AprogDirector-Medicare GME funding rules

[NeuroMD]

I am an IMG who is working as a preliminary intern in a surgery department of a university program. I have applied to the Neurology Residency Programs, and by one of the programs, I was told that since neurology requires a PGY-1 year in Internal Medicine or a primary medicine internship and Medicare funds residency slots based on what field you begin PGY-2 in, if I take another year in internal medicine, my slot will be medicare funded for only 3 years and neurology training is 3 yrs AFTER medicine. So I can get any funding for the last year of neurology residency.
I am really confused about this subject. Since if I apply this year to the Neurology Residency, I will begin neurology residency next year, in 2010. So I quess my Medicare GME funding starts in 2010, not in 2009, during my internal medicine internship. If this is correct, is there any possiblity that I start to neurology residency and continue residency without getting any Medicare funding at the 3rd year.
I will appreciate any comments. Thank you.

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[gutonc]

This has been asked and answered, in some form or another, about a hojillion times. Here are the basics.

1. Medicare funding clock starts when you start a "terminal" training program, i.e. any categorical or advanced program, NOT a prelim year. There are other (irrelevant to this discussion) parts to this rule but this is the fundamental issue.

2. What expires is not all CMS funding, but 100% funding. After the "clock" runs out, you get funded @ 50% rather than 100% for DME...IME is still funded the same. It boils down to your hospital only getting 1/2 rather than the total amount of your salary + benefits. Many programs already supplement salaries over the CMS amount anyway so it becomes less (or perhaps more) of an issue. All fellowships already have to deal with this so it's not really a big deal.

3. There is no 3.

 

[NotAProgDirector]

To clarify the above, your medicare clock gets "set" when you start a terminal residency. All training beforehand "counts" towards this limit.

So, in your case:

Year #1 - Prelim Surgery -- no effect on clock
Year #2 - Prelim IM -- no effect on clock ** This is incorrect, see later in thread
Year #3 - Neurology - Clock is now set at a maximum of 4 years.
Year #4 - Neuro -- Full funding expires at the end of this year
Year #5 - Neuro -- Funded at 50%


EDIT:
It appears (see post later down) that matching into prelim GS sets the funding clock at 5 years. Therefore, in this case, all 5 years would be fully funded.

 

[t33sg1rl]

I interviewed at a program I really liked and was told that they used to take 12 categoricals per year, but because of some kind of Medicare/funding stuff they can only take 8 now.

Is this a red flag that the program is in trouble?

 

[NotAProgDirector]

I interviewed at a program I really liked and was told that they used to take 12 categoricals per year, but because of some kind of Medicare/funding stuff they can only take 8 now.

Is this a red flag that the program is in trouble?

Probably not.

The problem is likely the Medicare Cap. In the 1997 Balanced Budget Amendment, as a mechanism to limit health care spending, hospitals were capped as to the number of total GME slots available. Prior to 1997, if you added more resident you simply got paid more money. After 1997, hospitals were capped at 1997 levels. The cap is for total slots, not for each program.

Thus, if you want to increase the size of a program, you now need to either 1) pay for the slots without medicare dollars, or 2) decrease the size of another program. Some institutions have shifted slots from some programs to others, likely due to $$$. Ortho residents who can increase OR productivity are much more valuable that IM/FP/Peds residents.

 

[sandraf]

Interesting. Thank you, aProgDirector.

 

[t33sg1rl]

Thanks! That makes sense.

 

[Howser]

Interesting. Did not know that.

 

[dmitrinyr]

To clarify the above, your medicare clock gets "set" when you start a terminal residency. All training beforehand "counts" towards this limit.

So, in your case:

Year #1 - Prelim Surgery -- no effect on clock
Year #2 - Prelim IM -- no effect on clock
Year #3 - Neurology - Clock is now set at a maximum of 4 years.
Year #4 - Neuro -- Full funding expires at the end of this year
Year #5 - Neuro -- Funded at 50%

Sorry to bring up an old thread but I'm trying to fully understand the medicare funding issue.

aPD, in the case that you pointed to above, how come "the Clock is now set at a maximum of 4 years" at the start of year #3, but then the 3rd year of Neuro residency the hospital is only funded at 50%? Shouldn't it be that once a resident starts at terminal residency, then after the resident finishes that terminal residency then the following years get 50% of funding (i.e. fellowship)?

