Representatives from the AAFP have requested a meeting with Herb Kuhn, director of the CMS Center for Medicare Management, to discuss the agency's rules on volunteer preceptors in residency training programs.
During the meeting, the Academy hopes to clarify CMS' interpretation of the law governing whether teaching hospitals must pay residency programs for volunteer, community-based physicians who supervise residents' care of patients.
Academy Requests CMS Meeting
Planned Discussion to Focus on Volunteer Preceptors
By Leslie Champlin
4/29/2005
Because most community-based teaching consists of exposing residents to direct patient care -- generating income in the process -- family medicine training programs have virtually no costs associated with residency training. Here, FP resident Curtis Franke, M.D., works with patient Sheila Middleton in a Trident Family Medicine Residency Program clinic in Charleston, S.C.
CMS tried to clarify the rule in a series of frequently asked questions posted April 8 at "Direct Graduate Medical Education Payments Under the Inpatient Prospective Payment System." In an internal analysis of the FAQs, AAFP has said the attempt to clarify was not helpful and actually caused more confusion.
The agency currently disallows graduate medical education payments to residency programs for time residents spend learning from community-based, volunteer preceptors, Kuhn said April 20 in remarks here to family physician leaders and others attending the Family Medicine Congressional Conference.
"The statute is quite clear in this area," he said. "Hospitals must pay all or substantially all of (residency training) costs -- period. We've pushed as hard as we could. But I can only do what the statute allows. If an organization believes it has information we haven't considered, I am open for business."
The CMS position puts family medicine residency training programs at risk, say AAFP analysts. If required to pay community-based preceptors for their time, many teaching hospitals would drop their community programs and concentrate residency training within the hospital. That, in turn, would dilute the educational experience, because they would miss experiences in private office settings, where most family physicians practice.
While acknowledging the statute's language, the AAFP raises questions about the interpretation of that language, said Jerome Connolly, senior government relations representative in the Division of Government Relations.
In the list of FAQs, CMS says, "The relevant question is not whether volunteerism is permissible, but whether there is a cost to the nonhospital site for supervising the resident training."
AAFP says the answer is no. Most nonhospital-based teaching involves supervising residents while they provide patient care. The volunteer FP preceptor takes virtually no time away from income-producing activity and, thus incurs virtually no "lost-opportunity" costs for the teaching hospital.
Moreover, if resident training does require time away from patient care, it is so negligible that it doesn't constitute a real cost to the physician's practice or to the training program, according to AAFP's analysis.
"It would be a very negligible amount of time that is taken away from the treating patients," explained Connolly. "It's not substantial. Therefore, even in such an instance, the hospital would be incurring 'all or substantially all' of the training costs."
The agency contends that residency programs incur costs when a physician-supervisor is on salary and earns income regardless of whether he or she sees patients. That cost, according to CMS, must be reimbursed by the teaching hospital.
However, AAFP contends most FP preceptors' income derives from patient care, regardless of whether they are salaried. When community-based FP preceptors teach residents, most education occurs within the context of direct patient care.
"Even a salaried physician could have all of his or her compensation depend upon revenue generated ... through patient treatment activity, an arrangement that is common in family medicine even in group practices," Connolly wrote in his analysis of the CMS FAQ document.
AAFP, other family medicine groups and numerous other health organizations have contacted CMS multiple times on the issue, according to Hope Wittenberg, director of government relations for the Academic Family Medicine Advocacy Alliance. In correspondence to CMS Administrator Mark McClellan and in personal meetings with CMS officials, the organizations have requested administrative action that would resurrect a moratorium on CMS audits of hospitals' GME payments and on retroactive demands for repayment for volunteer preceptors' time teaching residents.
The agency currently disallows graduate medical education payments to residency programs for time residents spend learning from community-based, volunteer preceptors, Kuhn said April 20 in remarks here to family physician leaders and others attending the Family Medicine Congressional Conference.
"The statute is quite clear in this area," he said. "Hospitals must pay all or substantially all of (residency training) costs -- period. We've pushed as hard as we could. But I can only do what the statute allows. If an organization believes it has information we haven't considered, I am open for business."
The CMS position puts family medicine residency training programs at risk, say AAFP analysts. If required to pay community-based preceptors for their time, many teaching hospitals would drop their community programs and concentrate residency training within the hospital. That, in turn, would dilute the educational experience, because they would miss experiences in private office settings, where most family physicians practice.
While acknowledging the statute's language, the AAFP raises questions about the interpretation of that language, said Jerome Connolly, senior government relations representative in the Division of Government Relations.
In the list of FAQs, CMS says, "The relevant question is not whether volunteerism is permissible, but whether there is a cost to the nonhospital site for supervising the resident training."
AAFP says the answer is no. Most nonhospital-based teaching involves supervising residents while they provide patient care. The volunteer FP preceptor takes virtually no time away from income-producing activity and, thus incurs virtually no "lost-opportunity" costs for the teaching hospital.
Moreover, if resident training does require time away from patient care, it is so negligible that it doesn't constitute a real cost to the physician's practice or to the training program, according to AAFP's analysis.
"It would be a very negligible amount of time that is taken away from the treating patients," explained Connolly. "It's not substantial. Therefore, even in such an instance, the hospital would be incurring 'all or substantially all' of the training costs."
The agency contends that residency programs incur costs when a physician-supervisor is on salary and earns income regardless of whether he or she sees patients. That cost, according to CMS, must be reimbursed by the teaching hospital.
However, AAFP contends most FP preceptors' income derives from patient care, regardless of whether they are salaried. When community-based FP preceptors teach residents, most education occurs within the context of direct patient care.
"Even a salaried physician could have all of his or her compensation depend upon revenue generated ... through patient treatment activity, an arrangement that is common in family medicine even in group practices," Connolly wrote in his analysis of the CMS FAQ document.
AAFP, other family medicine groups and numerous other health organizations have contacted CMS multiple times on the issue, according to Hope Wittenberg, director of government relations for the Academic Family Medicine Advocacy Alliance. In correspondence to CMS Administrator Mark McClellan and in personal meetings with CMS officials, the organizations have requested administrative action that would resurrect a moratorium on CMS audits of hospitals' GME payments and on retroactive demands for repayment for volunteer preceptors' time teaching residents.
