AAMC Comment Letter on BBRA
Interim Final Rule
August 31, 2000
Nancy-Ann Min DeParle, Administrator
Health Care Financing Administration
Room 443-G
Hubert H. Humphrey Building
200 Independence Ave, SW
Washington, DC 20201
Attention: HCFA-1131-IFC
Dear Administrator Min-DeParle:
The Association of American Medical Colleges (AAMC) welcomes
this opportunity to comment on the Health Care Financing Administration's
(HCFA or the Agency) interim final rule with comment period
entitled "Medicare Program; Provisions of the Balanced
Budget Refinement Act of 1999; Hospital Inpatient Payments
and Rates and Costs of Graduate Medical Education,"
65 Fed. Reg. 47026 (August 1, 2000). The AAMC represents over
400 major teaching hospitals; all 125 accredited U.S. medical
schools; 91 professional and academic societies; and the nation's
medical students and residents.
This letter focuses on those provisions of the interim final
rule that relate to Medicare graduate medical education (GME)
policies. In particular, we will address:
- Medicare+Choice nursing and allied health educational
payments,
- Resident limit adjustments for rural training track programs,
- Resident limit expansions for rural hospitals, and
- Resident limit adjustments to account for residents on
leaves of absences.
I. Medicare+Choice Nursing and Allied Health Educational
Payments
The interim final rule implements the mandate in the Balanced
Budget Refinement Act of 1999 (BBRA) to provide additional
payments associated with Medicare+Choice enrollees to hospitals
that receive pass-through payments associated with nursing
and allied health professional education programs under Medicare's
fee-for-service (FFS) program. The additional payments will
be financed through reductions to the Medicare+Choice direct
GME (DGME) payments that teaching hospitals receive.
The interim final rule sets forth the methodology for calculating
and distributing the nursing and allied health Medicare+Choice
payments. About $26 million in additional payments will be
distributed for calendar year 2000 to hospitals that operate
nursing and/or allied health training programs. According
to the interim regulation, each hospital will receive a share
of this amount, based on its level of Medicare FFS pass-through
nursing and allied health education payments. The result of
this methodology is that a hospital will receive additional
payments regardless of whether it treats any Medicare+Choice
enrollees.
The AAMC agrees that teaching hospitals that operate nursing
and allied health education programs should receive payments
associated with Medicare+Choice enrollees. Although, we do
not believe these additional payments should be financed by
reducing DGME payments to teaching hospitals. We recognize,
however, that changing the financing source requires additional
legislative action.
We also believe the additional payments should be tied to
Medicare+Choice utilization, similar to the way that Medicare+Choice
DGME and indirect medical education (IME) payments are distributed.
While the language in the BBRA did not specifically articulate
this requirement, we believe it was the legislation's clear
intent, and that HCFA has the authority to implement a requirement
that hospitals must treat Medicare+Choice enrollees to receive
the additional payments. This intent is demonstrated by the
title of the BBRA section authorizing these payments: "Medicare+Choice
Nursing and Allied Health Professional Education Payments."
(BBRA section 541) (emphasis added). The BBRA conference report
reinforces this intent when it states that "[h]ospitals
that operate approved nursing and allied health professional
training programs . . .would receive additional payments to
reflect utilization of Medicare+Choice enrollees. .
." (BBRA Conf. Rept. 106-479) (emphasis added).
It is our belief that hospitals should receive nursing and
allied health education payments based on their share of Medicare+Choice
patient days. This would ensure a payment policy that is consistent
with Medicare's method for determining nursing and allied
health payments under its fee-for-service (FFS) program (payments
are based on a hospital's share of Medicare FFS patient days),
as well as ensure consistency with the calculation of Medicare+Choice
DGME payments, which also is based on a hospital's share of
Medicare days.
II. Resident Limit Adjustments for Rural Training Track
Programs
The interim final rule permits resident limit adjustments
for urban hospitals if they have rural track or integrated
rural track residency education programs in which at least
two-thirds of the training occurs in a rural area. The resident
limit adjustment for the urban hospital is based on the time
that the rural track residents spend at the urban hospital.
The preamble to the regulations sets forth a number of examples
to illustrate how the resident limit adjustments will be computed.
These scenarios are very informative and we appreciate HCFA's
efforts in developing them. However, in the final rule, we
would appreciate HCFA clarifying several details related to
the scenarios. Specifically, HCFA should clarify that resident
limit adjustments are permissible when rural track residents
train at both rural hospitals and rural nonhospital sites,
in addition to their urban hospital rotation (the preamble
scenario discusses only urban and rural nonhospital training
combinations). In addition, we would like clarification that
in situations in which rural track training occurs at an urban
hospital and rural nonhospital site, the urban hospital's
resident limit may be adjusted for the training time at the
urban hospital even if it does not incur "all or substantially
all" of the training costs at the rural nonhospital site.
III. Resident Limit Expansions for Rural Hospitals
The interim final rule implements the BBRA provision to expand
rural hospitals' DGME and IME resident limits by 30 percent.
The interim final rule also provides that an urban hospital
that meets specified criteria may be reclassified as a rural
hospital for purposes of receiving "payment under the
Medicare inpatient [PPS]." (65 Fed. Reg. at 47030).
In the final rule, HCFA should clarify that an urban hospital
that is reclassified as a rural hospital under 42 C.F.R. §412.103
is permitted to expand its resident limit by 30 percent. A
hospital's resident limit is a key component in the computation
of its IME and DGME payments. Consequently, resident limit
expansions fall clearly within the payment purposes for which
reclassification decisions apply.
IV. Resident Limit Adjustments to Account for Residents
on Leaves of Absences
A hospital's resident limit may be adjusted by up to three
additional residents if the residents were a) not included
in the 1996 base year count because they were on maternity
or disability leave or a similar approved leave of absence,
and b) were training in primary care programs.
To receive the adjustment, a hospital must submit a request
to its fiscal intermediary within 6 months of the publication
of the interim final rule (by February 1) that includes documentation
that the leave was approved by the residency program director
and that the resident returned to the program after the absence.
We believe that hospitals should be permitted to include
in their 1996 base year count residents that were on approved
leave of absences even if the residents never returned to
the program. The purpose of this provision is to allow hospitals
to include residents that would have been present for the
1996 count but for an unexpected circumstance that required
them to take a leave of absence. In some cases, these residents
may have been unable to return to the program, but this does
not change the fact that they otherwise would have been in
the 1996 count but for their leave of absence.
Thank you for this opportunity to present our views. We would
be happy to work with HCFA on any of 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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