[Congressional Record Volume 151, Number 154 (Friday, November 18, 2005)]
[Senate]
[Pages S13377-S13378]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. SNOWE (for herself, Mr. Bingaman, Ms. Collins, Mr. Dorgan, 
        and Mr. Rockefeller):
  S. 2071. A bill to amend title XVIII of the Social Security Act to 
clarify congressional intent regarding the counting of residents in the 
nonhospital setting under the medicare program; to the Committee on 
Finance.
  Ms. SNOWE. Mr. President, I rise today to introduce the Community and 
Rural Medical Residency Preservation Act of 2005, which will serve to 
ensure the continued viability of medical residency training programs 
in our local communities. I am particularly pleased to introduce this 
bill with several of my colleagues, Senators Bingaman, Collins, Dorgan, 
and Rockefeller, who share my concerns about the need to clarify 
congressional intent so that teaching hospitals will be able to offer 
these essential residency training programs in the community and so 
that medical residents, as well as many who live in these communities, 
will be able to continue to benefit from these programs.
  Many medical residency training programs have traditionally operated 
in sites located outside the hospital setting for their educational 
programs. These nonhospital settings are, in fact, where most of this 
type of physician training occurs. The community and rural sites which 
operate these programs include physician offices, nursing homes, and 
community health centers--cornerstones of ambulatory training for 
graduate medical education, GME, programs. These programs often rely 
upon volunteer physician faculty to provide educational opportunities 
in practice settings which are similar to those in which these 
physicians in training will ultimately practice.
  Congress clearly stated support for this concept as part of the 
Balanced Budget Act of 1997, when they reformed the GME funding 
formulas to allow funding for residents training in nonhospital 
settings. However, recent rulemaking, agency interpretations, and 
guidance issued by the Centers for Medicare and Medicaid Services, CMS, 
are creating a chilling effect on these training programs. Teaching 
programs across the Nation are facing audits and scrutiny as a result 
of confusing and unclear CMS policies and guidance on this issue. This 
has happened in my State, as well as many others, and is posing a 
serious threat to our future physician workforce and to teaching 
hospitals and medical schools which offer these programs.

  If these agency policies are not halted and reversed, teaching 
hospitals throughout the country will be forced to train all residents 
in the hospital setting or potentially eliminate their residency 
programs. Not only does this do a disservice to medical residents who 
are able to obtain practical experience and be exposed to settings 
where they may ultimately practice, but these programs provide 
individuals living in medically underserved and rural areas with access 
to health care which might otherwise not be available.
  Training medical residents outside the hospital setting is sound 
educational policy and a worthwhile public policy goal that Congress 
clearly mandated in 1997. In an effort to preserve the utilization of 
nonhospital training sites, I am therefore introducing legislation 
today which would clarify the meaning of the term ``all, or 
substantially all, of the costs for the training program,'' a phrase 
which has been subject to differing, and confusing, interpretations by 
CMS.
  My legislation would clarify that, for teaching hospitals and 
entities operating training programs outside the hospital setting, the 
teaching hospital shall not be required to pay the entity operating the 
nonhospital setting any amounts other than those determined by the 
hospital and the entity for the hospital to be considered to have 
incurred all, or substantially all, of the costs for the training 
program. Medical associations, teaching hospitals, and academic 
medicine all strongly support this legislation.
  This language will also make clear that hospitals shall not be 
required to pay an entity operating a nonhospital setting for any 
actual or imputed costs of time voluntarily spent supervising interns 
or residents as a condition for computing residents for purposes of 
receiving either direct graduate medical education payments or indirect 
medical education payments.
  We have received strong support from a number of organizations who 
are in the forefront of training America's future physicians and who 
have confirmed the critical need for this legislation, including the 
Association of American Medical Colleges, the Academic Family Medicine 
Advocacy Alliance, representing the Society of Teachers of Family 
Medicine, the Association of Departments of Family Medicine, the 
Association of Family Medicine Residency Directors, and the North 
American Primary Care Research Group, and the American Osteopathic 
Association.
  I ask unanimous consent that the text of the bill and the letters of 
support from these organizations printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 2071

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Community and Rural Medical 
     Residency Preservation Act of 2005''.

