Many have had questions about how to work with the NRHA (and other related groups and organizations) to make things happen. The following is a call for those interested. The following link will take you to current events.

To: NRHA Membership

Re: 2003 Legislative and Regulatory Agenda

This fall, the National Rural Health Association will begin the process of establishing its 2003 legislative and regulatory agenda. Potential agenda items are reviewed within the Government Affairs Committee, and proposed to the NRHA Board of Trustees for approval. To begin this process, we are soliciting input from all NRHA members for inclusion in our 2003 agenda. The current legislative and regulatory agenda can be viewed at: http://www.nrharural.org/pagefile/na.html . The strength of NRHA is its diversity in the field of rural health. Please make us aware of additional policy issues that NRHA should be addressing on behalf of all rural Americans in our 2003 agenda. Please forward comments to: briggs@NRHArural.org

Thank you for this update. Can you tell me if there are any provisions in the NRHA health policy portfolio to encourage legislation or regulation to influence medical schools to favor rural medical educational programs (admissions, rural tracks, and residency) modeled after ones that have been shown to produce rural primary care physicians? (Seems that I remember a NRHA statement from the early 90's that promoted the use of educational resources in institutions whose missions favored rural medical education. Anything new?)

John Wheat, MD, MPH    jwheat@cchs.ua.edu

The RME is to have two policy papers ready by the Nov NRHA policy meeting.
It is best to have them out by October. They will be reviewed and suggestions given.
Byron Crouse, Mike French and Ken McBain are to work on the pipeline paper which will have the planks in it to advocate for particular areas that they see as pertinent. James Buechler, and his group are to get the one on GME together. NRHA staff wrote a draft. The definition has been a sticking point but the definition pertains more to RRC and CMS regulatory interpretation.

A status report on these papers would be appreciated.
Thanks
Debbie                Debra Phillips dphilli@adams.net

Good question, thanks.

The Medicare and Rx drug bill (H.R. 4954) passed by the House of
Representatives this summer included the following:
Priority for hospitals located in rural or small urban areas in
redistribution of unused graduate medical education residencies.

The following are items from the current Legislative and Regulatory
Agenda:

Training Rural Health Care Providers
The Quentin Burdick Rural Interdisciplinary Training Grant Program
operated by the Bureau of Health Professions, Health Resources and
Services Administration (HRSA), should be expanded. Other funded
training programs of HRSA should be encouraged to increase
interdisciplinary training. L

Ambulatory care entities that train health professions students and
residents should receive reimbursement for indirect, as well as direct,
costs of training. Such reimbursement will require development of a new
formula for estimation of the indirect costs of training in the
ambulatory setting, apart from those used to support other aspects of
the academic medical center. L/R

Rural ambulatory sites eligible for graduate medical education
reimbursement through Medicare should be broadly defined. L/R

Urban or other teaching hospitals sponsoring rural training tracks
should be allowed to recover costs through Medicare whenever they bear
all or substantially all of the costs of resident education, including
when residents are located at hospital sites that do not claim direct
and/or indirect costs through Medicare. L/R

The NRHA supports the Department of Health and Human Services removal of
the "cap" on residency positions for rural programs located in rural
locations. The cap was based upon 1996 resident FTE's, at which time
family physician residencies, the trainers of most physicians who
provide care in rural areas, were already spending significant
percentages of time in ambulatory care. That ambulatory time was
excluded in the base year count, with the net result that the very
programs leading the way in ambulatory training and in preparing doctors
for rural practice, are ever afterwards penalized by failure to
reimburse for a significant percentage of residents, unless program size
is reduced.

The Department of Health and Human Services should permit institutions
designated as "sole community providers" to obtain Indirect Medical
Education (IME) reimbursement from Medicare. This existing prohibition
discourages participation in graduate medical education (GME) when these
programs are among the most effective in placing graduates in rural
practice.

If you have other items to add, please send them to me.
Thanks.

Hello all, I would like to clarify a couple of points that I'm sure many of you are aware of, but nonetheless seem to be unclear in the preceding emails. I apologize in advance if I have misunderstood anything or taken anything out of context. First, the preceding emails seem to indicate that sole community hospitals (SCHs) cannot be reimbursed by Medicare for IME. However, this is only true under certain  circumstances. In fact, the existing regulations at 42 CFR 412.92 do allow SCHs that train residents and that are reimbursed under the applicable Federal rate to receive IME payments. For SCHs that had a GME program in its base year, and are paid based on the hospital-specific rate (HSR), its HSR already reflects the "indirect" higher costs of operating a GME program. However, when the costs of a residency program are not included in the SCH's base year costs, and the SCH is subsequently reimbursed on the HSR, the HSR cannot, under the Medicare statute, be adjusted to include payments for IME.

Second, the preceding emails indicated that only teaching hospitals can receive IME and if the residents go out to a rural hospital, the rural hospital cannot claim the IME and are reimbursed instead by the urban hospital. This is incorrect. Rural hospitals are hospitals too! All Medicare-participating hospitals paid under the Inpatient Prospective Payment System (PPS), regardless of whether they are urban or rural, may receive IME payments for the portion of the training time in which they train those residents. The same applies for direct GME payments. Each hospital, urban or rural, at which the residents train may claim the FTE training time for both direct GME and IME, regardless of who is incurring the training costs and regardless of who holds the sponsorship for the program. We have often heard people speak of rotations occurring at "non-teaching hospitals," but by virtue of the fact that residents in an approved program are rotating and training at a hospital, from the perspective of Medicare, the hospital is by definition a teaching hospital.

In a similar vein, in fact, under Federal Law and the regulations at 412.105(f) for IME and at 413.86(f) for direct GME, a hospital (urban or rural) cannot count the FTE time spent by residents at another hospital. Only the hospital where the residents are actually training can count those FTEs for that portion of time. Thus, generally, if a resident spends 9 months at Hospital A and 3 months at Hospital B, then A counts .75 FTE and B counts .25 FTE for both IME and direct GME.

We understand that there are some instances where an urban hospital may incur all the training costs of residents while the residents go out to train in a rural hospital, because the rural hospital does not have the resources or the infrastructure to claim those residency costs and FTEs on a Medicare cost report. However, even in this scenario, the urban hospital is precluded from claiming any FTEs for direct GME and IME for the proportion of time spent training at the rural hospital, or at any other hospital. However, we also understand that millions of dollars have been lost from rural hospitals because they do not file data for GME payments on their Medicare cost reports and thus, do not claim their fair share of Medicare IME and direct GME reimbursement. Rural hospitals, along with urban hospitals, are equally entitled to receive their fair share of IME and direct GME reimbursement, regardless of who incurs the cost of training at that hospital. (I note, however, that when residents train in nonhospital settings, such as clinics and physician practices, there is an obligation to incur the training costs in order for a hospital (urban or rural) to count the training time for IME and direct GME purposes--413.86(f)(4)).

That's all for now. Thanks
Miechal (Michelle) Lefkowitz, CMS
"Miechal Lefkowitz" <MLefkowitz@cms.hhs.gov>