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AAMC Submits Comments on 2011 Medicare Hospital Outpatient Proposed Rule, Including GME Proposals

September 10, 2010—The AAMC Aug. 31 submitted two comment letters to the Centers for Medicare and Medicaid Services (CMS) on the calendar year (CY) 2011 proposed rule for the Medicare hospital outpatient prospective payment system (OPPS). The first is on the direct graduate medical education (DGME) and indirect graduate medical education (IME) provisions required by the Affordable Care Act (ACA) included in the proposed rule, and the second is on the CY 2011 OPPS proposed rule.

In its comment letter regarding CMS's proposed implementation of ACA provisions affecting DGME and IME payments, the AAMC emphasized that while these policy changes are important steps toward promoting flexible policies that will help hospitals as they seek to have residents spend time in ambulatory training sites, they are but incremental steps that do little to address such problems as the nationwide physician shortage or the unjustified exclusion of certain didactic and research DGME and IME time from hospital resident counts. To this end, the AAMC encouraged CMS to adopt a policy of counting any and all time residents spend as part of accredited residency programs within the teaching hospital setting and at nonhospital sites and also urged CMS to work with Congress to lift the resident caps.

In response to specific regulatory proposals, the AAMC recommended that CMS reevaluate the agency's proposed requirements for reporting time in nonhospital sites (and comparing this time against a base year) to eliminate administrative burden. The AAMC also encouraged CMS to clarify what documentation is required when resident stipends and benefits are paid as part of global agreements. With respect to resident time spent in didactic training, research, and on approved leave, the AAMC's recommendations included that CMS should clarify the one-day rule for didactic time and adopt a true one-day threshold for didactic and research time, permit hospitals to count time residents spend on projects to improve patient care quality and safety, and leave the division of vacation time among hospitals to the hospitals' discretion.

With respect to the unused resident slot redistribution program, the AAMC recommended, among other things, that hospitals over their resident caps in any one year of the three-year look-back period should be exempt from resident cap reductions, that CMS should perform the initial cap-count comparison for hospitals in affiliated groups at the aggregate level, and that CMS extend the deadline for hospitals to apply for new slots under the program. Finally, with respect to the closed hospital slot redistribution program, the AAMC urged CMS to extend the initial application deadline, to publish a list of closed hospitals in the final rule, and to clarify various requirements for qualifying for residency slots.

In its comment letter on the proposed changes to the CY 2011 OPPS payment rates, the AAMC urged CMS to finalize the proposal to pay for separately payable drugs and biologicals at the average sales price (ASP) plus 6 percent until CMS establishes a more precise methodology for determining the acquisition and overhead costs of these products.

The letter also supported an adjustment for cancer hospitals, but recommended that the proposed methodology be modified so as to better reflect the transitional outpatient payments (TOPs) that these hospitals currently receive.

The AAMC also commented on the various quality provisions included in the proposed rule.


Jennifer Faerberg, MHSA
Director, Clinical Transformation Unit
Telephone: 202-862-6221

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