Academic medical centers (AMCs) across the country are on the front lines of the COVID-19 response. As the major safety net providers in many areas, AMCs are facing not only surging patient volumes but also significant pressure to stretch already limited resources. The educational mission of AMCs presents a unique challenge for these hospitals during the ongoing pandemic as they evaluate how best to utilize trainees to augment the healthcare workforce while complying with federal regulations and accreditation requirements.
The Centers for Medicare & Medicaid Services (CMS) recently released an interim final rule on policy revisions in response to the ongoing public health emergency. Among the policy revisions are several items specific to teaching hospitals and physicians, including:
- Allowing teaching physicians to meet the requirement for physical presence during patient care services via virtual means.
- Allowing teaching physicians to bill for services performed by residents, such as primary care evaluation and management, diagnostic test and imaging interpretation, and psychiatry services, as long as the resident is under direct supervision of the physician through virtual means.
- Permitting hospitals to claim resident time spent at home or in the home of a patient for direct graduate medical education and indirect medical education (IME) reimbursement purposes.
While the interim rule provides some regulatory relief for AMCs, additional action is needed to support these critical institutions. Outlined below are five key COVID-19 medical education advocacy topics for AMC leaders to champion.
1. Impact of Temporary Inpatient Bed Additions on IME Reimbursement
Under current regulations, the addition of inpatient beds may adversely impact IME reimbursement by diluting the intern- and resident-to-bed (IRB) ratio. The Greater New York Hospital Association and the Association of American Medical Colleges (AAMC) are advocating that CMS should not include temporary beds added in response to the ongoing COVID-19 pandemic in the denominator for the calculation of the IRB ratio for IME reimbursement purposes. Because the IME payment formula uses the lesser of either the current-year IRB ratio or the prior-year IRB ratio, this may impact not only the current fiscal year reimbursement but also the IME reimbursement for the following fiscal year. Teaching hospitals need to contact their representatives to join this advocacy effort.
2. Prioritizing Distribution of CARES Act Relief Fund
The AAMC is asking the Department of Health & Human Services to prioritize facilities based on a set of proposed criteria when determining the process, methodology, and funding levels for distribution from the CARES Act relief fund. The proposed criteria list includes:
- Historical experience managing care for highly complex patients, as demonstrated by:
- Case mix index.
- Patient transfers received.
- Number of intensive care unit beds.
- Care for financially vulnerable patient populations, as demonstrated by Disproportionate Share Hospital patient percentages or a comparable measure.
- Size, as demonstrated by number of beds.
- Number and complexity of COVID-19 patients.
Teaching hospital leaders can better position their organizations by advocating for additional criteria, such as major teaching status, IRB ratio, and/or resident FTE count, to also be included in determining priority for distribution of CARES Act funds.
3. Suspension of Resident FTE Cap-Building Period
A number of teaching hospitals around the country are working with their legislators to advocate that CMS temporarily suspend the five-year cap-building window for new teaching hospitals currently in the cap-building process. Health systems must evaluate their clinical training sites to determine if any are currently in the cap-building window and consider whether a temporary suspension would alleviate timing concerns in relation to setting the FTE cap.
4. Emergency Medicare GME-Affiliated Group Arrangements
Emergency Medicare GME-affiliated group arrangements permit hospitals to share cap space for residents displaced by a national emergency. Current regulations, enacted to help address training disruptions in the aftermath of Hurricane Katrina, allow such emergency affiliations only when the home hospital has seen a decrease in inpatient bed occupancy of 20% or more. Given the likely increase in occupancy under the pandemic, teaching hospitals need to push CMS to amend this requirement to remove the occupancy stipulations from the eligibility criteria. This would allow hospitals to redirect the resident workforce to support operations at hospitals facing patient surge volumes and transfer cap space to ensure reimbursement is available for that resident time.
5. Reimbursement for Early Medical School Graduate Support
Many medical schools are opting for early graduation of their fourth-year students to supplement the workforce. While the ACGME has advised that these early graduates should not matriculate into a PGY-1 position until the intended NRMP start date, there is an opportunity to utilize these trainees in a non-GME “medical worker” role. Each state is addressing the licensure of these providers differently. Federal Medicare GME reimbursement is not currently available to help cover the costs associated with employing the recent graduates as part of this special COVID-19 response team; table 1 highlights the reimbursement considerations.
July 1 and Later
Special COVID-19 response team
Currently not reimbursable
Eligible for Medicare GME reimbursement
Teaching hospitals need to advocate at the state and/or federal levels to be reimbursed for the costs associated with the employment of these recently graduated physicians as part of the COVID-19 response.
Medical education and AMC leaders must coordinate with their government relations offices and local, state, and federal representatives to recommend changes to current rules that will enable these critical institutions to lead the nation in responding to the COVID-19 pandemic.