[Congressional Record Volume 145, Number 34 (Thursday, March 4, 1999)]
[Senate]
[Pages S2316-S2318]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. COLLINS (for herself, Mr. Murkowski, and Mr. Roberts):
  S. 541. A bill to amend title XVIII of the Social Security Act to 
make certain changes related to payments for graduate medical education 
under the medicare program; to the Committee on Finance.


      THE GRADUATE MEDICAL EDUCATION TECHNICAL AMENDMENTS OF 1999

  Ms. COLLINS. Mr. President, I am pleased to be joining my colleague 
from Alaska, Senator Murkowski, in introducing the Graduate Medical 
Education Technical Amendments Act of 1999, which is intended to 
address some of the problems that small family practice residency 
programs in Maine and elsewhere are experiencing as a result of 
provisions in the Balanced Budget Act (BBA) of 1997 that were intended 
to control the growth in Medicare graduate medical education spending.
  Of specific concern are the provisions in the BBA that cap the total 
number of residents in a program at the level included in the 1996 
Medicare cost reports. Congress' goal in reforming Medicare's graduate 
medical education program was to slow down our nation's overall 
production of physicians, while still protecting the training of 
physicians who are in short supply and needed to meet local and 
national health care demands. While the BBA's provisions will indeed 
curb growth in the overall physician supply, they do so 
indiscriminately and are thwarting efforts in Maine and elsewhere to 
increase the supply of primary care physicians in underserved rural 
areas.
  Because Maine has only one medical school--the University of New 
England, which trains osteopathic physicians--we depend on a number of 
small family practice residency programs to introduce physicians to the 
practice opportunities in the state. Most of the graduates of these 
residency programs go on to establish practices in Maine, many in rural 
and underserved areas of the state. The new caps on residency slots 
included in the BBA penalize these programs in a number of ways.
  For instance, the current cap is based on the number of interns and 
residents who were ``in the hospital'' in FY 1996. Having a cap that is 
institution-specific rather than program-specific has caused several 
problems. For example, the Maine-Dartmouth Family Practice Residency 
Program had two residents out on leave in 1996--one on sick leave for 
chemotherapy treatments and one on maternity leave. Therefore, the 
program's cap was reduced by two, because it was based on the number of 
actual residents in the hospital in 1996 as opposed to the number of 
residents in the program.
  Moreover, residents in this program have spent one to two months 
training in obstetrics at Dartmouth's Mary Hitchcock's Medical Center 
in Lebanon, New Hampshire. Because the cap is based on a hospital's 
cost report, these residents are counted toward Dartmouth Medical 
School's cap instead of the Maine-Dartmouth Family Practice Residency 
Program's. Last

[[Page S2317]]

year, the Maine program was informed that Dartmouth would be cutting 
back the amount of time their residents are there. But the Maine-
Dartmouth Family Practice Residency Program has no way of recouping the 
resident count from them in order to have the funds to support 
obstetrical training for their residents elsewhere.
  Moreover, the cap does not include residents who continue to be part 
of the residency program, but who have been sent outside of the 
hospital for training. This penalizes all primary care specialties, but 
especially family medicine, where ambulatory training has historically 
been the hallmark of the specialty. This is particularly ironic since 
other specialty programs that now begin training in settings outside 
the hospital will, under the new rules, have those costs included in 
their Medicare graduate medical education funding.
  All told, the Maine Dartmouth Family Practice Residency Program will 
see its graduate medical education funding reduced by over half a 
million dollars a year as a result of the cap established by the BBA.
  The example I have just used is from Maine, but the problems created 
by the BBA's graduate medical education changes are national in scope. 
It has created disproportionately harmful effects on family practice 
residencies from Maine to Alaska. A recent survey of all family 
practice residency program directors has found that:
  56 percent of respondents who were in the process of developing new 
rural training sites have indicated that they will either not implement 
those plans or are unsure about their sponsoring institutions' 
continued support.
  21 percent of respondents report planning to decrease their family 
practice residency slots in the immediate future. The majority of those 
who are planning to decrease their slots are the sole residency program 
in a teaching hospital. This means that, under current law, they have 
no alternative way of achieving growth, such as through a reduction of 
other specialty slots in order to stay within the cap.

