BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.86.2950 pertaining to graduate medical education payment program
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On August 24, 2017, at 9:00 a.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana to consider the proposed amendment of the above-stated rule.
2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact the Department of Public Health and Human Services no later than 5:00 p.m. on August 9, 2017, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail firstname.lastname@example.org.
3. The rule as proposed to be amended provides as follows, new matter underlined, deleted matter interlined:
37.86.2950 GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM
(1) Subject to the availability of funding, restrictions imposed by federal law, and the approval of the state plan by the Centers for Medicare and Medicaid Services (CMS), the department will pay, in addition to the Medicaid payments provided for in ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, and 37.86.2947, a Graduate Medical Education (GME) payment for the purpose of partially funding
a primary care and psychiatry residency programs for eligible hospitals located in Montana.
(2) Revenue for the GME payment will be generated through a transfer of funds from the Montana University System to the
Department of Public Health and Human Services department through an Intergovernmental Transfer contract agreement. The transfer of funds from the University System will occur prior to July 31 of each year.
(3) The department will make an annual payment to each eligible hospital on or before August 31 of each year.
(a) remains the same.
(b) If an eligible hospital reports no primary care or psychiatry resident full time equivalents (FTE) participating in the GME program for any given program year or portion thereof, the eligible hospital will not receive payment for those time periods of nonparticipation. FTE totals include residents conducting rural rotations. For purposes of this rule, a rural rotation is a period of time of at least 28 days where a primary care or psychiatry resident is working in a rural location, outside of their primary facility and urbanized area, with the express purpose of the resident being available to provide care to the rural area's patient population.
(4) The GME payment regarding
the primary care and psychiatry residency programs must be computed, in order, as follows:
(a) divide the total Graduate Medical Education Full Time Equivalent (GMEFTE) count for each eligible facility based upon the most recently
as-filed cost report, Medicaid paid claims data, and approved self-attestation form by the Total Graduate Medical Education Full Time Equivalent (TGMEFTE) for all eligible facilities to determine the Hospital Percentage of Graduate Medical Education (HPGME);
GMEFTE = HPGME
(b) through (5) remain the same.
AUTH: 2-4-201, 53-2-201, 53-6-113, MCA
IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
Montana has a significant shortage of psychiatrists and primary care physicians, especially in rural areas, making it difficult for many Montanans to access health care in their communities. The shortage is related to a historical lack of physician residency, Graduate Medical Education (GME) training in the state and an aging physician workforce. Further, Montana is one of three states without a psychiatry residency program, making it challenging for physicians to learn and understand the behavioral health needs of the Montana population. Improvement in access to health care for rural Montanans can be achieved by adding psychiatry to the primary care residency program and encouraging resident physician training in rural communities; however, current administrative rules do not allow adequate funding for the development of new residencies or funding for rural training.
During the 65th Montana Legislature, the Montana Office of the Commissioner of Higher Education (Commissioner) and the Montana Graduate Medical Education Council (Council) discussed with the Legislature that while funding for residency training occurs primarily through the federal Centers for Medicare and Medicaid Services (CMS), CMS does not fund the total cost of resident physician training, and all additional funding is being provided by the five residency sponsoring hospitals in Billings, Kalispell, and Missoula. This lack of funding limits the training of resident physicians in Montana and specifically limits the rural physician supply. According to data supplied by the Council, the number of resident physicians being trained in Montana has increased from 18 in 2012 to 75 in 2017. In 2018, the number of resident physicians trained will increase to 78. To meet this need, the Legislature appropriated an additional $400,000 in House Bill 2 for the Montana University System, which will be used in conjunction with federal funding and the residency training costs assumed by the five residency sponsoring hospitals, with an end to supplement the current physician allocation and encourage residency training in rural Montana.
The department proposes to amend ARM 37.86.2950, regarding its administration of the GME payment program, to (i) add psychiatry to the primary care references in (1) and (4) of the rule as the types of residency training programs in Montana eligible for receiving GME payment under Medicaid; (ii) adopt new rule language in (4) which would provide that rural rotations made by resident physicians may be included in the FTE counts for an eligible hospital in order to receive additional GME payments; and (iii) amend (4)(a) to clarify the forms and sources of the data the department reviews and requires from GME eligible hospitals prior to making the calculations described in (4).
The first proposed amendment is necessary because Montanans lack access to behavioral health services, and adding psychiatry to the GME payment program may directly increase public access to these services by resident physicians practicing psychiatry. Participating hospitals will receive additional funding which has historically been used for primary care only. Hospitals currently provide these services at a loss since they are not funded under the primary care residency program. Adding psychiatry to the residency programs also executes the program funding increases authorized by the 65th Montana Legislature.
The second amendment, proposed to include FTE counts for rural rotations in the calculation for eligible facilities, is necessary as adding rural rotation FTE counts will enable hospitals to receive additional funding for resident physician training in rural communities for both primary care and psychiatry. Sending resident physicians out into rural areas for training increases the likelihood those physicians will practice in rural Montana, according to data compiled by the Council. The benefit from such a practice is seen by an increased clinical presence in rural areas for Montanans, greater diversity in training for the resident physician, and additional recoupment for the hospital of its residency training costs.
The third amendment is necessary because the department desires to improve accuracy of its GME payments calculations and current data reporting requirements are not as sufficient as they were when the rule was adopted in 2011. The additional forms and data reporting made available to the department include the department's proposed use of a self-attesting form on which eligible facilities will report FTE counts for rural rotations, approved by hospital authority since that information is difficult for the providers and the department to accurately track. The department believes the proposed changes are the minimum required to perform its duties as the financial intermediary under state and federal law.
After conversations with providers, the Commissioner, and the Council, the department believes the proposed amendments meet the needs of the Commission and the eligible hospitals that provide the resident physician training; satisfy the intention of the Legislature; and improve the department's administration of the GME payment program through this rule. Without these amendments, the unfunded obligation of the five residency sponsoring hospitals will continue to grow and become untenable, having an adverse impact on the availability of physicians to care for rural Montanans.
The proposed amendments do not have a direct fiscal impact to the department. The 65th Montana Legislature appropriated $400,000 to the Montana University System through House Bill 2. The funds for the appropriation are derived from the general fund.
The proposed rule is estimated to affect: 261,160 Medicaid members and the five residency sponsoring hospitals: Billings Clinic, St. Vincent Healthcare, Providence St. Patrick's Hospital, Community Medical Center, and Kalispell Regional Medical Center.
5. The department intends to apply this rule amendment retroactively to August 1, 2017. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.
6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail email@example.com, and must be received no later than 5:00 p.m., September 1, 2017.
7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.
9. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
10. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rule will not significantly and directly impact small businesses.
11. Section 53-6-196, MCA, requires that the department, when adopting by rule proposed changes in the delivery of services funded with Medicaid monies, make a determination of whether the principal reasons and rationale for the rule can be assessed by performance-based measures and, if the requirement is applicable, the method of such measurement. The statute provides that the requirement is not applicable if the rule is for the implementation of rate increases or of federal law.
The department has determined that the proposed program changes presented in this notice are not appropriate for performance-based measurement and therefore are subject to the performance-based measures requirement of 53-6-196, MCA.
/s/ Caroline Warne /s/ Marie Matthews for
Caroline Warne, Attorney Sheila Hogan, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State July 24, 2017.