[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2804 Introduced in House (IH)]

103d CONGRESS
  1st Session
                                H. R. 2804

 To establish a national policy respecting medical residency training 
    programs and the health care workforce, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 29, 1993

Mr. Waxman (for himself and Mr. Cardin) introduced the following bill; 
       which was referred to the Committee on Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
 To establish a national policy respecting medical residency training 
    programs and the health care workforce, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Primary Care Workforce Act of 
1993''.

SEC. 2. DEFINITIONS.

    In this Act, the following definitions shall apply:
            (1) The term ``approved medical residency training 
        program'' has the meaning given such term in section 
        1886(h)(5)(A) of the Social Security Act.
            (2) The term ``entry position'' means, with respect to a 
        medical residency training program, a position as a resident in 
        the initial year of study in the program.
            (3) The term ``primary care resident'' means (in accordance 
        with criteria established by the Secretary) a resident being 
        trained in a distinct program of primary health care (as 
        defined in section 723(d)(5) of the Public Health Service Act).
            (4) The term ``resident'' has the meaning given such term 
        in section 1886(h)(5)(H) of the Social Security Act.
            (5) The term ``Secretary'' means the Secretary of Health 
        and Human Services.
            (6) The term ``State'' has the meaning given such term 
        under section 799(9) of the Public Health Service Act.
            (7) The term ``United States medical graduate'' means a 
        resident who is a graduate of--
                    (A) a school of medicine accredited by the Liaison 
                Committee on Medical Education of the American Medical 
                Association and the Association of American Medical 
                Colleges (or approved by such Committee as meeting the 
                standards necessary for such accreditation); or
                    (B) a school of osteopathy accredited by the 
                American Osteopathic Association, or approved by such 
                Association as meeting the standards necessary for such 
                accreditation.

SEC. 3. ESTABLISHMENT AND ENFORCEMENT OF NATIONAL POLICY FOR APPROVED 
              MEDICAL RESIDENCY TRAINING PROGRAMS.

    (a) In General.--The Secretary of Health and Human Services shall 
establish a national policy respecting the number of positions in each 
State in each approved medical residency training program of the 
different medical specialties conducted in the State.
    (b) Specific Distribution Rules.--
            (1) Limit on total number of positions.--The national 
        policy established under subsection (a) shall provide that, 
        with respect to residents who begin an initial residency period 
        on or after June 1, 1998, the total number of entry positions 
        in approved medical residency training programs in the United 
        States in which residents may enroll without having previously 
        completed another medical residency training program may not 
        for any fiscal year exceed 110 percent of the number of United 
        States medical graduates.
            (2) Distribution of primary care and nonprimary care 
        positions.--
                    (A) General rule.--The national policy established 
                under subsection (a) shall provide that, after a three-
                year transition period beginning on June 1, 1995, the 
                number of entry positions in all approved medical 
                residency training programs in a State for residents 
                who begin an initial residency period on or after June 
                1, 1998, who are not primary care residents may not 
                exceed 50 percent of the total number of entry 
                positions in all such programs in a State for all 
