ADFM%Legislative%Update - COUNCIL OF ACADEMIC FAMILY MEDICINE

ADFM%Legislative%Update

                     HOPE%WITTENBERG
       D I R E C T O R , % G O V E R N M E N T % R E L AT I O N S
                     F E B R U A RY% 2 4 , % 2 0 1 8

CAFM             COUNCIL OF ACADEMIC FAMILY MEDICINE

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Teaching Health Centers and other HRSA
            Workforce Issues

Academic    Student Documentation guidelines

  Family    Rural GME

Medicine    President’s FY19 Budget: GME Plan

   Issues   Title VII - Appropriations

            Primary Care Research

            Single Accreditation System

            VA GME

Current'
  Status'
 Approps,'
THC,'CHIP

Jan 16       Feb 9th       Mar 23?
               THC
               CHC
  CHIP                      End of CR;
              NHSC
 6 year                      Omnibus
             Medicare     Appropriations
 Reauth      Extenders
             CHIP +4

Continuing   Bipartisan     Title VII
   Res       Budget Act      AHRQ

Teaching)Health)Centers

             Teaching)Health)Centers
              o   $126.5)million)for)each)of)
                  FY2018)and)FY2019)
              o   Priority)for)new)programs)
                  serving)underserved)
                  populations)or)in)rural)
                  areas.)
              o   Missing)guardrails)
                  between)current)and)
                  expansion)programs)
              o   PRA)not)specified))

THC$Implementation$Issues

! “maintenance)of)filled$positions
! “expansion)of)existing)programs”
! “establishment)of)new)programs”

CAFM        COUNCIL OF ACADEMIC FAMILY MEDICINE

THC$Implementation$Issues

! What%will%the%PRA%be?
 o   Costs%–
     o Secretary%to%“Consider”%the%costs
     o Match%numbers%will%have%impact%
     o Programs%below%the%number%of%positions%
      needed%for%accreditation
! How%many%new%Programs?
 o   3%yr vs%2%year%authorization
CAFM             COUNCIL OF ACADEMIC FAMILY MEDICINE

Community)Health)Centers/NHSC

! Reauthorized,for,two,years
! CHC,
  o FY18,7 $3.8,billion

  o FY19,7 $4,billion

! NHSC
  o $310,m,each

  o Possible,annual,appropriations,thereafter??

CAFM                 COUNCIL OF ACADEMIC FAMILY MEDICINE

Tactic 1 - Medicare Student
             Documentation Guidelines

Preceptor(
Expansion(
 Project

Revised Carrier Transmittal
                 Effective Mar 5, 2018

                Student Can Document
 Student'
  Docu+
mentation'      Teaching Physician Must
             Verify; No need to re-document
Guidelines
                TP must Perform or Re-
                       perform

Student'Documentation'Guidelines'

! Softening)the)Ground)– North)Carolina,)Bill)Roper)
    others)with)CMS)relationships
!   CAFM,)AAMC,)AAPA)> Very)positive)meeting)with)
    CMS)on)Dec.)20th
!   Provided)language)for)sub>regulatory)fix
!   Asked)us)to)quantify)time)lost/saved
!   Survey)sent)out)in)JanuaryN)11)day)rapid)response
!   Transmittal)Released)Feb)5)– Mar)5)implementation

CAFM              COUNCIL OF ACADEMIC FAMILY MEDICINE

Medicare(Student(Documentation(Guidelines

Students may document services in the medical record.
However, the teaching physician must verify in the medical
record all student documentation or findings, including
history, physical exam and/or medical decision making. The
teaching physician must personally perform (or re-perform)
the physical exam and medical decision making activities of
the E/M service being billed, but may verify any student
documentation of them in the medical record, rather than
re-documenting this work.

CAFM              COUNCIL OF ACADEMIC FAMILY MEDICINE

Rural&&GME

Rural&GME

4"Key"Issues:

1. Rotator"Issue

2. Critical"Access"
   Hospitals

3. Rural"Training"Track"
   (lifting"of"CAP)

4. Per"Resident"Payment"

Rotator&Fix

Allow%hospitals%with%very%small%caps%or%low%PRAs%
due%to%resident%rotators%to%start%fresh:

! Senate%re:introduction%(S.%1291)
! House%reintroduction%(HR%4552)%
 o Unable%to%get%House%W&M%Republican%(Stymied%
   by%House%Ways%and%Means%staff)
! Didn’t%get%into%Medicare%Extenders%– Hail%Mary%to%
  get%into%Omnibus%Appropriations%bill

CAFM            COUNCIL OF ACADEMIC FAMILY MEDICINE

Critical(Access(Hospital(CAH)

