CMS funding for postdoctoral psychology fellowship programs Kirk Stucky Psy.D. ABPP (Rp, Cn)Barbara Wolf Ph.D.Consortium for Advanced Psychology Training Postdoctoral Fellowship in Clinical Health Psychology 4/18/09
ArticleStucky, K., Buterakos, J., Crystal, T., & Hanks, R. (2008). Acquiring CMS funding for an APA accredited postdoctoral Psychology Fellowship program. Training and Education in Professional Psychology. Vol. 2, Iss. 3, pp. 165-175.
Basic summaryIn 2001 Congress reinterpreted existing legislation allowing hospital based, postdoctoral psychology training programs that were APA accredited to file for and receive allied health reimbursement through the Center for Medicare / Medicaid Services (CMS). This became effective on March 13, 2001.
Funding shiftsHistorically physician and other allied health training programs have received government funding, while psychology training has been non-funded. This new legislation symbolized a shift in federal health policy and recognized psychology as a valuable discipline within the health care system.
Brief historyGovernment funding for training programs in graduate medical education was established in 1965 when new federal legislation was passed regarding Medicare and Medicaid. This tradition has been based on the governments desire to support and maintain high quality health care services for the elderly and poor in the United States.
The social securities Amendments of 1965 (Public law 89-97)
Since the inception of Medicare in 1965, we have recognized an obligation to share in the costs of educational activities sponsored by participating providers until the community at large chose to bear them in some other manner. Medicare has historically reimbursed providers for the programs share of costs associated with approved educational activities. The activities may be broken down into three general categories, each with distinct payment policies: (Federal Register, 2001, pp. 3358)
Training modelsNursing and other allied health programs operated by colleges and universities are considered to be programs in which the costs are borne by the community. These CMS funds are only provided for particular educational programs that, according to industry norms, qualify an individual to be employed in a specialty in which the person could not have been employed before unless they completed a particular educational program.
Training models "The academic medical community often justifies Medicare GME funding, especially the indirect adjustment, as necessary to support the multiple missions of medical schools and teaching hospitals. These missions include educating the next generation of physicians; providing quality patient care to the poor, the uninsured and those with the most medically complex conditions; supporting excess medical care capacity and other stand-by-resources required to prepare for medical emergencies; maintaining the lead in medical technology; and performing groundbreaking research." (Dickenson, 2004)
What are CMS pass through dollars?
Additional dollars a hospital can receive for the training of various clinicians in a formally organized program of study that is maintained in order to enhance the quality of patient care in an institution. (Federal Register, 2001). Called pass through because they are identified as separate from other funds paid to a hospital by CMS (e.g. the prospective payment system) and paid separately (i.e. pass through) on a reasonable cost basis.
What are CMS pass through dollars?
CMS provides three general types of pass through dollars for educational programs. Approved Graduate Medical Education (GME) programs for physician training onlyApproved Nursing and Allied Health (paramedical) programs operated by a hospital for a variety of specialties (nurses, technicians, psychologists,)Other educational programs and activities (covered on a per case basis)
Direct Graduate Medical Education (DGME )Direct payment varies for each hospital and is based on a hospital specific per resident amount. In 1997, hospitals were capped on the number of residents Medicare would pay for. The limit was based on 1996 residents that trained in specific hospitals. Cover the direct costs of training residents such as salary and benefits, teaching physician salaries, and other related overhead expenses.
Indirect Graduate Medical EducationThe indirect medical education reimbursements are provided to teaching hospitals in recognition of the higher costs associated with treating patients there as compared to non teaching hospitals.
Allied health programsUnlike DGME payments, allied health programs typically receive less than the average cost per trainee. Additionally, while GME programs can be funded or controlled outside of the hospital (i.e. participating provider) CMS requires that allied health programs are run and funded by the hospital. CMS considers all psychology training programs as allied health
History summary1. Graduate Medical Education (GME) has received funding through the Medicare Program for quite some time, but little fiscal attention has been paid to psychology training programs 2. Medicine and nursing have traditionally enjoyed a virtual monopoly on GME training dollars and have often viewed the efforts of other health care professions to secure similar funds as a threat to their own training revenues
Dr. StuckyPractical issuesNuts and boltsFuture recommendations / thoughts
New developmentIn 2001, Congress reinterpreted existing legislation allowing hospital based, postdoctoral psychology training programs that were accredited by the American Psychological Association (APA) to apply for and receive allied health pass through reimbursement from the Center for Medicare / Medicaid Services (CMS). This became effective on March 13, 2001
New developmentThe APA sent out a Practice Organization Action Alert titled Update on Medicare Funding for Psychology Internship Training Programs on November 28, 2001 to make psychologists aware of this change (Marilyn Richmond, Assistant Executive Director for Government Relations, personal e-mail communication, November 28, 2001). A section from that practice alert stated;
APA Practice Organization Action Alert, 11/28/01I am pleased to tell you that HHS (U.S. Department of Health and Human Services) has very recently informed us that hospital-based psychology post-doctoral programs that are accredited by the American Psychological Association (APA) may now apply for Medicare funding of their programs. Unlike psychology internship training programs, post-doctoral programs required no rulemaking but rather an agency interpretation of current rules to allow for funding, and HHS has now interpreted the current funding requirements to allow for post-doctoral program funding.
Why arent more programs getting CMS funds?Lack of information regarding the process required to obtain CMS funding. Lack of organization among APA accredited postdoctoral programs Failure to adequately educate and inform eligible programsMany excellent and eligible postdoctoral programs are not APA accreditedCurrent structure of some programs
RequirementsThere are five requirements that must be met in order to qualify for these funds. The first four are called provider-operated criteria and the fifth is a minimum standard of accreditation.
#1 Hospital basedThe program must be hospital basedThus, other community based programs are not eligible.All funded allied health programs (e.g. nursing, radiology tech, etc) are hospital based.
#2 Hospital employs traineesThe hospital must incur the costs associated with both the clinical training and classroom instruction if that is a requirement for completion of the program. The hospital has to budget and pay for the cost of books, supplies, faculty salaries, and trainees salaries.
#3 Services in facilityPostdoctoral fellowship programs in which the majority of work is outpatient would not be eligiblePrograms that have inpatient and outpatient activities for trainees can only count inpatient related activities.
#4 Hospital control of trainingThe hospital is required to have administrative control over the program and its day-to-day function. The hospital must directly control the programs curriculum and determine the requirements for graduation.
#4 Hospital control of trainingThe hospital can enter into an agreement with a college or university to provide some basic course requirements. However, the hospital must financially incur the majority of training costs and independently award the degree. If the university absorbs some costs then these costs cannot be claimed by the program. Thus, a university based program that places its postdoctoral fellows at a hospital would not be eligible
Why not internship or non-hospital based programs?postdoctoral programs are by definition post degree which is similar to physician residencies. it was not necessary to write new law or rewrite current legislation. This would have been required to fund internships, which occur prior to degree completion. CMS funding has historically only been available for hospital based programs because of the way in which the original legislation was written.
Why not internship or non-hospital based programs?Essentially, implementing CMS funding for hospital based psychology fellowship programs only required reinterpretation of existing legislation (personal communication APA Government Relations, September 26, 2007).
Current statusAPPIC directory 4/12/09 l