RTT Collaborative Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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On behalf of The RTT Collaborative and the nationwide board-directed cooperative of rural programs in medical school and residency the collaborative represents, I write to provide comments on the FY 2022 Medicare Inpatient Prospective Payment System proposed rule.
The RTT Collaborative was established in 2012 as a cooperative funded by programs committed to developing and sustaining health professions education in rural places through mutual encouragement, peer learning, practice improvement, and the delivery of technical expertise, all in support of a quality rural workforce. Although initially comprised of programs considered "rural training tracks" or RTTs in the common vernacular, this cooperative now includes rurally located residencies, rural programs in medical school, and rural programs in specialties and disciplines other than family medicine.
J. Proposed Payment for Indirect and Direct Graduate Medical Education Costs (Secs. 412.105 and 413.75 through 413.83
The GME provisions in this legislation are critically important to sustaining the recent efforts by the federal government, through grant funding, to grow and sustain the education and training of physicians in rural communities. We generally support and commend CMS in its attempt to implement (1) the carve out for expanding rural programs in section 126; (2) the expansion of GME funding for not-separately-accredited rural tracks within successful urban-located residency programs and the elimination of the rolling average for newly created programs or tracks in section 127; and (3) the resetting of small caps and PRAs in section 131.
In 'rural-proofing' this rule as proposed, however, we have concerns regarding unintended consequences of the rule for established and planned rural programs. For clarity, I'm listing these comments by Sections relevant to GME in the following pages.
a. Distribution of Additional Residency Positions Under the Provisions of Section 126 of
Division CC of the Consolidated Appropriations Act, 2021 (CAA)
The rural 'carve out' section of the legislation and the regulations as proposed in this rule will apply each year (of five years) to twenty rural hospitals seeking to increase their cap for an existing residency program by one FTE.
We affirm:
1. We fully support limiting the number of positions for which any one hospital can apply, given the feeding frenzy for new positions that this legislation has evoked, although this needs to be clarified. We recommend these be awarded as one "position" for the duration of training, which for a Family Medicine residency would be a total cap of 3 additional slots (One each year for three years of training); for a General Surgery residency it would be 5 slots.
For small rural programs with two residents per year, 1 year's funding for 1 position will incur a 50% increase in cost over the course of 3 years of training (i.e., an RTT with 2 residents expanding to 3 per year => a 50% increase). Funding for only one year's training will likely be unacceptable to most small programs. Only for large programs or hospitals with multiple residencies and many residents can the 'marginal cost' of adding one resident for the remaining duration of their training be reasonably absorbed.
We recommend 1 position be awarded for at least 3 years agnostic of specialty or, as an alternative, the duration of the initial residency period in the appropriate specialty (e.g., 1 position => an ultimate cap increase of 3 for a family medicine residency). An award of one slot in a family medicine program in the first year would be associated with an additional obligated slot in each of the next 2 years, assuring support for at least one additional physician through the duration of their training. We further recommend that a major portion of the 1,000 slots be offered in this way in the early years, with a lesser number of slots being offered each year thereafter until, by the third year, all slots would be awarded or obligated.
2. (Category One) We fully support the definition of rural for this purpose with the following grammatical edits for clarification: "A hospital will be considered located in a rural area, or treated as such, if its main campus is located in an area outside of an urban CBSA and is classified as a rural hospital" (i.e., not reclassified as urban). CMS notes that "this definition of 'rural area' is consistent with their policy concerning designation of rural areas for wage index purposes." This restriction to geographically rural location avoids allowing large urban 'rural referral center' hospitals to expand an existing program and take these slots from hospitals geographically located in a rural place. This avoids thwarting what we believe to be the legislative intent of this statute.
3. (Category Four) We support the requirement in this category that hospitals participating in residency programs document that >50% of the training over the duration of the program must occur in a qualifying geographic HPSA. Most hospitals in the US "serve" areas designated as HPSAs, but few train their residents there and rarely for >50% of their duration of training.
4. (All categories) Regarding prioritization of requests in any category and for the remaining 60% of slots, we firmly support the use of HPSA scores, but only for geographic HPSAs.
