[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[H.R. 7192 Introduced in House (IH)]







110th CONGRESS
  2d Session
                                H. R. 7192

 To amend the Public Health Service Act and the Social Security Act to 
 increase the number of primary care physicians and to improve patient 
        access to primary care services, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 27, 2008

 Ms. Schwartz introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committees on 
the Judiciary, Education and Labor, and Ways and Means, for a period to 
      be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
                          committee concerned

_______________________________________________________________________

                                 A BILL


 
 To amend the Public Health Service Act and the Social Security Act to 
 increase the number of primary care physicians and to improve patient 
        access to primary care services, 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; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Preserving Patient 
Access to Primary Care Act''.
    (b) Table of Contents.--The table of contents is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Definitions.
                       TITLE I--MEDICAL EDUCATION

Sec. 101. Recruitment incentives.
Sec. 102. Debt forgiveness, scholarships, and service obligations.
Sec. 103. Deferment of loans during residency and internships.
Sec. 104. Immigration and Nationality provisions.
Sec. 105. Educating Medical Students about Primary Care Careers.
                 TITLE II--MEDICAID RELATED PROVISIONS

Sec. 201. Transformation grants to support patient centered medical 
                            homes under Medicaid and SCHIP.
Sec. 202. Promoting Children's Access to Covered Health Services.
                     TITLE III--MEDICARE PROVISIONS

                        Subtitle A--Primary Care

Sec. 301. Reforming payment systems under Medicare to support primary 
                            care.
Sec. 302. Coverage of patient-centered medical home services.
Sec. 303. Medicare primary care payment equity and access provision.
Sec. 304. Additional incentive payment program for primary care 
                            services furnished in health professional 
                            shortage areas.
Sec. 305. Permanent extension of floor on Medicare work geographic 
                            adjustment under the Medicare physician fee 
                            schedule.
Sec. 306. Permanent extension of Medicare incentive payment program for 
                            physician scarcity areas.
Sec. 307. HHS study and report on the process for determining relative 
                            value under the Medicare physician fee 
                            schedule.
                    Subtitle B--Preventive Services

Sec. 311. Eliminating time restriction for initial preventive physical 
                            examination.
Sec. 312. Elimination of cost-sharing for preventive benefits under the 
                            Medicare program.
Sec. 313. HHS study and report on facilitating the receipt of Medicare 
                            preventive services by Medicare 
                            beneficiaries.
                      Subtitle C--Other Provisions

Sec. 321. HHS study and report on improving the ability of physicians 
                            to assist Medicare beneficiaries in 
                            obtaining needed prescriptions under 
                            Medicare part D.
Sec. 322. Quality Improvement Organization Assistance for Physician 
                            Practices seeking to be patient-centered 
                            medical home practices.
Sec. 323. HHS study and report on improved patient care through 
                            increased caregiver and physician 
                            interaction.
Sec. 324. Improved patient care through expanded support for Limited 
                            English Proficiency services.
Sec. 325. HHS study and report on use of real-time Medicare claims 
                            adjudication.
                           TITLE IV--STUDIES

Sec. 401. Study concerning the designation of primary care as a 
                            shortage profession.
Sec. 402. Study concerning the education debt of medical school 
                            graduates.
Sec. 403. Study on minority representation in primary care.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) Approximately 21 percent of physicians who were board 
        certified in general internal medicine during the early 1990s 
        have left internal medicine, compared to a 5 percent departure 
        rate for those who were certified in subspecialties of internal 
        medicine.
            (2) The number of United States medical graduates going 
        into family medicine has fallen by more than 50 percent from 
        1997 to 2005.
            (3) In 2007, only 88 percent of the available medicine 
        residency positions were filled and only 42 percent of those 
        were filled by United States medical school graduates.
            (4) In 2006, only 24 percent of third-year internal 
        medicine resident intended to pursue careers in general 
        internal medicine, down from 54 percent in 1998.
            (5) Primary care physicians serve as the point of first 
        contact for most patients and are able to coordinate the care 
        of the whole person, reducing unnecessary care and duplicative 
        testing.
            (6) Primary care physicians practicing preventive care, 
        including screening for illness and treating diseases, can help 
        prevent complications that result in more costly care.
            (7) Patients with primary care physicians have lower health 
        care expenditures and primary care is correlated with better 
        health status, lower overall mortality, and longer life 
        expectancy.
            (8) Higher proportions of primary care physicians are 
        associated with significantly reduced utilization.
            (9) The United States has a higher ratio of specialists to 
        primary care physicians than other industrialized nations and 
        the population of the United States is growing faster than the 
        expected rate of growth in the supply of primary care 
        physicians.
            (10) The number of Americans age 65 and older, those 
        eligible for Medicare and who use far more ambulatory care 
        visits per person as those under age 65, is expected to double 
        from 2000 to 2030.
            (11) A decrease in Federal spending to carry out programs 
        authorized by title VII of the Public Health Service Act 
        threatens the viability of one of the programs used to solve 
        the problem of inadequate access to primary care.
            (12) The National Health Service Corps program has a proven 
        record of supplying physicians to underserved areas, and has 
        played an important role in expanding access for underserved 
        populations in rural and inner city communities.
            (13) Individuals in many geographic areas, especially rural 
        areas, lack adequate access to high quality preventive, primary 
        health care, contributing to significant health disparities 
        that impair America's public health and economic productivity.
            (14) About 20 percent of the population of the United 
        States resides in primary medical care Health Professional 
        Shortage Areas.

SEC. 3. DEFINITIONS.

