1.  General Considerations and Myths  Business Planning and Budget  Potential Funding Options Discussion Fellowship Program Funding Considerations Rodney Tucker, MD, MMM

2. 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

3. 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!

4. 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)

5. 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.

6. 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 $$$

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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!

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Sustenance and Expansion  Ongoing Funding  Second Year Funding

25. 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)