Scarce GME funding has states, organizations on a scavenger hunt

Training opportunities for medical residents are becoming fewer and farther between, but the need for trained physicians isn’t changing, causing state medical organizations and governments to search for ways to find the funds to pay for graduate medical education (GME). Those concerned are leaving no stone unturned to find funding or cut costs in existing programs.

Most of the money to support GME programs comes from the federal government through the Medicare and Medicaid programs. The problem is that, like other health-care programs, Congress capped spending over the years to reduce the drain on the federal budget.

Children’s hospital GME funding

To address this lack of funding, organizations such as the American Hospital Association, the American Academy of Pediatrics, and Children’s Hospital Association are starting at the top when it comes to requesting money. Together, they urged President Obama to fully fund the Children’s Hospitals Graduate Medical Education program at the authorized level of $300 million allocated in the Department of Health and Human Services budget for fiscal year 2017.

“The 56 freestanding children’s hospitals that receive CHGME funding train approximately half of all future pediatricians and the majority of all residents in pediatric subspecialties,” the organizations wrote. “CHGME funding has decreased 17% since FY 2010, from $317.5 million to $265 million in FY 2015. The effects of continued diminished support for pediatric training are felt by children and their families. Serious pediatric workforce shortages persist, most acutely among pediatric subspecialties. Localized shortages of pediatric primary care also continue, particularly in certain rural areas. There are also several pediatric specialties at risk of sustaining tremendous losses as the current workforce retires and not enough new specialists are trained. Additionally, cuts have slowed the ability to grow in areas of need, which will result in fewer pediatric subspecialists across the country.”

Unified funding

Physician advocates for GME funding have also found another place to save money by developing a single accreditation system which should be fully implemented by July 2020. The system will allow graduates of osteopathic and allopathic medical schools to complete their residency and fellowship education in Accreditation Council for Graduate Medical Education (ACGME) accredited programs. Under the new system, all physicians in training will be able to demonstrate their achievements by meeting a common set of milestones and competencies.

“Over the years, we’ve had a number of GME programs that are dually accredited—they were accredited by the ACGME and AOA—and those programs had to answer to two different accrediting bodies and pay two different sets of accrediting fees,” Dr. Buser, American Osteopathic Association (AOA) Trustee and President-Elect Boyd R. Buser, DO said. “This is an unnecessary duplication and cost.”

CMS provides status of Recovery Audit Program enhancements

The Recovery Audit Program is undergoing a series of changes to improve the program’s accuracy and to allow providers more opportunities to provide feedback on the process. CMS detailed the recent and ongoing enhancements that it is making to the program, which includes more stringent requirements for recovery audit contractors (RACs) to ensure that they make valid determinations and are held accountable for their decisions.

Provider assistance

CMS has taken steps in assisting providers with compliance matters, including posting compliance tips on its website. CMS also established the Provider Relations Coordinator in order to offer providers the means to efficiently resolve matters that cannot be solved by a RAC.


In order to ensure that RACs are making valid determinations, CMS now requires them to maintain an overturn rate of less than 10 percent at the first level of appeal. The failure to do so will result in the RAC being placed on a corrective action plan. RACs are also required to maintain an accuracy of at least 95 percent, and the failure to do so will result in a progressive reduction of additional documentation request (ADR) limits. Additionally, the look-back period has been limited to six months from the date of service for all patient status reviews when claims are submitted within three months of the date of service. All RACs are required to have a physician Contractor Medical Director who is available to discuss improper payment identifications.

ADR limits

CMS revised the ADR limits for facility claims, which are diversified across all claim types of a facility. Additionally, CMS is not raising the ADR limits for physicians and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers and suppliers. CMS is also establishing ADR limits that are based on a provider’s compliance with Medicare rules.

In progress

CMS is working on developing a Provider Satisfaction Survey, which would give providers an opportunity to provide feedback on the RACs’ performance. Additionally, CMS will provide information about the program through increase public reporting and quality assurance activities so as to allow the provider community to have access to the Recovery Audit Program data.

