[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1473 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                S. 1473

    To encourage an appropriate mixture of different specialties of 
physicians and other health care providers to meet national needs, and 
                          for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

           September 20 (legislative day, September 7), 1993

  Mr. Baucus introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
    To encourage an appropriate mixture of different specialties of 
physicians and other health care providers to meet national needs, 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 Health Care Support Act of 
1993''.

SEC. 2. FINDINGS AND PURPOSE.

    (a) Findings.--The Congress finds that:
            (1) Primary care physicians, including family physicians, 
        general internists, and general pediatricians, provide health 
        care services that are essential to the well-being of all 
        Americans.
            (2) There is a shortage of primary care physicians in many 
        areas of the United States.
            (3) A large majority of recent graduates of medical schools 
        located in the United States are entering non-primary care 
        specialty practices.
            (4) There is an oversupply of non-primary care specialists 
        in the practice of medicine in the United States.
            (5) An appropriate mix of physicians in the United States 
        is approximately one-half primary care physicians and one-half 
        physicians in other specialties.
            (6) The oversupply of non-primary care specialists has 
        helped to drive up health care costs through high fees and high 
        utilization of diagnostic tests and procedures.
            (7) The shortage of primary care physicians has affected 
        medical service quality because these physicians furnish 
        excellent continuity of care, are expert in diagnosing medical 
        problems, and can effectively deal with the interaction of 
        comorbid conditions.
            (8) The shortage of primary care physicians has amplified 
        the problems of access to medical care in areas with health 
        care professional shortages, especially inner city and rural 
        areas.
    (b) Purposes.--The purposes of this Act are to--
            (1) increase the relative income of primary care physicians 
        as compared to physicians in other specialties;
            (2) reform the system for payment of direct graduate 
        medical education costs to operators of graduate medical 
        education programs under the medicare program;
            (3) establish the National Physician Work Force Commission 
        to study and recommend national physician work force goals;
            (4) establish a program to designate physician residency 
        programs and the number of positions in those programs based on 
        national needs; and
            (5) increase the number of primary care physicians trained 
        and employed with the help of government programs.

SEC. 3. RESOURCE-BASED PRACTICE EXPENSE RELATIVE VALUE UNITS.

    (a) Resource-Based Practice Expenses.--Not later than October 1, 
1996, the Secretary of Health and Human Services (referred to in this 
section as the ``Secretary'') shall develop resource-based expenses for 
the determination of average practice expense relative value units to 
be utilized in determining payment for each physician service under 
part B of title XVIII of the Social Security Act.
    (b) Implementation.--
            (1) Computation of practice expense relative value units.--
        Section 1848(c)(2)(C)(ii) of the Social Security Act (42 U.S.C. 
        1395w-4(c)(2)(C)(ii)) is amended to read as follows:
                            ``(ii) Practice expense relative value 
                        units.--The Secretary shall determine a number 
                        of practice expense relative value units equal 
                        to the product of--
                                    ``(I) the resource-based expenses 
                                (as defined in subparagraph (E)) for 
                                the service, and
                                    ``(II) the practice expense 
                                percentage for the service (as 
                                determined under paragraph 
                                (3)(C)(ii)).''.
            (2) Resource-based expenses.--Subparagraph (E) of section 
        1848(c)(2) of the Social Security Act (42 U.S.C. 1395w-
        4(c)(2)), as added by section 13513 of the Omnibus Budget 
        Reconciliation Act of 1993, is amended to read as follows:
                    ``(E) Resource-based expenses defined.--In this 
                paragraph, the term `resource-based expenses' means, 
                with respect to a physician's service, the direct and 
                indirect costs of the resources needed to furnish the 
                service, as estimated by the Secretary using the most 
                recent data available. The resources shall be estimated 
                using accounting methods to measure direct and indirect 
                costs. The Secretary may use extrapolation and other 
                techniques to determine resource-based expenses for 
                services for which adequate data is not available.''.
    (c) Budget Neutrality.--The Secretary shall provide that in 
carrying out the amendments made by subsection (b) that payments under 
section 1848 of the Social Security Act are equal to what such payments 
would have been if such amendments had not been enacted.
    (d) Effective Date.--The amendments made by subsection (b) shall 
apply to services furnished on or after January 1, 1997.

