Transcript Slide 1

Integration of a
Transitional Year
J. L. Epps, M.D.
Chairman, Department of
Anesthesiology
RRC for Anesthesiology and
ACGME
“ A specific 48-month curriculum in graduate
medical education is necessary to train a
physician in anesthesiology. The RRC for
Anesthesiology and the ACGME accredit
programs only in those institutions that possess
the educational resources to provide the 48
months of training within the parent institution or
in combination with integrated or affiliated
institutions.”
48-Month Curriculum
Internal Medicine, General Surgery,
Neurology, Obstetrics and Gynecology,
and/or Pediatrics — 6 months
 Emergency Medicine — 1 month
 Preoperative Medicine — 1 month
 PACU Medicine — 1 month
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48-Month Curriculum
Pain Medicine — 3 months
 Clinical Anesthesiology — 24 months
 Critical Care Medicine — 6 months
 Anesthesia-related electives — 6 months
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48-Month Curriculum
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“At least 6 months of the first year of the 48month curriculum must include training in
internal medicine, general surgery, obstetrics &
gynecology, pediatrics, emergency medicine,
and/or neurology. Surgical Anesthesia, Pain
Medicine, and Critical Care Medicine should be
distributed throughout the curriculum to provide
progressive responsibility”
Incorporation of the Transitional
Year into the Residency
How to implement?
 How to fund?
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UTMCK Transitional Year
Director — Medical Intensivist
 9 positions
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3
dedicated to Radiology
 3 uncommitted
 3 dedicated to Anesthesiology
Suggested Transitional
Internship
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Internal Medicine (3 months)
Emergency Room (1 month)
Medical Critical Care (1 month)
Anesthesia-Surgical Critical Care (1 month)
General Surgery (2 months)
Obstetrics and Gynecology (1 month)
Pediatrics (1 month)
Electives (2 months)
Transitional Internship
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Suggested
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Internal Medicine
Emergency Room
Medical Critical Care
Anesthesia-Surgical Critical
Care
General Surgery
Obstetrics and Gynecology
Pediatrics
Electives
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Actual
 Internal Medicine
 Emergency Room
 Medical Critical Care
 Dermatology
 Radiology
 Endocrinology
 Cardiology
 Pediatric Clinic
 Electives
UTMCK Anesthesiology
Residency
7 residents per year
 Match for 6 through ERAS
 Reserve 1 position to fill “outside the
Match”
 3 - 5 ‘matched’ medical students desire
internship at UTMCK
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2003 SAAC
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Convinced that 48-month curriculum would
be implemented
 Verified
by correspondence with experienced
Chairman
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Convinced that changes at UTMCK should
be started ASAP to prepare for 48-month
curriculum
Implementation
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Graduate Medical Education
 Informed
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Dean of proposed changes
Arranged meeting with Chief Medical
Officer, Chairman of Internal Medicine,
Chief of Medical Critical Care, and the
Director of the Transitional Internship
Negotiations
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Offered one resident per month for Medical
Critical Care Coverage
Received a guarantee of 4 anesthesiology
transitional internship positions in 2004 and 5
positions in 2005
All anesthesiology residents must follow a
rotation schedule approved by the Transitional
Internship and Anesthesiology Program
Directors
Transitional Internship
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Internal Medicine (3 months)
Emergency Room (1 month)
Medical Critical Care (1 month)
Anesthesia-Surgical Critical Care (1 month)
General Surgery (2 months)
Obstetrics and Gynecology (1 month)
Pediatrics (1 month)
Electives (2 months)
Further Negotiations
Offered two more internships as ‘modified’
surgical by Program Director for General
Surgery
 Helped the General Surgery Residency
comply with 80-hour work week limitations
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Modified Surgical Preliminary
Year
Emergency Room (1 month)
 General Surgery (5 months)
 Internal Medicine (3 months)
 Medical Critical Care (1 month)
 Surgical Critical Care (1 month)
 Elective (1 month)
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Proposed 48 Versus Current
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Internal Medicine,
General Surgery,
Neurology, Obstetrics and
Gynecology, and/or
Pediatrics — 6 months
Emergency Medicine — 1
month
Preoperative Medicine —
1 month
PACU Medicine — 1
month
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Internal Medicine (3),
General Surgery (2),
Obstetrics/Gynecology
(1), and Pediatrics (1) —