Using a 'population HPSA' rather than a 'geographic HPSA' may be problematic, since it is our understanding that 'population HPSAs' are only designated when the geographic HPSA designation is not an option, i.e., that these categories are mutually exclusive. 63 of 88 counties in
The proposed alternative to HPSA score prioritization is unacceptable, as it would favor large urban medical centers who can 'check more boxes' and would further increase geographic maldistribution of physician training and subsequent placement.
We favor the addition of an impact factor in considering existing programs seeking to expand. Existing programs who have graduated physicians who practice in rural and/or urban underserved communities, for example as documented by the Graham Center GME tracker for all family medicine programs, could receive preference. Rural programs clearly graduate a greater percentage of physicians to initial and sustained rural practice./1
5. We are pleased by CMS's stated intention to track progress in meeting all statutory requirements over the course of implementation and to evaluate the need to modify the distribution methodology in future rulemaking.
We are concerned:
1. Unfortunately, Demonstrated Likelihood Criterion 2 (Expansion of an Existing Residency Program) is unlikely to fit many small rural hospitals, who, if over cap, are likely at capacity for reasons other than funding, and they are unlikely to ask for an increase in accredited slots for new positions. Such hospitals not uncommonly restrict the size of their programs for reasons of teaching capacity (e.g., patient numbers, available faculty) or recruiting challenges, not GME finance. Over cap situations do occur for large rural hospitals and hospitals with established programs and caps >3, who are ineligible for the cap-resetting provisions in Section 131. Only these large rurally located hospitals are likely to apply for these slots.
2. We are worried in using the 'County to CBSA Crosswalk and Urban CBSAs and Constituent Counties for Acute Care Hospitals File,' that urban hospitals reclassified to rural (i.e., Rural Referral Center hospitals) may still be able to claim treatment "as a rural hospital," even if located well within a CBSA.
3. We are concerned about the statutory language regarding 'fungibility' after 5 years. The statute allows movement of the position in an affiliation agreement.
We recommend there be some restriction in movement after 5 years to training in another rural location (for rural slots) or another HPSA (for HPSA slots).
b. Proposal for Implementation of Section 127 of the CAA, "Promoting Rural Hospital GME Funding Opportunity"
We affirm:
1. We support the application of the >50% threshold to total training time in an initial residency period in any specialty.
2. We support the ability of rural programs (with urban and rural participating hospitals) to expand to additional rural sites and believe this is aligned with legislative intent.
3. We support the Exemption from the 3-Year Rolling Average During the 5-Year Rural Track FTE Limitation Window
4. We applaud CMS's intention to adjust the Medicare cost report, CMS -2552-10, Worksheets E, Part A for IME, and E-4 for direct GME, to accommodate additional rural track limitations, making it easier for CMS to track such programs and to measure the impact of this legislation.
We are deeply concerned:
1. The language of the proposed rule is not aligned with the language of accreditation, doesn't recognize the emerging taxonomy of rural programs, will be difficult to implement as proposed, and risks thwarting legislative intent.
It may be "ease of reference" to use terms like "core," "hub," and "spoke," but it is confusing, since sponsoring institutions establish programs, not hospitals, and not every sponsoring institution is a hospital. Many if not most residency programs involve multiple participating hospitals and both provider and non-provider ambulatory sites. We recommend using ACGME terms like "participating hospital" and generally avoid the term "sponsor" in this rule.
For a program that is >50% located in a rural community, use of the term "core" and "hub" for the urban hospital is unnecessarily urban-centric and not consistent with what drives many successful rural programs, i.e., rural community ownership and investment in program success. Since Medicare GME only pay's Medicare's share of the costs and urban hospitals and health systems are often unwilling to subsidize the unfunded costs of these programs, it often falls on rural communities to ensure that these programs are sustained. We suggest that the language be changed to reflect these rural programs and rural tracks as 'networks' of participating hospitals and ambulatory sites, rather than 'hub and spoke' limited to one urban participating hospital and multiple rural hospital and/or non-hospital participating sites.
