AAMC Comment Letter on Children's
Hospital Graduate Medical Education Program (CHGME) Final
Federal Register Notice
April 2, 2001
Barbara Brookmyer, M.D.
Deputy Director
Division of Medicine and Dentistry
Bureau of Health Professions
Health Resources and Services Administration
Room 9A-27
Parklawn Building
5600 Fishers Lane
Rockville, MD 20857
Re: Children's Hospitals Graduate Medical Education Payment
Program
Dear Dr. Brookmyer:
The Association of American Medical Colleges (AAMC) welcomes
this opportunity to provide limited comments on the Health
Resources and Services Administration's (HRSA or the Agency)
notice entitled "Children's Hospital Graduate Medical
Education (CHGME) Payment Program: Final Eligibility and Funding
Criteria and List of Eligible Hospitals and Proposed Methodology
for Determining FTE Resident Count, Treatment of New Children's
Teaching Hospitals, and Calculating Indirect Medical Education
Payment." 66 Fed. Reg. 12940 (March 1, 2001). The AAMC
represents over 400 major teaching hospitals, including both
free-standing children's hospitals and general acute hospitals
with large pediatric divisions. The Association also represents
all 125 accredited U.S. medical schools; 91 professional and
academic societies; and the nation's medical students and
residents.
The March 1 notice finalizes a number of issues that were
proposed initially in a June 19, 2000 Federal Register notice.
The March 1 notice also requests comments on determining the
full-time equivalent (FTE) resident count, the treatment of
new children's teaching hospitals, and the methodology for
indirect medical education (IME) payments.
I. The CHGME Program Should Emulate Medicare Principles
and Methodologies
Most importantly, as stated in our comments on the June 19,
2000 notice, the AAMC believes that, to the extent possible,
the CHGME program should emulate Medicare principles and methodologies
in distributing payments to children's teaching hospitals.
The Medicare direct GME and indirect medical education (IME)
methodologies are a time-tested means of allocating resources
for educating residents and compensating for the higher patient
care costs of teaching hospitals. The authorizing legislation
for the CHGME program recognized the value of this history
and methodology through numerous references to the Medicare
statute and regulations. Adopting Medicare principles and
methodologies would provide a firm foundation for the CHGME
program, as well as carry out the intent of the authorizing
legislation.
In addition, almost all children's hospitals receive some
level of Medicare funding. Adopting Medicare principles and
methodologies for the CHGME program would reduce the confusion
and the administrative burden that would result from having
vastly disparate DGME payment programs.
II. The National Average Per Resident Amount Used in the
CHGME Program
Direct GME payments under the CHGME program are based on
a national average "per resident amount (PRA)."
The March 1 notice states that the national average per resident
amount for hospitals with Medicare cost reporting periods
ending in federal fiscal year 1997 is $67,688. However, this
number has since been updated. According to Medicare Program
Memorandum A-01-38 (March 21, 2001), the correct national
average is $68,464.
III. Determining Resident Counts in the CHGME Program
We continue to believe that the CHGME program should use
the Intern and Residents Information System (IRIS) system
to validate resident counts. This system is used in the Medicare
program and, as such, it would help to ensure consistency
in resident counts across both the Medicare and CHGME programs.
We concur with comments that will be submitted by the National
Association of Children's Hospitals (NACH) that respond to
HRSA's concerns about using IRIS as well NACH's comments urging
the Agency to adopt the IRIS system.
The March 1 notice raises the issue of accounting for time
spent by a resident on required research (page 12944). In
accordance with our overall premise, we believe that the CHGME
program should follow Medicare's policies regarding counting
time spent by residents performing research activities.
For clarification purposes, the sentence on page 12945 stating
that the 5-year limit for counting residents as a full FTE
was established because it is "reflective of the minimum
number of years required for the resident to reach initial
board eligibility" is incorrect. Initial board eligibility
can be reached in as few as three years.
IV. The IME Methodology
As we stated in our comments last summer, the AAMC believes
that the IME methodology under the CHGME program should follow
Medicare inpatient IME policy as closely as possible. This
could be accomplished by replicating Medicare's IME formula
with only those modifications that are necessary because of
the fixed pool of IME funds available under the CHGME program.
It is important to reiterate that IME payments are intended
to compensate for the higher patient care costs that teaching
hospitals incur. These payments are in contrast to direct
GME payments, which are intended to compensate for the direct
resident education costs incurred by teaching hospitals.
The AAMC appreciates HRSA's recognition that, in addition
to the inpatient setting, teaching hospitals' patient care
costs may be higher in the outpatient setting. The Medicare
program currently does not provide for an "IME-type adjustment"
under its outpatient payment system. Rather than the Agency
conducing extensive research in this area to determine if
an adjustment is warranted, we believe the more appropriate
process would be for HRSA to encourage the Health Care Financing
Administration (HCFA) to address this issue as part of its
refinements to the Medicare outpatient payment system. The
CHGME program could then apply Medicare's decisions to its
own IME methodology. In the meantime, it is important to remember
that the intern/resident-to-bed ratio (IRB) used in the IME
formula includes residents being educated in hospital outpatient
departments, as well as those training in non-hospital sites
if the hospital incurs all or substantially all of the training
costs at that site.
The CHGME proposed IME methodology departs from the Medicare
formula in terms of IME payments for children's hospitals
with an average length of stay (ALOS) that is greater than
or equal to 30 days. The March 1 notice provides little information
to permit an assessment as to whether this adjustment, and
its underlying methodology, is appropriate. For example, it
is unclear why the adjustment factor is based on the ALOS
of the individual hospital divided by the average ALOS for
all hospitals with ALOS less than 30 days, rather than dividing
by 30 days. We recommend that HRSA provide more information
on this adjustment, including data on the differences in patient
care costs among institutions with greater than and less than
ALOS of 30 days.
In response HRSA's specific requests for comments on page
12949, we believe:
- Teaching intensity should be measured according to the
ratio of residents to beds, as defined under the Medicare
program; and
- The IRB ratio should be capped-again, consistent with
Medicare policies.
V. Conclusion
Thank you for this opportunity to present our views. We would
be happy to work with HRSA on the issues discussed above or
other topics that involve the academic health care community.
If you have questions concerning these comments, please feel
free to call Robert Dickler, Senior Vice President of the
Association, or Karen Fisher, Associate Vice President, both
of whom may be reached at (202) 828-0490.
Sincerely,
Jordan J. Cohen, M.D.
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