The reason why I'm asking is because I finished a year of prelim IM training and now applying for an EM position in the 2010 match. I don't have a residency position at the moment, but lets say I would have started a PGY-2 year at an IM program. In that case, I would have only 2 more years of full federal funding, right?

One of the things I was considering was that if I take a PGY-2 IM position and have a job while I apply for EM and then match into an EM residency, I would only have 1 year of EM residency fully funded by medicare. I'm curious how important are these issues are when residency committees discuss candidates, especially ones such as myself who did a year of residency training in another specialty? Given the recent recession, would a possible "funding issue" effect a candidate's chances of matching at a particular program... maybe one that has financial issues to begin with? Thanks.

 

[AttyHubby]

Sorry to bring up an old thread but I'm trying to fully understand the medicare funding issue.

aPD, in the case that you pointed to above, how come "the Clock is now set at a maximum of 4 years" at the start of year #3, but then the 3rd year of Neuro residency the hospital is only funded at 50%? Shouldn't it be that once a resident starts at terminal residency, then after the resident finishes that terminal residency then the following years get 50% of funding (i.e. fellowship)?

The reason why I'm asking is because I finished a year of prelim IM training and now applying for an EM position in the 2010 match. I don't have a residency position at the moment, but lets say I would have started a PGY-2 year at an IM program. In that case, I would have only 2 more years of full federal funding, right?

One of the things I was considering was that if I take a PGY-2 IM position and have a job while I apply for EM and then match into an EM residency, I would only have 1 year of EM residency fully funded by medicare. I'm curious how important are these issues are when residency committees discuss candidates, especially ones such as myself who did a year of residency training in another specialty? Given the recent recession, would a possible "funding issue" effect a candidate's chances of matching at a particular program... maybe one that has financial issues to begin with? Thanks.

To clarify, by "clock setting" is meant "number of years paid for set". So, the number of years of funding you get is set whenever you begin your terminal program. To use the Neuro example again, beginning a Neuro residency sets your "clock" at 4 years because that is the time is should normally take to complete it: 1 year prelim+3 years Neuro. If for whatever reason you ended up doing 2 prelims years, you still lose that year because it should have only taken you 4. Thus the 5th year is funded at half.

 

[NotAProgDirector]

Sorry to bring up an old thread but I'm trying to fully understand the medicare funding issue.

aPD, in the case that you pointed to above, how come "the Clock is now set at a maximum of 4 years" at the start of year #3, but then the 3rd year of Neuro residency the hospital is only funded at 50%? Shouldn't it be that once a resident starts at terminal residency, then after the resident finishes that terminal residency then the following years get 50% of funding (i.e. fellowship)?

AttyHubby has already addressed this. When you start a "terminal residency" the total amount of funding is set. However, any funding used previous to this "counts" towards this total. Whether this is "right" or not or should be changed is another issue, but it's the way it is.

The reason why I'm asking is because I finished a year of prelim IM training and now applying for an EM position in the 2010 match. I don't have a residency position at the moment, but lets say I would have started a PGY-2 year at an IM program. In that case, I would have only 2 more years of full federal funding, right?

No. If you match into an EM program for July 2010, then you would be fine, I think. EM is a bit complicated since there are 3 year EM programs, 1+3 programs (1 prelim + 3 year EM) and 4 year EM programs. Hence, I assume that EM sets the clock at 4 years (although I could be wrong about that). If you start a categorical IM program, then your funding clock is set at 3 years. You would only have 1 year of full funding after your IM PGY-2.

One of the things I was considering was that if I take a PGY-2 IM position and have a job while I apply for EM and then match into an EM residency, I would only have 1 year of EM residency fully funded by medicare. I'm curious how important are these issues are when residency committees discuss candidates, especially ones such as myself who did a year of residency training in another specialty? Given the recent recession, would a possible "funding issue" effect a candidate's chances of matching at a particular program... maybe one that has financial issues to begin with? Thanks.

It's impossible to say how much this would affect your application, but I agree that any financially strapped GME office might see your application as weaker given the lack of funding. Of course, there is the chance that you don't get an EM spot. In that case, having an IM PGY-2 would be very good, as you could finish the PGY-3 and move on from there -- either as a hospitalist, or possibly apply for EM again. Although you would now have a very serious funding problem, there is some chance that EM programs might favor someone who completed a whole IM program successfully. But I don't know, this is a guess.

