AAFP Members, Leaders Pool Efforts to Solve Volunteer Preceptor Dispute

AAFP leaders have met with CMS Administrator Mark McClellan, M.D., Ph.D., and the Academy has launched a Speak Out Action Alert as part of an ongoing, concerted effort to resolve a dispute over Medicare payment to residency programs that use volunteer preceptors.

In the Speak Out alert, the Academy calls on members to urge their representatives and senators to support the Community and Rural Medical Residency Preservation Act of 2005, or S. 2071 in the Senate and H.R. 4403 in the House of Representatives. (At the Library of Congress' THOMAS Web site, type "S. 2071" or "H.R. 4403" in the search box after selecting "Bill Number.") The Academy also signed a letter to all 435 representatives and 100 senators asking each one to sign onto the legislation.

If passed, the bill would affect the 61 percent of AAFP members who serve as volunteer preceptors for medical students and family medicine residents, a figure derived from the 2005 AAFP Practice Profile Survey.

At issue is CMS' 2002 position that teaching hospitals should not receive direct graduate medical education or indirect medical education funds for the time residents spend with community-based, volunteer preceptors. CMS reasons that direct graduate medical education, or DGME, and indirect medical education, or IME, funds are paid to hospitals to help defray the cost of professors' and residents' salaries and benefits. Therefore, the hospitals incur no DGME or IME-eligible costs when they use community-based volunteer preceptors.

The AAFP and Academic Family Medicine Advocacy Alliance, or AFMAA, contend that hospitals do incur DGME and IME-eligible costs when residents learn with volunteer preceptors because the hospitals are paying salaries and benefits to residents during the hours they are learning from volunteer preceptors. Moreover, volunteer preceptors' teaching does represent an unpaid expense to the residency program because virtually all teaching time involves patient care for which the preceptors can bill third-party payers.

"We've had ongoing communication with CMS on this issue over the past four years," said AAFP President-Elect Rick Kellerman, M.D., of Wichita, Kan. "And when the (AAFP) Board of Directors met with (HHS) Secretary Michael Leavitt in March, we brought this issue up."

One AFMAA and AAFP-proposed solution is an attestation statement in which the hospital and volunteer preceptor affirm at least 90 percent of the preceptor's teaching time involves patient care activities. As such, that teaching time is reimbursed by private insurance, Medicare, Medicaid or patients, and the hospital is not responsible for additional payments for the preceptor's time.

On June 14, Kellerman; Academy EVP Douglas Henley, M.D.; Association of Family Medicine Residency Directors President Sam Jones, M.D., of Fairfax, Va.; and representatives of the American Osteopathic Association and Association of American Medical Colleges met with McClellan.

"He understood the issue as a physician and a former resident," said Kellerman. "He understood how resident education is conducted in both hospital and nonhospital settings. But as an administrator, he had to focus on the technicalities of how to interpret the law. Much of our discussion was on the attestation statement as a solution to the conundrum."

Without a solution, medical educators worry that residency programs will move out of the community and back into the hospital, Kellerman added.

Meanwhile, the AAFP also has turned to Congress. In addition to issuing the Speak Out, the Academy joined 78 other organizations in a letter urging every federal legislator to co-sponsor the Community and Rural Medical Residency Preservation Act of 2005.

"Congress has demonstrated clearly its support for nonhospital training opportunities," the letter says. The legislation "would establish, in statute, clear and concise guidance on the use of ambulatory sites in teaching programs. If enacted, it will preserve the quality education of resident physicians originally envisioned by Congress."