title: Modifying the Primary Care Exception Rule to Require Competency-Based Assessment.
abstract: Teaching residents to practice independently is a core objective of graduate medical education (GME). However, billing rules established by the Centers for Medicare and Medicaid Services (CMS) require that teaching physicians physically be present in the examination room for the care they bill, unless the training program qualifies for the Primary Care Exception Rule (PCER). Teaching physicians in programs that use this exception can bill for indirectly supervised ambulatory care once the resident who provides that care has completed six months of training. However, CMS does not mandate that programs assess or attest to residents' clinical competence before using this rule. By requiring this six-month probationary period, the implication is that residents are adequately prepared for indirectly supervised practice by this time. As residents' skill development varies, this may or may not be true. The PCER makes no attempt to delineate how residents' competence should be assessed, nor does the GME community have a standard for how and when to make this assessment specifically for the purpose of determining residents' readiness for indirectly supervised primary care practice.In this Perspective, the authors review the history and current requirements of the PCER, explore its limitations, and offer suggestions for how to modify the teaching physician billing requirements to mandate the evaluation of residents' competence using the existing milestones framework. They also recommend strategies to standardize this process of evaluation and to develop benchmarks across training programs.
authors.affiliation: D.G. Tobin is assistant professor of medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut. B.R. Doolittle is associate professor of medicine and pediatrics, Departments of Internal Medicine and Pediatrics, Yale University School of Medicine, New Haven, Connecticut. M.S. Ellman is associate professor of medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut. C.B. Ruser is associate professor of medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, and Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut. R.S. Brienza is assistant professor of medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, and Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut. I. Genao is associate professor of medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Tobin
authors.forename: Benjamin R
authors.initials: BR
authors.lastname: Doolittle
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Ellman
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Ruser
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Brienza
authors.forename: Inginia
authors.initials: I
authors.lastname: Genao
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D003695:Delivery of Health Care / Q000592:standards*; D004503:Education, Medical, Graduate / Q000592:standards*; D004521:Educational Measurement / Q000592:standards*; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D011320:Primary Health Care / Q000592:standards*; D011361:Professional Competence / Q000592:standards*; D014481:United States