  And finally, the vast majority of family practice residencies did not 
have their full residency FTEs captured in the 1996 cost reports upon 
which the cap is based.
  In addition to this survey, we have anecdotal information from 
residencies across the country detailing how they have lost funding 
either because of where they trained their residents or because their 
residents had been extended sick or maternity leave. For example, one 
family practice residency in Washington State last year had an 
equivalent of 14 residents training outside of the hospital and four in 
the hospital. Under the BBA, their cap would be four. By contrast, had 
all of their residents been trained in the hospital up to this point, 
their payment base would have been capped at 18, even if they trained 
residents in non-hospital settings in the future.
  The Medicare Graduate Medical Education Technical Amendments Act we 
are introducing today will address these problems by basing the cap on 
the number of residents ``who were appointed by the approved medical 
residency training programs for the hospital'' in 1996, rather than on 
the number of residents who were ``in the hospital.''
  I am also concerned that the Balanced Budget Act and its accompanying 
regulations will severely hamper primary care residency programs that 
are expanding to meet local needs. Specifically, a new residency 
program that had not met its full complement of accredited residency 
positions until after the cutoff date of August 5, 1997, is precluded 
from increasing its number of residents unless the hospital decreases 
the number of residents in one of its other specialty programs. 
However, over forty percent of the nation's family practice residency 
programs are the only program sponsored by the hospital. This provision 
therefore completely precludes such a hospital from expanding its 
residency program to meet emerging primary care needs.
  To address this problem, the legislation we are introducing today 
would allow the small number of programs at hospitals that sponsor just 
one residency program to increase their cap by one residency slot a 
year up to a maximum of three. In addition, to enable a number of 
family practice residency programs that are already in the pipeline to 
get accredited and grow to completion, the bill extends the cutoff date 
to September 1999.
  And finally, the Balanced Budget Act gave the Secretary of Health and 
Human Services the authority to give ``special consideration'' to new 
facilities that ``meet the needs of underserved rural areas.'' The 
Health Care Financing Administration has interpreted this to mean 
facilities that are actually in underserved rural areas. There have 
been several recent expansions in family practice residency programs 
that include a rural training track, with residents located in outlying 
hospitals, or with satellite programs designed specifically to train 
residents to work with underserved populations.
  Even though these new programs or satellites required accrediting 
body approval, they are still part of the ``mother'' residencies, which 
may not be physically located in an underserved rural area. While these 
are not technically new programs, I believe that the definition should 
be expanded to include such endeavors, given the value of these 
programs in addressing the needs of underserved populations. Therefore, 
the Medicare Graduate Medical Education Technical Amendments Act would 
expand the definition to include ``facilities which are not located in 
an underserved rural area, but which have established separately 
accredited rural training tracks.''
  Mr. President, while the changes we are proposing today are 
relatively minor and technical in nature, they are critical to the 
survival of the small family practice residency programs that are so 
important to our ability to meet health manpower needs in rural and 
underserved areas. I urge all of my colleagues to join us in 
cosponsoring the Medicare Graduate Medical Education Technical 
Amendments and ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                 S. 541

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Graduate Medical Education 
     Technical Amendments of 1999''.

     SEC. 2. INDIRECT GRADUATE MEDICAL EDUCATION ADJUSTMENT.

       (a) In General.--Section 1886(d)(5)(B)(v) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)) (as added by 
     section 4621(b) of the Balanced Budget Act of 1997) is 
     amended--
       (1) by striking ``(v) In determining'' and inserting 
     ``(v)(I) Subject to subclause (II), in determining'';
       (2) by striking ``in the hospital with respect to the 
     hospital's most recent cost reporting period ending on or 
     before December 31, 1996''; and inserting ``who were 
     appointed by the hospital's approved medical residency 
     training programs for the hospital's most recent cost 
     reporting period ending on or before December 31, 1996''; and
       (3) by adding at the end the following:
       ``(II) Beginning on or after January 1, 1997, in the case 
     of a hospital that sponsors only 1 allopathic or osteopathic 
     residency program, the limit determined for such hospital 
     under subclause (I) may, at the hospital's discretion, be 
     increased by 1 for each calendar year but shall not exceed a 
     total of 3 more than the limit determined for the hospital 
     under subclause (I).''.
       (b) Technical Amendments.--Section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 
     moving clauses (ii), (v), and (vi) 2 ems to the left.