 

[.edu-MD]

Probably not.

The problem is likely the Medicare Cap. In the 1997 Balanced Budget Amendment, as a mechanism to limit health care spending, hospitals were capped as to the number of total GME slots available. Prior to 1997, if you added more resident you simply got paid more money. After 1997, hospitals were capped at 1997 levels. The cap is for total slots, not for each program.

Thus, if you want to increase the size of a program, you now need to either 1) pay for the slots without medicare dollars, or 2) decrease the size of another program. Some institutions have shifted slots from some programs to others, likely due to $$$. Ortho residents who can increase OR productivity are much more valuable that IM/FP/Peds residents.

Does this apply to a hospital starting up a new residency program as well? That is, do they need to decrease spots in an existing residency in order to have spots for a new program?

 

[sweetspring]

To clarify the above, your medicare clock gets "set" when you start a terminal residency. All training beforehand "counts" towards this limit.

So, in your case:

Year #1 - Prelim Surgery -- no effect on clock
Year #2 - Prelim IM -- no effect on clock
Year #3 - Neurology - Clock is now set at a maximum of 4 years.
Year #4 - Neuro -- Full funding expires at the end of this year
Year #5 - Neuro -- Funded at 50%

Interesting. This may apply to my case. Psychiatry internship completed years ago at a top program, accepted offer to do quality of care consulting for the hospital system, miss clinical practice and applying to return. Likely to require repeat internship, given the time that has passed. Psychiatry is four years. This means my final year would be funded at 50%, correct?

Year #1 - PGY1 - completed
Year #2 - PGY1 - repeat
Year #3 - PGY2
Year #4 - PGY3 - full funding expires
Year #5 - PGY4 - 50% funding

Your input is very helpful. Thank you.

 

[NotAProgDirector]

Does this apply to a hospital starting up a new residency program as well? That is, do they need to decrease spots in an existing residency in order to have spots for a new program?

No.

New programs generate new slots, and increase the cap. As long as the program is not restarting a prior, closed program.

 

[einey]

Ok this totally confusing, I don't care if you explained 80 times it's still frekin' not clear. So keep your pants on and explain it some more.

If a transitional year was completed, and I started IM PGY1 last year and given credit for 6mths so I graduate 6 months earlier does that mean I have a year of funding left? I want to do ER in 2010 applied to ERAS

 

[NotAProgDirector]

You did a TY. That costs 1 year.
Then you started categorical IM. Got 6 months of credit. So, you're going to do 30 months of IM. So, 42 total months of funding used.

IM gets you 36 months of full funding. So, your current residency program is going to get 1/2 funding for the last 6 months of your IM residency, and you will have only half funding for any further training you do.

 

[AttyHubby]

Ok this totally confusing, I don't care if you explained 80 times it's still frekin' not clear. So keep your pants on and explain it some more.

You may want to consider using a different tone in the future when asking for help from strangers. Kudos to aPD for taking the high road.

 

[WhoisJohnGalt]

You may want to consider using a different tone in the future when asking for help from strangers. Kudos to aPD for taking the high road.

 

[sam100]

Greetings!

This is perhaps one of the most crucial decisions of my life so any advice would be really appreciated.

A snap shot of my case:
IMG, with very good profile and scores, masters degree from US, got multiple interviews and was offered a pre-match at the 1st interview itself at a good community hospital.
As an IMG, I had to take the pre-match as not getting matched would have been a big risk. However, now I have come to realize that I could have got into a much better program. (this program has no fellowships)

I will try to be very specific about my questions:
Question #1 Can I re-apply to a better IM program again for a PGY1 position as an IMG?

Question #2 Would one year of PGY1 training and better LORs improve my chances of getting matched at a good program? ( I will have LORs from the hospital where I did my Masters degree)

Question #3 I guess there are funding issues? (heard a lot of rumors). But I am willing to take a reduced pay in PGY-3 if I get into an excellent program as I desperately want to do Cardiology from one of the best institutes in the country.

