CMS Proposed Rule Could Cut Supply of Rural Physicians

AAFP, Other Family Medicine Groups Call for Revisions

July 02, 2014 01:08 pm Sheri Porter

The AAFP and the four organizations that make up the Council of Academic Family Medicine recently responded to a proposed rule from CMS that, if finalized as is, could infringe on the U.S. graduate medical education (GME) system and compromise health care for underserved rural Americans.

[Stock photo of physician in foreground of hospital room with patient in bed tended to by other medical staff]

The 2015 hospital inpatient prospective payment system proposed rule( was published in the May 15 Federal Register.

The AAFP, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine lay out their concerns regarding the GME portions of the proposal in a June 26 letter(5 page PDF) to CMS Administrator Marilyn Tavenner.

In the letter, the five organizations say their comments stem from a conviction that the primary health care needs of rural America are not being met.

Story Highlights
  • The AAFP and four other family medicine organizations collaborated on comments to CMS regarding portions of a proposed rule that affect graduate medical education.
  • The letter asked CMS to refocus its attention on the health care needs of America's underserved rural communities.
  • The groups said CMS could do more, through its rulemaking efforts, to boost the production of rural physicians.

"Of particular note, the production of primary care physicians, especially family physicians, is a key area where we believe CMS can and should do more to remove barriers to increased production," says the letter.

"We hope CMS will take to heart its authority to provide special consideration for underserved rural areas and will revise this proposal and construct regulations that enhance institutions' ability to produce physicians who will practice in rural areas and serve underserved rural populations."

A good portion of the letter deals with CMS' proposal to treat rural training tracks differently from full rural hospital programs.

Stan Kozakowski, M.D., the AAFP's director of medical education, provided some important historical background on this point in an interview with AAFP News.

"The 2010 census resulted in the reclassification of a number of rural hospitals as urban," said Kozakowski. "This reclassification has major implications for GME financing for these hospitals and also hampers their ability to increase the number of CMS-funded GME positions in the affected communities."

The letter to Tavenner points out that the proposed rule states that if an urban hospital begins to operate a rural training track at a rural hospital prior to the redesignation of that rural hospital as an urban facility, then the three-year period required to establish the complement of full-time equivalent resident positions could continue, thus setting the cap for the program.

However, the position cap limitation on the original urban hospital could only be used for counting residents training at the newly designed urban site for two years.

In other words, says the letter, "The original urban hospital has two years to either get the newly redesignated urban hospital to reclassify itself or set up a new training site in a rural area."

The letter points out that a newly designated urban hospital may well reject reclassification as a rural facility for financial reasons; urban facilities are paid more than their rural counterparts.

In addition, rural facilities do not receive "direct graduate medical education" payments for their residents, a situation the letter decries as a "serious financial limitation" for those rural facilities.

"Should the original training track site not wish to reclassify, the original urban hospital is caught in a Catch-22 position," says the letter. "If it wishes to establish training in another rural area, there is currently no recourse that allows the original urban hospital to grow its (resident) cap."

Interestingly, the letter points out that CMS wrote regulations in 2009 -- to which this same coalition of organizations objected -- that stated CMS could not classify any program as new if the program had the same program director, staff and hospital base as the original program.

The recent comment letter calls on CMS to completely rewrite portions of the proposed rule or, at the very least, "change its definition of 'new' under the authority the statute gives the (HHS) Secretary to 'give special consideration to facilities that meet the needs of underserved rural areas.'"

The organizations also took issue with CMS' assertion that the development of a new training site could be completed in two years.

"Typically, it takes three years for financial and operational planning" needed to establish a new site, says the letter. Multiple tasks such as hiring faculty and staff, creating on-call facilities, establishing educational activities and recruiting a new group of students to train at the site must be completed. In addition, it takes time to gain approval from the appropriate oversight organization to move a training site.

"We are concerned that CMS, in its rulemaking, has not given the issue of production of rural physicians enough consideration," says the letter. To bolster its case, the letter cites a recent study that shows only 4.8 percent of all graduates of 759 sponsoring institutions practiced in rural areas. Furthermore, of those 759 institutions, 198 produced no rural physicians.

The organizations note in their letter that this percentage compares unfavorably to the 19.3 percent of the population (about 62 million people, according to Kozakowski) living in rural American communities.

The five signatories had additional requests of CMS. Specifically, their letter urges CMS to

  • allow new programs in rural hospitals that have been redesignated as urban facilities to continue to complete their growth and cap-setting if they received their initial letter of accreditation prior to the redesignation,
  • impose the cap established in a program's fifth year for the cost-reporting period that follows -- rather than precedes -- the start of the sixth program year, and
  • adjust the calculations and timing of indirect medical education add-on payments made to teaching hospitals that are classified as sole community hospitals for the discharge of Medicare Advantage patients.

"We ask that CMS revise its regulations with respect to the establishment of 'new programs' to allow the increase in slots for rural training tracks that need to move their sites of training," says the letter in closing.

"We hope CMS will take to heart its authority to provide special consideration for underserved rural areas and will construct regulations that enhance institutions' ability to produce physicians who will practice in rural areas and serve underserved rural populations."