In addition, using the terms "rural track," "rural training track," or "RTT" interchangeably throughout this proposed rule will almost certainly have unintended consequences. The ACGME has just released a process for endorsing and designating a "Rural Track Program" in any specialty. This process will occur before accreditation, will not be specialty specific, and will demonstrate that the planned program meets the >50% threshold for percentage of training in a rural location through submission and verification of a rotation/curriculum calendar. The procedure does not ensure subsequent approval or accreditation by the specialty-specific review committee. It simply standardizes the determination of the designation across specialties. (See https://acgme.org/What-We-Do/Accreditation/Medically-Underserved-Areas-and-Populations/) A process for designating an urban program's 'rural track' (not a program and not separately accredited) has not yet been released. Until this development last month, there had been no clear ACGME definitions. Although the Family Medicine Review Committee (RC-FM) has accredited programs in the '1-2 format' in both rural and urban settings, the ACGME and RC-FM have not separately accounted for them in any public or internal listing.
We recommend language that aligns with the language of accreditation when possible and acknowledges the emerging taxonomy of rural programs over the past two decades - from the prototypical separately accredited rural training track (RTT) in the '1-2 format to separately accredited integrated RTTs where residents may spend all years of residency training in a rural location and only intermittently return to an urban location for rotations and intensive immersion experiences. The CAA2021 has acknowledged the value of rural tracks within established urban programs that are not separately accredited, but like separately accredited RTTs involve a network of participating hospitals and ambulatory sites, both urban and rural. We suggest the language of this proposed rule be changed to clarify the difference between a separately accredited program and a track within a program that is already accredited, and support the emerging diversity of rural track programs and rural tracks in the following way: a. Separately accredited rural track programs (traditional 'RTTs' or integrated rural tracks as described in the FY2003 Final Rule; or 'RTPs,' Rural Track Programs in the new ACGME language just published in
b. Urban programs with not-separately-accredited rural tracks ('RTs,' not programs)
c. We consider 'tracks' of urban programs that do not place residents for training in rural locations for >50% of their training time to be 'pathways.'
We support the proposal allowing successful networks to further expand to additional rural sites, whether they are separately accredited or not - i.e., either an expansion of an existing RTT program to another rural site, the addition of a new Rural Training Program in a rural location, or a not-separately-accredited rural track. I believe this approach is situated well within the statutory language and supports legislative intent as we understand it. However, we also believe the statutory language supports expansion of existing rural sites. As stated in the proposed rule, "Because the law now states, 'established or establishes,' both past tense and future tense, we believe the statute grants the Secretary unique authority not previously held; that is, the authority to prospectively allow (under certain circumstances) cap adjustments to existing RTTs expanded in a cost reporting period beginning on or after
2. The proposed rule will likely continue to discourage rural hospitals from participating in any rural program unless it is separately accredited and can be considered "new."
To our knowledge, since BBRA, separately accredited RTTs have almost always been "new" for the rural hospital and therefore eligible for a new cap. Most participating rural hospitals were new teaching hospitals. Since 2010, in our collective experience, newly created programs are only considered by CMS as "not new" if (1) they do not meet the CMS definition of "new" (e.g., a shared 'program director' with an established program) or (2) the urban program establishes a not-separately-accredited rural track. Rural tracks (not programs) have unfortunately often been referred to as RTTs by both the ACGME and many residency programs. They are not separately accredited, and many do not meet the threshold for >50% of the residents' total training time in a rural place. A "new" program by CMS rules, which require a new Program Director (an ACGME term), requires separate accreditation.
We recommend, consistent with ACGME language, that CMS require a new 'director' be named in supporting materials for any newly created RTT/RTP or RT but allow the program's 'director' to be any of the following in ACGME terms: a 'Program Director,' an 'Associate Program Director,' or even a participating 'site director' of a rural track that is not separately accredited.
3. There is little clarity as to what defines a not-separately-accredited rural track as described above, and it will be very difficult for MACs to implement.