Since, I am already into a PGY1 categorical IM; here is how my funding would work out:
Year 1# PGY1 Internal Medicine--100%
Year 2# PGY1-Internal Medicine (repeat)--100%
Year 3# PGY2-IM--100%
Year 4# PGY3-IM--50%

Question #4: Also please let me know how can I convince any PD who might call me for an interview, that I am willing to work at half pay in my PGY3?

Please advice...at the earliest. I am having sleepless nights on this.

Thank you.

Regards.

 

[peppy]

I don't think that you can agree to work for less/no pay. There are rules against that as I understand it.
If you absolutely are committed to trying to get into a better program, you would be better off inquiring about programs about PGY-2 openings that you might be able to transfer into.
It would be very unusual for a program to accept someone who already completed a PGY-1 in the same specialty for a repeat PGY-1 year (the only time I've heard of that happening was with preliminary surgery residents who repeat internship in a categorical surgery program).

 

[spinbarket]

Hi!

I have a similar question, but a bit more complicated.

I completed a preliminary medicine internship then entered an anesthesiology residency. Eleven months into my residency, I was charged with assaulting an off-duty police officer. I was eventually found not guilty, but it took over a year to clear everything up. During the time I was awaiting trial, 16 months, I was kept on administrative assignment - kept on payroll, but not allowed to train. I was payed as a PGY2 for my PGY2 year and what would've been my PGY3 year. Just before trial the residency program decided not to renew my contract. I was found not guilty of all charges, but without a job. I had a lot of family issues at the time, and had to help run my family's business for a couple of years.

Fast forward to now. It's been 6 years since I was actively in residency. I'm pretty sure I have to repeat my CA2 year. I may have to repeat my CA1 year.

I had an anesthesiology program director that wanted to hire me during the scramble, but he couldn't get an answer from the ACGME in time RE: funding so he offered my spot to another candidate. I offered to work for free or less pay for whatever period, but he said that there were rules against that.

Can anyone help please? I need information about funding and about whether I need to repeat my internship and or my CA1 year.

Thanks!

 

[deleted103644]

I don't think that you can agree to work for less/no pay. There are rules against that as I understand it.

Yup, that would be slavery. That's been illegal for a few years now.

Unpaid internships are a loophole, but they need to give you school credit (and people are fighting to make those paid as well).

 

[NotAProgDirector]

Hi!

I have a similar question, but a bit more complicated.

I completed a preliminary medicine internship then entered an anesthesiology residency. Eleven months into my residency, I was charged with assaulting an off-duty police officer. I was eventually found not guilty, but it took over a year to clear everything up. During the time I was awaiting trial, 16 months, I was kept on administrative assignment - kept on payroll, but not allowed to train. I was payed as a PGY2 for my PGY2 year and what would've been my PGY3 year. Just before trial the residency program decided not to renew my contract. I was found not guilty of all charges, but without a job. I had a lot of family issues at the time, and had to help run my family's business for a couple of years.

Fast forward to now. It's been 6 years since I was actively in residency. I'm pretty sure I have to repeat my CA2 year. I may have to repeat my CA1 year.

I had an anesthesiology program director that wanted to hire me during the scramble, but he couldn't get an answer from the ACGME in time RE: funding so he offered my spot to another candidate. I offered to work for free or less pay for whatever period, but he said that there were rules against that.

Can anyone help please? I need information about funding and about whether I need to repeat my internship and or my CA1 year.

Thanks!

Not a question that comes up every day...

Your last question is the easiest to answer -- do you have to repeat your CA-1 or internship. The answer is "maybe". There is no rule here -- training never expires. So, there's no law that says you have to repeat anything. The first question then is how much credit you received from your prior program -- chances are that it was 11 months. They may have paid you while you were on admin leave, but you shouldn't get any credit for that. The second question is whether anyone will still think that you can remember what you were supposed to have learned in your CA-1 -- i.e. would you be ready to take the responsibility of a CA-2 on day 1. Chances are the answer is no. However, it might not take you 12 months to get to that level of competency -- so doing 3 or 6 months of CA-1 work might be OK. In the grand scheme, you might be better off simply repeating your CA-1. I think there's no reason to repeat your PGY-1.

