CMS proposed rule could cut funding for family medicine training

The Centers for Medicare and Medicaid Services has issued a proposed rule that could have a detrimental effect on family medicine residency programs. If finalized, the proposal will deny payment for time spent in non-patient care activities like didactic lectures for both Indirect Medical Education and Direct Medical Education in non-hospital settings, and for IME in hospital settings.

The comment period on this rule will close at the end of business on Monday June 12, so there is little time to act. AAFP’s Director of Government Relations, Kevin Burke, says it is imperative that the country’s family physicians respond en masse to this proposed rule. In this situation, unlike our alerts regarding Congress, volume is more important than individualized personal responses, so the Academy has put together a draft statement that you can cut and paste into the CMS electronic response system. The letter and a set of easy-to-follow instructions are below.

This matter is of great importance. Please take a moment to follow these instructions and make your voice heard. Feel free to distribute this material as widely and as quickly as possible. Thank you for your help on this important issue.

Comments are due by 4:00 pm central time, Monday, June 12, 2006

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Step-by-step instructions for sending the comment letter to CMS:

1. Go to www.cms.hhs.gov/eRulemaking.
2. Click on “Submit electronic comments on CMS regulations with an open comment period.” (toward the bottom of the page)
3. Click on “CMS-1488-P”
4. Click on "Submit Comments"
5. Input your identifying information using the "Individual" designation in the drop down box under *Category
6. Click on "Continue"
7. Click on "GME Payments"
8. Copy and paste the text below into the comment area.
9. Click on "Continue"
10. You can attach supporting documents in the format noted. If you are not attaching files, click on "Save Comments"
11. 11) A text box will appear noting that your comments have been submitted - this completes the process.

Paste the following seven paragraphs into the “GME payments” section described above:

NOTE: The space for submitting comments is limited. The following text will meet the requirements.

As a family physician, I appreciate the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS or the Agency) proposed rule entitled “Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates.” 71 Fed. Reg. 23996 (April 25, 2006).

I strongly urge CMS to rescind the language in the proposed rule that sets up an artificial dichotomy between resident training time spent in didactic activities and time spent in “patient care activities.” The effect of the proposed rule is to exclude medical resident time spent in didactic activities in the calculation of Medicare direct graduate medical education (DGME) and indirect medical education (IME) payments.

Background

The proposed rule cites journal clubs, classroom lectures, and seminars as examples of didactic activities that must be excluded when determining the full-time equivalent resident counts for all IME payments (regardless of setting), and for DGME payments when the activities occur in a nonhospital setting, such as a physician’s office or affiliated medical school. The stated rationale for the exclusion of this time is that the time is not “related to patient care”.

This position reverses the Agency’s position expressed as recently as 1999, at which time the Director of Acute Care wrote in correspondence that patient care activities should be interpreted broadly to include “scholarly activities, such as educational seminars, classroom lectures . . . and presentation of papers and research results to fellow residents, medical students, and faculty.” [September 24, 1999 Letter from Tzvi Hefter, Director, Division of Acute Care to Scott McBride, Vinson & Elkins]. I support the Agency’s 1999 position. The activities cited in the 1999 letter and cited again in this proposal are an integral component of the patient care activities engaged in by residents during their residency programs.

Residency Program Activities and Patient Care

I firmly believe that with the possible exception of extended time for “bench research,” there is no residency experience that is not related to patient care activities. The learning model used in graduate medical education (GME) is delivery of care to patients under the supervision of fully-trained physicians. Everything that a resident physician learns as part of an approved residency training program is built upon the delivery of patient care and the resident physician’s educational development into an autonomous practitioner.

To separate out CMS’s newly defined “patient care time” from didactic sessions in which general issues devolve to discussions of particular patients seems an exercise in futility. Moreover, as a family physician, I believe this policy would require additional staff that would be responsible for sitting in on each of these didactic sessions and keep count of patient care time. Such documentation requirements are unreasonable and would add an extremely large and unnecessary administrative burden.

I urge CMS to rescind its clarification in the proposed rule relating to the counting of didactic time for purposes of DGME and IME payments and recognize the integral nature of these activities to the patient care experiences of residents during their residency programs.