                residents who are United States medical graduates.
                    (B) Waiver for certain states.--The Secretary may 
                waive the application of the general rule described in 
                subparagraph (A) to a State if the Secretary finds that 
                the application of the rule to the State is not 
                practicable.
    (c) Timetable.--
            (1) Publication of interim final regulation.--The Secretary 
        shall publish an interim final regulation carrying out the 
        national policy referred to in subsection (a) not later than 
        sixty days after the National Health Professional Workforce 
        Advisory Board submits its recommendations to the Secretary 
        regarding such national policy pursuant to section 3(b).
            (2) Use of board's recommendations as default policy.--If 
        the Secretary does not meet the requirements of paragraph (1), 
        the recommendations of the National Health Professional 
        Workforce Advisory Board submitted to the Secretary pursuant to 
        section 3(b) shall, for purposes of this Act and the amendments 
        made by this Act, be deemed to be the national policy 
        established by the Secretary under subsection (a) respecting 
        the number of positions in each State in the approved medical 
        residency training programs of the different medical 
        specialities conducted in the State.
    (d) Assuring Conformity of Medicare Payments for Medical Education 
With National Policy.--
            (1) Payment for direct medical education.--Section 
        1886(h)(5)(A) of the Social Security Act (42 U.S.C. 
        1395ww(h)(5)(A)) is amended--
                    (A) by striking ``means'' and inserting ``means, 
                with respect to a hospital,''; and
                    (B) by striking the period at the end and inserting 
                the following: ``, but only if (with respect to 
                residents who begin an initial residency period on or 
                after June 1, 1995) entry positions in each such 
                program of the hospital are in accordance with the 
                national policy established by the Secretary under 
                section 3(a) of the Primary Care Workforce Act of 1993 
                respecting the number of positions in such program.''.
            (2) Payment for indirect medical education.--Section 
        1886(d)(5)(B) of such Act (42 U.S.C. 1395ww(d)(5)(B)) is 
        amended by adding at the end the following new clauses:
            ``(v) In determining such adjustment, the Secretary may not 
        take into account the services of any interns and residents in 
        a medical residency training program for a specialty or 
        subspecialty unless, with respect to interns and residents who 
        begin an initial residency period (as defined in subsection 
        (h)(5)(F)) on or after June 1, 1995, entry positions in each 
        such program of the hospital are in accordance with the 
        national policy established by the Secretary under section 3(a) 
        of the Primary Care Workforce Act of 1993 respecting the number 
        of positions in such program.
            ``(vi) With respect to payments during each of the first 5 
        fiscal years for which clause (v) is in effect, the application 
        of such clause may not result in a reduction of the additional 
        payment amount made to the hospital under this subparagraph 
        during the fiscal year to an amount that is less than--
                    ``(I) in the case of a hospital receiving an 
                additional payment amount under subparagraph (F) during 
                the fiscal year that is computed under clause (vii)(I) 
                of such subparagraph, 95 percent of the additional 
                payment amount made to the hospital under this 
                subparagraph during the previous fiscal year; or
                    ``(II) in the case of any other hospital, 90 
                percent of the additional payment amount made to the 
                hospital under this subparagraph during the previous 
                fiscal year.''.

