National GME Trust Fund annually defined amount there would be a Medicare and a general DME fund, and a Medicare and a general IME fund. Each would have an annually determined amount, or part of the total fund.
To maintain a consistent Medicare commitment to GME, Medicare funding should reflect, ideally, a base period expenditure for DME and IME, trended forward. Adjustments to these amounts could be legislated by Congress, because, in the final analysis, the fund amounts will be whatever Congress determines are necessary to support GME and teaching hospitals. A general, non-Medicare amount could be set by Congress in the budgeting process. Each payer for health care services should contribute in proportion to its share of total health care expenditures recognizing, as previously mentioned, the ongoing, though diminishing non-Medicare support through private-sector health care service payments.
The DME funds should pay a uniform per resident amount, without reference to individual institutional Medicare (or non-Medicare) caseload, but continuing current weighting for work force composition.
The system should provide a transition that moves gradually toward a uniform payment with the initial change occurring over 5 years. The initial transition discussed could fall short of achieving uniformity in many institutions. During this initial 5-year transition, however, a better DME distribution plan should be designed that recognizes the need for greater uniformity and for a reasonably standard resident training price, but also accounts for differences in costs of inputs and, if possible, other factors such as locations of special need. This new system would be initiated (or phased in) following the initial 5-year phase-in. Beginning immediately, residents added to an institution's total resident number should be paid for at the lesser of the projected uniform rate or the actual rate.
Eligibility for DME payments should be expanded to include any entity that is a formal educational or health care service institution, that meets accrediting body standards for GME, and that assumes overall training program responsibility. These entities should be paid directly.
Nursing DME should be structured like physician DME and be paid to sponsoring institutions for the support of advanced practice, graduate clinical trainees. This provision should be neutral with respect to the proportion of DME that has supported nursing; diploma, undergraduate nurse education support should be phased out in 4 years or less to allow present students to complete their training.