    (a) General Definitions.--In this Act:
            (1) Chronic care coordination.--In this Act, the term 
        ``chronic care coordination'' means the coordination of 
        services that is based on the Chronic Care Model that provides 
        on-going health care to patients with chronic diseases that may 
        include any of the following services:
                    (A) The development of an initial plan of care, and 
                subsequent appropriate revisions to such plan of care.
                    (B) The management of, and referral for, medical 
                and other health services, including interdisciplinary 
                care conferences and management with other providers.
                    (C) The monitoring and management of medications.
                    (D) Patient education and counseling services.
                    (E) Family caregiver education and counseling 
                services.
                    (F) Self-management services, including health 
                education and risk appraisal to identify behavioral 
                risk factors through self-assessment.
                    (G) Providing access by telephone with physicians 
                and other appropriate health care professionals, 
                including 24-hour availability of such professionals 
                for emergencies.
                    (H) Management with the principal nonprofessional 
                caregiver in the home.
                    (I) Managing and facilitating transitions among 
                health care professionals and across settings of care, 
                including the following:
                            (i) Pursuing the treatment option elected 
                        by the individual.
                            (ii) Including any advance directive 
                        executed by the individual in the medical file 
                        of the individual.
                    (J) Information about, and referral to, hospice 
                care, including patient and family caregiver education 
                and counseling about hospice care, and facilitating 
                transition to hospice care when elected.
                    (K) Information about, referral to, and management 
                with, community services.
                    (L) Such additional services for which payment 
                would not otherwise be made under this title that the 
                Secretary may specify that encourage the receipt of, or 
                improve the effectiveness of, the services described in 
                this paragraph.
            (2) Critical shortage health facility.--The term ``critical 
        shortage health facility'' means a public or private nonprofit 
        health facility that does not serve a health professional 
        shortage area (as designated under section 332 of the Public 
        Health Service Act), but that has a critical shortage of 
        physicians (as determined by the Secretary) in the field of 
        family practice, internal medicine and pediatrics.
            (3) Primary care.--The term ``primary care'' means the 
        provision of integrated, high-quality, accessible health care 
        services by health care providers who are accountable for 
        addressing a full range of personal health and health care 
        needs, developing a sustained partnership with patients, 
        practicing in the context of family and community, and working 
        to minimize disparities across population subgroups.
            (4) Primary care physician.--The term ``primary care 
        physician'' means a physician (as defined in section 1886 of 
        the Social Security Act) who is trained in the fields of family 
        practice, internal medicine, and pediatrics who provides first 
        contact, continuous, and comprehensive care to patients.
            (5) Principal care.--The term ``principal care'' means 
        integrated, accessible health care that is provided by medical 
        subspecialists that addresses the majority of the personal 
        health care needs of patients with chronic conditions requiring 
        the subspecialist's expertise, and for whom the subspecialist 
        assumes care management, developing a sustained physician-
        patient partnership and practicing within the context of family 
        and community.
            (6) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
    (b) Primary Medical Care Shortage Area.--
            (1) In general.--In this Act, the term ``primary medical 
        care shortage area'' or ``PMCSA'' means a geographic area with 
        a shortage of physicians (as designated by the Secretary) in 
        the field of family practice, internal medicine, or pediatrics, 
        as designated in accordance with paragraph (2).
            (2) Designation.--To be designated by the Secretary as a 
        PMCSA, the Secretary must find that the geographic area 
        involved has an established shortage of primary care physicians 
        for the population served. The Secretary shall make such a 
        designation with respect to an urban or rural geographic area 
        if the following criteria are met:
                    (A) The area is a rational area for the delivery of 
                primary medical care services.
                    (B) One of the following conditions prevails within 
                the area--
                            (i) the area has a population to full-time-
                        equivalent primary care physician ratio of at 
                        least 3,500 to 1; or
                            (ii) the area has a population to full-
                        time-equivalent primary care physician ratio of 
                        less than 3,500 to 1 but greater than 3,000 to 
                        1 and has unusually high needs for primary care 
                        services or insufficient capacity of existing 
                        primary care providers.
                    (C) Primary medical care professionals in 
                contiguous geographic areas are over-utilized.
    (c) Medically Underserved Area.--
            (1) In general.--In this Act, the term ``medically 
        underserved area'' or ``MUA'' means a rational service area 
        with a demonstrable shortage of primary healthcare resources 
        relative to the needs of the entire population within the 
        service area as determined in accordance with paragraph (2) 
        through the use of the Index of Medical Underservice (referred 
        to in this subsection as the ``IMU'') with respect to data on a 
        service area.
            (2) Determinations.--Under criteria to be established by 
        the Secretary with respect to the IMU, if a service area is 
        determined by the Secretary to have a score of 62.0 or less, 
        such area shall be eligible to be designated as a MUA.
            (3) IMU variables.--In establishing criteria under 
        paragraph (2), the Secretary shall ensure that the following 
        variable are utilized:
                    (A) The ratio of primary medical care physicians 
                per 1,000 individuals in the population of the area 
                involved.
                    (B) The infant mortality rate in the area involved.
                    (C) The percentage of the population involved with 
                incomes below the poverty level.
                    (D) The percentage of the population involved age 
                65 or over.
        The value of each of such variables for the service area 
        involved shall be converted by the Secretary to a weighted 
        value, according to established criteria, and added together to 
        obtain the area's IMU score.
    (d) Patient Centered Medical Home.--
            (1) In general.--In this Act, the term ``patient centered 
        medical home'' means a physician-directed practice that has 
        been certified by an organization under paragraph (2) as 
        meeting the following standards:
                    (A) The practice provides patients who elect to 
                obtain care through a patient centered medical home 
                (referred to as ``participating patients'') with direct 
                and ongoing access to a primary or principal care 
                physician who accepts responsibility for providing 
                first contact, continuous, and comprehensive care to 
                the whole person, in collaboration with teams of other 
                health professionals, including nurses and specialist 
                physicians, as needed and appropriate.
                    (B) The practice applies standards for access to 
                care and communication with participating 
                beneficiaries.
                    (C) The practice has readily accessible, clinically 
                useful information on participating patients that 
                enables the practice to treat such patients 
                comprehensively and systematically.
                    (D) The practice maintains continuous relationships 
                with participating patients by implementing evidence-
                based guidelines and applying such guidelines to the 
                identified needs of individual beneficiaries over time 
                and with the intensity needed by such beneficiaries.
                    (E) The practice--
                            (i) collaborates with participating 
                        patients to pursue their goals for optimal 
                        achievable health; and
                            (ii) assesses patient-specific barriers to 
                        communication and conducts activities to 
                        support patient self-management.
                    (F) The practice has in place the resources and 
                processes necessary to achieve improvements in the 
                management and coordination of care for participating 
                patients.
                    (G) The practice monitors its clinical process and 
                performance (including outcome measures) in meeting the 
                applicable standards under this paragraph and provides 
                information in a form and manner specified by the 
                Secretary with respect to such process and performance.
            (2) Standard setting and qualification process for medical 
        homes.--The Secretary shall establish a process for the 
        selection of a qualified standard setting and certification 
        organization--
                    (A) to establish standards, consistent with this 
                subsection, to enable medical practices to qualify as 
                patient centered medical homes; and
                    (B) to provide for the review and certification of 
                medical practices as meeting such standards.

                       TITLE I--MEDICAL EDUCATION

SEC. 101. RECRUITMENT INCENTIVES.

    Title VII of the Higher Education Act of 1965 (20 U.S.C. 1133 et 
seq.) is amended by adding at the end the following:

           ``PART F--MEDICAL EDUCATION RECRUITMENT INCENTIVES

``SEC. 786. MEDICAL EDUCATION RECRUITMENT INCENTIVES.

    ``(a) In General.--The Secretary is authorized to award grants or 
contracts to institutions of higher education that are graduate medical 
schools, to enable the graduate medical schools to improve primary care 
education and training for medical students.
    ``(b) Application.--A graduate medical school that desires to 
receive a grant under this section shall submit to the Secretary an 
application at such time, in such manner, and containing such 
information as the Secretary may require.
    ``(c) Uses of Funds.--A graduate medical school that receives a 
grant under this section shall use such grant funds to carry out 1 or 
more of the following:
            ``(1) The creation of primary care mentorship programs.
            ``(2) Curriculum development for population-based primary 
        care models of care, such as the patient-centered medical home.
            ``(3) Increased opportunities for ambulatory, community-
        based training.
    ``(d) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this section $50,000,000 for each of the 
fiscal years 2010 through 2012.''.

SEC. 102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERVICE OBLIGATIONS.

    (a) Purpose.--It is the purpose of this section to encourage 
individuals to enter and continue in primary care physician careers.
    (b) Amendment to the Public Health Service Act.--Part D of title 
III of the Public Health Service Act (42 U.S.C. 254b et seq.) is 
amended by adding at the end the following:

              ``Subpart XI--Primary Care Medical Education

``SEC. 340I. SCHOLARSHIPS.

    ``(a) In General.--The Secretary, acting through the Administrator 
of the Health Resources and Services Administration, shall award grants 
to critical shortage health facilities to enable such facilities to 
provide scholarships to individuals who agree to serve as physicians at 
such facilities after completing a residency in the field of family 
practice, pediatrics, or internal medicine.
    ``(b) Scholarships.--A health facility shall use amounts received 
under a grant under this section to enter into contracts with eligible 
individuals under which--
            ``(1) the facility agrees to provide the individual with a 
        scholarship for each school year (not to exceed 4 school years) 
        in which the individual is enrolled as a full-time student in a 
        school of medicine or a school of osteopathic medicine; and
            ``(2) the individual agrees--
                    ``(A) to maintain an acceptable level of academic 
                standing;
                    ``(B) to complete a residency in the field of 
                family practice, internal medicine, or pediatrics; and
                    ``(C) after completing the residency, to serve as a 
                primary care physician at such facility in such field 
                for a time period equal to the greater of--
                            ``(i) one year for each school year for 
                        which the individual was provided a scholarship 
                        under this section; or
                            ``(ii) two years.
    ``(c) Amount.--
            ``(1) In general.--The amount paid by a health facility to 
        an individual under a scholarship under this section shall not 
        exceed $30,000 for any school year.
            ``(2) Considerations.--In determining the amount of a 
        scholarship to be provided to an individual under this section, 
        a health facility may take into consideration the individual's 
        financial need, geographic differences, and educational costs.
            ``(3) Exclusion from gross income.--For purposes of the 
        Internal Revenue Code of 1986, gross income shall not include 
        any amount received as a scholarship under this section.
    ``(d) Application of Certain Provisions.--The provisions of subpart 
III of part D shall, except as inconsistent with this section, apply to 
the program established in subsection (a) in the same manner and to the 
same extent as such provisions apply to the National Health Service 
Corps Scholarship Program established in such subpart.
    ``(e) Definitions.--In this section:
            ``(1) Critical shortage health facility.--The term 
        `critical shortage health facility' means a public or private 
        nonprofit health facility that does not serve a health 
        professional shortage area (as designated under section 332), 
        but has a critical shortage of physicians (as determined by the 
        Secretary) in the field of family practice, internal medicine, 
        or pediatrics.
            ``(2) Eligible individual.--The term `eligible individual' 
        means an individual who is enrolled, or accepted for 
        enrollment, as a full-time student in an accredited school of 
        medicine or school of osteopathic medicine.
    ``(f) Authorization of Appropriations.--To carry out this section, 
there is authorized to be appropriated $5,000,000 for each of fiscal 
years 2009 through 2013.

``SEC. 340J. LOAN REPAYMENT PROGRAM.

