Primary Care Organizations Fight for GME Residency Slots, Funding

AAFP, Others, Urge CMS to Refine Proposed Rule

June 29, 2012 05:40 pm News Staff

In an effort to ensure that primary care residency positions are not just maintained, but increased, the AAFP joined the Council of Academic Family Medicine and four other primary care organizations in highlighting their concerns regarding CMS' proposed regulation covering the inpatient prospective payment system for 2013.

Through its federal advocacy efforts, the AAFP aims to ensure that medical students, such as these University of Missouri-Kansas City School of Medicine students -- shown here receiving notice of the residency programs to which they matched in March 2012 -- continue to enjoy a rich selection of U.S. medical residency programs.

In a June 25 letter(5 page PDF) to CMS Acting Administrator Marilyn Tavenner, the organizations focus their attention on sections of the proposed rule (CMS-1588-P), which was published in the May 11 Federal Register(, that concern graduate medical education (GME).

Although the letter commends CMS for its efforts to implement new policies consistent with the Patient Protection and Affordable Care Act's charge to promote the growth of primary care residency positions, the groups take issue with certain pieces of the regulation.

For example, the letter expresses concern about CMS' proposed methodology for the allocation of cap adjustments to new teaching hospitals when those hospitals move residents to other hospital facilities during the first five years of resident training.

story highlights

  • The AAFP joined other primary care organizations in urging CMS to refine its inpatient prospective payment system proposed rule for 2013.
  • The groups expressed concern about CMS' proposal to attribute caps to nonteaching hospitals that accept resident rotations, regardless of whether the hospitals seek payment for training the residents.
  • The letter argues that assigning unreasonably small caps to nonteaching hospitals and teaching health centers (THCs) will hinder the growth of both residency programs and new THCs.

"This proposal seeks to attribute caps to nonteaching hospitals that accept resident rotations, whether or not those hospitals seek payment for training the residents," says the letter, noting that the clock starts ticking on CMS' cap and per-resident amount establishment process when residents rotate to a nonteaching hospital, even for a short period of time.

"This effectively forces it to become a teaching hospital with an extremely small cap, which essentially bars it from ever establishing a viable residency program in the future," says the letter.

Additionally, it appears from reports generated in the field that the same misguided policy has already been adopted with respect to teaching health centers (THCs), says the letter. "We are especially concerned about this as it would have a profoundly negative effect on the creation of new THCs."

If CMS stands by this proposed policy, the letter signees urge the agency to further refine the policy by adding wording that would allow

  • teaching hospitals to rotate residents for a period of as many as three months per resident, per year without triggering the calculation of a cap and per-resident amount;
  • a new teaching hospital to rotate residents in high-need specialties, such as primary care and general surgery, without triggering the above actions; and
  • hospitals located in rural areas to rotate residents to nonteaching hospitals without triggering caps or per-resident amounts.

In addition, the letter proposes setting a time limit on the cap established by the initiation of residency positions. "If an institution has not had residents rotating through it for a reasonable period of time (perhaps three or five years), its cap should expire, returning the hospital to a nonteaching hospital classification," says the letter.

The letter also states opposition to the proposed policy change that would amend existing regulations to include labor and delivery beds in the hospital available-bed count for the purpose of calculating the indirect medical education (IME) adjustment.

"GME payment rules are designed to ensure that Medicare pays its share of physician training costs," the letter points out. "Even though, in theory, these beds could be used for Medicare patients, it is difficult to see what relevance labor and delivery beds have for the Medicare patient population.

"We oppose the addition of labor and delivery beds to the 'available bed' definition for IME purposes," says the letter. "The only result would be to dilute the intern and resident-to-bed ratio, thereby decreasing IME payments."

The presidents of the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group joined AAFP President Glen Stream, M.D., M.B.I, of Spokane, Wash., in signing the comment letter initiated by the Council of Academic Family Medicine.