Now, the funding issue. Interestingly, that might be very straightforward. Medicare will only reimburse the hospital for a total of 4 years for your training. However, each month the institution has to submit a report of how many residents it was training, and which of them qualified for reimbursement. While you were on admin leave, assuming you had no clinical duties, you would NOT have qualified for reimbursement. Hence, your institution decided to pay you but did not ask Medicare for reimbursement of your costs (ie. did not submit your data on the "Medicare Cost Report"). If they did, that's medicare fraud. Assuming they didn't, you would still have all of your funding in place. You could try to contact your prior institution to see if they can check their records, but I doubt you'll ever get a straight answer (it's a huge accounting mess).

 

[IMvrach]

It's a fellowship funding question, but it's related to the topic so I didn't want to start a new thread.

Does funding for fellows on visa depend on the state? Most West Coast Hem/Onc programs don't accept them without exceptions, explaining that only US permanent residents can have NIH funding, while most East Coast programs are OK with them.

Stanford Hem/Onc
Due to NIH funding restrictions, ALL hematology and oncology applicants must be either United States citizens or have permanent resident status in the United States by the beginning date of their fellowship training. There are no exceptions.

Hopkins Hem/Onc
Permanent resident or eligible for J-1 visa. Holders of an H-1 visa are eligible, however, Johns Hopkins does not initiate sponsorship of an H-1 visa.

Arguments about what's fair or not are just a waste of time and I absolutely wouldn't argue with "we just don't want to mess with the visas/pay for the visas" arguments. But being unable to explain the East/West discrepancy, I've checked the NIH site and found that the funding argument is factually wrong - fellows can have NIH funding. Am I missing something? Is it similar to the urban legend, that IMGs and AMGs have different Medicare residency funding?

This has been asked and answered, in some form or another, about a hojillion times. Here are the basics.

1. Medicare funding clock starts when you start a "terminal" training program, i.e. any categorical or advanced program, NOT a prelim year. There are other (irrelevant to this discussion) parts to this rule but this is the fundamental issue.

2. What expires is not all CMS funding, but 100% funding. After the "clock" runs out, you get funded @ 50% rather than 100% for DME...IME is still funded the same. It boils down to your hospital only getting 1/2 rather than the total amount of your salary + benefits. Many programs already supplement salaries over the CMS amount anyway so it becomes less (or perhaps more) of an issue. All fellowships already have to deal with this so it's not really a big deal.

3. There is no 3.

 

[NotAProgDirector]

The key difference here is the term "NIH funding"

Funding for fellowships themselves is exactly the same -- whether the applicant is an AMG, IMG, US citizen, or on a visa. Doesn't matter, all exactly the same.

But research time can be funded via other sources, such as the NIH. Some fellowships have an extra year of research added on. NIH funds can only be used to fund the salaries of US citizens (or so I am told). So, fellowships that use NIH money to help pay for the research time of their fellows may limit applications to US citizens / PR's only. I don't think this is specifically an East/West coast thing. Some programs may use NIH funds for US citizens, and other funds for non-US citizens.

 

[gutonc]

It's a fellowship funding question, but it's related to the topic so I didn't want to start a new thread.

Does funding for fellows on visa depend on the state? Most West Coast Hem/Onc programs don't accept them without exceptions, explaining that only US permanent residents can have NIH funding, while most East Coast programs are OK with them.

Stanford Hem/Onc
Due to NIH funding restrictions, ALL hematology and oncology applicants must be either United States citizens or have permanent resident status in the United States by the beginning date of their fellowship training. There are no exceptions.

Hopkins Hem/Onc
Permanent resident or eligible for J-1 visa. Holders of an H-1 visa are eligible, however, Johns Hopkins does not initiate sponsorship of an H-1 visa.

Arguments about what's fair or not are just a waste of time and I absolutely wouldn't argue with "we just don't want to mess with the visas/pay for the visas" arguments. But being unable to explain the East/West discrepancy, I've checked the NIH site and found that the funding argument is factually wrong - fellows can have NIH funding. Am I missing something? Is it similar to the urban legend, that IMGs and AMGs have different Medicare residency funding?

While foreign citizens can have some kinds of NIH funding, they can't have all kinds of NIH funding. As aPD points out, this is an issue where NIH training grants (T32) are used to pay some portion of a fellow's salary. And non-citizen/PRs aren't allowed to receive T32 funding.