Allow%urban%hospitals%to%again%count%
resident%time%spent%in%CAHs%for%
GME/IME%purposes
! S.%455%Restoring%Rural%Residencies%Act
! Senator%Jon%Tester%(DFMT)%introduced
! Only%Democrats%cosponsoring%to%date%
! Need%for%more%cosponsors

CAFM        COUNCIL OF ACADEMIC FAMILY MEDICINE

RAP$GME

CAFM   COUNCIL OF ACADEMIC FAMILY MEDICINE

RAP$GME(Principles

GME$Initiative5(Senator(Cory(Gardner((R$CO)
! Alternative*National*Per*Resident*Payment*(NPRP)
 o   Election
! Training*of*8*weeks*or*more*in*rural*areas
! Rural*Training*Track*and*Integrated*RTTs
! No*cap,*no*PRA*–setting,*avoids*Rotator*issue
! Corrects*CAH*issue

CAFM              COUNCIL OF ACADEMIC FAMILY MEDICINE

Consolidate GME

President’s*
   FY19*
  Budget*
   GME

President’s*Budget*GME

! “Consolidate,GME”,11 includes,Medicaid
! Save,$48,billion,net,over,10,years
! Make,it,a,grant,program,– jointly,run,by,HRSA,and,
  CMS,
! Funded,by,general,fund,of,the,Treasury
! Set,rate,(FY16,levels),and,update,by,CPI1U,1 1%
! Directed,to,Physician,specialty,and,geographic,
  shortages

CAFM             COUNCIL OF ACADEMIC FAMILY MEDICINE

President’s*GME*proposal,*cont.

! Pay$for$slots$up$to$resident$CAP$level4$portion$of$
  Medicare$and$Medicaid$inpatient$days
! Secretary$would$have$authority$to$modify$the$
  amounts$distributed$based$on:$
 o   priority$specialties$(e.g.,$primary$care,$geriatrics)
 o   other$criteria,$including$HPSAs$and$educational$priorities

CAFM                  COUNCIL OF ACADEMIC FAMILY MEDICINE

FY18 Under CR until March 23rd

            Primary care –$38.9 m in both
Title&VII   House and Senate

            President’s FY19 - Zeros out
            again

Primary'
  Care
Research

PCORI

! Mandatory)funding)
    through)2019
!   At)Risk7)Will)it)be)
    reauthorized?
!   New)Friends)of)PCORI)
    established
!   Beginning)efforts)to)raise)
    awareness)– Advocacy)
    Day)Oct.)31
!   Spending)$$$)on)opioids

Survival(of(AHRQ
! Both%House%and%Senate%appropriations%bills%keep%AHRQ%as%
    separate%agency%(House%$300%m?%Senate%$324%m)
!   Report%Language%in%both%to%study%feasibility%of%moving%
    AHRQ%elsewhere%(NIH%or%otherwise)
!   Lack%of%understanding%that%Primary%Care%Research%is%more%
    than%just%health%services%research%(HSR)%
!   CAFM%has%requested%revised%report%language%to%include%
    primary%care
!   National%Academy%of%Medicine%Roundtable%on%HSR%in%
    February%(ABFM%support)%
!   President’s%FY19%budget%similar%to%FY18%– move%to%NIH%%%%%%%%%%

CAFM                 COUNCIL OF ACADEMIC FAMILY MEDICINE

AHRQ

! Some%ADFM%Leadership%met%yesterday%
  with%new%AHRQ%Director
! Working%to%enhance%Primary%Care%
  Center%
! Looking%for%a%Champion%on%the%Hill%to%
  support%Primary%Care%within%AHRQ%

CAFM         COUNCIL OF ACADEMIC FAMILY MEDICINE

Unknowns

             ! How(many(of(the(137(programs(
               will(actually(achieve(
 Single'       accreditation?(49(with(Initial(
Accredit'-     Accreditation
  ation      ! How(many(slots(does(this(
               represent?
 System
             ! How(many(can(be(absorbed(by(
               their(hospitals(or(systems?
             CAFM(recommends(redistribution(
             to(rural(areas

! Shift&in&Congressional&support&
            ! More&concern&with&“growing&their&
             own”:&
             o   VA&floated&several&proposals&last&year&–
                 so&far&none&are&workable.&
             o   Proposal&for&service&obligation&years&if&
                 VA&pays&for&residency&training.&
Veterans’    o   Rep.&Roe&– will&not&allow&VA&to&pay&for&
  GME            training&time&“outside&the&VA&linoleum.”
             o   New&proposal&out&of&VA&would&pay&for&
                 time&of&VACAA&residents&at&nonEVA&
                 facilities