SEC. 4. PAYMENTS FOR DIRECT GRADUATE MEDICAL EDUCATION COSTS.

    (a) In General.--
            (1) Determining per resident standard amount.--Section 
        1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), as 
        amended by section 13563 of the Omnibus Budget Reconciliation 
        Act of 1993, is amended by redesignating paragraphs (3), (4), 
        (5), and (6) as paragraphs (4), (5), (6), and (7), respectively 
        and by inserting after paragraph (2) the following new 
        paragraph:
            ``(3) Determination of per resident standard amount.--The 
        Secretary shall determine a national per resident standard 
        amount for each fiscal year beginning on or after October 1, 
        1994, as follows:
                    ``(A) Base amount.--The Secretary shall determine 
                the weighted national mean of all FTE resident amounts 
                calculated under paragraph (2) and updated in 
                accordance with paragraph (2)(D) to the midpoint of 
                fiscal year 1994 for the most recent cost reporting 
                periods for which data are available.
                    ``(B) Inflation adjustment to base amount.--
                            ``(i) Fiscal year 1995.--For fiscal year 
                        1995, the per resident standard amount is the 
                        amount determined under subparagraph (A) 
                        updated in accordance with paragraph (2)(D) 
                        through the midpoint of fiscal year 1995.
                            ``(ii) Subsequent fiscal years.--For fiscal 
                        year 1996 and any subsequent fiscal year, the 
                        per resident standard amount is equal to the 
                        amount determined under this paragraph for the 
                        previous fiscal year updated, through the 
                        midpoint of the fiscal 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 underestimations or 
                        overestimations under this subparagraph in the 
                        projected percentage change in the Consumer 
                        Price Index.
                    ``(C) Special rule.--In the case of a hospital that 
                received payment under this subsection prior to October 
                1, 1994, the per resident standard amount for such 
                hospital for fiscal year 1995 shall be equal to the sum 
                of--
                            ``(i) 50 percent of the hospital specific 
                        approved FTE resident amount determined under 
                        paragraph (2) for such hospital; and
                            ``(ii) 50 percent of the per resident 
                        standard amount determined under subparagraph 
                        (B)(i).''.
            (2) Payment amount per resident.--Paragraph (4) of section 
        1886(h) of such Act (42 U.S.C. 1395ww(h)), as redesignated by 
        paragraph (1), is amended to read as follows:
            ``(4) GME operator payment amount per resident.--
                    ``(A) In general.--The payment amount, for a GME 
                operator cost reporting period beginning on or after 
                October 1, 1994, is equal to the product of--
                            ``(i) the aggregate approved amount (as 
                        defined in subparagraph (B)) for that period, 
                        and
                            ``(ii) the GME operator's medicare patient 
                        load (as determined by the Secretary) for that 
                        period.
                    ``(B) Aggregate approved amount.--As used in 
                subparagraph (A), the term `aggregate approved amount' 
                means, for a GME operator cost reporting period, the 
                product of--
                            ``(i) the per resident standard amount 
                        determined under paragraph (3) for that period, 
                        and
                            ``(ii) the weighted average number of full-
                        time-equivalent residents (as determined under 
                        paragraph (5)) in the GME operator's approved 
                        medical residency training programs in that 
                        period.''.
            (3) Weighting factors.--Subparagraph (C) of paragraph (5) 
        of section 1886(h) of such Act (42 U.S.C. 1395ww(h)), as 
        redesignated by paragraph (1), is amended to read as follows:
                    ``(C) Weighting factors for certain residents.--
                Subject to subparagraph (D), such rules shall provide, 
                in calculating the number of full-time-equivalent 
                residents in an approved medical residency training 
                program--
                            ``(i) for a resident who is in the 
                        resident's initial residency period, the 
                        weighting factor is 0.80 (1.20, in the case of 
                        a resident who is a primary care resident), and
                            ``(ii) for a resident who is not in the 
                        resident's initial residency period, the 
                        weighting factor is 0.50.''.
            (4) Definitions.--Paragraph (6) of section 1886(h) of such 
        Act (42 U.S.C. 1395ww(h)), as redesignated by paragraph (1), is 
        amended by adding at the end the following new subparagraph:
                    ``(K) GME operator.--The term `GME operator' means 
                a hospital, rural health clinic, health maintenance 
                organization, medical school, group practice, 
                physician's office, area health education center, 
                community health center, or consortium of institutional 
                providers or health professionals that has an approved 
                medical residency training program.''.
            (5) Conforming amendments.--Section 1886(h) of such Act (42 
        U.S.C. 1395ww(h)) is amended--
                    (A) in paragraph (1)--
                            (i) by striking ``hospitals'' each place it 
                        appears and inserting ``GME operators''; and
                            (ii) by striking ``paragraph (3)'' and 
                        inserting ``paragraph (4)'';
                    (B) in paragraph (2), in the matter preceding 
                subparagraph (A), by inserting ``and ending on or 
                before September 30, 1995,'' after ``1985,''; and
                    (C) in paragraph (5), as redesignated by subsection 
                (a)--
                            (i) by adding at the end of subparagraph 
                        (A) the following new sentence: ``Such rules 
                        shall provide that only time spent in 
                        activities relating to patient care shall be 
                        counted and that all the time so spent by a 
                        resident under an approved medical residency 
                        training program sponsored by a GME operator 
                        shall be counted toward the determination of 
                        full-time-equivalency, without regard to the 
                        setting in which the activities are 
                        performed.'';
                            (ii) in subparagraph (B), by striking 
                        ``hospital'' each place it appears and 
                        inserting ``GME operator''; and
                            (iii) by striking subparagraph (E).
    (b) Budget Neutrality.--Through fiscal year 1998, the Secretary of 
Health and Human Services shall provide that in carrying out the 
amendments made by subsection (a), payments under section 1886(h) of 
the Social Security Act shall be equal to what such payments would have 
been if such amendments had not been enacted.
    (c) Conforming Amendment.--Section 1861(u) of the Social Security 
Act (42 U.S.C. 1395x(u)) is amended by striking ``hospice program,'' 
and inserting ``hospice program, GME operator (as defined in section 
1886(h)(6)(K)),''.
    (d) Effective Date.--The amendments made by this section shall be 
effective for cost reporting periods beginning on or after October 1, 
1994.