Additional enhancements

RACs will have 30 days instead of 60 days to complete complex reviews and notify providers of their findings. RACs will also be required to wait 30 days to allow for a discussion request prior to sending a claim to the Medicare administrative contractor (MAC) for adjustment. RACs must also enhance their provider portals and broaden their review topics.

Contingency fees

All new contracts will withhold contingency fees for RACs until after the second level of appeals are exhausted.

New breast exam guidelines are confusing, counterintuitive

Recent changes to the American Cancer Society guidelines on screening and early detection of breast cancer are confusing and contradictory. Oddly, the screening methods that are easiest and least expensive are not recommended. The ACS recommends that women between 45 and 54 who are at average risk for cancer and have no symptoms get annual mammograms and that women age between 40 and 45 should be able to have them if they choose. After 55, women can choose to have them every two years as long as they are otherwise healthy and can expect to live at least ten years.

The U.S. Preventive Services Task Force (USPSTF) recommends less frequent mammograms. The organization is in the process of updating its 2009 guidelines, but major changes are not expected.

Are routine mammograms helpful?

Mammography has been promoted as a life-saving procedure in that it leads to early detection, and cancer is more treatable and curable when detected early. But there also is evidence that mammography leads to false positive results. The image may reveal an anomaly, such as a small mass, requiring the woman to be called back for additional screening or a biopsy. The call-back alone can be anxiety-producing; even if the test reveals cancer, the mammogram may not save her life. It may be that the cancer is so small, and so localized, that there is little or no risk to life. But once the doctor finds cancer, the next step is likely to be treatment.

A 2012 study published in the New England Journal of Medicine examined the relationship between the rising use of mammograms to detect breast cancer and the frequency of breast cancer deaths. As exposure to mammograms rose, beginning in the mid-1970s, there were more diagnoses of early-stage cancer.

When the study began, it was commonly recommended that women begin to have regular screening mammograms at age 40. Screening mammograms, to check for disease in the absence of any symptoms, were not recommended for women under 40 unless they were at higher-than-usual risk. As mammography technology improved, the number of early-stage cancers found also grew. But the number of invasive cancers found did not drop as much as the number of early cases grew. The investigators concluded that a significant portion of the cancers detected by mammograms would never have progressed to late-stage, life-threatening cancer.

Although the number of deaths from breast cancer dropped significantly, the investigators could not attribute the drop to early detection through mammography. The rate of breast cancer deaths in women over 40 dropped 28 percent during the three decades covered by the study. The death rate among women under 40, the group who did not undergo screening mammograms, dropped 42 percent during the same period. Moreover, the frequency of patients presenting with late-stage cancer, which had spread beyond the breasts, remained relatively constant. The investigators concluded that other factors, particularly improvements in treatment, had more impact on breast cancer deaths than screening mammograms.

The Preventive Services Task Force grades

The United States Preventive Services Task Force (PSTF) uses letter grades to rate the relative benefits of preventive services. Its 2009 guidelines gave a B grade to screening mammograms every two years for women between the ages of 50 and 74; the 2015 draft guidelines make no change to this recommendation. The B grade means that there is a “good chance of moderate to substantial benefit” to women who follow the guidelines; women between the ages of 60 and 69 are most likely to avoid death from breast cancer through screening mammograms.

The controversy concerns the recommendation for women between the ages of 40 and 49. The PSTF gave biannual mammograms a grade of C for this age group, meaning that there is “moderate certainty of a small net benefit” for women at average risk. A small number of cancer cases would be caught, and a larger number of women would be treated unnecessarily. Women who have a parent, child or sibling with a history of the disease are more likely to benefit.

Clinical and self-examination

The PSTF gives  a grade of D to teaching women BSE and a grade of I to clinical examination of the breast (CBE) by a physician during exams. The D grade means “there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” Therefore, the use of the service is discouraged.  Still, the National Cancer Institute and the ACS recommend that women be familiar with how their breasts look and feel and report any changes to their physician. The clinical examination was given a grade of I, meaning that there is insufficient evidence to determine the extent of benefit or harm. The “clinical considerations” discussion stated that CBE may detect a significant portion of breast cancers if it is the only screening test available, as in parts of the world where mammography is unavailable.  But the disadvantage is that apparently there is no standard method either to perform the examination or to report the results. And aside from the danger of false positives, there is the “opportunity cost” to the clinician. So the PSTF recommends that clinicians who are “committed to spending time on CBE would benefit their patients by considering the evidence of a structured, standardized examination.”