    ``(a) Purpose.--It is the purpose of this section to alleviate 
critical shortages of physicians in the fields of family practice, 
internal medicine, and pediatrics.
    ``(b) Loan Repayments.--The Secretary, acting through the 
Administrator of the Health Resources and Services Administration, 
shall establish a program of entering into contracts with eligible 
individuals under which--
            ``(1) the individual agrees to serve--
                    ``(A) as a primary care physician in the field of 
                family practice, internal medicine, or pediatrics; and
                    ``(B) in an area that is not a health professional 
                shortage area (as designated under section 332), but 
                has a critical shortage of physicians (as determined by 
                the Secretary) in such field; and
            ``(2) the Secretary agrees to pay, for each year of such 
        service, not more than $35,000 of the principal and interest of 
        the undergraduate or graduate educational loans of the 
        individual.
    ``(c) Service Requirement.--A contract entered into under this 
section shall allow the individual receiving the loan repayment to 
satisfy the service requirement described in subsection (a)(1) through 
employment in a solo or group practice, a clinic, a public or private 
nonprofit hospital, or any other appropriate health care entity.
    ``(d) Application of Certain Provisions.--The provisions of subpart 
III of part D shall, except as inconsistent with this section, apply to 
the program established in subsection (a) in the same manner and to the 
same extent as such provisions apply to the National Health Service 
Corps Scholarship Program established in such subpart.
    ``(e) Definition.--In this section, the term `eligible individual' 
means an individual with a degree in medicine or osteopathic medicine.
    ``(f) Authorization of Appropriations.--To carry out this section, 
there is authorized to be appropriated $5,000,000 for each of fiscal 
years 2009 through 2013.

``SEC. 340K. REPORTS.

    ``Not later than 18 months after the date of enactment of this Act, 
and annually thereafter, the Secretary shall submit to Congress a 
report that describes the programs carried out under this subpart, 
including statements concerning--
            ``(1) the number of enrollees, scholarships, loan 
        repayments, and grant recipients;
            ``(2) the number of graduates;
            ``(3) the amount of scholarship payments and loan 
        repayments made;
            ``(4) which educational institution the recipients 
        attended;
            ``(5) the number and placement location of the scholarship 
        and loan repayment recipients at health care facilities with a 
        critical shortage of primary care physicians;
            ``(6) the default rate and actions required;
            ``(7) the amount of outstanding default funds of both the 
        scholarship and loan repayment programs;
            ``(8) to the extent that it can be determined, the reason 
        for the default;
            ``(9) the demographics of the individuals participating in 
        the scholarship and loan repayment programs;
            ``(10) the justification for the allocation of funds 
        between the scholarship and loan repayment programs; and
            ``(11) an evaluation of the overall costs and benefits of 
        the programs.''.

SEC. 103. DEFERMENT OF LOANS DURING RESIDENCY AND INTERNSHIPS.

    (a) Loan Requirements.--Section 427(a)(2)(C)(i) of the Higher 
Education Act of 1965 (20 U.S.C. 1077(a)(2)(C)(i)) is amended by 
inserting ``unless the medical internship or residency program is in 
family medicine, internal medicine, or pediatric medicine'' after 
``residency program''.
    (b) FFEL Loans.--Section 428(b)(1)(M)(i) of the Higher Education 
Act of 1965 (20 U.S.C. 1078(b)(1)(M)(i)) is amended by inserting 
``unless the medical internship or residency program is in family 
medicine, internal medicine, or pediatric medicine'' after ``residency 
program''.
    (c) Federal Direct Loans.--Section 455(f)(2)(A) of the Higher 
Education Act of 1965 (20 U.S.C. 1087e(f)(2)(A)) is amended by 
inserting ``unless the medical internship or residency program is in 
family medicine, internal medicine, or pediatric medicine'' after 
``residency program''.
    (d) Federal Perkins Loans.--Section 464(c)(2)(A)(i) of the Higher 
Education Act of 1965 (20 U.S.C. 1087dd(c)(2)(A)(i)) is amended by 
inserting ``unless the medical internship or residency program is in 
family medicine, internal medicine, or pediatric medicine'' after 
``residency program''.

SEC. 104. IMMIGRATION AND NATIONALITY PROVISIONS.

    (a) Conrad State 30 J-1 Visa Waiver Program.--Section 220(c) of the 
Immigration and Nationality Technical Corrections Act of 1994 (8 U.S.C. 
1182 note) is amended by striking ``and before June 1, 2008''.
    (b) Exemption to H-1B Visa Limitation.--Section 214(g)(5) of the 
Immigration and Nationality Act (8 U.S.C. 1184(g)(5)) is amended--
            (1) in subparagraph (B), by striking ``or'' at the end;
            (2) in subparagraph (C), by striking the period at the end 
        and inserting ``; or''; and
            (3) by adding at the end the following:
            ``(D) has been awarded a medical specialty certification in 
        internal medicine, pediatrics, or family medicine by the 
        appropriate medical board based on post-doctoral training and 
        experience in the United States.''.

SEC. 105. EDUCATING MEDICAL STUDENTS ABOUT PRIMARY CARE CAREERS.

    Part C of title VII of the Public Health Service Act (42 U.S.C. 
293k) is amended by adding at the end the following:

``SEC. 749. EDUCATING MEDICAL STUDENTS ABOUT PRIMARY CARE CAREERS.

    ``(a) In General.--The Secretary shall award grants to eligible 
State and local government entities for the development of 
informational materials that promote careers in primary care by 
highlighting the advantages and rewards of primary care, and that 
encourage medical students, particularly students from disadvantaged 
backgrounds, to become primary care physicians.
    ``(b) Announcement.--The grants described in subsection (a) shall 
be announced through a publication in the Federal Register and through 
appropriate media outlets in a manner intended to reach medical 
education institutions, associations, physician groups, and others who 
communicate with medical students.
    ``(c) Eligibility.--To be eligible to receive a grant under this 
section an entity shall--
            ``(1) be a State or local entity; and
            ``(2) submit to the Secretary an application at such time, 
        in such manner, and containing such information as the 
        Secretary may require.
    ``(d) Use of Funds.--
            ``(1) In general.--An entity shall use amounts received 
        under a grant under this section to support State and local 
        campaigns through appropriate media outlets to promote careers 
        in primary care and to encourage individuals from disadvantaged 
        backgrounds to enter and pursue careers in primary care.
            ``(2) Specific uses.--In carrying out activities under 
        paragraph (1), an entity shall use grants funds to develop 
        informational materials in a manner intended to reach as wide 
        and diverse an audience of medical students as possible, in 
        order to--
                    ``(A) advertise and promote careers in primary 
                care;
                    ``(B) promote primary care medical education 
                programs;
                    ``(C) inform the public of financial assistance 
                regarding such education programs;
                    ``(D) highlight individuals in the community who 
                are practicing primary care physicians in order to 
                recruit physicians; or
                    ``(E) provide any other information to recruit 
                individuals for careers in primary care.
    ``(e) Limitation.--An entity shall not use amounts received under a 
grant under this section to advertise particular employment 
opportunities.
    ``(f) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this section, such sums as may be necessary 
for each of fiscal years 2009 through 2012.''.

                 TITLE II--MEDICAID RELATED PROVISIONS

SEC. 201. TRANSFORMATION GRANTS TO SUPPORT PATIENT CENTERED MEDICAL 
              HOMES UNDER MEDICAID AND SCHIP.

    (a) In General.--Section 1903(z) of the Social Security Act (42 
U.S.C. 1396b(z)) is amended--
            (1) in paragraph (2), by adding at the end the following 
        new subparagraph:
                    ``(G) Methods for improving the effectiveness and 
                efficiency of medical assistance provided under this 
                title and child health assistance provided under title 
                XXI by encouraging the adoption of medical practices 
                that satisfy the standards established by the Secretary 
                under paragraph (2) of section 3(d) of the Preserving 
                Patient Access to Primary Care Act for medical 
                practices to qualify as patient centered medical homes 
                (as defined subsection (d)(1) of such section).''; and
            (2) in paragraph (4)--
                    (A) in subparagraph (A)--
                            (i) in clause (i), by striking ``and'' at 
                        the end;
                            (ii) in clause (ii), by striking the period 
                        at the end and inserting ``; and''; and
                            (iii) by inserting after clause (ii), the 
                        following new clause:
                            ``(iii) $25,000,000 for each of fiscal 
                        years 2010, 2011, and 2012.''; and
                    (B) in subparagraph (B), by striking the second and 
                third sentences and inserting the following: ``Such 
                method shall provide that 100 percent of such funds for 
                each of fiscal years 2010, 2011, and 2012 shall be 
                allocated among States that design programs to adopt 
                the innovative methods described in paragraph (2)(G), 
                with preference given to States that design programs 
                involving multipayers (including under title XVIII and 
                private health plans) test projects for implementation 
                of the elements necessary to be recognized as a patient 
                centered medical home practice under the National 
                Committee for Quality Assurance Physicians Practice 
                Connection-PCMH module (or any other equivalent 
                process, as determined by the Secretary).''.
    (b) Effective Date.--The amendments made by this section take 
effect on October 1, 2009.

SEC. 202. PROMOTING CHILDREN'S ACCESS TO COVERED HEALTH SERVICES.