SEC. 5. NATIONAL PHYSICIAN WORK FORCE COMMISSION.

    (a) Establishment of Commission.--
            (1) Establishment.--There is established a commission to be 
        known as the National Physician Work Force Commission (referred 
        to in this section as the ``Commission'') which shall be 
        composed of the Secretary of Health and Human Services 
        (referred to in this section as the ``Secretary'') and 10 other 
        members to be appointed by the Director of the Congressional 
        Office of Technology Assessment (referred to in this section as 
        the ``Director''), on or before the date that is 60 days after 
        the date of the enactment of this Act.
            (2) Membership.--The members of the Commission appointed 
        under paragraph (1) shall include individuals with national 
        recognition for expertise in health service delivery, research, 
        health economics, physician medical education, and physician 
        work force issues. The professions of members of the Commission 
        shall include physicians, mid-level health professionals, 
        employers, third party payers, and health research experts. In 
        appointing individuals, the Director shall assure 
        representation of various professions, different geographic 
        regions, and urban and rural regions.
            (3) Terms.--The members of the Commission appointed under 
        paragraph (1) shall be appointed to serve for terms of 3 years, 
        except that the terms of the members first appointed may be 
        staggered so that the terms of no more than 4 members expire in 
        any 1 year. Any individual appointed to fill a vacancy created 
        in the Commission shall be appointed for the remainder of the 
        term of such individual's predecessor.
            (4) Chairman and vice chairman.--The Director shall select 
        the Chairman and Vice Chairman of the Commission.
            (5) Meetings.--
                    (A) In general.--The Commission shall meet at the 
                call of the Chairman.
                    (B)  Initial meeting.--No later than 30 days after 
                the date on which all members of the Commission have 
                been appointed, the Commission shall hold its first 
                meeting.
                    (C) Quorum.--A majority of the members of the 
                Commission shall constitute a quorum, but a lesser 
                number of members may hold hearings.
    (b) Powers of the Commission.--
            (1) Hearings.--The Commission may hold such hearings, sit 
        and act at such times and places, take such testimony, and 
        receive such evidence as the Commission considers advisable to 
        carry out the purposes of this section.
            (2) Information from federal agencies.--The Commission may 
        secure directly from any Federal department or agency such 
        information as the Commission considers necessary to carry out 
        the provisions of this Act. Upon request of the Chairman of the 
        Commission, the head of such department or agency shall furnish 
        such information to the Commission.
            (3) Postal services.--The Commission may use the United 
        States mails in the same manner and under the same conditions 
        as other departments and agencies of the Federal Government.
            (4) Gifts.--The Commission may accept, use, and dispose of 
        gifts or donations of services or property.
    (c) Commission Personnel Matters.--
            (1) Compensation of members.--Each member of the Commission 
        who is not an officer or employee of the Federal Government 
        shall be compensated at a rate equal to the daily equivalent of 
        the annual rate of basic pay prescribed for level IV of the 
        Executive Schedule under section 5315 of title 5, United States 
        Code, for each day (including travel time) during which such 
        member is engaged in the performance of the duties of the 
        Commission. All members of the Commission who are officers or 
        employees of the United States shall serve without compensation 
        in addition to that received for their services as officers or 
        employees of the United States.
            (2) Travel expenses.--The members of the Commission shall 
        be allowed travel expenses, including per diem in lieu of 
        subsistence, at rates authorized for employees of agencies 
        under subchapter I of chapter 57 of title 5, United States 
        Code, while away from their homes or regular places of business 
        in the performance of services for the Commission.
            (3) Staff.--
                    (A) In general.--The Chairman of the Commission 
                may, without regard to the civil service laws and 
                regulations, appoint and terminate an executive 
                director and such other additional personnel as may be 
                necessary to enable the Commission to perform its 
                duties. The employment of an executive director shall 
                be subject to confirmation by the Commission.
                    (B) Compensation.--The Chairman of the Commission 
                may fix the compensation of the executive director and 
                other personnel without regard to the provisions of 
                chapter 51 and subchapter III of chapter 53 of title 5, 
                United States Code, relating to classification of 
                positions and General Schedule pay rates, except that 
                the rate of pay for the executive director and other 
                personnel may not exceed the rate payable for level V 
                of the Executive Schedule under section 5316 of such 
                title.
            (4) Detail of government employees.--Any Federal Government 
        employee may be detailed to the Commission without 
        reimbursement, and such detail shall be without interruption or 