     SEC. 2. CLARIFICATION OF CONGRESSIONAL INTENT REGARDING THE 
                   COUNTING OF RESIDENTS IN A NONHOSPITAL SETTING.

       (a) D-GME.--Section 1886(h)(4)(E) (42 U.S.C. 
     1395ww(h)(4)(E)) is amended by adding at the end the 
     following new sentences: ``For purposes of the preceding 
     sentence, the term `all, or substantially all, of the costs 
     for the training program' means the stipends and benefits 
     provided to the resident and other amounts, if any, as 
     determined by the hospital and the entity operating the 
     nonhospital setting. The hospital is not required to pay the 
     entity any amounts other than those determined by the 
     hospital and the entity in order for the hospital to be 
     considered to have incurred all, or substantially all, of the 
     costs for the training program in that setting.''.
       (b) IME.--Section 1886(d)(5)(B)(iv) (42 U.S.C. 
     1395ww(d)(5)(B)(iv)) is amended by adding at the end the 
     following new sentences: ``For purposes of the preceding 
     sentence, the term `all, or substantially all, of the costs 
     for the training program' means the stipends and benefits 
     provided to the resident and other amounts, if any, as 
     determined by the hospital and the entity operating the 
     nonhospital setting. The hospital is not required to pay the 
     entity any amounts other than those determined by the 
     hospital and the entity in order for the hospital to be 
     considered to have incurred all, or substantially all, of the 
     costs for the training program in that setting.''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect on January 1, 2005.
                                  ____

                                 American Osteopathic Association,


                           Department of Government Relations,

                                 Washington, DC, November 2, 2005.
     Hon. Olympia J. Snowe,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Snowe: As President of the American 
     Osteopathic Association (AOA), I write to express our strong 
     support for the ``Community and Rural Medical Residency 
     Preservation Act of 2005.'' On behalf of the

[[Page S13378]]

     56,000 osteopathic physicians represented by the AOA, thank 
     you for your tireless efforts to protect and promote quality 
     graduate medical education.
       A majority of osteopathic residency programs, in all 
     specialties, use non-hospital settings in their educational 
     programs. These non-hospital sites, which consist of 
     physician offices, nursing homes, community health centers, 
     and other ambulatory settings, provide resident physicians 
     with valuable educational experiences in settings similar to 
     those in which they ultimately will practice. This concept is 
     a cornerstone of osteopathic graduate medical education.
       The training of residents in non-hospital settings is sound 
     educational policy and a worthwhile public policy goal that 
     Congress clearly mandated in 1997. It continues to enjoy 
     strong Congressional support. Congress endorsed this concept 
     as part of the Balanced Budget Act of 1997, when the graduate 
     medical education, GME, funding formulas were reformed to 
     allow funding for residents training in non-hospital settings 
     with volunteer faculty.
       However, recent rule-making, agency interpretations, and 
     guidance issued by the Centers for Medicare and Medicaid 
     Services, CMS, create a chilling effect on residency training 
     programs. If CMS policy is not halted, hospitals will be 
     forced to train all residents in the hospital setting or 
     potentially eliminate programs. Teaching programs across the 
     nation face audits and scrutiny as a result of confusing and 
     unclear CMS policy on this issue.
       Your legislation establishes, in statute, clear and concise 
     guidance on the use of ambulatory sites in teaching programs. 
     If enacted, it will preserve the quality education of 
     resident physicians originally envisioned by Congress in 
     1997. The AOA and our members stand ready to use all 
     available resources to ensure enactment of this important 
     legislation.
           Sincerely,
                                             Philip Shettle, D.O.,
     President.
                                  ____



