The AAMC submitted comments on Feb. 25 to the Centers for Medicare & Medicaid Services (CMS) in response to graduate medical education (GME) provisions in the fiscal year (FY) 2022 Inpatient Prospective Payment System (IPPS) final rule with comment period, published on Dec. 27, 2021 [refer to Washington Highlights, Jan. 7]. In June 2021, the AAMC provided a detailed comment letter to the CMS regarding the FY 2022 IPPS proposed rule. While a number of other proposals were finalized on Aug. 13, 2021, the GME provisions were delayed to allow CMS more time to review comments.
Under Sec. 126 of the Consolidated Appropriations Act, 2021 (CAA, P.L. 116-260), 1,000 new Medicare-funded GME full-time-equivalent (FTE) slots will be distributed to four categories of qualifying hospitals starting in FY 2023: (1) hospitals located in rural areas or that are treated as being located in a rural area, (2) hospitals in which the reference resident level of the hospital is greater than the otherwise applicable resident limit, (3) hospitals in states with new medical schools or additional locations and branches of existing medical schools, and (4) hospitals that serve areas designated as Health Professional Shortage Areas (HPSAs). In the final rule, the CMS prioritized distribution of the slots based on the HPSA scores of training sites, with the additional requirement that at least 50% of the residency program’s training must occur at HPSA sites.
In the final rule with comment, the CMS requested comments “to inform potential future rulemaking on incorporating a measure of care provided outside of a HPSA to HPSA residents.” The AAMC suggested that the CMS could account for care to HPSA residents outside of the HPSA by developing a metric based on the number of people treated by a hospital that live in a HPSA. The AAMC also reiterated the association’s opposition to basing slot distribution on HPSA scores and to the “at least 50% training requirement” in HPSAs.
The AAMC made several additional requests regarding the new slots. To understand and evaluate CMS’s methodology for slot distribution, the AAMC asked CMS to publish information following the slot awards about each applicant, to include the provider number, qualifying category, HPSA score, specialty of the program, and number of requested slots and awarded slots.
The AAMC highlighted other concerns related to the distribution of new slots. As finalized, hospitals may not aggregate training time in more than one HPSA. This means that though hospitals may have multiple training sites within HPSAs, they are not eligible for prioritization unless at least 50% of training takes place within the same HPSA. The AAMC also noted that the CMS should allow hospitals to use a HPSA designation conferred up to the application deadline and should update HPSA designations posted to the CMS website monthly.
In another area, Sec. 131 of the CAA allows certain hospitals to reset low or zero per-resident amount (PRA) or low FTE cap counts. Hospitals that wish to participate in resets may review reported PRA and FTE count information on the CMS Direct Graduate Medical Education website through the Healthcare Cost Report Information System (HCRIS). The CMS sought proposals on what information to accept for hospitals with closed cost reports that dispute PRA or FTE counts reflected in HCRIS. For a small set of hospitals with PRA or FTE caps set long ago, there is likely a lack of verifiable information to corroborate a disputed cap. The AAMC noted the CMS should accept corroborating contemporaneous information or the attestation of an officer of the hospital if no documentation exists.