will be used for primary care training.
In the proposed regulation, CMS states its intention to have a December 1, 2010, deadline for applications for unused positions. Institutions interested in applying should closely review the proposed regulation as it is unlikely to change significantly before finalization this fall.
The 157-page proposed rule also provides information on how CMS will calculate the reduction of unused positions (but does not provide its own estimate of the number to be redistributed) and includes language concerning the redistribution of positions from closed hospitals, another change in ACA.
With respect to non-hospital training, CMS also proposes to change its definition concerning the hospital’s payment of “all, or substantially all” of the costs of non-hospital training in order to claim this resident time for Medicare GME payment purposes. Per ACA, the hospital need only pay the resident salary and fringe benefits to claim non-hospital training time, assuming all other requirements are met. To assess whether this change will increase the time residents spend in non-hospital settings, CMS will require additional reporting of resident schedules.
Also in regard to non-hospital training, the proposal would institute regulatory changes that allow hospitals to claim resident time for didactic conferences and seminars held in non-hospital settings primarily engaged in patient care. CMS states its intention to continue disallowing time for conferences and seminars held in non-hospital, non-patient care venues, including medical school buildings.
On a final note, the CMS proposal affirms the ACA language that “research not associated with the treatment or diagnosis of a particular patient” is not countable for Medicare GME payment purposes.