7 months
Emergency Medicine — 1
month
Preoperative Medicine —
1 month
PACU Medicine — 1
month
Proposed 48 Versus Current
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Pain Medicine (3)
Clinical
Anesthesiology (24)
Critical Care Medicine
(6)
Anesthesia-related
electives (6)
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Pain Medicine (2)
Clinical
Anesthesiology (26)
Critical Care Medicine
(5)
Anesthesia-related
electives (5)
How to Fund
DGME
 IME
 Medicaid DGME/IME
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Direct Graduate Medical Education
Payments (DGME)
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DGME covers the direct costs of resident
education such as resident and faculty
salaries, salaries of support staff and other
expenses directly incurred by the
Graduate School of Medicine
DGME Calculation
Hospital-specific
base year
direct cost
per resident
X
Inflation
X
Number of
Residents
MC Inpatient Days
÷
X
Total Inpatient
Days
Hospital-Specific Direct Cost
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Result of HCFA audits of GME base-year
costs
 Coincided
with teaching hospital’s fiscal year
1984 or 1985
 HCFA audits conducted in 1989 or 1990
Range from <$20,000 to >$100,000
 Average $42,000
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Hospital-Specific Direct Cost
Range reflects the differences in
accounting for GME costs among teaching
hospitals & the various organizational
arrangements between hospitals,
physicians, and medical schools
 Inflation factor applied to primary care
residents only
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BBA of 1997
Balanced Budget Act of 1997 (BBA)
limited the number of residents that
teaching hospitals could count for
determining DGME and IME
 In general, the resident limit still remains
the number of allopathic and osteopathic
residents noted in the hospital cost report
to CMS on 12/31/96
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Resident Limit Policy
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2002 Medicare hospital cost reports
 46%
of teaching hospitals under the “cap”
 44% of teaching hospital over the “cap”
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Congress’s intent is to redistribute “unused”
resident limit slots
Complex regulations proposed
Cannot “count on” increased slots for the 48month curriculum expansion
Indirect Graduate Medical
Education Payments (IME)
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IME payments capture the “indirect” cost to the
hospital incurred in supporting a graduate
medical education program
Based on calendar year
Increase due to changes in the Medicare
Prescription Drug, Improvement and
Modernization Act of 2003 (MMA)
 UTMCK
$1.2 million dollars
IME Calculation
I.89 [(1 + {# residents/# beds}).405 -1]
X
TOTAL DRG Revenues
IME Calculation
11.59% add-on to each DRG rate for every
10% increase in in a teaching hospital’s
resident-to-bed ratio (1984)
 Subsequently affected (decreased) by
multiple budgetary legislative acts
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 COBRA,
OBRA, BBA, BBRA, & BIPA
IME Calculation
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COBRA reduced IME to 8.1%
OBRA reduced IME to 7.7% in 1989
BBA reduced IME to 6.5% for 1999, 6%in 2000,
& 5.5% in 2001
BBRA delayed the decrease to 5.5% for one
more year
BIPA restored IME to 6.5% until FY 2003
Currently 5.5%
Medicaid DGME/IME in 2002
47 states & DC provided DGME/IME
under Medicaid
 @ ½ states & DC made payment explicitly
and directly to teaching hospitals
 Some link payments influence physician
workforce
 @ $2.5 -2.7 billion
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DGME/IME Funding
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Indirect Medical Education
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Direct Medical Education
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UTMCK 164.69 FTEs
UTMCK 155.16 FTEs
Some residents exceeded their initial residency period
Only receive 0.5 FTE if training exceeds the time allotted
for the initial residency period (IRP)
Lowers their weight in the DGME count but not in the
IME count
Initial Residency Period
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Used to determine DGME
Based upon the specialty of the first year of
postgraduate training
Residents counted as 1 FTE during the number
of years required to become board-eligible
No resident can be counted as 1 FTE for more
than 5 years
Counted as 0.5 FTE for training after the IRP
CMS Comments in the Federal
Register May 18, 2004
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"There are numerous programs, including
anesthesiology, dermatology, psychiatry, and
radiology, that require a year of generalized
clinical training to be used as a prerequisite for
the subsequent training in the particular
specialty. For example, in order to become
board eligible in anesthesiology, a resident must
first complete a generalized training year and
then complete 3 years of training in
anesthesiology.”
