CMS Proposal Would Have 'Chilling Effect' on FP Training, Say AAFP, Other Family Medicine Groups

The AAFP is warning CMS that a proposed rule (608-page PDF; see page 113, "Clarification of Definition of New Medical Residency Training Program"; About PDFs) regarding new residency training programs will have a "chilling effect" on the training of primary care physicians at a time when primary care is expected to be a centerpiece of health care reform.

In a detailed June 30 letter (5-page PDF; About PDFs) to CMS Acting Administrator Charlene Frizzera, the Academy and organizations in the Academic Family Medicine Advocacy Alliance said that the proposed rule, if enacted, would lead to more closings of family medicine residencies and more losses of first-year family medicine residency slots.

"Family medicine has been, and continues to be, the only specialty that is fully primary care at all levels. Now is not the time to reduce the ability of family medicine programs to establish themselves and provide critical training for primary care physician production," said leaders of the Academy, the Society of Teachers of Family Medicine, the Association of Family Medicine Residency Directors, the Association of Departments of Family Medicine and the North American Primary Care Research Group in the letter.

Perry Pugno, M.D., M.P.H., director of the Academy's Division of Medical Education, said the letter was written in response to a CMS decision in March to end funding for graduate medical education at the Stanislaus Family Medicine Residency Program in Modesto, Calif. CMS also demanded that the residency repay $19 million in Medicare payments.

The Academy and the California AFP protested the CMS decision at that time, saying the agency's actions would spell the end of the residency and, consequently, increase health care costs and hurt patients' access to care in the medically underserved Central Valley of California.

At issue was CMS' 1997 reclassification of the residency as a "new" program after it moved from a debt-ridden county hospital that county supervisors were forced to close to Doctors Medical Center of Modesto. In 2007, CMS re-evaluated the residency -- applying rules that weren't written in 1997, said AAFP leaders -- which led to the decision to end Medicare support for GME at the residency and to demand the $19 million payback.

The Stanislaus County Board of Supervisors subsequently approved more than $11 million (6-page PDF; About PDFs) to help the residency repay CMS and to keep the program alive through June 2010.

Now, say Academy leaders, CMS' proposed rule would endanger any residency program that leaves one sponsoring hospital and goes to another.

"Essentially," the groups said in their June 30 letter, "the proposal states that if a program closes (no matter the reason behind the closure), and a university, medical school, hospital or other entity applies … to get approval for a 'new' program at a different hospital (that has never had residents before), CMS will no longer guarantee the counting of those residents for GME reimbursement purposes."

What this means, said Pugno, is that the previous hospital retains its residency positions -- and GME money -- but the new sponsor gets nothing, making the new program fiscally impossible and almost certainly killing it. If the rule is applied retroactively -- as CMS has done in this instance, he added -- it would deny the relocated Stanislaus residency any federal GME money and, in effect, eliminate it.

"The region would lose the positions, and all those patients would go unserved," said Pugno. "Patients will not get the health care they need, and some will die as a result. The region will no longer produce family physicians and the access problem will get worse.

"It's a lose-lose situation."

According to the June 30 letter, the proposed rule also would require hospitals to use "ambiguous" criteria to decide whether a residency is deemed to be a new program, based on such factors as whether the program has a new director or teaching staff members and whether only new residents are training in the program at the new site.

Programs might not know for several years if they have passed the "newness" test. "This ambiguity will have a chilling effect on the ability of any new programs to be established," said the letter. Residency programs also would be reluctant to hire experienced directors and faculty coming from another facility's program.

"We are very concerned that CMS is promoting new regulations without an assessment of the impact of such a proposal," the groups' said in their letter. "We are extremely concerned that primary care programs in general and family medicine (programs) in specific will be disproportionately affected.

"The loss of primary care resident positions, at a time when our nation needs a larger production of primary care physicians, is not the direction federal policy should take."