     SEC. 3. DIRECT GRADUATE MEDICAL EDUCATION ADJUSTMENT.

       (a) Limitation on Number of Residents.--Section 
     1886(h)(4)(F) of the Social Security Act (42 U.S.C. 
     1395ww(h)(4)(F)) (as added by section 4623 of the Balanced 
     Budget Act of 1997) is amended by inserting ``who were 
     appointed by the hospital's approved medical residency 
     training programs'' after ``may not exceed the number of such 
     full-time equivalent residents''.
       (b) Funding for New Programs.--The first sentence of 
     section 1886(h)(4)(H)(i) of the Social Security Act (42 
     U.S.C. 1395ww(h)(4)(H)(i)) (as added by section 4623 of the 
     Balanced Budget Act of 1997) is amended inserting ``and 
     before September 30, 1999'' after ``January 1, 1995''.
       (c) Funding for Programs Meeting Rural Needs.--The second 
     sentence of section 1886(h)(4)(H)(i) of the Social Security 
     Act (42 U.S.C. 1395ww(h)(4)(H)(i)) (as added by section 4623 
     of the Balanced Budget Act of 1997) is amended by striking 
     the period at the end and inserting ``, including facilities 
     that are not located in an underserved rural area but have 
     established separately accredited rural training tracks.''.

     SEC. 4. EFFECTIVE DATE.

       The amendments made by this Act shall take effect as if 
     included in the enactment of the Balanced Budget Act of 1997.


[[Page S2318]]


  Mr. MURKOWSKI. Mr. President, I am pleased today to introduce with my 
distinguished colleague from Maine, Senator Collins, the Graduate 
Medical Education Technical Amendments Act of 1999. This legislation 
will alleviate unintended consequences of the Balanced Budget Act of 
1997 regarding Graduate Medical Education (GME).
  The Balanced Budget Act of 1997 contained important and necessary GME 
reform. However, a small number of the changes in the Balanced Budget 
Act of 1997, have grave consequences for many residency programs, 
particularly for programs that have been training in ambulatory 
settings, are small, or who produce physicians to serve in rural areas. 
The impact has been disproportionately harmful to programs that: have 
already been training in ambulatory settings (because the hospitals in 
which they were located were not allowed to count the residents they 
had serving in community settings in the cap); are small, such as 
hospitals with only one residency program; and train physicians for 
practice in rural areas.
  The impact is especially damaging to family practice residency 
programs. Only family practice residents have been trained extensively 
out of the hospital and only family practice residencies were 
significantly harmed by this provision in the BBA. In fact, a recent 
survey indicates that 56 percent of family residency program directors 
believe that the BBA provisions will preclude their development of 
rural training sites.
  Senator Collins' and my legislation would include the following 
legislative remedies:
  Recalculate the IME and DME caps based on the number of interns and 
residents who were appointed by the approved medical residency training 
programs for FY 1996, whether they were being trained in the hospital 
or in the community;
  Change the cutoff date for adjusting the DME funding cap to September 
30, 1999, to allow those programs already in the approval process for 
accreditation to continue to realization; and
  Expand the exception to the funding caps to include programs with 
separately accredited rural training tracks even if the sponsoring 
hospital is not located in a rural area, and for residency programs 
where a primary care training program is the only one offered in the 
hospital.
  This legislation is important for Alaska's first and only residency 
program. The Alaska Family Practice Residency is specifically designed 
to train physicians to practice medicine in rural Alaska.
  Alaska's rural health care problems are tough: 74% of Alaska is 
medically under-served. Many villages populated by 25-1000 individuals 
do not have access to physicians. Physician turn-over rate is high 
which makes it impossible for patients to establish long-term 
relationships with their physician to manage chronic disease or to do 
preventative medicine. The result is that bush Alaska has much higher 
rates of preventable diseases.
  This legislation is truly imperative to Alaska health care. While 
other residency programs have the luxury of educating their residents 
on rural health issues, for us it is a necessity.
  Mr. President, our legislation corrects a small deficiency in the BBA 
of 1997 that has had a large, unintended impact on programs training 
community-based and rural doctors. I hope my colleagues can join our 
efforts and support this important legislation.
                                 ______