SEC. 4. NATIONAL HEALTH PROFESSIONAL WORKFORCE ADVISORY BOARD.

    (a) Establishment; Composition.--There is hereby established the 
National Health Professional Workforce Advisory Board (hereafter in 
this section referred to as the ``Board''), to be composed of the 
Secretary of Health and Human Services, the Secretary of Veterans' 
Affairs, and seven other members appointed by the President not later 
than three months after the date of the enactment of this Act, of 
whom--
            (1) at least one shall be a dean of a school of medicine;
            (2) at least one shall be a health care professional who is 
        not a physician;
            (3) at least one shall be the program director of an 
        approved medical residency training program;
            (4) at least one shall be the chief executive officer of a 
        hospital that operates an approved medical residency training 
        program;
            (5) at least one shall be the vice-president or vice-
        chancellor for health affairs of a multi-disciplinary academic 
        health center; and
            (6) at least one shall represent the general public.
    (b) Duties.--
            (1) In general.--The Board shall--
                    (A) prepare initial recommendations regarding the 
                national policy referred to in section 3(a) for the 
                number of positions in approved medical residency 
                training programs of the different medical specialties 
                (subject to the requirements of section 3(b) regarding 
                the total number of entry positions in such programs 
                and the distribution of such positions under such 
                programs among primary care and non-primary care 
                residents at various sites), and submit such 
                recommendations to the Secretary not later than one 
                year after the date of the enactment of this Act;
                    (B) submit recommendations to the Secretary 
                regarding the supply and role of providers of primary 
                care services who are not physicians;
                    (C) with respect to funds available pursuant to 
                title XVIII of the Social Security Act for direct 
                graduate medical education for the clinical training of 
                physicians and nurses, study the appropriateness of 
                expending such funds to make reimbursements under such 
                title for the clinical training in primary care of 
                additional practitioners;
                    (D) submit annual reports to Congress and the 
                Secretary on the implementation of such national 
                policy; and
                    (E) provide the Secretary with such technical and 
                other assistance regarding such national policy as the 
                Secretary may request.
            (2) Criteria for recommendations.--In preparing its 
        recommendations under paragraph (1), the Board shall take into 
        consideration--
                    (A) the quality of graduate medical residency 
                training programs;
                    (B) the need to maintain the operation of such 
                programs that have demonstrated success in recruiting, 
                retaining, and promoting minority practitioners;
                    (C) the need to assure that the distribution of 
                entry positions in such programs is not inequitable in 
                relation to the States and hospitals in urban and rural 
                areas that are qualified to offer such programs;
                    (D) the need to assure the provision of primary 
                care and other health care services to medically 
                underserved communities; and
                    (E) such other criteria as the Board (in 
                consultation with the accrediting bodies referred to in 
                subsection (c)) considers appropriate.
    (c) Role of Accrediting Bodies and Certifying Boards.--In preparing 
its recommendations regarding the national policy referred to in 
section 3(a), the Board shall--
            (1) request each accrediting body for approved medical 
        residency training programs for a specialty or subspecialty, 
        and each certification board for such specialty or 
        subspecialty, to prepare and submit a plan that provides for 
        the achievement of such national policy with respect to 
        approved medical residency training programs for such specialty 
        or subspecialty;
            (2) analyze the extent to which the Board may adopt such 
        plans as the basis for its recommendations; and
            (3) maintain close consultation with such bodies and boards 
        throughout the process of preparing its recommendations.
    (d) Chairperson; Additional Duties.--The President shall designate 
a Chairperson from among the members, who (subject to the approval of 
the Board) may--
            (1) employ and fix the compensation of an Executive 
        Director and such other personnel (not to exceed twenty-five) 
        as may be necessary to carry out the Board's duties;
            (2) seek such assistance and support as may be required in 
        the performance of the Board's duties from appropriate Federal 
        departments and agencies;
            (3) enter into contracts or make other arrangements, as may 
        be necessary for the conduct of the work of the Board (without 
        regard to section 3709 of the Revised Statutes (41 U.S.C. 5));
            (4) make advance, progress, and other payments which relate 
        to the work of the Commission;
            (5) provide transportation and subsistence for persons 
        serving without compensation; and
            (6) prescribe such rules and regulations as the Board deems 
        necessary with respect to its internal organization and 
        operation.
    (e) Compensation.--Members of the Board who are full-time officers 
or employees of the United States may not receive additional pay, 
allowances, or benefits by reason of their service on the Board, but 
may receive travel expenses, including per diem in lieu of subsistence, 
in accordance with sections 5702 and 5703 of title 5, United States 
Code.
    (f) Termination.--The Board shall terminate upon the expiration of 
the six-year period that begins on the date of the enactment of this 
Act. Section 14(a) of the Federal Advisory Committee Act (5 U.S.C. 
App.; relating to the termination of advisory committees) shall not 
apply to the Board.
    (g) Conforming Amendment Repealing Council on Graduate Medical 
Education.--Effective on the date of the enactment of this Act, section 
301 of the Health Professions Education Extension Amendments of 1992 
(Public Law 102-408) is repealed.

SEC. 5. REVISIONS TO MEDICARE METHODOLOGY FOR DETERMINING PAYMENTS FOR 
              MEDICAL RESIDENCY.

    (a) Payments for Direct Medical Education Costs of Non-Hospital 
Providers.--Title XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.) is amended by inserting after section 1889 the following new 
section:

    ``graduate medical education payments for non-hospital providers

    ``Sec. 1890. (a) In General.--Notwithstanding any other provision 
of this title, in the case of any entity (other than a hospital) 
eligible to receive payments under this title that operates an approved 
medical residency training program, in addition to any other payments 
that may be made to the entity under this title, the Secretary shall 
provide for payment to the entity for direct graduate medical education 
costs in accordance with subsection (b).
    ``(b) Determination of Amount of Payment.--
            ``(1) In general.--The amount of payment made to an entity 
        under this section for direct medical education for a fiscal 
        year is equal to the product of--
                    ``(A) the aggregate approved amount (as defined in 
                paragraph (2)) for the year; and
                    ``(B) the entity's medicare patient load (as 
                defined in subsection (d)(2)) for the year.
            ``(2) Aggregate approved amount.--In paragraph (1), the 
        term `aggregate approved amount' means, for a fiscal year, the 
        product of--
                    ``(A) the approved FTE resident amount (determined 
                under paragraph (3)) for the year; and
                    ``(B) the weighted average number of full-time 
                equivalent residents (as determined by the Secretary in 
                a manner similar to the manner used to determine the 
                number of such residents under section 1886(h)(4)) in 
                the entity's approved medical residency training 
                programs in the year.
            ``(3) Determination of approved fte resident amount.--
                    ``(A) In general.--For each approved medical 
                residency training program, the Secretary shall 
                determine an approved FTE resident amount for each 
                fiscal year (beginning with fiscal year 1995) equal to 
                the applicable percentage (as defined in subparagraph 
                (C)) of the national average salary for the year (as 
                defined in subparagraph (B)(ii)).
                    ``(B) Determination of national average salary.--
                            ``(i) Determination of base amount.--The 
                        Secretary shall determine a base salary amount 
                        equal to the Secretary's estimate (using the 
                        most recent available audited cost reports) of 
                        the national average salary, including fringe 
                        benefits, for a full-time-equivalent resident 
                        in an approved medical residency training 
                        program during fiscal year 1990, increased (in 
                        a compounded manner) by the sum of the 
                        estimated percentage changes in the consumer 
                        price index during the 12-month periods between 
                        the midpoint of fiscal year 1990 and the 
                        midpoint of fiscal year 1994.
                            ``(ii) National average salary defined.--In 
                        this paragraph, the `national average salary' 
                        for a fiscal year is equal to--
                                    ``(I) for fiscal year 1995, the 
                                base amount determined under clause (i) 
                                updated through the midpoint of the 
                                year by projecting the estimated 
                                percentage change in the consumer price 
                                index during the 12-month period ending 
                                at that midpoint (with appropriate 
                                adjustments to reflect previous under- 
                                or over-estimations under this 
                                subparagraph in the projected 
                                percentage change in the consumer price 
                                index); and
                                    ``(II) for a subsequent fiscal 
                                year, the amount determined under this 
                                clause for the previous fiscal year up-
                                dated through the midpoint of the year 
                                by projecting the estimated percentage 
                                change in the consumer price index 
                                during the 12-month period ending at 
                                that midpoint (with appropriate 
                                adjustments to reflect previous under- 
                                or over-estimations under this 
                                subparagraph in the projected 
                                percentage change in the consumer price 
                                index).
                    ``(C) Applicable percentage.--In subparagraph (A), 
                the `applicable percentage' is--
                            ``(i) in the case of a primary care 
                        residency training program, 200 percent; or
                            ``(ii) in the case of medical residency 
                        training program that is not a primary care 
                        residency training program, 150 percent.
    ``(c) Allocation of Payments Among Trust Funds.--In providing for 
payments under this section, the Secretary shall provide for an 
allocation of such payments between part A and part B (and the trust 
funds established under the respective parts) as reasonably reflects 
the proportion of direct graduate medical costs of entities associated 
with the provision of services under each respective part.
    ``(d) Definitions.--In this section:
            ``(1) The terms `approved medical residency training 
        program', `consumer price index', `direct graduate medical 
        education costs', and `resident' have the meaning given such 
        terms under section 1886(h)(5).
            ``(2) The term `medicare patient load' means, with respect 
        to an entity for a year, the fraction of the entity's services 
        during the year which are attributable to individuals entitled 
        to benefits under this title (based on such measure of services 
        as the Secretary determines to be appropriate for purposes of 
        this section).
            ``(3) The term `primary care medical residency training 
        program' means an approved medical residency training program 
        consisting of a distinct program of primary health care (as 
        defined in section 723(d)(5) of the Public Health Service 
        Act).''.
    (b) Payment for Hospital Costs of Indirect Medical Education 
Provided Off-Site.--Section 1886(d)(5)(B)(iv) of the Social Security 
Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended by inserting by striking 
the period at the end and inserting the following: ``, without regard 
to the setting in which the services are furnished (if the hospital 
incurs all, or substantially all, of the costs of the services 
furnished to the hospital by such interns and residents).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to cost reporting periods (or portions thereof) beginning on or 
after October 1, 1994.