        loss of civil service status or privilege.
            (5) Procurement of temporary and intermittent services.--
        The Chairman of the Commission may procure temporary and 
        intermittent services under section 3109(b) of title 5, United 
        States Code, at rates for individuals which do not exceed the 
        daily equivalent of the annual rate of basic pay prescribed for 
        level V of the Executive Schedule under section 5316 of such 
        title.
    (d) Studies and Reports.--
            (1) General studies and recommendations.--
                    (A) In general.--The Commission shall conduct a 
                thorough study of all matters relating to physician 
                work force goals and issues.
                    (B) Matters studied.--The matters studied by the 
                Commission shall include--
                            (i) national physician supply, composition, 
                        and trends;
                            (ii) national physician work force goals;
                            (iii) policies to attain national physician 
                        work force goals;
                            (iv) the desirable number of medical 
                        residents by specialty;
                            (v) the designation of appropriate 
                        operators of graduate medical education 
                        programs in each specialty;
                            (vi) the designation of the appropriate 
                        number of positions allocated to the graduate 
                        medical education programs at each program 
                        operator and its affiliated institutions;
                            (vii) the match of residents and graduate 
                        medical education positions;
                            (viii) means of implementing policies 
                        related to physician work force issues; and
                            (ix) the effects of the physician work 
                        force composition, supply and trends of the 
                        health care system in the United States, 
                        including issues of access to care, quality of 
                        care, and cost of health care.
                    (C) Recommendations.--The Commission shall develop 
                recommendations on each of the matters studied under 
                subparagraph (B).
                    (D) Annual report.--Not later than October 1, 1994, 
                and annually thereafter, the Commission shall deliver a 
                report to Congress and the Secretary which shall 
                contain the findings and conclusions of the Commission, 
                together with its recommendations on each of the 
                matters studied under subparagraph (B).
            (2) Medical education study.--
                    (A) In general.--The Commission shall evaluate the 
                undergraduate medical education programs operated by 
                medical schools and graduate medical education programs 
                located in the United States, including an evaluation 
                of whether such programs are properly designed to train 
                generalist physicians prepared to practice and whether 
                such programs are adequately training physicians to 
                treat the nonacute care needs of patients.
                    (B) Report.--Not later than 18 months after the 
                date of the enactment of this Act, the Commission shall 
                deliver a report to Congress and the Secretary which 
                shall contain the evaluation required by subparagraph 
                (A).
            (3) Direct medical education funding.--
                    (A) In general.--The Commission shall perform a 
                study of the sources of available funds for graduate 
                medical education other than funding available under 
                title XVIII of the Social Security Act, and whether it 
                is desirable for all medical service payers to 
                contribute to funding for graduate medical education. 
                The Commission shall determine the amount of funds that 
                would be needed in a system in which all medical 
                service payers, other than the medicare program under 
                title XVIII of the Social Security Act, paid a portion 
                of the funds necessary for graduate medical education, 
                the assessments to be imposed on such payers in order 
                to obtain the necessary funds, policies necessary to 
                implement such a program, and the probable effects of 
                such a program.
                    (B) Report.--Not later than 1 year after the date 
                of the enactment of this Act, the Commission shall 
                deliver a report to Congress and the Secretary which 
                shall contain the evaluation required by subparagraph 
                (A).
    (e) Implementing Bill on Number of Residency Positions and 
Allocation of Residency Positions.--
            (1) In general.--
                    (A) Implementing bill.--Not later than 15 months 
                after the date of the enactment of this Act, the 
                Commission shall submit to Congress an implementing 
                bill with respect to the legislative proposal developed 
                under paragraph (2) which contains such provisions 
                necessary or appropriate to implement such proposal 
                either repealing or amending existing laws or providing 
                new statutory authority.
                    (B) Consideration of implementing bill.--The 
                implementing bill described in subparagraph (A) shall 
                be considered by Congress under the procedures for 
                consideration described in paragraph (3).