That said, you frame this as a "coastal" thing but, in reality, you picked 2 of the most well regarded programs in the country (at least for IM and many of it's subspecialties) to make your point. I'd be curious to see what those policies are like at Loma Linda, USC, GWU and UMDNJ-RWJ. Hopkins and Stanford use those statements as their public excuse for not accepting IMGs for Hem/Onc fellowships but the reality is that their actual excuse is "we're Hopkins/Stanford...are you f***ing kidding me? No way we're taking IMGs."

 

[IMvrach]

Thanks for clarifications, aPD & Gutonc.

@gutonc Actually, Hopkins was an example of an East Coast program, accepting people on visa. In fact, they have had quite a few of IMGs.

Hopkins fellows' med schools and residencies.

But I get the point that it's not an East/West issue and frequently "don't take people on visa" simply means "we don't take IMGs".

 

[Resident2015]

Anyone have any experience how this effects interviews offered or ranking for matching to a second residency? Bump

 

[NotAProgDirector]

I wanted to add a note to point out that some of my "advice" above appears to be incorrect. In the most current version of the DME/IME explanation brochure, it states that prelim training does set the clock -- that matching into a prelim IM position locks you into 3 years, and prelim GS locks you into 5 years. A TY doesn't lock you into anything, and you only get locked into funding once you start a terminal program.

https://members.aamc.org/eweb/upload/Medicare Payments for Graduate Medical Education 2013.pdf

 

[Maxwellfan]

I'm sorry for reviving an old thread but my question might actually make this discussion more complete, hopefully helping others as well.

I wander if doing fellowship before residency training starts your IRP "clock". After completing residency training overseas I returned to US and did a fellowship training in pain medicine and hospice and palliative care. Now I'm IM prelim resident looking for a categorical spot and wonder if I have full funding left for PGY 2 add 3.

 

[NotAProgDirector]

There's lots of confusion in this thread. Some of it generated by me. And some might be because the gov't has changed the rules somewhat. But probably I was just confused. Now I might be smarter. Or not. Here's what I think is correct:

IRP = Initial Residency Period = max time you get full funding. I'm trying to get away from the idea of a "clock" which is confusing.

For categorical programs: Very straightforward, your IRP = length of training to become board certified.
If you match into categorical IM, the IRP is 3 years.
If you match into categorical GS, the IRP is 5 years.

For Prelim/Advanced programs: Your IRP is the total time required for board eligibility. This would include the 1 yr prelim + advanced.
If you match into a prelim IM and Radiology, IRP is 4 years. 1 year IM prelim + 3 years of rads. Total = 4 years.
If you match into a prelim GS and Dermatology, IRP is 4 years. 1 year prelim GS + 3 years Derm = 4 years.
I have seen two different explanations for this, which might be part of the confusion:

1. The IRP = total years of training. So in both examples above, IRP = 4 years.
2. The IRP = Advanced years of training. But IRP does not start until advanced training (i.e. prelim year "does not count")

Both of these explanations yield the same result in the end. I believe #2 is actually correct, this only matters in the TY only option below.

Matching only to a Prelim: Depends on which
If you match only into prelim IM, IRP is 3 years. You use 1 year for your prelim IM. You have 2 years left, no matter what you do next. Getting a rads or derm spot doesn't change the IRP. You can complete IM with full funding. Almost everything else will leave you short.
If you match only into prelim GS, IRP is 5 years. Prelim GS counts as 1, you have 4 left.

Matching only to TY: IRP not set
If you match into a TY, your IRP is not set. When you end up in something else the next year, your IRP gets set by that.
This is where those two options above yield different results. If you continue into an Advanced program, it doesn't matter at all. But if you start what would have been a Categorical program, it does. Let's say you do a TY, then decide you want IM and need to start again as a PGY-1. If Option #1 is true, then your IRP is set at 3 years and the TY counts as one of those three -- two left. If Option #2 is true, then your IRP is set at 3 years but the TY doesn't count, so you still have 3 years. Not sure which is correct.

After the IRP:
After full funding, everyone then gets partial funding. Which is 50% of DME, and 100% of IME. Since in many places the IME>DME, this ends up being about 80% of what you'd get with full funding. So less, but nowhere near zero. Most fellowships are paid this way.

