Resolution 22(17) EM Residency Training Requirements for Dual Training Programs
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Resolution 22(17) EM Residency Training Requirements for Dual Training Programs
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RESOLUTION: 22(17)
SUBMITTED BY: Dual Training Section
SUBJECT: Emergency Medicine Residency Training Requirements for Dual Training Programs
PURPOSE: Work with ABEM and possibly ABMS to create a new definition of Initial Residency Period that would permit Graduate Medical Education funding for the duration of dual training periods.
FISCAL IMPACT: Budgeted committee and staff resources.
Resolution 22(17) EM Residency Training Requirements for Dual Training Programs
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WHEREAS, The Initial Residency Period (IRP) determines the reimbursement received by the hospital where the training takes place; and
WHEREAS, For emergency medicine the IRP is established by the American Board of Emergency Medicine and currently the IRP is listed as either 3 or 4 years; and
WHEREAS, These IRPs were established before dual training programs such as Emergency Medicine-Pediatrics, Emergency Medicine-Internal Medicine, or Emergency Medicine-Critical Care were common; and
WHEREAS, An IRP that does not reflect more extended periods of training may be a financial disincentive to the creation of additional dual training programs; therefore be it
RESOLVED, That ACEP work with the American Board of Emergency Medicine, and possibly the American Board of Medical Specialties, to create a new definition of Initial Residency Period that would permit Graduate Medical Education funding for the duration of residency, including dual training periods.
Resolution 22(17) EM Residency Training Requirements for Dual Training Programs
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Background
This resolution calls for ACEP to work with ABEM and possibly ABMS to create a new definition of Initial Residency Period that would permit Graduate Medical Education funding for the duration of dual training periods.
Historically, Medicare has been the primary funding source for graduate medical education (GME). 47 states also provide support as a secondary GME funding source. Since its inception in 1965, Medicare has reimbursed teaching hospitals for their portion of the direct GME costs (DGME or DME). DME costs include resident stipends and fringe benefits, faculty salaries and fringe benefits, and administrative overhead.
With the advent of diagnosis-related groups (DRGs) in 1983, Medicare began to include reimbursement for indirect GME costs (IGME or IME). IME payments compensate teaching hospitals for greater inpatient costs from treating higher acuity patients, and indirect costs of GME programs such as decreased faculty productivity and increased lab and diagnostic tests ordered by residents in training.
Over the years, Congress has changed the law upon which formulas for determining DME and IME payments were based. In 1985, the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services or CMS) began to limit DME payments to a resident's period of board eligibility plus one year, with a maximum of five years. After that, Medicare pays 50% of the per resident amount (PRA). For emergency medicine, the initial residency period (IRP) limitation was three years. Considering the recent movement of osteopathic residencies into ACGME, ABEM now affirms an IRP of 3 or 4 years.
For physicians who want to train in more than one specialty (EM/IM, EM/Peds, etc.), CMS notes that “counting for GME purposes, a physician would be limited by his/her ‘initial residency period’ which generally limits full funding to a first residency only. Generally, for a second residency, for direct GME purposes, he/she would be weighted at 0.5 FTE.” The initial residency period rules do not apply for IME and thus, he/she would be counted at 1.0 FTE for IME regardless of how long he/she trains.
Dual training has significant advantages; creating a workforce that can bridge two specialties and provide a perspective otherwise lost. Individuals who practice these dual specialties often receive less reimbursement, yet remain enthusiastic about their practice environment. However, because of the reduced payment, some institutions that provide the training have begun to question this investment. A recent closure of a long-standing EM/IM program for financial reasons raises questions of the financial viability of dual programs.
ABEM sets the IRP, but CMS determines the rules by which the IRP is paid. In addition to ABEM and ABMS, it will be important to advocate with CMS to enact changes to the IRP to reflect dual training.
ACEP Strategic Plan Reference
Goal 1 – Reform and Improve the Delivery System for Emergency Care
Objective D – Develop and implement solutions for workforce issues that promote and sustain quality and patient safety.
Fiscal Impact
Budgeted committee and staff resources.
Prior Council Action
Amended Resolution 15(09) Emergency Medicine Workforce Solutions adopted. Called for the College to address workforce shortage by lobbying for increased EM residency slots and meeting with appropriate organizations to address development of an EM fellowship.
Amended Substitute Resolution 24(01) Work Force Shortage in Emergency Medicine adopted. Directed ACEP to lobby Congress and pertinent government agencies to reduce the shortage of board certified emergency physicians and lobby Congress and the federal government to eliminate barriers to creating adequate emergency medicine residency positions and achieving optimal funding for those positions.
Prior Board Action
October 2012, approved the revised policy statement “Financing of Graduate Medical Education in Emergency Medicine;” reaffirmed September 2005; originally approved September 1999.
April 2012 reaffirmed the policy statement “Emergency Medicine Workforce;” reaffirmed June 2006; revised and approved September 1999; originally approved November 1987 with the title “Manpower.”
Amended Resolution 15(09) Emergency Medicine Workforce Solutions adopted.
Amended Substitute Resolution 24(01) Work Force Shortage in Emergency Medicine adopted.
Background Information Prepared by: Sandra M. Schneider, MD, FACEP
Associate Executive Director, Policy, Practice, & Academics
Reviewed by: James Cusick, MD, FACEP, Speaker
John McManus, MD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director