            (2) Legislative proposal.--
                    (A) In general.--The Commission shall develop a 
                legislative proposal that--
                            (i) specifies, by specialty and 
                        subspecialty, the total number of first-year 
                        residency positions for which payment will be 
                        available under section 1886(h) of the Social 
                        Security Act for each year of the initial 4-
                        year period and allocates to GME operators such 
                        first-year residency positions;
                            (ii) for each 4-year period subsequent to 
                        the initial 4-year period, directs the 
                        Secretary to determine, by specialty and 
                        subspecialty, the appropriate number of first-
                        year residency positions for which payment will 
                        be available under section 1886(h) of such Act 
                        and allocate to GME operators such first-year 
                        residency positions taking into consideration 
                        the recommendations of the Commission contained 
                        in the report submitted to the Secretary under 
                        subsection (d)(1)(D);
                            (iii) requires the Secretary to deny 
                        payment under subsections (d)(5)(B) and (h) of 
                        section 1886 of the Social Security Act to a 
                        GME operator or any of its affiliated 
                        institutions which provide for any residency 
                        position in addition to the residency positions 
                        allocated to such GME operator;
                            (iv) provides that the Secretary shall have 
                        the authority to increase or decrease the 
                        number of residency training positions allotted 
                        in a specialty or subspecialty area to a GME 
                        operator during any 4-year period by up to 10 
                        percent of the original allotment if the 
                        aggregate number of all residency positions 
                        allotted to GME operators is not altered; and
                            (v) provides that a resident who is 
                        enrolled in an approved medical residency 
                        training program prior to the date on which the 
                        initial 4-year period begins shall not be 
                        restricted from completing such program due to 
                        the enactment of any implementing bill 
                        described in paragraph (1) if such resident 
                        does not change specialties or start a 
                        subspecialty program after such date.
                    (B) Guidelines for legislative proposal.--
                            (i) Number of residents.--In developing the 
                        legislative proposal under this paragraph, the 
                        Commission shall--
                                    (I) work toward achieving the ideal 
                                distribution of the Nation's physicians 
                                by specialty and subspecialty through 
                                the allocation of residency positions;
                                    (II) work toward a goal of 
                                developing a physician workforce made 
                                up of one-half generalists and primary-
                                care physicians and one-half other 
                                specialists and subspecialists; and
                                    (III) propose a total number of 
                                first-year residency positions for the 
                                fourth year of the initial 4-year 
                                period equal to 110 percent of the 
                                total number of graduates of United 
                                States medical schools for the calendar 
                                year immediately preceding the calendar 
                                year in which the legislative proposal 
                                is submitted to Congress.
                            (ii) Allocation of residents.--In 
                        developing the legislative proposal under this 
                        paragraph, the Commission shall allot first-
                        year residency positions to individual GME 
                        operators based on the following selection 
                        factors:
                                    (I) The academic quality of the 
                                approved medical training program, 
                                including evidence of whether the 
                                program provides an appropriate amount 
                                of ambulatory and subacute training for 
                                the residents in the specialty or 
                                subspecialty area under consideration.
                                    (II) The equitable distribution of 
                                the programs in different regions of 
                                the United States and in rural and 
                                urban areas.
                                    (III) The structure of the GME 
                                operator, including whether the GME 
                                operator is a consortium made up of 
                                medical schools, hospitals, and 
                                ambulatory care sites.
                                    (IV) Medical services delivered by 
                                the GME operator to medically 
