Assault on Graduate Medical Education

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Assault on Graduate Medical Education

• Program Directors Workshop
• June 11, 2007
• Hope Wittenberg
• Director, Government Relations

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Todays Agenda

• Recent Regulatory Hurdles re GME
• Status of GME on the Hill
• Status of Title VII
• What you can and should do!

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President Bushs Plan an all-out assault on
graduate medical education
Senator Charles Schumer (R-NY) February 2007
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Graduate Medical EducationRecent Regulatory
Hurdles

• Had picture of cover of book with the words
  Clear and Present Danger

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Graduate Medical EducationRecent Regulatory
Hurdles I

• August 18, 2006 Medicare Final Rule on changes to
  FY2007 Inpatient Prospective Payment
• CMS clarifies that only time spent by residents
  on patient care is to be counted for IME purposes
  in the hospital complex and for direct GME and
  IME purposes in nonhospital sites
• A definition of the term patient care
  activities has been added the care and
  treatment of particular patients, including
  services for which a physician or other
  practitioner may bill.

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Graduate Medical EducationRecent Regulatory
Hurdles II

• May 3, 2007, CMS proposes Changes to FY2008
  Inpatient Prospective Payment
• Proposal would remove resident vacation and sick
  leave time from the formula used to determine IME
  and DME reimbursement.
• Comments due June 12

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Graduate Medical EducationRecent Regulatory
Hurdles III

• May 11, 2007, Non-Hospital Teaching Rule
  (included in Long Term Care Rule)
• Rule puts in place formula for determining how
  much a hospital must pay a teaching physician in
  a non-hospital site.

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Medicare Teaching in Non-Hospital Settings

• We have had a problem with using volunteer
  faculty since CMS audits in 2002
• Regulations over the years have been confusing at
  best
• Compliance has been extremely difficult to
  accomplish

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Medicare Teaching in Non-Hospital Settings

• New Regulation is CMSs attempt to resolve
  compliance difficulties
• They missed the mark!
• Established a formula using proxies to identify
  amount of payments to individual preceptors

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Medicare Teaching in Non-Hospital Settings

• Sets up a regulatory and paperwork nightmare in
  order for hospitals to comply.
• No matter which payment determination method you
  use (formula with proxies or individual
  time/motion/salary) it must be applied for every
  resident and every preceptor.
• Most FM programs would have to pay most
  preceptors
• Group practices acting like solo practices are
  not exempt

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Medicare Teaching in Non-Hospital Settings

• Formula
• 1. (Avg. MD salary by specialty) X
• (3 hours didactic time per week
• total clinic/office hours per week)
• portion of MD salary to pay
• 2. Resident stipends plus benefits portion of
  MD salary X
• 3. Hospital must pay 90 X

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Graduate Medical EducationRecent Regulatory
Hurdles IV

• May 23, 2007, CMS proposed rule would eliminate
  Medicaid payments for Graduate Medical Education
• This follows the Presidents Budget proposal
• Basis for the proposal is the belief that the
  Medicaid statute doesnt specifically allow it.
• Recent FY 2007 supplemental appropriations bill
  was enacted and included a one-year moratorium
  against implementation of this proposal.
• Comments are still due by June 22, 2007

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Status of GME on the Hill

• Difficulty getting our volunteer preceptor Fix
  due to cost
• Potentially moderate the formula?
• Lower substantially all threshold
• Define group practice with expanded exemption
• Define patient-care activities to include
  didactic time
• Will Congress lower the IME Factor again??

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Status of Title VII

• House and Senate Budget Resolutions include
  increased funding for health programs
• House and Senate Dear Colleague letters support
  more funding for health professions
• Veto threat by President if Labor/HHS bill is
  well over Presidents budget request

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Status of Title VII

• House Labor/HHS Appropriations Subcommittee acted
  last week
• Primary Care Medicine and Dentistry held at FY 07
  levels
• Our request for increases was not supported by
  Subcommittee
• Full Committee to mark-up later this week
• Senate will act shortly thereafter

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What you can and should do!

• Respond to my alerts
• And PLEASE let me know when you have done so
• Become a true key contact
• Get to know your legislator and his/her staff
• Come to the Family Medicine Congressional
  Conference (FMCC) each Spring

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What you can and should do!

• To Paraphrase Rabbinic scholar Hillel
• If I am not for me, who will be? If not now,
  when?

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What happens if you dont make the effort?
Had picture from the web of Headlines on
Newspaper With picture of President Bush.
Headline stated Democracy Fails
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Need Help?

• Contact me
• Hwittenberg_at_stfm.org
• 202-986-3309

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For More Information regarding Didactic Time
Compliance

• See Next Slides

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Applicable Medicare Regulations Exclusion of
Didactic Teaching Time

• Summary of August 18, 2006 Medicare Final Rule on
  changes to FY2007 Inpatient Prospective Payment
• Rule does three things relating to the FTE count
• Finalizes CMSs clarification that only time
  spent in patient care activities may be counted
  for IME purposes in the hospital complex and for
  direct GME and IME purposes in nonhospital sites.
• A definition of the term patient care
  activities has been added the care and
  treatment of particular patients, including
  services for which a physician or other
  practitioner may bill. IME regulations are
  amended also to state that in order to be
  counted, a resident must be spending time in
  patient care activities, as defined above.
• For cost reporting periods beginning on or after
  October 1, 2006, CMS is implementing a new
  approach, called a one workday approach to
  documentation of residents time. Basically, if
  a residents workday consists entirely of
  scheduled nonpatient care activities (didactic
  time, research, etc.), that workday must be
  identified as nonpatient care time and must be
  subtracted from the allowable FTE count (for IME,
  if the training occurred in the hospital complex,
  and for both IME and DGME, if the training
  occurred in a nonhospital site.)

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Applicable Medicare Regulations Exclusion of
Didactic Teaching Time

• What do the documentation requirements mean? It
  is all in what is visible to CMS!
• CMS is not requiring a program to show didactic
  or non-patient care time on a rotation schedule
  if it is less than a days duration
• But -- if a program uses a rotation schedule that
  shows time increments of a day or less, that
  non-patient care time will be excluded from the
  FTE count.
• Fiscal Intermediaries (FIs) are not expected to
  go beyond the rotation schedule for additional
  information.
• If, however, they have other information because
  they were examining another issue, (volunteer
  preceptors for example) and that information
  shows non-patient care time, even that of less
  than a day, they will exclude that time.

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Applicable Medicare Regulations Exclusion of
Didactic Teaching Time

• Examples
• Block rotation schedule (one month or one week,
  or anything over one day.) There is no need to
  change that schedule, but the program must put a
  footnote on the rotation schedule for when a
  resident spends a full day of didactic or other
  non-patient care time. When that occurs, that day
  is deleted from the time counted for FTE. Any
  non-patient care time of less than a days
  duration need not be shown.
• Daily rotation schedule Any day that is fully
  devoted to non-patient care training, such as a
  day-long conference, or research time, would be
  subtracted from time counted toward the FTE
  count.
• Half-day rotation schedule Any time shown on
  the rotation schedule that is non-patient care
  time would be deleted from the FTE count. A
  morning spent away from patients and the hospital
  would be considered non-countable. Still unclear
  is what happens when lunchtime is dedicated to
  some didactic learning. CMS still has to decide
  how to handle that instance.
• Hourly rotation schedule Any non-patient care
  time increment of less than a day will still be
  excluded if it shows up on the rotation schedule,
  so hourly rotations that are non-patient care
  time will not count towards the FTE count.