We agree with the language of the proposed rule with the following highlights and edits: "Therefore, for all accredited specialties, we are proposing to require that an urban hospital may include in its FTE count, not to exceed its rural track FTE limitation, residents training in the urban hospital that are designated to rotate to a rural area for greater than 50 percent of the duration of the particular program initial residency period in any specialty." This will be difficult in specialties other than family medicine and psychiatry, but not impossible, particularly if urban hospitals partner with large rural hospitals with an appropriate scope of service and if the OMB definition of metropolitan changes as proposed (micropolitan = <100,000 population) We are concerned, however, that these not-separately-accredited rural tracks (not programs) need further definition. For this purpose, we propose that CMS adopt criteria parallel to that published for rural tracks in undergraduate medical education,/2 perhaps as follows:
An organized and deliberate urban residency program strategy to produce physicians to rural practice as indicated by all the following:
1. A name for the rural track
2. A director
3. A program-specific goal or objective(s) to recruit, nurture, educate, train, or encourage residents toward rural practice, including a separate NRMP number or another process for assigning individual residents to this track early in the first program year.
4. A description that explicitly articulates a rural focus, including a rotation schedule that demonstrates how the track will meet the 50% threshold for assigned residents training in a rural location
In additional support of this designation, we recommend the following items already included in the proposed rule under "Documentation Required for Medicare Administrative Contractor (MAC) to Pay for RTTs" with suggested edits in red:
1. The accreditation for the "spoke, "Approval of the urban program's rural track from the ACGME and information whether the track is in the same specialty as an RTT/RTP program that the urban hospital already has, or whether the "spoke" track is a newly created RTT rural track in a different specialty.
2. Intern and resident rotation schedules (or similar documentation) showing that residents in each particular RTT program (both hub and spokes overall) the specified rural track spend greater than 50 percent of their training in the initial residency period in a geographically rural area in order to receive IME and direct GME rural track FTE limitations.
3. The number of FTE residents and the amount of time training in all program years at both the urban and rural settings since establishment of the particular "spoke", any already accredited RTT/RTP or approved not-separately-accredited RT, so that the MAC may be able to verify the RTT cap and appropriately adjust the rural FTE limitation.
4. The rolling average correction is to be implemented "for RTTs started in cost reporting periods beginning on or after
So as not to affect all 7 new RTT programs implementing on
5. Finally, we have concerns around the implementation of a new OMB definition of non-metropolitan (i.e. 'rural' and 'not urban'), and recommend it be addressed in a generic way, covering changes that occur every census anyway from population change.
The proposed OMB change could open more areas for locating rural track programs and urban hospitals participating in programs with rural tracks. It would also likely increase the number of 'now newly rural' teaching hospitals of significant size that could more easily meet the requirements of rural training in other specialties.
However, the OMB redefinition could present a problem for an urban hospital planning to participate in the initiation of multiple rural tracks over time. If the hospital became rural, further growth might be dis-allowed as an "expansion of an existing program," particularly if only urban hospitals ("hubs" in CMS speak) are given the ability to partner with multiple sites ad infinitum. This represents another reason to extend this ability to rural hospitals. Rural hospitals, like urban hospitals, should be allowed to participate in a residency program expansion to additional, not-separately-accredited rural sites.
We question:
In addition to lack of clarity around the use of the terms 'rural track,' 'RTT,' and 'rural training program,' we question the validity of the following section of the proposed rule, because it doesn't align with our own collective experience nor with that of individuals who championed the inclusion of these GME provisions in the CAA2021:
"Because of this explicit incentive and permission for FTE resident cap adjustments for an urban hospital that establishes a rural track, the rural track does not need to be new for Medicare payment purposes, as it otherwise would for the urban hospital to qualify for the FTE resident cap adjustments. That is, under section 1886(h)(
We are not aware that the law has been enforced in this way. We would have to explore cost report data on each not-separately-accredited 'IRTT-like' program on our RTTC map, since the map reserves the term 'integrated RTT (IRTT)' to refer to all separately accredited rural track programs, whether or not they are integrated with another program in a prototypical '1-2 format.'/3
https://rttcollaborative.net/rural-programs/residency-map/ Unfortunately, the list of not separately accredited "IRTT-like" tracks on our map is almost certainly incomplete, since we know of no way through publicly available sources to discern how many other programs meet the >50% threshold. Those rural tracks listed on the map as "IRTT-like" have individually provided The RTT Collaborative with a curricular schedule as substantiation.
