Alternative GME Funding. Thomas Mohr, D.O., FACOI Vice Dean RVUCOM Executive Director/CAO RMOPTI

Transcription

1 Alternative GME Funding Thomas Mohr, D.O., FACOI Vice Dean RVUCOM Executive Director/CAO RMOPTI

2 Objectives Share ideas and promote discussion on potential methods for funding GME programs when federal funding is not available or is insufficient.

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4 Primary Sources of Funding Medicare Medicaid Ventrans Affairs Department of Defense Burea of Health Professions Other Young JQ, Coffman JM. Overview of graduate medical education. Funding streams, policy problems, and options for reform. West J Med. 1998;168(5):

5 Current CMS Funding System Accountability for Costs? Accountability for workforce issues? Does the system meet the Public Good? Medicare Payment Advisory Commission. Report to the Congress: Improving Incentives in the Medicare Program. Available at:

6 AMA Center for Transforming Medical Education 2010 Summit State level physician data is essential to show the need to expand GME in underserved areas throughout the US Additional sources of GME funding must be identified and current sources must be preserved Innovative methods to distribute GME funds in states and regions must be developed. Flexibility in GME training methods, venues, and sites will be required to meet future patient need.

7 SELF FUNDED GME PROGRAMS

8 Case Study #1 Dermatology Group Dedicated to teaching Approached COM for help No options for hospital ownership One hospital capped at 2 slots Other hospital Virgin but in major transition Docs willing to pay out of pocket for all expenses

9 Case Study #1 Issue #1: CEE Concerned about PD personally funding residency no check and balance Issue #2: No Educational Infrastructure Solution: Have the COM own and operate the program and invoice for all costs COM provides infrastructure, oversight, DME DME is also the OPTI Director

10 Case Study #2 Largest Private Neurosurgical Group in Suburbs Full spectrum of services with large patient base Three hospitals Surgeons all previous faculty for GME Strong desire to start community based GME Understand financial motivations Cost of surgical Pas versus resident salaries

11 Case Study #2 Group not tied to one facility need all 3 to maintain appropriate numbers for program 1 hospital with new GME under the cap 1 hospital capped at 2 1 hospital virgin but no interest in running GME Approached COM to operate the program They will fund all expenses out of pocket Currently under feasibility review

12 PARTIAL CMS/SELF FUNDED MODEL

13 Case Study #3 For Profit Psych Hospital with 2 sister hospitals all virgin for GME Over 300 beds total Strong interest in teaching DO as Medical Director Agreed to take ALL 3 rd year core rotations Agreed to teach 2 nd year Behavioral Med Course

14 Case Study #3 Issue #1: Medicare Utilization Rate 1/3 Pediatric, 1/3 Adult, 1/3 Geriatric Projected CMS $30K per resident/year (Generally need $100K $150K for viable program) Solution Hospital pays the overage Offset by night/weekend call coverage Offset by recruiting expenses for corporate office Offset by COM teaching stipends & support Potential state funding?

15 COM OWNERSHIP WITH CMS FUNDING PASS THROUGH

16 Case Study #4 250 bed virgin GME hospital Large for profit system Local administration willing to host GME, but refuses to own and operate programs Want the benefits without the financial risks Closest hospital to COM and important partner

17 Case Study #4 Issue: Hospital will not move forward without assurance of NO financial risk Projected to be profitable, but concern about future changes in CMS funding Solution: COM owns and operates the program and employs the trainees with 5 year rolling agreement to host training at hospital Hospital agrees to pass through all funds to the COM. COM controls the expenses and will accrue the profit Both agree to a teach out if program must close

18 TRADITIONAL CMS FUNDING WITH ADDITIONAL FEDERAL GRANT

19 Case Study #5 350 bed private non profit virgin GME hospital Strong admin and physician support for developing GME High Medicare Utilization Rate MUC, HPSA, MUA with rural ties

20 Case Study #5 Planned to launch program anyway Poised for HRSA Grant Postdoctoral Training in Primary Care Grant Funded for 5 years at over $770,000 Hospital foundation also provided an additional $1M grant for start up costs

21 HRSA Training Grants Usually come out in summer with SHORT time to due date Must prepare in advance Funding NOT set for next year

22 Residency Training in Primary Care Grant Purposes Plan, develop, and operate or participate in an accredited residency or internship program in the field of family medicine, general internal medicine, general pediatrics and/or combined internal medicine and pediatrics ( med peds ) for medical students, interns, residents, or practicing physicians as defined by the Secretary; Provide need based financial assistance in the form of traineeships and fellowships to medical students, interns, residents, practicing physicians, or other medical personnel who are participants in any such program, and who plan to specialize or practice in the fields of family medicine, general internal medicine, general pediatrics or combined internal medicine and pediatrics ( med peds ); and Plan, develop, and operate a program for the training of physicians teaching in community based settings.