                                underserved areas in the specialty 
                                under consideration.
                                    (V) The resources devoted by the 
                                GME operator to the program and the 
                                equity of the GME operator's financing 
                                arrangements with its affiliated 
                                institutions.
                                    (VI) Any other factors that the 
                                Commission may determine appropriate.
                    (C) Initial 4-year period.--The term ``initial 4-
                year period'' means the 4-year period beginning on July 
                1 of the calendar year following the calendar year in 
                which the implementing bill described in paragraph (1) 
                is submitted.
            (3) Congressional consideration.--
                    (A) Rules of house of representatives and senate.--
                This paragraph is enacted by Congress--
                            (i) as an exercise of the rulemaking power 
                        of the House of Representatives and the Senate, 
                        respectively, and as such is deemed a part of 
                        the rules of each House, respectively, but 
                        applicable only with respect to the procedure 
                        to be followed in that House in the case of an 
                        implementing bill described in paragraph 
                        (1)(A), and supersedes other rules only to the 
                        extent that such rules are inconsistent 
                        therewith; and
                            (ii) with full recognition of the 
                        constitutional right of either House to change 
                        the rules (so far as relating to the procedure 
                        of that House) at any time, in the same manner 
                        and to the same extent as in the case of any 
                        other rule of that House.
                    (B) Introduction and referral.--On the day on which 
                the implementing bill described in paragraph (1)(A) is 
                transmitted to the House of Representatives and the 
                Senate, such bill shall be introduced (by request) in 
                the House of Representatives by the Majority Leader of 
                the House, for himself and the Minority Leader of the 
                House, or by Members of the House designated by the 
                Majority Leader and Minority Leader of the House and 
                shall be introduced (by request) in the Senate by the 
                Majority Leader of the Senate, for himself and the 
                Minority Leader of the Senate, or by Members of the 
                Senate designated by the Majority Leader and Minority 
                Leader of the Senate. If either House is not in session 
                on the day on which the implementing bill is 
                transmitted, the bill shall be introduced in the House, 
                as provided in the preceding sentence, on the first day 
                thereafter on which the House is in session. The 
                implementing bill introduced in the House of 
                Representatives and the Senate shall be referred to the 
                appropriate committees of each House.
                    (C) Amendments prohibited.--No amendment to an 
                implementing bill shall be in order in either the House 
                of Representatives or the Senate and no motion to 
                suspend the application of this paragraph shall be in 
                order in either House, nor shall it be in order in 
                either House for the Presiding Officer to entertain a 
                request to suspend the application of this paragraph by 
                unanimous consent.
                    (D) Period for committee and floor consideration.--
                            (i) In general.--Except as provided in 
                        clause (ii), if the committee or committees of 
                        either House to which an implementing bill has 
                        been referred have not reported it at the close 
                        of the 45th day after its introduction, such 
                        committee or committees shall be automatically 
                        discharged from further consideration of the 
                        implementing bill and it shall be placed on the 
                        appropriate calendar. A vote on final passage 
                        of the implementing bill shall be taken in each 
                        House on or before the close of the 45th day 
                        after the implementing bill is reported by the 
                        committees or committee of that House to which 
                        it was referred, or after such committee or 
                        committees have been discharged from further 
                        consideration of the implementing bill. If 
                        prior to the passage by 1 House of an 
                        implementing bill of that House, that House 
                        receives the same implementing bill from the 
                        other House then--
                                    (I) the procedure in that House 
                                shall be the same as if no implementing 
                                bill had been received from the other 
                                House; but
                                    (II) the vote on final passage 
                                shall be on the implementing bill of 
                                the other House.
                            (ii) Computation of days.--For purposes of 
                        clause (i), in computing a number of days in 
