Everything You Always Wanted

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• Everything You Always Wanted
• to Know About GME Funding(but were afraid to
  ask)
• Karen Broquet, MD
• Southern Illinois University
• School of Medicine
• Springfield, Illinois

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• Disclosure

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Key Points to Cover

• Brief Overview of GME Funding
• Understanding GME funding in your system
• Demonstrating the value of your program

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Medicare/CMS Funding

• Direct Medical Education Payments (DME)
• Indirect Medical Education Payments (IME)

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DME Payments

• Compensate teaching hospitals for costs directly
  related to training
• Stipend/benefits
• Faculty/supervisory costs
• GME office
• Based on local DME costs in 1985, updated
  annually by an inflation factor
• Huge regional variability in payments
• About 2.5 Billion in FY 2006

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DME payments

• Payment Formula
• of allowable resident FTEs X hospital specific
  per-resident amount X the Medicare bed ratio
• Allowable FTEs
• Fellows are .5 FTE
• Time spent on research in the hospital is
  allowable
• Time spent in ambulatory (non-hospital sites)
  settings may or may not be allowable

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IME Payments

• To recognize the higher patient care costs for
  teaching hospitals
• For every Medicare patient, the hospital receives
  an additional payment calculated as a percentage
  add-on
• Based on the federal IME adjustment and the
  hospitals intern-to-bed ratio
• Federal IME adjustment declining currently
  5.35
• IME payments /- 5 Billion in FY 06

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IME Payments

• IME payments to hospital double that of DME
  payments
• Hospitals can claim
• Fellows Residents
• Time spent in hospital
• May or may not claim ambulatory/didactic time
• Hospitals cannot claim
• Research time
• Time spent in other institutions

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BBA of 1997

• Introduced the cap CMS reimbursement frozen at
  position number in 1996
• Planned phased - in reduction of IME adjustment
• Very limited provision for new programs

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2002 Redistribution

• Hospitals under cap would lose 75 of unused
  positions
• Hospitals over cap could gain a limited number of
  positions
• Redistributed positions given an IME factor of
  2.5

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Things to know.

• Cant cost-separate service and education, UGME
  and GME
• Hospitals are under no obligation to
• Spend CMS GME dollars on GMEOR
• Limit GME support to CMS dollars

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Things to know

• CMS is not the only source of GME Funding
• According to the AAMC
• Medicare provided about 34 of DGME expenditures
  in 1996
• 50 of teaching hospitals are over cap
• 50 of teaching hospital are under cap

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1996 Medicare Final Rule (60 Federal Register
63124)

• The AAMC has always believed that the billing
  for services of a clinical fellow in his/her own
  name when the fellow is in an approved GME
  program generally is not permitted under
  currentguidelines. The new rule governing
  teaching physicians payment.clearly confirms
  this policy.
• Not claiming the fellow under Part A (i.e. DME
  payments) does not automatically make billing
  under Part B allowable.
• .very limited exceptions to this rule
• AAMC Memorandum 96-12
• March 1996

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Situations that allow billing for the services
of a fellow in his/her own name are

• Fellow not in an approved program
• Fellow in an approved program who is moonlighting
• Separate contract for moonlighting that clearly
  states services are outside the scope of training
• Must be a separate salary paid for services
• If at home institution, can be ER or OP only,
  not IP
• Must still comply with duty hour rules

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Fellow in Non-Provider Settings

• 3. A fellow in an approved program may bill
  regardless of whether the fellow is functioning
  within the scope of his/her GME program if
• 1) The fellow is in a non-provider setting
• and
• 2) The hospital does not count the fellows time
  spent in the non-provider setting for DME
• Whats a non-provider setting?
• State laws may still preclude Medicaid billing

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Do You Understand Your System?
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Do You Know

• Relationship between ACGME, AAMC and CMS
• Sponsoring Institution (ACGME)
• Teaching Hospital (CMS)
• Is your hospice part of your teaching hospital?
  (is it a provider setting?)

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Models of ACGME/CMS Relationships
Sponsoring Institution Teaching Hospital
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Models of ACGME/CMS Relationships
Sponsoring Institution
Teaching Hospital
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Models of ACGME/CMS Relationships
TH 2 Multiple Programs
TH 1 Multiple Programs
SI (SIU)
TH Single Program
TH Single Program
TH Single Program
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• Sponsoring Institution
• DIO
• GMEC Chair
• Other

• Teaching Hospital
• CEO
• COO
• DIO
• Other

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Do you know..

• Relationship between your SI and TH?
• Is your teaching hospital over or under cap?
• Is there a process for GME slot allocation in
  your system?
• Who makes the decision re GME funding?
• Who understands the ? (Who fills out the
  Medicare cost report?)
• Exactly what you need?

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Demonstrating the Value of Your Program
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Demonstrating Valueto your Chair/DIO

• Will PM fellows enhance
• the academic mission of the school/department/divi
  sion?
• other clinical services/departments?
• clinical revenue?
• recruitment of faculty?
• recruitment into IM or FM core residencies?

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Demonstrating valueto your teaching hospital

• How will PM fellows enhance
• Clinical revenues (decreases in LOS, ICU days,
  etc?)
• Clinical Outcomes
• Patient Satisfaction
• Staff (nursing) satisfaction
• www.capc.org
• Building a Program

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Demonstrating value

• Dont assume that others know what you know
• Know the mission of your hospital
• Opportunities for collaborative or
  multidisciplinary projects/grants
• Potentially big benefit for small investment
• Because its the right thing to do

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In Summary.

• GME Funding is a little complex
• Understand how your system works and who can tell
  you what you dont know
• Be ready to demonstrate your programs value