Herb Kuhn, Director
Center for Medicare Services
Centers for Medicare and Medicaid Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Mr. Kuhn:
On behalf of the undersigned family medicine organizations representing the practice and education of family medicine throughout the United States, we recommend that CMS implement a system by which teaching hospitals could verify to CMS that they have met the “all or substantially all” legislative criterion for community preceptors in non-hospital settings. Our organizations have sought diligently to achieve a reasonable and satisfactory solution to the problems associated with the agency’s interpretation of law and regulation of the clause requiring the teaching program to bear “all or substantially all” of the costs associated with the resident’s time spent in a nonhospital setting. The current interpretation has adversely affected family physicians who volunteer their time to serve as clinical faculty and preceptors for family practice residents.
The Medicare statute permits teaching hospitals to claim resident time spent at nonhospital sites if the hospital incurs “all or substantially all” of the training costs at that site. Under the CMS regulations in effect through 1998, this requirement was met if the hospital paid the residents’ stipends and benefits. Effective January 1, 1999 CMS, on its own authority, changed its regulatory definition of “all or substantially all” to require hospitals to also incur “the portion of the cost of teaching physicians’ salaries and fringe benefits attributable to direct graduate medical education.” [42 C.F.R. §413.75(b) and 42 C.F.R. §413.78(e)].
The vast majority of resident supervision is done by volunteer physicians. Moreover, it has also been repeatedly demonstrated that the time spent by volunteer faculty that is dedicated to the supervision of a resident in non patient care activities is de minimis. However, Medicare fiscal intermediaries are disallowing nonhospital resident counts for the hospital’s failure to incur supervisory costs, even though the agreements between the hospital and nonhospital site state that the supervising physician is volunteering.
Family medicine supports a proposal raised by William Rogers, MD at the recent meeting of the Practicing Physicians Advisory Council (PPAC) that would allow preceptors to attest that at least 90 percent of the time they spend with residents is spent delivering clinical services and that CMS accept such attestations as evidence that "all or substantially all" of the costs are being borne by the hospital.
If the physician cannot attest to that time distribution, or should the precepting physician wish to be compensated for time spent in non-patient care activities, then the hospital should pay the precepting physician an amount agreed upon by the parties. Any payment for such teaching is a matter between the hospital and the preceptor and the amount should not be determined by CMS or any formula CMS recommends.
The undersigned organizations urge CMS to make formal and official the above described process. Such action shall enable the agency to inform the intermediaries and other authorities that audits seeking verification of the amount of preceptor time spent, the way that precepting time is spent and the arrangement between the hospital and the precepting physician are no longer necessary.
Thank you for your continued work on this issue and we look forward to receiving official notification of its resolution.
Sincerely,
Mary E Frank, MD, FAAFP, Board Chair, American Academy of Family Physicians
William K. Mygdal, EdD, President, Society of Teachers of Family Medicine
Warren Newton, MD, President, Association of Departments of Family Medicine
Penny Tenzer, MD, President, Association of Family Practice Residency Directors
Perry Dickinson, MD, President, North American Primary Care Research Group
cc: Dr. William Rogers