                        either House, there shall be excluded--
                                    (I) the days on which either House 
                                is not in session because of an 
                                adjournment of more than 3 days to a 
                                day certain, or an adjournment of the 
                                Congress sine die, and
                                    (II) any Saturday and Sunday not 
                                excluded under subclause (I) when 
                                either House is not in session.
                    (E) Floor consideration in the house of 
                representatives.--
                            (i) Motion to proceed.--A motion in the 
                        House of Representatives to proceed to the 
                        consideration of an implementing bill shall be 
                        highly privileged and not debatable. An 
                        amendment to the motion shall not be in order, 
                        nor shall it be in order to move to reconsider 
                        the vote by which the motion is agreed to or 
                        disagreed to.
                            (ii) Debate.--Debate in the House of 
                        Representatives on an implementing bill shall 
                        be limited to not more than 20 hours, which 
                        shall be divided equally between those favoring 
                        and those opposing the bill. A motion further 
                        to limit debate shall not be debatable. It 
                        shall not be in order to move to recommit an 
                        implementing bill or to move to reconsider the 
                        vote by which an implementing bill is agreed to 
                        or disagreed to.
                            (iii) Motion to postpone.--Motions to 
                        postpone, made in the House of Representatives 
                        with respect to the consideration of an 
                        implementing bill, and motions to proceed to 
                        the consideration of other business, shall be 
                        decided without debate.
                            (iv) Appeals.--All appeals from the 
                        decisions of the Chair relating to the 
                        application of the Rules of the House of 
                        Representatives to the procedure relating to an 
                        implementing bill shall be decided without 
                        debate.
                            (v) General rules apply.--Except to the 
                        extent specifically provided in the preceding 
                        provisions of this subparagraph, consideration 
                        of an implementing bill shall be governed by 
                        the Rules of the House of Representatives 
                        applicable to other bills and resolutions in 
                        similar circumstances.
                    (F) Floor consideration in the senate.--
                          (i) Motion to proceed.--A motion in the 
                        Senate to proceed to the consideration of an 
                        implementing bill shall be privileged and not 
                        debatable. An amendment to the motion shall not 
                        be in order, nor shall it be in order to move 
                        to reconsider the vote by which the motion is 
                        agreed to or disagreed to.
                            (ii) General debate.--Debate in the Senate 
                        on an implementing bill, and all debatable 
                        motions and appeals in connection therewith, 
                        shall be limited to not more than 20 hours. The 
                        time shall be equally divided between, and 
                        controlled by, the Majority Leader and the 
                        Minority Leader or their designees.
                            (iii) Debate of motions and appeals.--
                        Debate in the Senate on any debatable motion or 
                        appeal in connection with an implementing bill 
                        shall be limited to not more than 1 hour, to be 
                        equally divided between, and controlled by, the 
                        mover and the manager of the implementing bill, 
                        except that in the event the manager of the 
                        implementing bill is in favor of any such 
                        motion or appeal, the time in opposition 
                        thereto, shall be controlled by the Minority 
                        Leader or his designee. Such leaders, or either 
                        of them, may, from time under their control on 
                        the passage of an implementing bill, allot 
                        additional time to any Senator during the 
                        consideration of any debatable motion or 
                        appeal.
                            (iv) Other motions.--A motion in the Senate 
                        to further limit debate is not debatable. A 
                        motion to recommit an implementing bill is not 
                        in order.
            (4) Resubmissions.--If an implementing bill of the 
        Commission is not approved by Congress or is vetoed by the 
        President (and such veto is not overridden by the Congress), 
        the Commission shall resubmit a new implementing bill not later 
        than 90 days after Congress failed to approve such bill or 
        failed to override the President's veto, and such new 
        implementing bill shall be subject to congressional 
        consideration as provided in paragraph (3).
    (f) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as may be necessary to carry out the purposes of 
this section.

