Integration of a Transitional Year J. L. Epps, M.D. Chairman, Department of Anesthesiology

RRC for Anesthesiology and ACGME “ A specific 48-month curriculum in graduate medical education is necessary to train a physician in anesthesiology. The RRC for Anesthesiology and the ACGME accredit programs only in those institutions that possess the educational resources to provide the 48 months of training within the parent institution or in combination with integrated or affiliated institutions.”

48-Month Curriculum Internal Medicine, General Surgery, Neurology, Obstetrics and Gynecology, and/or Pediatrics — 6 months Emergency Medicine — 1 month Preoperative Medicine — 1 month PACU Medicine — 1 month

48-Month Curriculum Pain Medicine — 3 months Clinical Anesthesiology — 24 months Critical Care Medicine — 6 months Anesthesia-related electives — 6 months

48-Month Curriculum “At least 6 months of the first year of the 48- month curriculum must include training in internal medicine, general surgery, obstetrics & gynecology, pediatrics, emergency medicine, and/or neurology. Surgical Anesthesia, Pain Medicine, and Critical Care Medicine should be distributed throughout the curriculum to provide progressive responsibility”

Incorporation of the Transitional Year into the Residency How to implement? How to fund?

UTMCK Transitional Year Director — Medical Intensivist 9 positions  3 dedicated to Radiology  3 uncommitted  3 dedicated to Anesthesiology

Suggested Transitional Internship Internal Medicine (3 months) Emergency Room (1 month) Medical Critical Care (1 month) Anesthesia-Surgical Critical Care (1 month) General Surgery (2 months) Obstetrics and Gynecology (1 month) Pediatrics (1 month) Electives (2 months)

Transitional Internship Suggested  Internal Medicine  Emergency Room  Medical Critical Care  Anesthesia-Surgical Critical Care  General Surgery  Obstetrics and Gynecology  Pediatrics  Electives Actual  Internal Medicine  Emergency Room  Medical Critical Care  Dermatology  Radiology  Endocrinology  Cardiology  Pediatric Clinic  Electives

UTMCK Anesthesiology Residency 7 residents per year Match for 6 through ERAS Reserve 1 position to fill “outside the Match” ‘matched’ medical students desire internship at UTMCK

2003 SAAC Convinced that 48-month curriculum would be implemented  Verified by correspondence with experienced Chairman Convinced that changes at UTMCK should be started ASAP to prepare for 48-month curriculum

Implementation Graduate Medical Education  Informed Dean of proposed changes Arranged meeting with Chief Medical Officer, Chairman of Internal Medicine, Chief of Medical Critical Care, and the Director of the Transitional Internship

Negotiations Offered one resident per month for Medical Critical Care Coverage Received a guarantee of 4 anesthesiology transitional internship positions in 2004 and 5 positions in 2005 All anesthesiology residents must follow a rotation schedule approved by the Transitional Internship and Anesthesiology Program Directors

Transitional Internship Internal Medicine (3 months) Emergency Room (1 month) Medical Critical Care (1 month) Anesthesia-Surgical Critical Care (1 month) General Surgery (2 months) Obstetrics and Gynecology (1 month) Pediatrics (1 month) Electives (2 months)

Further Negotiations Offered two more internships as ‘modified’ surgical by Program Director for General Surgery Helped the General Surgery Residency comply with 80-hour work week limitations

Modified Surgical Preliminary Year Emergency Room (1 month) General Surgery (5 months) Internal Medicine (3 months) Medical Critical Care (1 month) Surgical Critical Care (1 month) Elective (1 month)

Proposed 48 Versus Current Internal Medicine, General Surgery, Neurology, Obstetrics and Gynecology, and/or Pediatrics — 6 months Emergency Medicine — 1 month Preoperative Medicine — 1 month PACU Medicine — 1 month Internal Medicine (3), General Surgery (2), Obstetrics/Gynecology (1), and Pediatrics (1) — 7 months Emergency Medicine — 1 month Preoperative Medicine — 1 month PACU Medicine — 1 month

Proposed 48 Versus Current Pain Medicine (3) Clinical Anesthesiology (24) Critical Care Medicine (6) Anesthesia-related electives (6) Pain Medicine (2) Clinical Anesthesiology (26) Critical Care Medicine (5) Anesthesia-related electives (5)

How to Fund DGME IME Medicaid DGME/IME

Direct Graduate Medical Education Payments (DGME) DGME covers the direct costs of resident education such as resident and faculty salaries, salaries of support staff and other expenses directly incurred by the Graduate School of Medicine

DGME Calculation Hospital-specific base year direct cost per resident Inflation Number of Residents MC Inpatient Days ÷ Total Inpatient Days XXX

Hospital-Specific Direct Cost Result of HCFA audits of GME base-year costs  Coincided with teaching hospital’s fiscal year 1984 or 1985  HCFA audits conducted in 1989 or 1990 Range from $100,000 Average $42,000

Hospital-Specific Direct Cost Range reflects the differences in accounting for GME costs among teaching hospitals & the various organizational arrangements between hospitals, physicians, and medical schools Inflation factor applied to primary care residents only

BBA of 1997 Balanced Budget Act of 1997 (BBA) limited the number of residents that teaching hospitals could count for determining DGME and IME In general, the resident limit still remains the number of allopathic and osteopathic residents noted in the hospital cost report to CMS on 12/31/96