    (a) Medicaid and CHIP Payment and Access Commission.--Title XIX (42 
U.S.C. 1396 et seq.) is amended by inserting before section 1901 the 
following new section:

           ``medicaid and chip payment and access commission

    ``Sec. 1900.  (a) Establishment.--There is hereby established the 
Medicaid and CHIP Payment and Access Commission (in this section 
referred to as `MACPAC').
    ``(b) Duties.--
            ``(1) Review of access policies and annual reports.--MACPAC 
        shall--
                    ``(A) review policies of the Medicaid program 
                established under this title (in this section referred 
                to as `Medicaid') and the State Children's Health 
                Insurance Program established under title XXI (in this 
                section referred to as `CHIP') affecting access to 
                covered items and services, including topics described 
                in paragraph (2);
                    ``(B) make recommendations to Congress concerning 
                such access policies;
                    ``(C) by not later than March 1 of each year 
                (beginning with 2009), submit a report to Congress 
                containing the results of such reviews and MACPAC's 
                recommendations concerning such policies; and
                    ``(D) by not later than June 1 of each year 
                (beginning with 2009), submit a report to Congress 
                containing an examination of issues affecting Medicaid 
                and CHIP, including the implications of changes in 
                health care delivery in the United States and in the 
                market for health care services on such programs.
            ``(2) Specific topics to be reviewed.--Specifically, MACPAC 
        shall review and assess the following:
                    ``(A) Medicaid and chip payment policies.--Payment 
                policies under Medicaid and CHIP, including--
                            ``(i) the factors affecting expenditures 
                        for items and services in different sectors, 
                        including the process for updating hospital, 
                        skilled nursing facility, physician, federally 
                        qualified health center, rural health center, 
                        and other fees;
                            ``(ii) payment methodologies; and
                            ``(iii) the relationship of such factors 
                        and methodologies to access and quality of care 
                        for Medicaid and CHIP beneficiaries.
                    ``(B) Interaction of medicaid and chip payment 
                policies with health care delivery generally.--The 
                effect of Medicaid and CHIP payment policies on access 
                to items and services for children and other Medicaid 
                and CHIP populations other than under this title or 
                title XXI and the implications of changes in health 
                care delivery in the United States and in the general 
                market for health care items and services on Medicaid 
                and CHIP.
                    ``(C) Other access policies.--The effect of other 
                Medicaid and CHIP policies on access to covered items 
                and services, including policies relating to 
                transportation and language barriers.
            ``(3) Creation of early-warning system.--MACPAC shall 
        create an early-warning system to identify provider shortage 
        areas or any other problems that threaten access to care or the 
        health care status of Medicaid and CHIP beneficiaries.
            ``(4) Comments on certain secretarial reports.--If the 
        Secretary submits to Congress (or a committee of Congress) a 
        report that is required by law and that relates to access 
        policies, including with respect to payment policies, under 
        Medicaid or CHIP, the Secretary shall transmit a copy of the 
        report to MACPAC. MACPAC shall review the report and, not later 
        than 6 months after the date of submittal of the Secretary's 
        report to Congress, shall submit to the appropriate committees 
        of Congress written comments on such report. Such comments may 
        include such recommendations as MACPAC deems appropriate.
            ``(5) Agenda and additional reviews.--MACPAC shall consult 
        periodically with the chairmen and ranking minority members of 
        the appropriate committees of Congress regarding MACPAC's 
        agenda and progress towards achieving the agenda. MACPAC may 
        conduct additional reviews, and submit additional reports to 
        the appropriate committees of Congress, from time to time on 
        such topics relating to the program under this title or title 
        XXI as may be requested by such chairmen and members and as 
        MACPAC deems appropriate.
            ``(6) Availability of reports.--MACPAC shall transmit to 
        the Secretary a copy of each report submitted under this 
        subsection and shall make such reports available to the public.
            ``(7) Appropriate committee of congress.--For purposes of 
        this section, the term `appropriate committees of Congress' 
        means the Committee on Energy and Commerce of the House of 
        Representatives and the Committee on Finance of the Senate.
            ``(8) Voting and reporting requirements.--With respect to 
        each recommendation contained in a report submitted under 
        paragraph (1), each member of MACPAC shall vote on the 
        recommendation, and MACPAC shall include, by member, the 
        results of that vote in the report containing the 
        recommendation.
            ``(9) Examination of budget consequences.--Before making 
        any recommendations, MACPAC shall examine the budget 
        consequences of such recommendations, directly or through 
        consultation with appropriate expert entities.
    ``(c) Membership.--
            ``(1) Number and appointment.--MACPAC shall be composed of 
        17 members appointed by the Comptroller General of the United 
        States.
            ``(2) Qualifications.--
                    ``(A) In general.--The membership of MACPAC shall 
                include individuals who have had direct experience as 
                enrollees or parents of enrollees in Medicaid or CHIP 
                and individuals with national recognition for their 
                expertise in Federal safety net health programs, health 
                finance and economics, actuarial science, health 
                facility management, health plans and integrated 
                delivery systems, reimbursement of health facilities, 
                health information technology, pediatric physicians, 
                dentists, and other providers of health services, and 
                other related fields, who provide a mix of different 
                professionals, broad geographic representation, and a 
                balance between urban and rural representatives.
                    ``(B) Inclusion.--The membership of MACPAC shall 
                include (but not be limited to) physicians and other 
                health professionals, employers, third-party payers, 
                and individuals with expertise in the delivery of 
                health services. Such membership shall also include 
                consumers representing children, pregnant women, the 
                elderly, and individuals with disabilities, current or 
                former representatives of State agencies responsible 
                for administering Medicaid, and current or former 
                representatives of State agencies responsible for 
                administering CHIP.
                    ``(C) Majority nonproviders.--Individuals who are 
                directly involved in the provision, or management of 
                the delivery, of items and services covered under 
                Medicaid or CHIP shall not constitute a majority of the 
                membership of MACPAC.
                    ``(D) Ethical disclosure.--The Comptroller General 
                of the United States shall establish a system for 
                public disclosure by members of MACPAC of financial and 
                other potential conflicts of interest relating to such 
                members. Members of MACPAC shall be treated as 
                employees of Congress for purposes of applying title I 
                of the Ethics in Government Act of 1978 (Public Law 95-
                521).
            ``(3) Terms.--
                    ``(A) In general.--The terms of members of MACPAC 
                shall be for 3 years except that the Comptroller 
                General of the United States shall designate staggered 
                terms for the members first appointed.
                    ``(B) Vacancies.--Any member appointed to fill a 
                vacancy occurring before the expiration of the term for 
                which the member's predecessor was appointed shall be 
                appointed only for the remainder of that term. A member 
                may serve after the expiration of that member's term 
                until a successor has taken office. A vacancy in MACPAC 
                shall be filled in the manner in which the original 
                appointment was made.
            ``(4) Compensation.--While serving on the business of 
        MACPAC (including travel time), a member of MACPAC shall be 
        entitled to compensation at the per diem equivalent of the rate 
        provided for level IV of the Executive Schedule under section 
        5315 of title 5, United States Code; and while so serving away 
        from home and the member's regular place of business, a member 
        may be allowed travel expenses, as authorized by the Chairman 
        of MACPAC. Physicians serving as personnel of MACPAC may be 
        provided a physician comparability allowance by MACPAC in the 
        same manner as Government physicians may be provided such an 
        allowance by an agency under section 5948 of title 5, United 
        States Code, and for such purpose subsection (i) of such 
        section shall apply to MACPAC in the same manner as it applies 
        to the Tennessee Valley Authority. For purposes of pay (other 
        than pay of members of MACPAC) and employment benefits, rights, 
        and privileges, all personnel of MACPAC shall be treated as if 
        they were employees of the United States Senate.
            ``(5) Chairman; vice chairman.--The Comptroller General of 
        the United States shall designate a member of MACPAC, at the 
        time of appointment of the member as Chairman and a member as 
        Vice Chairman for that term of appointment, except that in the 
        case of vacancy of the Chairmanship or Vice Chairmanship, the 
        Comptroller General of the United States may designate another 
        member for the remainder of that member's term.
            ``(6) Meetings.--MACPAC shall meet at the call of the 
        Chairman.
    ``(d) Director and Staff; Experts and Consultants.--Subject to such 
review as the Comptroller General of the United States deems necessary 
to assure the efficient administration of MACPAC, MACPAC may--
            ``(1) employ and fix the compensation of an Executive 
        Director (subject to the approval of the Comptroller General of 
        the United States) and such other personnel as may be necessary 
        to carry out its duties (without regard to the provisions of 
        title 5, United States Code, governing appointments in the 
        competitive service);
            ``(2) seek such assistance and support as may be required 
        in the performance of its 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 MACPAC (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 MACPAC;
            ``(5) provide transportation and subsistence for persons 
        serving without compensation; and
            ``(6) prescribe such rules and regulations as it deems 
        necessary with respect to the internal organization and 
        operation of MACPAC.
    ``(e) Powers.--
            ``(1) Obtaining official data.--MACPAC may secure directly 
        from any department or agency of the United States information 
        necessary to enable it to carry out this section. Upon request 
        of the Chairman, the head of that department or agency shall 
        furnish that information to MACPAC on an agreed upon schedule.
            ``(2) Data collection.--In order to carry out its 
        functions, MACPAC shall--
                    ``(A) utilize existing information, both published 
                and unpublished, where possible, collected and assessed 
                either by its own staff or under other arrangements 
                made in accordance with this section;
                    ``(B) carry out, or award grants or contracts for, 
                original research and experimentation, where existing 
                information is inadequate; and
                    ``(C) adopt procedures allowing any interested 
                party to submit information for MACPAC's use in making 
                reports and recommendations.
            ``(3) Access of gao to information.--The Comptroller 
        General of the United States shall have unrestricted access to 
        all deliberations, records, and nonproprietary data of MACPAC, 
        immediately upon request.
            ``(4) Periodic audit.--MACPAC shall be subject to periodic 
        audit by the Comptroller General of the United States.
    ``(f) Authorization of Appropriations.--
            ``(1) Request for appropriations.--MACPAC shall submit 
        requests for appropriations in the same manner as the 
        Comptroller General of the United States submits requests for 
        appropriations, but amounts appropriated for MACPAC shall be 
        separate from amounts appropriated for the Comptroller General 
        of the United States.
            ``(2) Authorization.--There are authorized to be 
        appropriated such sums as may be necessary to carry out the 
        provisions of this section.''.
    (b) Deadline for Initial Appointments.--Not later than January 1, 
2009, the Comptroller General of the United States shall appoint the 
initial members of the Medicaid and CHIP Payment and Access Commission 
established under section 1900 of the Social Security Act (as added by 
subsection (a)).