23 Objectives of Our Grant Create a new educational infrastructure at Parkview Medical Center including a new Office of Graduate Medical Education, dedicated educational facilities, professional staff and support staff. Plan, develop, and implement a new primary care general internal medicine curriculum and matriculate high quality residents. Implement structured curriculum components and training experiences in rural and community medicine that focus on community oriented primary care, behavioral medicine, physicianpatient communications, and the special needs of medically underserved populations Implement structured Faculty Development curriculum in Cultural Competence and Health Literacy.

24 Helpful Hints for HRSA Grants Get help from someone who knows HRSA grants being a HRSA reviewer helps Pay close attention to funding priorities Remember, it more about what HRSA wants to see than what you want to do Watch eligibility requirements and page limits Violators will be sent back unread Grant guidance and technical support calls are key to determining what s important to HRSA

25 Helpful Hints for HRSA Grants Start BEFORE the grant guidance come out Get a DUNS number if you don t have one Register for Grants.gov Use last year s and hope it doesn t change much The Feds may decide not to fund the program If Approved but not Funded submit again Address any points the reviewers mention

26 COMMUNITY BASED TRAINING WITH TEACHING HEALTH CENTER GRANT

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28 Eligible Entities Federally Qualified Healthcare Centers Community Mental Health Centers Rural Health Clinics Indian Health Services Indian Tribe or Organization GME Consortium/OPTI Collaborating with Health Center & Hospital Goals must include high quality training in teaching health centers and demonstration of new models for community based GME.

29 Funding for THCs THC GME payments support: Direct expenses associated with sponsoring approved GME program Indirect expenses associated with the additional costs of GME. As directed by the THC GME statute, the Secretary will determine GME payments based on the estimation of direct medical education (DME) and indirect medical education (IME) costs for THC residency programs. The Affordable Care Act establishes the direct GME payment mechanism. Consistent with the statute, the indirect cost formula will be determined by the Secretary of Health and Human Services. Funding supports the costs of new residents in a newly established THC or an expanded number of residents in an existing THC. The baseline number of residents for an existing THC is the number of residents enrolled during the academic year prior to the funding request. Funding will only be available to support residents trained above this baseline. Ask for $150,000 per resident

30 Case #6 FQHC with 20 outpatient centers No residency training affiliations Expecting a 30 40% increase in patients with PPACA and cannot recruit sufficient doctors to Meet the projected needs. Utilizing physician extenders to a great extent But would rather grow their own docs.

31 Case #6 Issue #1: Chicken or the Egg? Cannot apply for THC grant unless accredited Difficult to get buy in without funding Solution: Apply for accreditation now Have 3 years to launch program once funded Apply for THC grant this summer No obligation to proceed if no funding

32 Case #6 Issue #2: What happens after THC? THC program ends in 2015 Are we starting a program that will have to close? Solution: Obtain alternate funding RICO, Foundation COM teaching stipend FQHC shifting funds from PA salaries to residents State grant Commission on Family Medicine

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34 Case #6 Issue #3: Where to do inpatient rotations? One hospital in area capped at 2 One hospital is virgin, but waiting to start GME Rotating at the virgin hospital may start their cap Solution: Will do all rotations at the capped hospital Residents NOT included on CMS cost report Hospital acts as affiliate site DME/DIO of program not the DME/DIO of hospital Residents employed by the program, not the hospital

35 Case #6 Issue #4: FQHC lacks educational infrastructure Solution: Educational Infrastructure COM/OPTI as sponsor of program

36 STATE FUNDED PROGRAMS

37 Case #7 Wyoming Residencies Casper FP (8/8/8) Cheyenne FP (6/6/6) Dually accredited WWAMI/RMOPTI Funding from State No DGME/IME funds

38 Governor s Budget Request

39 OTHER THOUGHTS

40 Hybrid UME/GME with Loans Cut a year off Med school No audition rotations Must go into primary care Use loans for internship Have to deal with Title IV By PGY 2, hospitals, FQHCs, or groups more likely to foot the bill If can obtain a license Residents still financially better off in the end

41 Leveraging Current Events

42 Resident Coverage Contract Minute clinic/urgent care service as part of GME program. Program contracts for coverage Telemedicine for supervision if needed Take the Minute Clinics away from the NPs

43 DISCUSSION