SEC. 6. CERTAIN PRIMARY CARE PROGRAMS UNDER PUBLIC HEALTH SERVICE ACT.

    (a) Increase in Funding for Scholarship and Loan Repayment Programs 
of National Health Service Corps.--Section 338H(b)(1) of the Public 
Health Service Act (42 U.S.C. 254q(b)(1)) is amended--
            (1) by striking ``and'' after ``1991,'';
            (2) by striking ``through 2000'' and inserting ``and 
        1993''; and
            (3) by inserting before the period the following: 
        ``,$226,000,000 for fiscal year 1994, $294,000,000 for fiscal 
        year 1995, $381,000,000 for fiscal year 1996, $496,000,000 for 
        fiscal year 1997, $644,000,000 for fiscal year 1998, 
        $837,000,000 for fiscal year 1999, and $1,089,000,000 for 
        fiscal year 2000''.
    (b) Demonstration Grants to States for Community Scholarship 
Programs.--Section 338L(l)(1) of the Public Health Service Act (42 
U.S.C. 254t(l)(1)) is amended--
            (1) by striking ``and'' after ``1992,''; and
            (2) by inserting before the period the following: ``, and 
        $5,000,000 for each of the fiscal years 1994 through 2000''.
    (c) National Research Service Awards.--Section 487(d)(3) of the 
Public Health Service Act (42 U.S.C. 288(d)(3)), as amended by section 
1641(2) of Public Law 103-43, is amended--
            (1) by striking ``1 percent'' the first place such terms 
        appears and inserting ``2 percent''; and
            (2) by striking ``Awards which (A) are made'' and all that 
        follows through ``(B) are for research in primary medical 
        care;'' and inserting the following ``Awards made for research 
        in primary medical care;''.
    (d) Health Care Policy and Research.--
            (1) Funding.--Section 926 of the Public Health Service Act 
        (42 U.S.C. 299c-5), as amended by section 10 of Public Law 102-
        410 (106 Stat. 2101), is amended by adding at the end the 
        following subsection:
    ``(f) Allocation Regarding Primary Care.--Of the amounts made 
available for a fiscal year for carrying out this title, the Secretary 
shall obligate not less than 15 percent for carrying out section 902 
with respect to primary care.''.
            (2) Retraining programs.--Section 902 of the Public Health 
        Service Act (42 U.S.C. 299a), as amended by section 2 of Public 
        Law 102-410 (106 Stat. 2094), is amended by adding at the end 
        the following subsection:
    ``(f) Retraining of Specialists.--With respect to physicians who 
are in a specialty, the Administrator shall, in carrying out subsection 
(a), conduct or support programs for training such physicians in 
primary care.''.
    (e) Commission on Obligated Service.--
            (1) In general.--Not later than one hundred and eighty days 
        after the date of the enactment of this Act, there shall be 
        established in accordance with this subsection an advisory 
        commission to carry out the duties described in paragraph (2).
            (2) Duties.--The duties referred to in paragraph (1) are 
        making recommendations to the President and the Secretary on 
        Health and Human Services on whether and to what extent 
        students attending health professions schools pursuant to 
        direct or indirect federal financial assistance (for the 
        students or for the schools, or both) should, as a condition of 
        such attendance, be contractually required to complete a period 
        of providing health services to medically undeserved 
        individuals. Recommendations under the preceding sentence shall 
        include recommendations with respect to establishing such a 
        requirement for each student who attends a health professions 
        school pursuant to such assistance.
            (3) Membership.--The advisory commission established under 
        paragraph (1) shall be comprised of five individuals appointed 
        by the President.
            (4) Administrative provisions.--The advisory commission 
        established under paragraph (1) shall be established within the 
        Department of Health and Human Services. The Secretary shall 
        provide to the commission such staff, quarters, information, 
        and other assistance as may be necessary for the commission to 
        carry out paragraph (2).

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HR 2804 IH----2