CMS Comments in the Federal
Register
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"This first year of generalized residency training
is commonly known as the "clinical base year.''
Commonly, the clinical base year requirement is
fulfilled by completing either a preliminary year
in internal medicine (although the preliminary
year can also be in other specialties such as
general surgery or family practice), or a
transitional year program (which is not
associated with any particular medical
specialty)."
CMS Comments in the Federal
Register
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“ Current CMS policy is that the initial
residency period is determined for a
resident based on the program in which
he or she participates in the resident's
first year of training, without regard to
the specialty in which the resident
ultimately seeks board certification.”
CMS Comments in the Federal
Register May 18, 2004
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Therefore, for example, a resident that chooses
to fulfill the clinical base year requirement for an
anesthesiology program with a preliminary year
in an internal medicine program will be "labeled''
with the initial residency period associated with
internal medicine, or 3 years (3 years of training
are required to become board eligible in internal
medicine), even though the resident may seek
board certification in anesthesiology, which
requires a minimum of 4 years of training to
become board eligible
CMS Comments in the Federal
Register May 18, 2004
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As a result, this resident would be
weighted at 0.5 FTE in his or her fourth
year of training for purposes of direct GME
payment."
Interpretation of CMS Comments
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If a resident participates in a transitional
preliminary year program prior to the start
of an anesthesiology residency,
DMGE/IME funding for four years will be
available because the IRP is based upon
the specialty in which the resident will be
training i.e. anesthesiology
Interpretation of CMS Comments
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If, however, a resident completed a preliminary
year in Family Practice, his initial residency was
considered “Family Practice" even though the
resident “matched” in an anesthesiology
program. Only three years of DGME funding
would be available because Family Practice is
considered a 3-year residency. Only 50% of the
direct GME payment would be available to “fund”
the fourth year of post-graduate medical training.
CMS & Federal Fiscal Year 2005
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"To address these concerns, CMS is
making final the change in policy that
addresses “simultaneous match”
residents. Specifically, if a hospital can
document that a particular resident
matches simultaneously for a first year of
training in a clinical base year in one
medical specialty, and for additional
year(s) of training in a different specialty
program,
CMS & Federal Fiscal Year 2005
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“…..the resident's initial residency period
would be based on the period of board
eligibility associated with the specialty
program in which the resident matches for
the subsequent year(s) of training and not
on the period of board eligibility associated
with the clinical base year program, for
purposes of direct GME payment.”
CMS & Federal Fiscal Year 2005
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“In addition, CMS is considering a new
definition of “residency match” to mean, for
purposes of direct GME, a national
process by which applicants to approved
medical residency programs are paired
with programs on the basis of preferences
expressed by both the applicants and the
program directors."
How to Fund: Increase in the
Resident “Cap”
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CMS “Demonstrated Likelihood” Criteria
 Will
 Will
use the slots for a new program
use the slots for additional residents due to a
residency program expansion
 The hospital’s resident count exceeds its
corresponding cap
 Residency program at risk of losing accreditation
because of insufficient residents
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10-point evaluation criteria to stratify hospital
requests
How to Fund: Phagocytosis
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“Engulf and incorporate”
Designate internship positions at the teaching
hospital where the residency is based as PGY-1
anesthesia slots
Paramount importance to foster cooperation
between program directors and the GME
department of the teaching hospital
UTMCK: five transitional positions are ‘slotted’
for our program; will increase to 6