Title: REPORT OF THE BOARD OF TRUSTEES
Author: Michael J. Scotti, Jr., MD
Last saved by: Political Science Computer Lab
Company: American Medical Association

CME Rep. 6 - A-99 -- page

REPORT OF THE COUNCIL ON MEDICAL EDUCATION

								CME Report 6 - A-99

Subject:	Medicare Payments to Teaching Physicians, The Primary Care Exception
		(Resolution 810, A-98)

Presented by:	Robert M. Daugherty, Jr., MD, PhD, Chair

Referred to:	Reference Committee C
		(James P. Marvel, Jr., MD, Chair)

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Resolution 810 (A-98), introduced by the American College of Physicians, was referred to 
the Board of Trustees.  Resolution 810 reads as follows:

RESOLVED, That the American Medical Association work with Health Care Financing Administration, and Congress if necessary, to modify the primary care exception rule to allow 
on-site teaching physicians in primary care clinics and physician offices to bill for lower and 
mid-level E/M services that they provide directly as well as those provided by residents under their supervision.

Testimony before the Reference Committee universally favored support wherever possible for attending physicians providing instruction and supervision to resident physicians.  In relation to this issue, the Reference Committee also considered Resolution 825 (A-98), which requested the AMA to develop a CPT modifier for this function; both resolutions were referred to the Board 
of Trustees.  Resolution 825 (A-98) will be considered elsewhere and reported separately to the House of Delegates.

When Direct Medical Education (DME) adjustment payments to teaching hospitals from Part A of the Medicare Trust Fund were authorized, they were designed to pay Medicare’s share of the costs of resident physician salaries and that portion of faculty salaries expended on teaching resident physicians for the service provided to Medicare patients.  The Health Care Financing Administration (HCFA) therefore takes a dim view of paying for the same services a second time through Part B of the Fund, which covers physician services to Medicare patients.  While the history of this issue and the Physicians at Teaching Hospitals (PATH) attendant audits will not 
be repeated here, the Office of the Inspector General of HCFA considers separate billing through part B by the teaching physician to be valid only if the physician performed the service or was physically present when the key portion of the service was provided.

Representatives of the American Academy of Family Physicians and the Organizations of Academic Family Medicine convinced HCFA that an exception should be made for training resident physicians in primary care.  The argument was made that the need to develop an appropriate level of independence in the provision of care could be achieved only if the attending staff physician did not always accompany the resident physician during patient care.  The exception was narrowly drawn and specified that the teaching physician be in close proximity (immediately available), supervise no more that four resident physicians at any one time, and have no other responsibilities at the time of service.  The services are specified to take place in 
a hospital outpatient department or similar ambulatory care department, the sites where part A payments are made.
The same reasoning for the exception would apply equally, if not more forcefully, to resident physician-patient interactions in a physician’s office or in the patient’s home if they were eligible for payments through part A of the Medicare Trust Fund.  At this time payments in these settings are paid through part B of the Fund to all physicians who are licensed, have Medicare provider numbers, and document and bill appropriately for the services provided.  The Council can find 
no reason for restricting the “primary care exception” to hospital outpatient and ambulatory care departments if other sites become eligible for part A payments through consortia or other legal academic structures. 

The issue of permitting the teaching physician to bill HCFA under the “primary care exception” for resident physician services while at the same time the teaching physician is performing other billable services is more problematic. Under current statutes, this does not appear allowable.  As significant changes in Medicare support of graduate medical education are currently under discussion at the Bipartisan Commission on the Future of Medicare and in the Medicare Payment Advisory Commission, the time does not appear ripe for the development and successful passage of legislation directed to this narrow issue of permitting billing of two entities for services at the same time by expanding the concept of the “primary care exception.”

Recommendations:

The Council on Medical Education recommends that the AMA adopt the following recommendations in lieu of Resolution 810 (A-98), and that the remainder of this report be filed.

1.	That the AMA support the continuation of the “primary care exception” for teaching physicians providing Part A Medicare covered services.

2.	That the AMA work with the Health Care Financing Administration, and Congress 
if necessary, to modify the primary care exception rule to extend to physicians’ 
offices and patients’ homes the same provisions that now apply to hospital outpatient 
departments and ambulatory care departments when and if such sites become eligible 
for payments under part A of the Medicare Trust Fund.

3.	That the AMA monitor ongoing legislative initiatives and support specific language to enhance the availability of teaching physicians through fair and consistent compensation for this vital service.