MedPac estimated “x” was 2.7% for every 10% increased in resident to bed ratio They argue that teaching hospitals have lower cost growth than other hospitals AND Increase in resident to bed ratio does not necessarily result in higher costs. X remains at 5.5% despite med-pac recommendation IN FY 2003, IME payments counted for 2.5% of total medicare payments
“Inappropriate payments” including matching of state-funding dollars. As pressure on existing workforce strengthens, necessitating increased training of residents- must work to protect our medicaid funding.
Pays 0.5 FTE for every year thereafter (after 5 years have elapsed)
…if it incurs “all or substantially all” of training costs. ..because they do not incur all or substantially all of training costs. e.g. large local community hospital who pays for all resident costs while rotating at that hospital (food, salary fte contribution, malpractice) can get reimbursed by CMS, but smaller settings who do not provide these things but want residents may not be able to get residents to rotate there, because costs will have to be paid by home residency institution
Graduate Medical Education Reimbursement and Residency Funding
Graduate Medical Education
Reimbursement and Residency Funding
Erin E. Schneider, MD
Emergency Medicine Resident, PGY-2
Oregon Health and Science University
GME Funding- who pays?
• Centers for Medicare and Medicaid
• Veterans Administration (9%)
• Private Insurers
• Costs are separated into direct and
Direct vs. Indirect costs
• Direct Costs:
– resident salaries
– faculty supervision
• Indirect Costs: costs to hospital of training
- higher acuity patients
- state-of-the-art technology
- multiple learners creating inefficiency
- added staff
How are indirect costs reimbursed?
• Congress determines multiplier “X”
• Inpatient cost per case increases by “X” %
for every 10% increase in resident to bed
• “X” decreased 11.6% (1980s) to 5.5%
– MedPac recommended elimination of X
• Potential loss of $340 million per year
Report to the Congress: Medicare Payment Policy. March 2003. MedPac. P 56
Medicaid Funding in Jeopardy
• 2007: CMS proposed to eliminate
“inappropriate” payments to hospitals
• Issue may continue to arise in current
healthcare reform debates
• Potential place for resident advocacy
Resident Position Allocations
• CMS pays 1.0 FTE (full time equivalent)
for every resident up to 5 years of
• Balanced Budget Act of 1997 placed cap
on residency positions in the US
• Resulted in redistribution of residency
positions to rural/small urban areas
Outside EM rotations
• Hospital paid by CMS for residents
rotating at non-hospital settings
• Community outside rotations may get
reimbursed, but non-hospital settings (e.g
poison centers, some rural hospitals) do
EMRA Position Statement
• "EMRA will support current research and studies aimed
toward revising current Graduate Medical Education funding
mechanisms and work to change current Direct Medical
Education regulations that limit research and extramural
EMRA will work with other healthcare organizations to better
define the problem of Graduate Medical Education funding
and propose alternatives and solutions that may involve both
the public and private sectors.
EMRA opposes reductions in Medicare funding for Graduate
Medical Education at the Federal and State level and
supports diversified sources of funding that help meet the
overall goals of residency training.”
• Original policy adopted by Resolution Council, 5/08 9
• Multiple pressures to reduce payments
• Limitations on physicians does not reflect
expanded need of growing population
• Funding improvements and redistribution
needed for adequate training
• Fishman LE. Medicare Payment With an Educational Label: Fundamentals and the Future.
Washington, DC: Association of American Medical Colleges; 1996
• American College of Emergency Physicians Issue Paper: GME Funding. Updated 2007
CRS Report for Congress. Medicaid and GME funding.
http://aging.senate.gov/crs/medicaid8.pdf. Accessed January 8, 2008.
Ramano, M. Modern Healthcare. 2003. Vol. 33 Issue 40, p10.
Report to the Congress: Medicare Payment Policy. March 2003. MedPac. Pp 53-59
• http://www.medpac.gov/documents/Mar03_Entire_report.pdf. accessed December 28, 2008
Indirect Medical Education (IME). Center for Medicare and Medicaid Services.
http://www.cms.hhs.gov/AcuteInpatientPPS/07_ime.asp#TopOfPage, accessed December 22,
Medicare Indirect Medical Education Payments (IME).
http://www.aamc.org/advocacy/library/gme/gme0002.htm. Accessed January 28, 2009
Medicare payments for Graduate Medical Education: What Every Medical Student, Resident,
and Advisor Needs to Know. Association of American Medical Colleges 2006.
Securing Medicare GME funding for Outside Rotations. ACEP
• http://www.acep.org/practres.aspx?id=22488, accessed December 22, 2008.
“Public Law 110-252: Making appropriations for military construction, the Department of
Veterans Affairs, and related agencies for the fiscal year ending September 30, 2008, and for
other purposes.” (6/30/08; enacted HR 2642). Text from: United States Public Laws. Available
from: The Library of Congress; Accessed: 12/22/08.
Section X: Education and Professional Development - Securing GME Funding for Resident
Education. EMRA.org. Accessed 12/22/08