Actually, a structured, standardized examination is exactly what women were taught to do. And there is  evidence that it can catch some cancers that arise between mammograms. So why wouldn’t physicians want to learn to perform a proper exam?

Senate eyes mental health as emergency physicians express concerns about treatment options

On October 29, 2015, the Senate Committee on Health, Education, Labor & Pensions held a full committee hearing on the status of the country’s mental health and substance abuse treatments. The panel of witnesses was made up of the acting administrator of the Health Resources and Services Administration, the acting administrator of the Substance Abuse and Mental Health Services Administration, and the director of the National Institute of Mental Health. The witnesses emphasized the extent to which mental illness pervades the country’s population and the necessity of providing early treatment, as well as the challenges the industry faces providing the necessary services.

This hearing comes the same week that the American College of Emergency Physicians released survey results indicating that an overwhelming amount of emergency physicians think that the mental health system is failing patients. Almost 1,500 doctors responded to the survey, and the results emphasize the necessity of additional efforts to treat this population. Forbes reports that of patients with chronic conditions seen by emergency departments, those with mental illness and mood disorders are the most common.

An ongoing problem

The problem, however, is not new. On Christmas Day of 2013, the New York Times reported that emergency room costs for treating the mental ill were on the rise, forcing hospitals to find better ways of meeting their patient’s needs. In Raleigh, North Carolina, Holly Hill Hospital instituted a pilot program in which paramedics took mentally ill patients to the commercial psychiatric facility instead of the nearest emergency department.

According to the New York Times, federal estimates for the cost of treating the mentally ill in emergency rooms for 2014 hovered around $38.5 billion, a stark increase from 2003’s $20.3 billion. As the mental health system shifted toward new models of care, communities were not able to handle the burden. Some hospitals created separate emergency departments or extensions for the mentally ill. North Carolina, a state that felt the issue particularly deeply, responded by attempting to steer patients away from emergency departments altogether.

Solutions created more problems

In the 1960s, states began closing psychiatric facilities and reducing the number of beds available for these patients in an effort to provide community-based treatment. Yet during the economic downturn, funding was reduced to these programs and many went without care. Now, patients are showing up at emergency departments that are unable to properly handle the demand. The 2013 New York Times article revealed that WakeMed Health and Hospitals saw between 25 and 50 mentally ill patients each day. The hospital employs many people simply for the purpose of finding better options for care for these patients.

An op-ed in Raleigh’s The News & Observer in June 2015 provided an update, and the problem is still rampant. Mental health facilities are often full, and patients who first go to the emergency room have to wait an average of three-and-a-half days for an inpatient bed. No real treatment is provided beyond sedation during this wait. The article reported that WakeMed had 60 people waiting for an inpatient psychiatric bed at one time.

The pilot program helped by allowing paramedics to offer prospective patients the opportunity to go to a different type of facility as opposed to the emergency room. Other states took notice as they tried to come up with their own creative solutions. But some states have laws preventing ambulances from taking patients to anywhere besides an emergency room, and Medicare and Medicaid will usually not reimburse for transportation to alternative facilities.

How to COPE?

The newest effort to combat the problem will be launched by emergency and psychiatric physicians: the Coalition on Psychiatric Emergencies (COPE). Cope has several aims, such as decreasing waiting for psychiatric beds in emergency departments, providing better training for emergency physicians caring for psychiatric patients, advancing research, and developing plans for care that include prevention and follow up care. Dr. Amanda Itzkoff told Forbes that the best answer to reducing the costs of expensive psychiatric care is actually treating the illnesses. She feels that the  disappearing inpatient beds are a necessity and will ultimately improve outcomes.