Americans know Medicare as the federal program that covers health care costs for people age 65 and older. Medicare also is the nation's largest funder of doctor training.
Medicare pays for a big share of physician residency training, which U.S. doctors must complete after graduation from medical school. In 2015, Medicare paid an estimated $11 billion to support more than 85,000 doctors in training.
Most of those payments go to hospitals. The payment formulas are complex, but based on the size of the hospital and the number of residents. A different payment is calculated for each hospital and there is wide variation in how much hospitals are paid.
The federal government limits spending on this program by limiting the number of residency slots it will fund.
Because Medicare is the biggest funder of doctor training (also paying for dental and podiatry residencies), Medicare rules have an enormous impact on how many are trained, where they are trained and what specialties are trained. Historically, some longtime specialty residencies have been big money makers for their hospitals. Meanwhile, other residencies struggle to train physicians for health care professional shortage areas, such as Montana.
Considering how complicated this system is, the celebration held Tuesday at Billings Clinic is significant: One rule on Medicare GME was changed this month so that, starting on Oct. 1, hospitals can get payment for work their residents do in small rural hospitals. The rule change by the Centers for Medicare and Medicaid Services is the result of years of advocacy by Montana health care leaders and Sen. Jon Tester.
Tester held a rural health care summit in 2017 where participants requested having Medicare count medical residents' work in Critical Access Hospitals in the GME payment to teaching hospitals. That would make rural rotations more financially feasible. Outside of Montana's seven largest cities, all our community hospitals are Critical Access Hospitals.
When Billings Clinic launched its internal medicine residency, it included a requirement that every one of its doctors in training work at a small rural hospital before graduating from the three-year program. Because Medicare GME wouldn't cover any costs of training doctors in rural settings, the Leona M. and Harry B. Helmsley Charitable Trust stepped up with a grant to cover those costs for three years.
Tester introduced legislation in 2017 to change the Medicare rule. Montana's senior U.S. senator reintroduced the legislation in the current session and continued writing letters to CMS Administrator Seema Verma.
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Verma changed the rule administratively earlier this month.
The Montana Family Medicine Residency, based at RiverStone Health, also incorporates rural hospital rotations in its training, according to Dr. Jim Guyer, residency director.
"Residents currently can and are encouraged to do a month-long rotation in a rural hospital, often a Critical Access Hospital, to experience all the variety of rural medicine, and as an opportunity for that community to interest and attract the resident and family," RiverStone spokeswoman Barbara Schneeman said. "The rule change will help offset the costs of these rotations, and may make it possible to support more resident time in critical access hospitals."
The Montana Family Medicine Residency has succeeded in training dozens of primary care doctors who choose to stay and practice in Montana. Nationally, on average, 60% of residents stay where they train.
That's one reason Dr. Laura Bennett, a Lewistown family doctor and interim co-CEO at Central Montana Medical Center, is thankful for the Medicare rule change. Bennett wants the experience of having residents in her hospital and the opportunity to show them the rewards of rural practice.
Billings Clinic internal medicine residents are doing rotations in Lewistown and Sheridan, Wyoming.
"We've had WAMI medical students for 25 years," Bennett said. "Now we're seeing physicians come back to Lewistown."
Tester gives the Trump administration credit for breaking down that rule barrier, adding: "If we want to see more doctors in rural areas, we've got to train them in rural areas."
We urge Tester to keep working to improve the funding system so it better supports training the physicians that Montana and America need most. A report released by the Congressional Research Service in February notes: "With few exceptions, Medicare GME payments do not address changing health care workforce needs or trends."