AAFP Fine-tunes Proposed Rule on GME, Rural Workforce

Measure Updates Problematic 2015 IPPS Policies

June 26, 2019 12:19 pm News Staff

A newly released proposed rule could clear a longstanding barrier and potentially increase the primary care workforce but needs further adjustment, the Academy recently told CMS.

[physician working at desk]

In a June 19 letter to CMS Administrator Seema Verma, M.P.H.,(2 page PDF) the AAFP praised a proposed policy change that would allow residents training in critical-access hospitals to be included in full-time equivalent counts for purposes of direct and indirect graduate medical education payments, but called on the agency to provide additional consideration for underserved rural areas and correct previous oversights when it releases its final determination.

The letter, which was signed by Board Chair Michael Munger, M.D., of Overland Park, Kan., was responding to CMS' 2020 Hospital Inpatient Prospective Payment Systems proposed rule(www.govinfo.gov) published in the May 3 Federal Register.

A previous iteration of the rule drew strenuous objection from the AAFP. The current proposal offers cause for some optimism, however, said the letter.

"The AAFP applauds and strongly supports the section of the proposed rule regarding graduate medical education related to critical-access hospitals," the letter said. "We are delighted to see that CMS proposes to define the term 'nonprovider' to include CAHs for the purposes of Section 5504 (of the Patient Protection and Affordable Care Act) and urge CMS to finalize the proposal.

"Doing so helps address Medicare reimbursement for residents' training time spent at CAHs, and we believe the proposed change will help better meet the health care needs provided in CAHs in rural America. This appropriate proposal removes an unnecessary barrier and, if finalized, would help increase the production of family physicians, particularly in underserved rural areas."

The Academy's letter called on CMS to consider three additional revisions to the rule that would benefit primary care:

Change the Effective Date

As written, the proposed CMS rule would be effective for cost-reporting periods beginning Oct. 1, 2019. Noting that some hospitals previously have been unable to claim FTEs for reimbursement under existing IPPS policy, the AAFP said that backdating the change would help institutions that otherwise stand to be "permanently and continually harmed" by the Oct. 1 date.

"We urge CMS to make the effective date fiscal year 2014," the Academy wrote, "especially since the proposed rule discusses how the agency has 'reassessed and agree with prior comments we have received …' and that it is 'important to support residency training in rural and underserved areas, including residency training at CAHs.'"

Revise the Cap-building Period

The Academy also asked CMS for another important timeframe adjustment to allow IPPS hospitals partnering with CAHs in rural residency programs to recalculate their cost reporting.

Such facilities still within a three-year "re-opening window" for cost reports, and for which a cap was set due to the end of the five-year cap-building period, should be allowed to recalculate their caps to include time spent by residents in CAHs, the letter said.

"Doing so would not require any changes or resubmission of cost reports would allow Medicare administrative contractors to recalculate the cap to include time spent by residents in CAHs and help remedy harm caused by previous CMS policy."

Allow Retrospective Claims for Training/Expenses

"The AAFP urges CMS to allow an IPPS hospital to claim CAH rotation time for unsettled cost reports in the 2013-2019 window should they wish and if the CAH agrees," the letter said.

This would afford further relief from the 2014 IPPS rule, which left many CAHs unable to claim allowable direct expenses related to residency training, additional resident training time and costs.

As written, the proposed rule retains problematic elements regarding reimbursement, the Academy warned.

"Since there are resident rotations at CAHs in the intervening time between October 1, 2013, and the present for which no IPPS hospital has claimed FTEs and for which no claims have been made by the CAH for direct educational costs, there are clear barriers to receiving payments based on incurred training costs," the letter said.

"If a CAH does not have the resources, financial or otherwise, to develop this payment mechanism, this new interpretation has the power to disrupt existing training relationships and discourage training in rural areas."

Related AAFP News Coverage
Rural Health Policy Institute
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(2/13/2019)

Rural Health Disparities Summit
Filling the Rural Gap With Good Recruiting, Telemedicine

(2/12/2019)

More From AAFP
Rural Health Care in Medical Education

Additional Resource
HealthLandscape Rural Health Explorer(www.healthlandscape.org)