SEC. 6. COUNCIL ON GRADUATE MEDICAL EDUCATION.

    (a) Council Abolished.--Section 301 of the Health Professions 
Education Extension Amendments of 1992 is repealed.
    (b) Effective Date.--Subsection (a) shall become effective upon the 
appointment of the initial 11 members of the National Physician Work 
Force Commission under section 5(a).

SEC. 7. STUDY OF EFFECT OF RESEARCH GRANTS ON PRIMARY CARE MEDICAL 
              TRAINING.

    (a) In General.--The Secretary of Health and Human Services 
(referred to in this section as the ``Secretary'') shall conduct 
research on the effect of United States Government research grants and 
contracts (including research grants and contracts from the National 
Institutes of Health, the Agency for Health Care Policy Research, and 
other organizations administered by the Secretary). The Secretary shall 
evaluate whether there are policy changes that should be made in order 
to alter the medical school environment to encourage medical students 
to seek careers in generalist primary care medicine.
    (b) Report.--Not later than 18 months after the date of the 
enactment of this Act, the Secretary shall deliver a report to Congress 
containing the results of the research and evaluation required by 
subsection (a).

SEC. 8. PAYMENTS FOR SERVICES FURNISHED IN HEALTH PROFESSIONAL SHORTAGE 
              AREAS.

    Section 1833(m) of the Social Security Act (42 U.S.C. 1395l(m)) is 
amended to read as follows:
    ``(m)(1) If a physician furnishes a qualified physicians' service 
in an area that is designated as a health professional shortage area 
under section 332(a)(1)(A) of the Public Health Service Act, in 
addition to the payment amount for such service determined without 
regard to this subsection, the physician shall be paid an amount equal 
to 20 percent of such payment amount.
    ``(2) If an area that is designated as a health professional 
shortage area under such section ceases to be so designated, any 
physician who furnished qualified physicians's services in such area 
and received payments under paragraph (1) shall continue to be eligible 
to receive payments under such paragraph for qualified physicians' 
services furnished in such area during the 10-consecutive-year period 
beginning on the date the area ceases to be designated as a health 
professional shortage area.
    ``(3) Any amount paid under paragraph (1) shall be paid on a 
monthly or quarterly basis from the Federal Supplementary Medical 
Insurance Trust Fund to the physician furnishing the service (or to an 
employer or facility in cases described in section 1842(b)(6)(A)).
    ``(4) For purposes of determining the payment amount for a 
qualified physicians' service under paragraph (1), if the index 
established under paragraph (1)(A)(i) or (1)(B) of section 1848(e) for 
the area in which such service is furnished is less than 1, the 
geographic cost-of-practice index value under paragraph (3)(B) of such 
section 1848(e) for such area shall be 1.
    ``(5) For purposes of this subsection, the term `qualified 
physician's service' means any physicians' service provided to an 
individual who is covered under the insurance program under this part, 
except that, in the case of an urban area, such term shall only include 
primary care services.''.

SEC. 9. PAYMENT FOR INDIRECT COSTS OF MEDICAL EDUCATION.

    Section 1886(d)(5)(B)(ii) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)(ii)) is amended to read as follows:
            ``(ii) For purposes of clause (i)(II), the indirect 
        teaching adjustment factor is equal to c  x  (((1+r) to the nth 
        power) -1), where `r' is the ratio of the hospital's full-time 
        equivalent interns and residents to beds and `n' equals .405. 
        For discharges occurring on or after--
                    ``(I) May 1, 1986, and before January 1, 1994, `c' 
                is equal to 1.89,
                    ``(II) January 1, 1994, and before January 1, 1996, 
                `c' is equal to 1.728, and
                    ``(III) January 1, 1996, `c' is equal to 1.605.''.

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