Since 1996, when Congress capped the number of Medicare-supported residency positions at each teaching hospital, institutions have struggled to find ways to fund expansions to residency training programs. These Medicare graduate medical education (GME) caps are incredibly strict, but there are several exceptions existing teaching hospitals can use to increase their complement of trainees and increase funding.

One of these few exceptions is the Medicare Rural Training Track (RTT) program. The Medicare RTT program allows urban and rural hospitals and rural physician practices to partner to build residency programs and expand their caps, while also helping to meet the needs of underserved rural areas with primary care physician shortages. An urban teaching hospital that forms an RTT program can receive additional Medicare direct GME (DGME) and indirect medical education (IME) funding (beyond its 1996 GME caps) up to what is known as the "RTT FTE limitation" or "RTT cap." Establishing this separate RTT cap requires adherence to the complex Medicare regulations that explain which FTE residents may be counted toward the RTT cap, how their training must be apportioned between the urban and rural hospitals or non-hospital sites and how new RTT programs initially build their RTT caps. 

If you are a teaching hospital contemplating establishing an RTT program, or if you would like to learn more about how creating these programs would allow you to grow your GME program and receive additional Medicare funding, there are several important issues you should consider. The following are a few questions that you will need take into account:

• Will the amount of time residents spend training in the rural area meet the Medicare requirements for the urban hospital to build an RTT cap? Which resident FTEs may be included in an urban hospital's RTT cap?
• How does a rural hospital that partners with an urban hospital to establish a new RTT program expand its existing caps to account for the new program? 
• How much time do urban and rural hospitals starting new RTT programs have to build their RTT caps?
• How does rotating residents to rural hospitals versus rotating residents to rural non-hospital sites affect the RTT cap-building process?
• How are urban and rural hospitals paid to train the residents in the new RTT program during the cap-building period?
• If updated Census data results in reclassification of a rural hospital participating in an RTT program, what happens to the RTT program and the other hospitals participating in it?

Understanding these nuances of the applicable regulations and how they apply to the program you would like to establish is extremely important. How you address these questions will determine whether or not you are entitled to receive Medicare GME funding for a new RTT program and therefore must be considered carefully.