General Considerations and Myths Business Planning and Budget Potential Funding Options Discussion

Fellowship Program Funding ConsiderationsRodney Tucker, MD, MMM

Learning Objectives

At the end of this session, you will be able to: Gain an initial understanding of the common

challenges related to funding your HPM fellow spots

Identify the 4 primary sources of fellowship funding

Gain an initial understanding of the common pros and cons of each approach

Myths and Considerations

Myth #1- Because Palliative Medicine is a recognized specialty and fellowship training programs can be ACGME accredited, federal or Medicare $$$$ for training suddenly appeared!

Myths and Considerations

Myth #2- All GME offices and programs operate under the same procedures, priorities, or mandates. “If you have seen one GME operation, you have

seen one GME operation”- UAB GME Designated Institutional Official (DIO)

Myths and Considerations

Myth #3- Your institution, DIO’s and other training program directors are anxiously awaiting your arrival as another training program within your institution and know exactly how to help you.

Considerations and Pointers

Know the GME structure and key people within the institution

Verify that training and education are truly a part of the mission of the institution

Make sure that the portion of the institution that houses the GME office is a provider able to receive Medicare $$$

Considerations and Pointers

Inquire and globally understand the concept of Medicare caps for trainees Institutional caps based on 1996 cost reports and

have not changed significantly since 1997 Medicare reimbursement and cost caps in two

categories: DME and IME- Numbers may be different in the two categories

Represents FTE’s and not specific bodies

DME and IME

Direct Medical Education- Allowable cost include the direct costs of Sal and Bene of residents, Sal attributable to supervisory time of teaching MD’s, other teacher’s salaries and the indirect costs that are appropriately allocated to the particular medical education cost center

DME and IME

Indirect Medical Education- Indirect cost of medical education means those additional operating costs incurred by hospital by GME programs and could include costs for example resulting from an increased # of tests ordered by residents and compared to number usually ordered by experienced MD’s

Bottom Line

Medicare reimbursement for GME training is very complex and has had very little revision in over 10 years

November 2005- Medicare Redistribution of Residents as a part of the Medicare Modernization Act (MMA) included a provision that mandates redistributing “unused” resident positions

Institutions vary in cost accounting of DME & IME

Current status

For PM residents (fellows) to be funded through the “GME” mechanism then: Have unused or empty “slots” under their cap Funding comes through the institution or

hospital as part of the mission Funding has been committed through

institutional affiliates such as the VA system, other hospitals (county, Children’s, or hospice organizations as examples)

Summary

Allocation of funds for the post-graduate training of physicians through institutional GME offices is a complex process requiring strict cost accounting and reporting of residents time and setting where educational experience occurs

So now Build the Case!

Business Plan and Budgeting

Not the same thing Should spend equal time although business plan

may take more thought in building the case depending on institutional culture, finances, etc.

Should be viewed much the same as building the business case for the PC program in general

Business Planning

Follow institutional form or template e.g. many institutions have standardized forms for presenting new programs or expansion of existing programs to upper administration or Boards

Typical business plans include Background, Competitors, Description of program, Proforma (Budget and projections), Outcome metrics, Summary

Business Planning Pointers

Concise but emphatic including key statistics but not overwhelmed with numbers- Essentially a case statement

Matching any verbiage in the plan with items in the institution mission or vision statement

Create a sense of urgency Global concise description of curriculum

Business Planning Pointers

Emphasize opportunities for collaboration or synergy with other training experiences

Budget should be clear and as specific as possible

Outcome metrics may or may not be important depending on institutional culture

Budget Components

Salary and Benefits- Should match the institutional set salaries for the specific year of PG training as well as benefit %

Training materials costs- Coats, beepers, books (if institution allows)

Travel or conference expense (if institution allows)

Budget Components

Coordinator % effort with resultant S & B Specialized training or curriculum costs, if any

(Example: ethics training, pain management training, communication workshops, etc.)

Malpractice costs, if any Faculty % effort with resultant S & B

Potential Funding Options

Primarily four funding sources Institutional/Hospital mission support- Pays for

residents above “the cap” as part of mission and administers through GME

Institutional affiliates- Other hospitals (VA) or hospices

Philanthropy Foundations or Education grants

Institutional Mission Support

Depends on several variables including Mission of the organization/institution Financial status Current GME programs and caps Success of the PC program in general Ability to collaborate or create synergy with

other training experiences

Institutional Affiliates

May be very positive relationship or affiliation or may have several challenges esp. in terms of VA federal funding and the restrictions on resident time and location of training experience

Caution to avoid any institutional conflict of interest

Philanthropy

Has been very positive in terms of garnering support for PC training in the past

Caution that philanthropic funders don’t assume that PC will now get Medicare $$$ because accredited

Also caution to avoid and perceived conflict of interest

Foundations or Education Grants

More limited and competitive Opportunities to enhance, expand, and

collaborate with other training experiences May be synergistic with other types of

training already in existence Curriculum development component may be

selling point

Sustenance and Expansion

Ongoing Funding Second Year Funding

Panelists and Attendee Discussion

Jo Shapiro, MD (Former Senior Associate Director Graduate Medical Education Office, Massachusetts General and Brigham and Women’s Hospitals)

V J Periyakoil, MD (Program Director, Stanford University Hospice and Palliative Medicine Fellowship)