                     TITLE III--MEDICARE PROVISIONS

                        Subtitle A--Primary Care

SEC. 301. REFORMING PAYMENT SYSTEMS UNDER MEDICARE TO SUPPORT PRIMARY 
              CARE.

    (a) Increasing Budget Neutrality Limits Under the Physician Fee 
Schedule To Account for Anticipated Savings Resulting From Payments for 
Certain Services and the Coordination of Beneficiary Care.--Section 
1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)), 
as amended by section 133 of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110-275), is amended--
            (1) in clause (ii)(II), by striking ``(iv) and (v)'' and 
        inserting ``(iv), (v), and (vii)''; and
            (2) by adding at the end the following new clause:
                            ``(vii) Increase in limitation to account 
                        for certain anticipated savings.--
                                    ``(I) In general.--Effective for 
                                fee schedules established beginning 
                                with 2009, the Secretary shall increase 
                                the limitation on annual adjustments 
                                under clause (ii)(II) by an amount 
                                equal to the anticipated savings under 
                                parts A, B, and D (including any 
                                savings with respect to items and 
                                services for which payment is not made 
                                under this section) which are a result 
                                of payments for designated primary care 
                                services and comprehensive care 
                                coordination services under section 
                                1834(m) and the coverage of patient-
                                centered medical home services under 
                                section 1861(s)(2)(FF) (as determined 
                                by the Secretary).
                                    ``(II) Mechanism to determine 
                                application of increase.--The Secretary 
                                shall establish a mechanism for 
                                determining which relative value units 
                                established under this paragraph for 
                                physicians' services shall be subject 
                                to an adjustment under clause (ii)(I) 
                                as a result of the increase under 
                                subclause (I).
                                    ``(III) Additional funding as 
                                determined necessary by the 
                                secretary.--In addition to any funding 
                                that may be made available as a result 
                                of an increase in the limitation on 
                                annual adjustments under subclause (I), 
                                there shall also be available to the 
                                Secretary, for purposes of making 
                                payments under this title for new 
                                services and capabilities to improve 
                                care provided to individuals under this 
                                title and to generate efficiencies 
                                under this title, such additional funds 
                                as the Secretary determines are 
                                necessary.''.
    (b) Separate Medicare Payment for Designated Primary Care Services 
and Comprehensive Care Coordination Services.--
            (1) In general.--Section 1834 of the Social Security Act 
        (42 U.S.C. 1395m) is amended by adding at the end the following 
        new subsection:
    ``(m) Payment for Designated Primary Care Services and 
Comprehensive Care Coordination Services.--
            ``(1) In general.--The Secretary shall pay for designated 
        primary care services and comprehensive care coordination 
        services furnished to an individual enrolled under this part.
            ``(2) Payment amount.--The Secretary shall determine the 
        amount of payment for designated primary care services and 
        comprehensive care coordination services under this subsection.
            ``(3) Documentation requirements.--The Secretary shall 
        propose appropriate documentation requirements to justify 
        payments for designated primary care services and comprehensive 
        care coordination services under this subsection.
            ``(4) Definitions.--
                    ``(A) Comprehensive care coordination services.--
                The term `comprehensive care coordination services' 
                means care coordination services with procedure codes 
                established by the Secretary (as appropriate) which are 
                furnished to an individual enrolled under this part by 
                a primary or principal care physician.
                    ``(B) Designated primary care services.--The term 
                `designated primary care service' means a service which 
                the Secretary determines has a procedure code which 
                involves a clinical interaction with an individual 
                enrolled under this part that is inherent to care 
                coordination, including interactions outside of a face-
                to-face encounter. Such term includes the following:
                            ``(i) Care plan oversight.
                            ``(ii) Evaluation and management provided 
                        by phone.
                            ``(iii) Evaluation and management provided 
                        using internet resources.
                            ``(iv) Collection and review of physiologic 
                        data, such as from a remote monitoring device.
                            ``(v) Education and training for patient 
                        self management.
                            ``(vi) Anticoagulation management services.
                            ``(vii) Any other service determined 
                        appropriate by the Secretary.''.
            (2) Effective date.--The amendment made by this section 
        shall apply to items and services furnished on or after January 
        1, 2009.

SEC. 302. COVERAGE OF PATIENT-CENTERED MEDICAL HOME SERVICES.

    (a) In General.--Section 1861(s)(2) of the Social Security Act (42 
U.S.C. 1395x(s)(2)), as amended by section 152 of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275), is amended--
            (1) in subparagraph (DD), by striking ``and'' at the end;
            (2) in subparagraph (EE), by inserting ``and'' at the end; 
        and
            (3) by adding at the end the following new subparagraph:
            ``(FF) patient-centered medical home services (as defined 
        in subsection (hhh)(1));''.
    (b) Definition of Patient-Centered Medical Home Services.--Section 
1861 of the Social Security Act (42 U.S.C. 1395x), as amended by such 
section 152, is amended by adding at the end the following new 
subsection:

