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Moreover, residents in this program have spent one to two months training in obstetrics at Dartmouth's Mary Hitchcock's Medical Center in Lebanon, New Hampshire. Because the cap is based on a hospi tal's cost report, these residents are counted toward Dartmouth Medical School's cap instead of the Maine-Dartmouth Family Practice Residency Program's. Last
[Page: S2317] GPO's PDF
Moreover, the cap does not include residents who continue to be part of the residency program, but who have been sent outside of the hospital for training. This penalizes all primary care specialties, but especially family medicine, where ambulatory training has historically been the hallmark of the specialty. This is particularly ironic since other specialty programs that now begin training in settings outside the hospital will, under the new rules, have those costs included in their Medicare graduate medical education funding.
All told, the Maine Dartmout h Family P ractice Residency Program will see its graduate medical education funding reduced by over half a million dollars a ye ar as a result of the cap established by the BBA.
The example I have just used is from Maine, but the problems created by the BBA's graduate medical education changes are national in scope. It has created dispr oportion ately harm ful effects on family practice residencies from Maine to Alaska. A recent survey of all family practice residency program directors has found that:
56 percent of respondents who were in the process of developing new rural training sites have indicated that they will either not implement those plans or are unsure about their sponsoring institutions' continued support.
21 percent of respondents report planning to decrease their family practice residency slots in the immediate future. The majority of those who are planning to decrease their slots are the sole residency program in a teaching hospital. This means that, under current law, they have no alternative way of achieving growth, such as through a reduction of other specialty slots in
order to stay within the cap.
And finally, the vast majority of family practice residencies did not have their full residency FTEs captured in the 1996 cost reports upon which the cap is based.
In addition to this survey, we have anecdotal information from residencies across the country detailing how they have lost funding either because of where they trained their residents or because their residents had been extended sick or maternity leave. For example, one family practice residency in Washington State last year had an equivalent of 14 residents training outside of the hospital and four in the hospital. Under the BBA, their cap would be four. By contrast, had all of their residents been trained in the hospital up to this point, their payment base would have been capped at 18, even if they trained residents in non-hospital settings in the future.
The Medicare Graduate Medical Education Technical Amendments Act we are introducing today w ill addr ess these problems by basing the cap on the number of residents ``who were appointed by the approved medical residency training programs for the hospital'' in 1996, rather than o n the number of residents who were ``in the hospital.''
I am also concerned that the Balanced Budget Act and its accompanying regulations will severely hamper primary care residency programs that are expanding to meet local needs. Specifically, a new residency program that had not met its full complement of accredited residency positions until after the cutoff date of August 5, 1997, is precluded from increasing its number of residents unless the hospital decreases the number of residents in one of its other specialty programs. However, over forty percent of the nation's family practice residency programs are the only program sponsored by the hospital. This provision therefore completely precludes such a hospital from expanding its residency program to meet emerging primary care needs.
To address this problem, the legislation we are introducing today would allow the small number of programs at hospitals that sponsor just one residency program to increase their cap by one residency slot a year up to a maximum of three. In addition, to enable a number of family practice residency programs that are already in the pipeline to get accredited and grow to completion, the bill extends the cutoff date to September 1999.
And finally, the Balanced Budget Act gave the Secretary of Health and Human Services the authority to give ``special consideration'' to new facilities that ``meet the needs of underserved rural areas.'' The Health Care Financing Administration has interpreted this to mean facilities that are actually in underserved rural areas. There have been several recent expansions in family practice residency programs that include a rural training track, with residents located in outlying hospitals, or with satellite programs designed specifically to train residents to work with underserved populations.
Even though these new programs or satellites required accrediting body approval, they are still part of the ``mother'' residencies, which may not be physically located in an underserved rural area. While these are not technically new programs, I believe that the definition should be expanded to include such endeavors, given the value of these programs in addressing the needs of underserved populations. Therefore, the Medicare Graduate Medical Education Technical Amendments Act would expand the definiti on to in clude ``fa cilities which are not located in an underserved rural area, but which have established separately accredited rural training tracks.''
Mr. President, while the changes we are proposing today are relatively minor and technical in nature, they are critical to the survival of the small family practice residency programs that are so important to our ability to meet health manpower needs in rural and underserved areas. I urge all of my colleagues to join us in cosponsoring the Medicare Graduate Medical Education Technical Amendments and ask unanimous consent that the tex t of the b ill be printed in the RECORD.
There being no objection, the bill was ordered to be printed in the RECORD, as follows:
Be it enacted by the Senate and House of Representa tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Graduate Medical Education Technical Amendments of 1999''.
&nbs p;SEC . 2. INDIR ECT GRADUATE MEDICAL EDUCATION ADJUSTMENT.