Resident Limit Policy 2002 Medicare hospital cost reports  46% of teaching hospitals under the “cap”  44% of teaching hospital over the “cap” Congress’s intent is to redistribute “unused” resident limit slots Complex regulations proposed Cannot “count on” increased slots for the 48- month curriculum expansion

Indirect Graduate Medical Education Payments (IME) IME payments capture the “indirect” cost to the hospital incurred in supporting a graduate medical education program Based on calendar year Increase due to changes in the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA)  UTMCK $1.2 million dollars

IME Calculation I.89 [(1 + {# residents/# beds}) ] X TOTAL DRG Revenues

IME Calculation 11.59% add-on to each DRG rate for every 10% increase in in a teaching hospital’s resident-to-bed ratio (1984) Subsequently affected (decreased) by multiple budgetary legislative acts  COBRA, OBRA, BBA, BBRA, & BIPA

IME Calculation COBRA reduced IME to 8.1% OBRA reduced IME to 7.7% in 1989 BBA reduced IME to 6.5% for 1999, 6%in 2000, & 5.5% in 2001 BBRA delayed the decrease to 5.5% for one more year BIPA restored IME to 6.5% until FY 2003 Currently 5.5%

Medicaid DGME/IME in states & DC provided DGME/IME under ½ states & DC made payment explicitly and directly to teaching hospitals Some link payments influence physician $ billion

DGME/IME Funding Indirect Medical Education  UTMCK FTEs Direct Medical Education  UTMCK FTEs Some residents exceeded their initial residency period Only receive 0.5 FTE if training exceeds the time allotted for the initial residency period (IRP) Lowers their weight in the DGME count but not in the IME count

Initial Residency Period Used to determine DGME Based upon the specialty of the first year of postgraduate training Residents counted as 1 FTE during the number of years required to become board-eligible No resident can be counted as 1 FTE for more than 5 years Counted as 0.5 FTE for training after the IRP

CMS Comments in the Federal Register May 18, 2004 "There are numerous programs, including anesthesiology, dermatology, psychiatry, and radiology, that require a year of generalized clinical training to be used as a prerequisite for the subsequent training in the particular specialty. For example, in order to become board eligible in anesthesiology, a resident must first complete a generalized training year and then complete 3 years of training in anesthesiology.”

CMS Comments in the Federal Register "This first year of generalized residency training is commonly known as the "clinical base year.'' Commonly, the clinical base year requirement is fulfilled by completing either a preliminary year in internal medicine (although the preliminary year can also be in other specialties such as general surgery or family practice), or a transitional year program (which is not associated with any particular medical specialty)."

CMS Comments in the Federal Register “ Current CMS policy is that the initial residency period is determined for a resident based on the program in which he or she participates in the resident's first year of training, without regard to the specialty in which the resident ultimately seeks board certification.”

CMS Comments in the Federal Register May 18, 2004 Therefore, for example, a resident that chooses to fulfill the clinical base year requirement for an anesthesiology program with a preliminary year in an internal medicine program will be "labeled'' with the initial residency period associated with internal medicine, or 3 years (3 years of training are required to become board eligible in internal medicine), even though the resident may seek board certification in anesthesiology, which requires a minimum of 4 years of training to become board eligible

CMS Comments in the Federal Register May 18, 2004 As a result, this resident would be weighted at 0.5 FTE in his or her fourth year of training for purposes of direct GME payment."

Interpretation of CMS Comments If a resident participates in a transitional preliminary year program prior to the start of an anesthesiology residency, DMGE/IME funding for four years will be available because the IRP is based upon the specialty in which the resident will be training i.e. anesthesiology

Interpretation of CMS Comments If, however, a resident completed a preliminary year in Family Practice, his initial residency was considered “Family Practice" even though the resident “matched” in an anesthesiology program. Only three years of DGME funding would be available because Family Practice is considered a 3-year residency. Only 50% of the direct GME payment would be available to “fund” the fourth year of post-graduate medical training.

CMS & Federal Fiscal Year 2005 "To address these concerns, CMS is making final the change in policy that addresses “simultaneous match” residents. Specifically, if a hospital can document that a particular resident matches simultaneously for a first year of training in a clinical base year in one medical specialty, and for additional year(s) of training in a different specialty program,

CMS & Federal Fiscal Year 2005 “…..the resident's initial residency period would be based on the period of board eligibility associated with the specialty program in which the resident matches for the subsequent year(s) of training and not on the period of board eligibility associated with the clinical base year program, for purposes of direct GME payment.”

CMS & Federal Fiscal Year 2005 “In addition, CMS is considering a new definition of “residency match” to mean, for purposes of direct GME, a national process by which applicants to approved medical residency programs are paired with programs on the basis of preferences expressed by both the applicants and the program directors."

How to Fund: Increase in the Resident “Cap” CMS “Demonstrated Likelihood” Criteria  Will use the slots for a new program  Will use the slots for additional residents due to a residency program expansion  The hospital’s resident count exceeds its corresponding cap  Residency program at risk of losing accreditation because of insufficient residents 10-point evaluation criteria to stratify hospital requests

How to Fund: Phagocytosis “Engulf and incorporate” Designate internship positions at the teaching hospital where the residency is based as PGY-1 anesthesia slots Paramount importance to foster cooperation between program directors and the GME department of the teaching hospital UTMCK: five transitional positions are ‘slotted’ for our program; will increase to 6