                ``Patient-Centered Medical Home Services

    ``(hhh)(1) The term `patient-centered medical home services' means 
care coordination services furnished by a qualified patient-centered 
medical home.
    ``(2) The term `qualified patient-centered medical home' means a 
patient-centered medical home which has been recognized as a patient-
centered medical home through an appropriate process, including a 
patient-centered medical home which is recognized through the Physician 
Practice Connections--Patient-Centered Medical Home (`PPC-PCMH') 
voluntary recognition process of the National Committee for Quality 
Assurance (or any other equivalent process, as determined by the 
Secretary).''.
    (c) Monthly Fee for Patient-Centered Medical Home Services.--
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended 
by section 131 of the Medicare Improvements for Patients and Providers 
Act of 2008 (Public Law 110-275), is amended by adding at the end the 
following new subsection:
    ``(o) Monthly Fee for Patient-Centered Medical Home Services.--
            ``(1) Monthly fee.--
                    ``(A) In general.--Not later than January 1, 2012, 
                the Secretary shall establish a payment methodology for 
                patient-centered medical home services (as defined in 
                paragraph (1) of section 1861(hhh)). Under such payment 
                methodology, the Secretary shall pay qualified patient-
                centered medical homes (as defined in paragraph (2) of 
                such section) a monthly fee for each individual who 
                elects to receive patient-centered medical home 
                services at that medical home. Such fee shall be paid 
                on a prospective basis.
                    ``(B) Considerations.--The Secretary shall take 
                into account the results of the Medicare medical home 
                demonstration project under section 204 of Division B 
                of the Tax Relief and Health Care Act of 2008 (42 
                U.S.C. 1395b-1 note) in establishing the payment 
                methodology under subparagraph (A).
            ``(2) Amount of payment.--
                    ``(A) Considerations.--In determining the amount of 
                such fee, subject to paragraph (3), the Secretary shall 
                consider the following:
                            ``(i) The clinical work and practice 
                        expenses involved in providing care 
                        coordination services consistent with the 
                        patient-centered medical home model (such as 
                        providing increased access, care coordination, 
                        disease population management, and education) 
                        for which payment is not made under this 
                        section as of the date of enactment of this 
                        subsection.
                            ``(ii) Ensuring that the amount of payment 
                        is sufficient to support the acquisition, use, 
                        and maintenance of clinical information systems 
                        which--
                                    ``(I) are needed by a qualified 
                                patient-centered medical home (as so 
                                defined); and
                                    ``(II) have been shown to 
                                facilitate improved outcomes through 
                                care coordination.
                            ``(iii) The establishment of a tiered 
                        monthly care management fee that provides for a 
                        range of payment depending on how advanced the 
                        capabilities of a qualified patient-centered 
                        medical home (as so defined) are in having the 
                        information systems needed to support care 
                        coordination.
                    ``(B) Risk-adjustment.--The Secretary shall use 
                appropriate risk-adjustment in determining the amount 
                of the monthly fee under this paragraph.
            ``(3) Funding.--
                    ``(A) In general.--The Secretary shall determine 
                the aggregate estimated savings for a calendar year as 
                a result of the implementation of this subsection on 
                reducing preventable hospital admissions, duplicate 
                testing, medication errors and drug interactions, and 
                other savings under this part and part A (including any 
                savings with respect to items and services for which 
                payment is not made under this section).
                    ``(B) Funding.--Subject to subparagraph (C), the 
                aggregate amount available for payment of the monthly 
                fee under this subsection during a calendar year shall 
                be equal to the aggregate estimated savings (as 
                determined under subparagraph (A)) for the calendar 
                year (as determined by the Secretary).
                    ``(C) Additional funding.--In the case where the 
                amount of the aggregate actual savings during the 
                preceding 3 years exceeds the amount of the aggregate 
                estimated savings (as determined under subparagraph 
                (A)) during such period, the aggregate amount available 
                for payment of the monthly fee under this subsection 
                during the calendar year (as determined under 
                subparagraph (B)) shall be increased by the amount of 
                such excess.
                    ``(D) Additional funding as determined necessary by 
                the secretary.--In addition to any funding made 
                available under subparagraphs (B) and (C), there shall 
                also be available to the Secretary, for purposes of 
                effectively implementing this subsection, such 
                additional funds as the Secretary determines are 
                necessary.
            ``(4) Performance-based bonus payments.--The Secretary 
        shall establish a process for paying a performance-based bonus 
        to qualified patient-centered medical homes which meet or 
        achieve substantial improvements in performance (as specified 
        under clinical, patient satisfaction, and efficiency benchmarks 
        established by the Secretary). Such bonus shall be in an amount 
        determined appropriate by the Secretary.
            ``(5) No effect on payments for evaluation and management 
        services.--The monthly fee under this subsection shall have no 
        effect on the amount of payment for evaluation and management 
        services under this title.''.
    (d) Coinsurance.--Section 1833(a)(1) of the Social Security Act (42 
U.S.C. 1395l(a)(1)) is amended--
            (1) by striking ``and'' before ``(W)''; and
            (2) by inserting before the semicolon at the end the 
        following: ``, and (X) with respect to patient-centered medical 
        home services (as defined in section 1861(hhh)(1)), the amount 
        paid shall be (i) in the case of such services which are 
        physicians' services, the amount determined under subparagraph 
        (N), and (ii) in the case of all other such services, 80 
        percent of the lesser of the actual charge for the service or 
        the amount determined under a fee schedule established by the 
        Secretary for purposes of this subparagraph''.
    (e) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2012.

SEC. 303. MEDICARE PRIMARY CARE PAYMENT EQUITY AND ACCESS PROVISION.

    (a) In General.--Section 1848 of the Social Security Act (42 U.S.C. 
1395w-4), as amended by section 202, is amended by adding at the end 
the following new subsection:
    ``(p) Primary Care Payment Equity and Access.--
            ``(1) In general.--Not later than January 1, 2010, the 
        Secretary shall develop a methodology, in consultation with 
        primary care physician organizations, the Medicare Payment 
        Advisory Commission, and other experts, to increase payments 
        under this section for designated evaluation and management 
        services provided by primary and principal care physicians 
        through 1 or more of the following:
                    ``(A) A service-specific modifier to the relative 
                value units established for such services.
                    ``(B) Service-specific bonus payments.
                    ``(C) Any other methodology determined appropriate 
                by the Secretary.
            ``(2) Inclusion of proposed criteria.--The methodology 
        developed under paragraph (1) shall include proposed criteria 
        for physicians to qualify for such increased payments, 
        including consideration of--
                    ``(A) the type of service being rendered;
                    ``(B) the specialty of the physician providing the 
                service; and
                    ``(C) demonstration by the physician of voluntary 
                participation in programs to improve quality, such as 
                participation in the Physician Quality Reporting 
                Initiative (as determined by the Secretary) or 
                practice-level qualification as a patient-centered 
                medical home.
            ``(3) Funding.--
                    ``(A) Determination.--The Secretary shall determine 
                the aggregate estimated savings for a calendar year as 
                a result of such increased payments on reducing 
                preventable hospital admissions, duplicate testing, 
                medication errors and drug interactions, Intensive Care 
                Unit admissions, per capita health care expenditures, 
                and other savings under this part and part A (including 
                any savings with respect to items and services for 
                which payment is not made under this section).
                    ``(B) Funding.--The aggregate amount available for 
                such increased payments during a calendar year shall be 
                equal to the aggregate estimated savings (as determined 
                under subparagraph (A)) for the calendar year (as 
                determined by the Secretary).
                    ``(C) Additional funding as determined necessary by 
                the secretary.--In addition to any funding made 
                available under subparagraph (B), there shall also be 
                available to the Secretary, for purposes of effectively 
                implementing this subsection, such additional funds as 
                the Secretary determines are necessary.''.
    (b) Effective Date.--The amendment made by this section shall apply 
to services furnished on or after January 1, 2010.

SEC. 304. ADDITIONAL INCENTIVE PAYMENT PROGRAM FOR PRIMARY CARE 
              SERVICES FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.

    (a) In General.--Section 1833 of the Social Security Act (42 U.S.C. 
1395l) is amended by adding at the end the following new subsection:
    ``(v) Additional Incentive Payments for Primary Care Services 
Furnished in Health Professional Shortage Areas.--
            ``(1) In general.--In the case of primary care services 
        furnished on or after January 1, 2009, by a primary care 
        physician in an area that is designated (under section 
        332(a)(1)(A) of the Public Health Service Act) as a health 
        professional shortage area as identified by the Secretary prior 
        to the beginning of the year involved, in addition to the 
        amount of payment that would otherwise be made for such 
        services under this part, there also shall be paid (on a 
        monthly or quarterly basis) an amount equal to 10 percent of 
        the payment amount for the service under this part.
            ``(2) Definitions.--In this subsection:
                    ``(A) Primary care physician.--The term `primary 
                care physician' means a physician (as described in 
                section 1861(r)(1)) for whom primary care services 
                accounted for at least a specified percent (as 
                determined by the Secretary) of the allowed charges 
                under this part for such physician in a prior period as 
                determined appropriate by the Secretary.
                    ``(B) Primary care services.--The term `primary 
                care services' means procedure codes for services in 
                the category of the Healthcare Common Procedure Coding 
                System, as established by the Secretary under section 
                1848(c)(5) (as of December 31, 2008 and as subsequently 
                modified by the Secretary) consisting of evaluation and 
                management services, but limited to such procedure 
                codes in the category of office or other outpatient 
                services, and consisting of subcategories of such 
                procedure codes for services for both new and 
                established patients.
            ``(3) Judicial review.--There shall be no administrative or 
        judicial review under section 1869, 1878, or otherwise, 
        respecting the identification of primary care physicians or 
        primary care services under this subsection.''.
    (b) Conforming Amendment.--Section 1834(g)(2)(B) of the Social 
Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by adding at the end 
the following sentence: ``Section 1833(v) shall not be taken into 
account in determining the amounts that would otherwise be paid 
pursuant to the preceding sentence.''.

SEC. 305. PERMANENT EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC 
              ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

    Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)), as amended by section 134 of the Medicare Improvements for 
Patients and Providers Act of 2008 (Public Law 110-275), is amended by 
striking ``and before January 1, 2010,''.

SEC. 306. PERMANENT EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR 
              PHYSICIAN SCARCITY AREAS.

    Section 1833(u) of the Social Security Act (42 U.S.C. 1395l(u)), as 
amended by section 102 of the Medicare, Medicaid, and SCHIP Extension 
Act of 2007 (Public Law 110-173), is amended--
            (1) in paragraph (1)--
                    (A) by striking ``, and before July 1, 2008''; and
                    (B) by inserting ``(or, in the case of services 
                furnished on or after July 1, 2008, 10 percent)'' after 
                ``5 percent''; and
            (2) in paragraph (4)(D), by striking ``before July 1, 
        2008'' and inserting ``before January 1, 2010''.