(a) IN GENERAL.--Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)) (as added by section 4621(b) of the Balanced Budget Act of 1997) is amended--
(1) by striking ``(v) In determining'' and inserting ``(v)(I) Subject to subclause (II), in determining'';
(2) by striking ``in the hospital with respect to the hospital's most recent cost reporting period ending on or before December 31, 1996''; and inserting ``who were appointed by the hospital's approved medical residency training programs for the hospital's most recent cost repor ting period ending on or before December 31, 1996''; and
(3) by adding at the end the following:
``(II) Beginning on or after January 1, 1997, in the case of a hospital that sponsors only 1 allopathic or osteopathic residency program, the limit determined for such hospital under subclause (I) may, at the hospital's discretion, be increased by 1 for each calendar year but shall not exceed a total of 3 more than the limit determined for the hospital under subclause (I).''.
(b) TECHNICAL AMENDMENTS.--Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by moving clauses (ii), (v), and (vi) 2 ems to the left.
SEC. 3. DIRECT GRADUATE MEDICAL EDUCATION ADJUSTMENT.
(a) LIMITATION ON NUMBER OF RESIDENTS.--Section 1886(h)(4)(F) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(F)) (as added by section 4623 of the Balanced Budget Act of 1997) is amended by inserting ``who were appointed by the hospital's approved medical residency training programs'' after ``may not exceed the number of su ch full-time equivalent residents''.
(b) FUNDING FOR NEW PROGRAMS.--The first sentence of section 1886(h)(4)(H)(i) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)(i)) (as added by section 4623 of the Balanced Budget Act of 1997) is amended inserting ``and before September 30, 1999'' after ``January 1, 1995''.
(c) FUNDING FOR PROGRAMS MEETING RURAL NEEDS.--The second sentence of section 1886(h)(4)(H)(i) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)(i)) (as added by section 4623 of the Balanced Budget Act of 1997) is amended by striking the period at the end and inserting ``, including facilities that are not located in an underserved rural area but have established separately accredited rural training tracks.''.
SEC. 4. EFFECTIVE DATE.
The amendments made by this Act shall take effect as if included in the enactment of the Balanced Budget Act of 1997.
Mr. MURKOWSKI. Mr. President, I am pleased today to introduce with my distinguished colleague from Maine, Senator COLLINS, the Graduate Medical Education Technical Amendments Act of 1999. This legislation will all eviate uni ntended consequences of the Balanced Budget Act of 1997 regarding Graduate Medical Education (GME).
The Balanced Budget Act of 1997 contained important and necessary GME reform. However, a small number of the changes in the Balanced Budget Act of 1997, have grave consequences for many residency programs, particularly for programs that have been training in ambulatory settings, are small, or who produce physicians to serve in rural areas. The impact has been disproportionately harmful to programs that: have already been training in ambulatory settings (because the hospitals in which they were located were not allowed to count the residents they had serving in community settings in the cap); are small, such as hospitals with only one residency program; and train physicians for practice in rural areas.
The impact is especially damaging to family practice residency programs. Only family practice residents have been trained extensively out of the hospital and only family practice residencies were significantly harmed by this provision in the BBA. In fact, a recent survey indicates that 56 percent of family residency program directors believe that the BBA provisions will preclude their development of rural training sites.
Senator COLLINS' and my legislation would include the following legislative remedies:
Recalculate the IME and DME caps based on the number of interns and residents who were appointed by the approved medical residency training programs for FY 1996, whether they were being trai ned in the hospital or in the community;
Change the cutoff date for adjusting the DME funding cap to September 30, 1999, to allow those programs already in the approval process for accreditation to continue to realization; and
Expand the exception to the funding caps to include programs with separately accredited rural training tracks even if the sponsoring hospital is not located in a rural area, and for residency programs where a primary care training program is the only one offered in the hospital.
This legislation is important for Alaska's first and only residency program. The Alaska Family Practice Residency is specifically designed to train physicians to practice medicine in rural Alaska.
Alaska's rural health care problems are tough: 74% of Alaska is medically under-served. Many villages populated by 25-1000 individuals do not have access to physicians. Physician turn-over rate is high which makes it impossible for patients to establish long-term relationships with their physician to manage chronic disease or to do preventative medicine. The result is that bush Alaska has much higher rates of preventable diseases.
This legislation is truly imperative to Alaska health care. While other residency programs have the luxury of educating their residents on rural health issues, for us it is a necessity.
Mr. President, our legislation corrects a small deficiency in the BBA of 1997 that has had a large, unintended impact on programs training community-based and rural doctors. I hope my colleagues can join our efforts and support this important legislation.
By Mr. ABRAHAM (for himself, Mr. WYDEN, Mr. HATCH, Mr. KERREY, Mr. COVERDELL, Mr. DASCHLE, Mr. JEFFORDS, Mr. LIEBERMAN, Mr. ALLARD, Mr. GORTON, Mr. BURNS, and Mr. MCCONNELL):
S. 542. A bill to amend the Internal Revenue Code of 1986 to expand the deduction for computer donations to schools and allow a tax credit for donated computers; to the Committee on Finance.
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