The exceptions:
There are a few carve outs for full funding: Geriatric fellowships, Preventive medicine fellowships. Child Neuro is 5 years (Peds + 2).

Combined programs are complicated. in general, the IRP is the shorter program + 1 year. But there are exceptions, and depends upon whether both programs count as Primary Care.

Non-accredited programs do not claim Medicare funds, so don't count for anything. Accredited = is ACGME accredited OR leads to possible ABMS certification.

Each institution has a maximum cap of residents they can claim, it was set in 1997. Above that, they can't claim any more. If a program is above their cap, then they will get zero funding for some residents and they can pick and choose which ones -- hence having less funding may not be an issue at all. But even if your institution doesn't count you on the Medicare report, it still "counts" towards your IRP.

Time residents spend on leave (that extends training), on research years, etc, do not count. You still have your full funding. Leave that doesn't extend training "counts".

If you want to read the Fed Register where this is all described: 42 CFR § 413.79 - Direct GME payments: Determination of the weighted number of FTE residents. | CFR | US Law | LII / Legal Information Institute (cornell.edu)

A very comprehensive slide show: Microsoft PowerPoint - ADME Basic GME financing [Compatibility Mode] (aacom.org)

 

[NotAProgDirector]

I'm sorry for reviving an old thread but my question might actually make this discussion more complete, hopefully helping others as well.

I wander if doing fellowship before residency training starts your IRP "clock". After completing residency training overseas I returned to US and did a fellowship training in pain medicine and hospice and palliative care. Now I'm IM prelim resident looking for a categorical spot and wonder if I have full funding left for PGY 2 add 3.

OK, now let's answer your question. Full disclosure: You're not going to like the answer.

I'm not certain, but I think what happens is this:

If the fellowships were non-accredited = not ACGME accredited and couldn't lead to certification, then they don't count at all and your IRP is 3 years since you started as an IM prelim. That's the easy option.

If the fellowships were accredited, then the basic rules apply. Your IRP is set by the length to board certification as specified in the GME Directory of the initial program you trained in. According to that, Pain Medicine is 1 year. Thus, your IRP was probably 1 year. I'm not sure what you mean by "Pain medicine and hospice and palliative care". If those were two fellowships back-to-back, I think the same applies.

In reality, your IRP is whatever your GME office declares it to be. I don't think there's lots of double checking on this. I expect that many programs either knowingly or unknowingly just claim full credit for all their residents. I doubt Medicare does much checking. if discovered, the fines are enormous.

 

[NotAProgDirector]

I spoke to my local GME funding expert. According to her, if a resident starts in a fellowship first, the IRP is set to the underlying core field. So, if someone were to start with an Endo or Neph fellowship (both 2 years long), their IRP would be 3 years (since both are subs of IM).

Unfortunately, this doesn't clarify things for the situation posted. Pain is not a sub of anything -- it's a stand alone field now. Hospice and Pall care is technically under Family Medicine. If @Maxwellfan did Pain first and Pall second, then their IRP is probably 1 year. If they did Pall first, then their IRP is 3 years. If it's a true combined program, then (?perhaps) the combined program rules are applied, which would be an IRP of 2 years (1 plus the shorter of the two programs).

But pain used to be under anesthesia, so that might apply. Clear as mud.

 

[Maxwellfan]

OK, now let's answer your question. Full disclosure: You're not going to like the answer.

I'm not certain, but I think what happens is this:

If the fellowships were non-accredited = not ACGME accredited and couldn't lead to certification, then they don't count at all and your IRP is 3 years since you started as an IM prelim. That's the easy option.

If the fellowships were accredited, then the basic rules apply. Your IRP is set by the length to board certification as specified in the GME Directory of the initial program you trained in. According to that, Pain Medicine is 1 year. Thus, your IRP was probably 1 year. I'm not sure what you mean by "Pain medicine and hospice and palliative care". If those were two fellowships back-to-back, I think the same applies.

In reality, your IRP is whatever your GME office declares it to be. I don't think there's lots of double checking on this. I expect that many programs either knowingly or unknowingly just claim full credit for all their residents. I doubt Medicare does much checking. if discovered, the fines are enormous.

Thank you for your reply!

For clarification, I did 2 fellowships back to back, Pain first than Pall and both were ACGME accredited. I'll touch base with my current programs GME and reply back