SEC. 307. HHS STUDY AND REPORT ON THE PROCESS FOR DETERMINING RELATIVE 
              VALUE UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

    (a) Study.--The Secretary shall conduct a study on the process used 
by the Secretary for determining relative value under the Medicare 
physician fee schedule under section 1848(c) of the Social Security Act 
(42 U.S.C. 1395w-4(c)). Such study shall include an analysis of the 
following:
            (1)(A) Whether the existing process includes equitable 
        representation of primary care physicians (as defined in 
        section 3(a)(4)); and
            (B) any changes that may be necessary to ensure such 
        equitable representation.
            (2)(A) Whether the existing process provides the Secretary 
        with expert and impartial input from physicians in medical 
        specialties that provide primary care to patients with multiple 
        chronic diseases, the fastest growing part of the Medicare 
        population; and
            (B) any changes that may be necessary to ensure such input.
            (3)(A) Whether the existing process includes equitable 
        representation of physician medical specialties in proportion 
        to their relative contributions toward caring for Medicare 
        beneficiaries, as determined by the percentage of Medicare 
        billings per specialty, percentage of Medicare encounters by 
        specialty, or such other measures of relative contributions to 
        patient care as determined by the Secretary; and
            (B) any changes that may be necessary to reflect such 
        equitable representation.
            (4)(A) Whether the existing process, including the 
        application of budget neutrality rules, unfairly disadvantages 
        primary care physicians and other physicians who principally 
        provide evaluation and management services; and
            (B) any changes that may be necessary to eliminate such 
        disadvantages.
    (b) Report.--Not later than 12 months after the date of enactment 
of this Act, the Secretary shall submit to Congress a report containing 
the results of the study conducted under subsection (a), together with 
recommendations for such legislation and administrative action as the 
Secretary determines appropriate.

                    Subtitle B--Preventive Services

SEC. 311. ELIMINATING TIME RESTRICTION FOR INITIAL PREVENTIVE PHYSICAL 
              EXAMINATION.

    (a) In General.--Section 1862(a)(1)(K) of the Social Security Act 
(42 U.S.C. 1395y(a)(1)(K)), as amended by section 101(b)(3) of the 
Medicare Improvements for Patients and Providers Act of 2008 (Public 
Law 110-275), is amended by striking ``more than'' and all that follows 
before the comma at the end and inserting ``more than one time during 
the lifetime of the individual''.
    (b) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2009.

SEC. 312. ELIMINATION OF COST-SHARING FOR PREVENTIVE BENEFITS UNDER THE 
              MEDICARE PROGRAM.

    (a) Definition of Preventive Services.--Section 1861(ddd) of the 
Social Security Act, as added by section 101 of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275), is amended--
            (1) in the heading, by inserting ``; Preventive Services'' 
        after ``Services'';
            (2) in paragraph (1), by striking ``not otherwise described 
        in this title'' and inserting ``not described in subparagraphs 
        (A) through (N) of paragraph (3)''; and
            (3) by adding at the end the following new paragraph:
    ``(3) The term `preventive services' means the following:
            ``(A) Prostate cancer screening tests (as defined in 
        subsection (oo)).
            ``(B) Colorectal cancer screening tests (as defined in 
        subsection (pp)).
            ``(C) Diabetes outpatient self-management training services 
        (as defined in subsection (qq)).
            ``(D) Screening for glaucoma for certain individuals (as 
        described in subsection (s)(2)(U)).
            ``(E) Medical nutrition therapy services for certain 
        individuals (as described in subsection (s)(2)(V)).
            ``(F) An initial preventive physical examination (as 
        defined in subsection (ww)).
            ``(G) Cardiovascular screening blood tests (as defined in 
        subsection (xx)(1)).
            ``(H) Diabetes screening tests (as defined in subsection 
        (yy)).
            ``(I) Ultrasound screening for abdominal aortic aneurysm 
        for certain individuals (as described in subsection 
        (s)(2)(AA)).
            ``(J) Pneumococcal and influenza vaccine and their 
        administration (as described in subsection (s)(10)(A)).
            ``(K) Hepatitis B vaccine and its administration for 
        certain individuals (as described in subsection (s)(10)(B)).
            ``(L) Screening mammography (as defined in subsection 
        (jj)).
            ``(M) Screening pap smear and screening pelvic exam (as 
        described in subsection (s)(14)).
            ``(N) Bone mass measurement (as defined in subsection 
        (rr)).
            ``(O) Additional preventive services (as determined under 
        paragraph (1)).''.
    (b) Coinsurance.--
            (1) General application.--
                    (A) In general.--Section 1833(a)(1) of the Social 
                Security Act (42 U.S.C. 1395l(a)(1)), as amended by 
                section 101 of the Medicare Improvements for Patients 
                and Providers Act of 2008 (Public Law 110-275) and 
                section 202, is amended--
                            (i) in subparagraph (T), by striking ``80 
                        percent'' and inserting ``100 percent'';
                            (ii) in subparagraph (W), by striking ``80 
                        percent'' and inserting ``100 percent'';
                            (iii) by striking ``and'' before ``(X)''; 
                        and
                            (iv) by inserting before the semicolon at 
                        the end the following: ``, and (Y) with respect 
                        to preventive services described in 
                        subparagraphs (A) through (O) of section 
                        1861(ddd)(1), the amount paid shall be 100 
                        percent of the lesser of the actual charge for 
                        the services or the amount determined under the 
                        fee schedule that applies to such services 
                        under this part''.
            (2) Elimination of coinsurance for screening 
        sigmoidoscopies and colonoscopies.--Section 1834(d) of the 
        Social Security Act (42 U.S.C. 1395m(d)) is amended--
                    (A) in paragraph (2)--
                            (i) in subparagraph (A), by inserting ``, 
                        except that payment for such tests under such 
                        section shall be 100 percent of the payment 
                        determined under such section for such tests'' 
                        before the period at the end; and
                            (ii) in subparagraph (C)--
                                    (I) by striking clause (ii); and
                                    (II) in clause (i)--
                                            (aa) by striking ``(i) In 
                                        general.--Notwithstanding'' and 
                                        inserting ``Notwithstanding'';
                                            (bb) by redesignating 
                                        subclauses (I) and (II) as 
                                        clauses (i) and (ii), 
                                        respectively, and moving such 
                                        clauses 2 ems to the left; and
                                            (cc) in the flush matter 
                                        following clause (ii), as so 
                                        redesignated, by inserting 
                                        ``100 percent of'' after 
                                        ``based on''; and
                    (B) in paragraph (3)--
                            (i) in subparagraph (A), by inserting ``, 
                        except that payment for such tests under such 
                        section shall be 100 percent of the payment 
                        determined under such section for such tests'' 
                        before the period at the end; and
                            (ii) in subparagraph (C)--
                                    (I) by striking clause (ii); and
                                    (II) in clause (i)--
                                            (aa) by striking ``(i) In 
                                        general.--Notwithstanding'' and 
                                        inserting ``Notwithstanding''; 
                                        and
                                            (bb) by inserting ``100 
                                        percent of'' after ``based 
                                        on''.
            (3) Elimination of coinsurance in outpatient hospital 
        settings.--
                    (A) Exclusion from opd fee schedule.--Section 
                1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
                1395l(t)(1)(B)(iv)) is amended by striking ``and 
                diagnostic mammography'' and inserting ``, diagnostic 
                mammography, and preventive services (as defined in 
                section 1861(ddd)(3))''.
                    (B) Conforming amendments.--Section 1833(a)(2) of 
                the Social Security Act (42 U.S.C. 1395l(a)(2)) is 
                amended--
                            (i) in subparagraph (F), by striking 
                        ``and'' after the semicolon at the end;
                            (ii) in subparagraph (G)(ii), by adding 
                        ``and'' at the end; and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(H) with respect to preventive services (as 
                defined in section 1861(ddd)(3)) furnished by an 
                outpatient department of a hospital, the amount 
                determined under paragraph (1)(W) or (1)(X), as 
                applicable;''.
    (c) Waiver of Application of Deductible.--The first sentence of 
section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as 
amended by section 101 of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110-275), is amended--
            (1) in clause (1), by striking ``items and services 
        described in section 1861(s)(10)(A)'' and inserting 
        ``preventive services (as defined in section 1861(ddd)(3))'';
            (2) by inserting ``and'' before ``(4)''; and
            (3) by striking subparagraphs (5) through (9).

SEC. 313. HHS STUDY AND REPORT ON FACILITATING THE RECEIPT OF MEDICARE 
              PREVENTIVE SERVICES BY MEDICARE BENEFICIARIES.

    (a) Study.--The Secretary, in consultation with physician 
organizations and other appropriate stakeholders, shall conduct a study 
on--
            (1) ways to assist primary care physicians (as defined in 
        section 3(a)(4)) in--
                    (A) furnishing appropriate preventive services (as 
                defined in section 1861(ddd)(3) of the Social Security 
                Act, as added by section 212) to individuals enrolled 
                under part B of title XVIII of such Act; and
                    (B) referring such individuals for other items and 
                services furnished by other physicians and health care 
                providers; and
            (2) the advisability and feasability of making additional 
        payments under the Medicare program to physicians for--
                    (A) the work involved in ensuring that such 
                individuals receive appropriate preventive services 
                furnished by other physicians and health care 
                providers; and
                    (B) incorporating the resulting clinical 
                information into the treatment plan for the individual.
    (b) Report.--Not later than 12 months after the date of enactment 
of this Act, the Secretary shall submit to Congress a report containing 
the results of the study conducted under subsection (a), together with 
recommendations for such legislation and administrative action as the 
Secretary determines appropriate.