                     Association of American Medical Colleges,

                                Washington, DC, November 18, 2005.
     Hon. Olympia Snowe,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Snowe: On behalf of the Association of the 
     American Medical Colleges, AAMC, I write to endorse the 
     ``Community and Rural Medical Residency Preservation Act of 
     2005.'' The AAMC represents 125 accredited U.S. medical 
     schools; approximately 400 major teaching hospitals and 
     health systems, 94 academic and professional societies, 
     representing 109,000 faculty members; and the nation's 67,000 
     medical students and 104,000 residents.
       Your bill would ensure that CMS regulations and guidance no 
     longer impede the ability of teaching programs to train 
     resident physicians in ambulatory and rural settings. As you 
     know, ambulatory training is a vital aspect of every 
     resident's training and is designed to expose residents to a 
     variety of rural, suburban and urban settings in which they 
     ultimately choose to practice such as physicians offices, 
     nursing homes, and community health centers. Such training is 
     coordinated by program directors at teaching hospitals in 
     conjunction with community physicians--many of whom volunteer 
     their time as a professional commitment to train the next 
     generation of physicians.
       Specifically, your bill clarifies that supervising 
     physicians in non-hospital settings would be allowed to 
     volunteer their teaching time. It also ensures that any 
     teaching costs associated with supervising physicians who are 
     not volunteers would be based on negotiations between the 
     hospital and the nonhospital setting, rather than a 
     complicated formula requiring unreasonable administrative 
     burdens on both the teaching programs and nonhospital 
     training settings.
       We appreciate your continued interest in this issue and 
     your efforts to ensure the viability of community and rural 
     residency training. The AAMC looks forward to continuing to 
     work with you and your staff to advance this important 
     legislation.
           Sincerely,

     Jordan Cohen, M.D.
                                  ____



                   Academic Family Medicine Advocacy Alliance,

                                                November 11, 2005.
     Hon. Olympia J. Snowe,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Snowe: On behalf of the undersigned academic 
     family medicine organizations I would like to commend you for 
     introducing the ``Community and Rural Medical Residency 
     Preservation Act of 2005'', legislation intended to solve a 
     longstanding problem in Medicare regulations that deals with 
     volunteer teachers of residents in nonhospital settings.
       We have appreciated your support through the years on this 
     issue, and value your continued efforts to find a solution to 
     the problem. As you know, the Balanced Budget Act, BBA, 
     included a change in statute that allowed forthe counting of 
     training time in non-hospital settings to be included in 
     Medicare cost reports forboth IME and DME FTE counts. As part 
     of that change, the statute, stated that a hospital must 
     incur ``all pr substantially all'' the costs ofthe training 
     in that setting. In the implementing regulations CMS (then 
     HCFA) added the faculty costs to the already included 
     residents' salary and benefits, and required a written 
     agreement between the hospital and the non hospital site.
       This change in regulation, and the interpretations of it 
     that CMS has used during audits have caused many hospitals to 
     lose the ability to count residents that train in non-
     hospital settings, and required them to refund large sums of 
     IMEand DME money to CMS.
       Congress made the change in statute. to encourage training 
     in rural and underserved settings. Unfortunately. CMS's, 
     actions have had just the opposite effect. It has had a 
     dampening effect on training in the non-hospital setting--
     including rural rotations. It has resulted in much training 
     being brought back into the hospital, ironically both at a 
     time when accrediting bodies are requiring more training 
     outside the hospital, and contrary to the wishes of Congress.
       As you are well aware, several of the Family Medicine 
     residency programs in Maine are at risk of closing due to the 
     financial implications of CMS's interpretations. We are also 
     aware of similar situations throughout the United States. For 
     example, if the current situation continues, we have heard 
     that in Iowa, four of the eight Family Medicine training 
     programs are at risk of closing in the next couple of years. 
     In Oregon, several residencies are at risk of losing many 
     FTE's, including Internal Medicine, Surgery, OB-Gyn, and 
     Emergency Medicine. In Montana, the only Family Medicine 
     residency program in the state is in danger of losing funding 
     oJ all it's outside rotations due to CMS's unreasonable 
     requirements related to non-hospital rotations. Across the 
     country, residency programs are at risk. CMS has had several 
     years to solve the problem. The report of the Office of 
     Inspector General (OIG) that was required by Congress in the 
     MMA has given CMS several options, and yet nothing has been 
     done.
       We appreciate your efforts to put an end to this war of 
     attrition. Please count on us to support your efforts at 
     resolving this situation legislatively. Thank you for your 
     help in this area. We look forward to your moving this 
     legislation forward.
           Sincerely,
     William K. Mygdal, EdD,
       President, Society of Teachers of Family Medicine.
     Penny Tenzer, MD,
       President, Association of Family Practice Residency 
     Directors.
     Warren Newton, MD,
       President, Association of Departments of Family Medicine.
     Perry Dickinson, MD,
       President, North American Primary Care Research Group.
                                 ______