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

48-Month Curriculum

Pain Medicine — 3 months Clinical Anesthesiology — 24 months Critical Care Medicine — 6 months Anesthesia-related electives — 6 months

48-Month Curriculum

“At least 6 months of the first year of the 48-month 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?

UTMCK Transitional Year

Director — Medical Intensivist 9 positions

3 dedicated to Radiology3 uncommitted3 dedicated to Anesthesiology

Suggested Transitional Internship 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

Suggested Internal Medicine Emergency Room Medical Critical Care Anesthesia-Surgical Critical

Care General Surgery Obstetrics and Gynecology Pediatrics Electives

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

2003 SAAC

Convinced that 48-month curriculum would be implementedVerified by correspondence with experienced

Chairman Convinced that changes at UTMCK should

be started ASAP to prepare for 48-month curriculum

Implementation

Graduate Medical Education Informed 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

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

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

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)

Proposed 48 Versus Current

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

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

Pain Medicine (3) Clinical

Anesthesiology (24) Critical Care Medicine

(6) Anesthesia-related

electives (6)

Pain Medicine (2) Clinical

Anesthesiology (26) Critical Care Medicine

(5) Anesthesia-related

electives (5)

How to Fund

DGME IME Medicaid DGME/IME

Direct Graduate Medical Education Payments (DGME) 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 yeardirect cost

per resident

InflationNumber of Residents

MC Inpatient Days÷

Total InpatientDays

X X X

Hospital-Specific Direct Cost

Result of HCFA audits of GME base-year costsCoincided with teaching hospital’s fiscal year

1984 or 1985HCFA audits conducted in 1989 or 1990

Range from <$20,000 to >$100,000 Average $42,000

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

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

Resident Limit Policy

2002 Medicare hospital cost reports 46% of teaching hospitals under the “cap” 44% of teaching hospital over the “cap”

Congress’s intent is to redistribute “unused” resident limit slots

Complex regulations proposed Cannot “count on” increased slots for the 48-

month curriculum expansion

Indirect Graduate Medical Education Payments (IME) 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 actsCOBRA, OBRA, BBA, BBRA, & BIPA

IME Calculation

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

DGME/IME Funding

Indirect Medical Education UTMCK 164.69 FTEs

Direct Medical Education 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

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 "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 "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

“ 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 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 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

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

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

"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

“…..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

“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” CMS “Demonstrated Likelihood” Criteria

Will use the slots for a new program Will 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 10-point evaluation criteria to stratify hospital

requests

How to Fund: Phagocytosis

“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