                      Subtitle C--Other Provisions

SEC. 321. HHS STUDY AND REPORT ON IMPROVING THE ABILITY OF PHYSICIANS 
              TO ASSIST MEDICARE BENEFICIARIES IN OBTAINING NEEDED 
              PRESCRIPTIONS UNDER MEDICARE PART D.

    (a) Study.--The Secretary, in consultation with physician 
organizations and other appropriate stakeholders, shall conduct a study 
on the development and implementation of mechanisms to facilitate 
increased efficiency relating to the physician's role in Medicare 
beneficiaries obtaining needed prescription drugs under the Medicare 
prescription drug program under part D of title XVIII of the Social 
Security Act. Such study shall include an analysis of ways to--
            (1) improve the accessibility of formulary information;
            (2) streamline the prior authorization, exception, and 
        appeals processes, through, at a minimum, standardizing formats 
        and allowing electronic exchange of information; and
            (3) recognize the physician work involved in the 
        prescribing process, especially work that may extend beyond the 
        amount considered to be bundled into payment for evaluation and 
        management services.
    (b) Report.--Not later than 12 months after the date of enactment 
of this Act, the Secretary shall submit to Congress a report containing 
the results of the study conducted under subsection (a), together with 
recommendations for such legislation and administrative action as the 
Secretary determines appropriate.

SEC. 322. QUALITY IMPROVEMENT ORGANIZATION ASSISTANCE FOR PHYSICIAN 
              PRACTICES SEEKING TO BE PATIENT-CENTERED MEDICAL HOME 
              PRACTICES.

    Not later than 90 days after the date of enactment of this Act, the 
Secretary shall revise the 9th Statement of Work under the Quality 
Improvement Program to include a requirement that, in order to be an 
eligible Quality Improvement Organization (in this section referred to 
as a ``QIO'') for the 9th Statement of Work contract cycle, a QIO shall 
provide assistance, including technical assistance, to physicians under 
the Medicare program under title XVIII of the Social Security Act that 
seek to acquire the elements necessary to be recognized as a patient-
centered medical home practice under the National Committee for Quality 
Assurance's Physician Practice Connections-PCMH module (or any 
successor module issued by such Committee).

SEC. 323. HHS STUDY AND REPORT ON IMPROVED PATIENT CARE THROUGH 
              INCREASED CAREGIVER AND PHYSICIAN INTERACTION.

    (a) Study.--The Secretary, in consultation with appropriate 
stakeholders, shall conduct a study on the development and 
implementation of mechanisms to promote and increase interaction 
between physicians and the families of Medicare beneficiaries, as well 
as other caregivers who support such beneficiaries, for the purpose of 
improving patient care under the Medicare program. Such study shall 
include an analysis of--
            (1) ways to recognize the physician work involved in 
        discussing clinical issues with caregivers that relate to the 
        care of the beneficiary; and
            (2) regulations under the Medicare program that are 
        barriers to interactions between physicians and caregivers and 
        how such regulations should be revised to eliminate such 
        barriers.
    (b) Report.--Not later than 12 months after the date of enactment 
of this Act, the Secretary shall submit to Congress a report containing 
the results of the study conducted under subsection (a), together with 
recommendations for such legislation and administrative action as the 
Secretary determines appropriate.

SEC. 324. IMPROVED PATIENT CARE THROUGH EXPANDED SUPPORT FOR LIMITED 
              ENGLISH PROFICIENCY SERVICES.

    (a) Additional Payments for Physicians.--Section 1833 of the Social 
Security Act (42 U.S.C. 1395l), as amended by section 204, is amended 
by adding at the end the following new subsection:
    ``(w) Additional Payments for Providing Services to Individuals 
With Limited English Proficiency.--
            ``(1) In general.--In the case of physicians' services 
        furnished on or after January 1, 2010 to an individual with 
        limited English proficiency by a physician, in addition to the 
        amount of payment that would otherwise be made for such 
        services under this part, there shall also be paid an 
        appropriate amount (as determined by the Secretary) in order to 
        recognize the additional time involved in furnishing the 
        service to such individual.
            ``(2) Judicial review.--There shall be no administrative or 
        judicial review under section 1869, 1878, or otherwise, 
        respecting the determination of the amount of additional 
        payment under this subsection.''.
    (b) National Clearinghouse.--Not later than 180 days after the date 
of enactment of this Act, the Secretary shall establish a national 
clearinghouse to make available to the providers, patients, and States 
translated documents regarding patient care and education under the 
Medicare program, the Medicaid program, and the State Children's Health 
Insurance Program under titles XVIII, XIX, and XXI, respectively, of 
the Social Security Act.
    (c) Grants To Support Language Translation Services in Underserved 
Communities.--
            (1) Authority to award grants.--The Secretary shall award 
        grants to support language translation services for primary 
        care practices in medically underserved areas (as defined in 
        section 3(c)).
            (2) Authorization of appropriations.--There are authorized 
        to be appropriated to the Secretary to award grants under this 
        subsection, such sums as are necessary for fiscal years 
        beginning with fiscal year 2009.

SEC. 325. HHS STUDY AND REPORT ON USE OF REAL-TIME MEDICARE CLAIMS 
              ADJUDICATION.

    (a) Study.--The Secretary of Health and Human Services (in this 
subsection referred to as the ``Secretary'') shall conduct a study to 
assess the ability of the Medicare program under title XVIII of the 
Social Security Act to engage in real-time claims adjudication for 
items and services furnished to Medicare beneficiaries.
    (b) Consultation.--In conducting the study under subsection (a), 
the Secretary consult with stakeholders in the private sector, 
including stakeholders who are using or are testing real-time claims 
adjudication systems.
    (c) Report.--Not later than January 1, 2010, the Secretary shall 
submit to Congress a report containing the results of the study 
conducted under subsection (a), together with recommendations for such 
legislation and administrative action as the Secretary determines 
appropriate.

                           TITLE IV--STUDIES

SEC. 401. STUDY CONCERNING THE DESIGNATION OF PRIMARY CARE AS A 
              SHORTAGE PROFESSION.

    (a) In General.--Not later than June 30, 2009, the Secretary of 
Labor shall conduct a study and submit to the Committee on Education 
and Labor of the House of Representatives and the Committee on Health, 
Education, Labor, and Pensions a report that contains--
            (1) a description of the criteria for the designation of 
        primary care physicians as professions in shortage as defined 
        by the Secretary under section 212(a)(5)(A) of the Immigration 
        and Nationality Act;
            (2) the findings of the Secretary on whether primary care 
        physician professions will, on the date on which the report is 
        submitted, or within the 5-year period beginning on such date, 
        satisfy the criteria referred to in paragraph (1); and
            (3) if the Secretary finds that such professions will not 
        satisfy such criteria, recommendations for modifications to 
        such criteria to enable primary care physicians to be so 
        designated as a profession in shortage.
    (b) Requirements.--In conducting the study under subsection (a), 
the Secretary of Labor shall consider workforce data from the Health 
Resources and Services Administration, the Council on Graduate Medical 
Education, the Association of American Medical Colleges, and input from 
physician membership organizations that represent primary care 
physicians.

SEC. 402. STUDY CONCERNING THE EDUCATION DEBT OF MEDICAL SCHOOL 
              GRADUATES.

    (a) Study.--The Comptroller General of the United States shall 
conduct a study to evaluate the higher education-related indebtedness 
of medical school graduates in the United States at the time of 
graduation from medical school, and the impact of such indebtedness on 
specialty choice, including the impact on the field of primary care.
    (b) Report.--
            (1) Submission and dissemination of report.--Not later than 
        1 year after the date of enactment of this Act, the Comptroller 
        General shall submit a report on the study required by 
        subsection (a) to the Committee on Health, Education, Labor, 
        and Pensions of the Senate and the Committee on Education and 
        Labor of the House of Representatives, and shall make such 
        report widely available to the public.
            (2) Additional reports.--The Comptroller General may 
        periodically prepare and release as necessary additional 
        reports on the topic described in subsection (a).

SEC. 403. STUDY ON MINORITY REPRESENTATION IN PRIMARY CARE.

    (a) Study.--The Secretary of Health and Human Services, acting 
through the Administrator of the Health Resources and Services 
Administration, shall conduct a study of minority representation in 
training, and in practice, in primary care specialties.
    (b) Report.--Not later than 1 year after the date of enactment of 
this Act, the Secretary of Health and Human Services, acting through 
the Administrator of the Health Resources and Services Administration, 
shall submit to the appropriate committees of Congress a report 
concerning the study conducted under subsection (a), including 
recommendations for achieving a primary care workforce that is more 
representative of the population of the United States.
                                 <all>