c. Proposal for Implementation of Section 131 of the CAA, Addressing Adjustment of Low Per Resident Amounts (Direct GME) and Low FTE Resident Caps (Direct GME and IME) for Certain Hospitals
It is our opinion that this section is generally well written and reflects Congressional intent. Both established and new programs will be able to reset low PRA's and non-CBSA hospitals with a known low PRA will now be able to reset their PRA to "the updated weighted mean value of per resident amounts of all hospitals located in the same census region as that term is used in subpart D of part 412 of this subchapter."
We affirm:
From
We are supportive of the opportunity for all hospitals going forward to set a PRA if included in a Medicare Affiliation Agreement. This will provide hospitals who allow rotations for less than 1.0 FTE an opportunity to set a PRA for future resident training and still avoid triggering an FTE cap until ready to develop a more robust program of training.
"Thus, effective for a cost reporting period beginning on or after enactment (
CMS makes a leap from the legislative language "begins training" to the language of the proposed rule, "first begins training," that we do not believe is justified. Hospitals 'begin training' new residents every year, and the legislative language could just as easily be interpreted as "begins training a new resident class after implementation of this rule." Unfortunately, programs that have a cap of less than 3, but started new programs after that cap was set, are in the cold - never being able to reset their cap. We don't think that's in keeping with Congressional intent.
We also are concerned about the hospitals, many of them rural, who have no immediate plans to become a teaching hospital, who have no cap, and who are unaware of any PRA - a third category or Category C, if you will. Per resident amounts have not been proactively assigned to every hospital in the US, and under current regulations a PRA of
Until such time as hospitals have the opportunity for a certified audit financed by CMS prior to training residents, we recommend that all hospitals without a PRA or cap be assigned a PRA that is "the updated weighted mean value of per resident amounts of all hospitals located in the same census region as that term is used in subpart D of part 412 of this subchapter," or until a hospital can demonstrate its ability to train residents for less than that amount.
We are also concerned that the new PRA is not reduced using the concept of "Community support and redistribution of costs." This principle, where Medicare will not reimburse for situations after another entity has paid for resident training, is not appropriate in the face of this new legislation. Historically statutory and regulatory actions have prevented hospitals from appropriate reimbursement for residency positions from Medicare.
We are concerned that the legislation dictates that a PRA be set in the first cost report year beginning after enactment, meaning that by the time these proposed rules are final a hospital currently training residents with a
Second, many hospitals may not fit either a Category A or Category B designation. Unbeknownst to them, they may be found to have a
The following is problematic for hospitals who do not think of themselves as teaching hospitals and do not usually report or claim small numbers of rotating residents. The proposed rule says,
"A hospital shall report full-time equivalent residents on its cost report for a cost reporting period if the hospital trains at least 1.0 full-time equivalent residents in an approved medical resident training program or programs in such period."
How will a hospital know that it "shall" and what happens if it doesn't? Will these hospitals in the future, beyond the 5-year window included in this legislation and proposed rule, again have PRAs of
Thank you for the opportunity to offer these comments and I am available for any questions or points of clarification you may have regarding this letter.
Sincerely,
Executive Director, The RTT Collaborative
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Footnotes:
1/ Meyers P, Wilkinson E, Petterson S, Patterson DG, Longenecker R, Schmitz D, Bazemore A. Rural Workforce Years: Quantifying the Rural Workforce Contribution of Family Medicine Residency Program Graduates, J Grad Med Educ
2/ Longenecker RL, Andrilla CHA, Jopson AD,
3/ Longenecker R. Rural Medical Education Programs: A Proposed Nomenclature.
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The proposed rule can be viewed at: https://www.regulations.gov/document/CMS-2021-0070-0002
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