M. R. Dimon1, B. H. Ahmed1, P. Pieper1, B. Burns1, J. J. Tepas1 1University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA
Introduction:
In July 2014 the Institute of Medicine released a review of the governance and financing of Graduate Medical Education (GME). It concluded that major changes to GME financing were needed to redesign the system to reward desired performance and reshape the physician workforce to better meet the nation’s needs. A 10 year transition period was recommended during which the role of Medicare in GME funding could be altered, phasing out the current system. Anticipating significant changes in funding, we investigated an alternate funding system based on resident reimbursement for the provision of care. We aim to show that resident billing of assistant surgeon fees in appropriate cases could generate significant income to support a GME program.
Methods:
The Department of Surgery Business Group Manager provided CPT codes for procedures performed by the General/Acute Care surgical services with resident involvement at our institution between July 1, 2011 and June 30, 2012. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule, and this fee was calculated as 20% of the primary charge. This fee was multiplied by the number of CPT instances, resulting in the total potential resident contribution for each code. These were summed to determine the total potential resident contribution to GME funding.
Results:
A total of 515 unique CPTs were billed for a total of 6,578 cases with resident involvement, of which 2,552 (39%) were reimbursable. The allowable CPTs generated $1,882,854 in billable assistant charges. The top 50 most frequently performed CPTs resulted in 4,247 procedures, 65% of the total. Within the top 50, 1362 CPTs (32% of the top 50, 21% of the total) were reimbursable. Of the total billable assistant charges, $963,227.00 (51%) occurred in the top 50 most frequent procedures.
Conclusion:
Assistant surgeon billing would average $67,244.76 per resident when evenly distributed within our program. This compares to our current Medicare Direct and Indirect GME funding level of $142,635.78 per resident. Use of this system could therefore provide 47% of our current CMS funding. While this would not entirely fund our GME program, it would be a significant source of added funding should changes in the current Medicare funding levels lead to a decrease in monies directed towards surgical training. Moreover, the obvious skew in distribution of procedures in which 21% (billable portion of the top fifty procedures) drives 51% of charges suggests that this system could monitor resident experience and possibly guide a more balanced operative experience. Performance and competency based credentialing of residents could be used to ensure appropriate personnel are involved with cases billing for assistant fees; furthermore, reimbursements could be adjusted based on quality metrics to provide a tool for transformational change in GME and patient outcomes.