[Congressional Record Volume 147, Number 112 (Friday, August 3, 2001)]
[Senate]
[Pages S8961-S8963]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Domenici and Mr. Rockefeller):
  S. 1387. A bill to conduct a demonstration program to show that 
physician shortage, recruitment, and retention problems may be 
ameliorated in rural States by developing comprehensive program that 
will result in statewide physician population growth, and for other 
purposes; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, I rise today to introduce legislation, 
the ``Rural States Physician Recruitment and Retention Demonstration 
Act of 2001,'' with Senators Domenici and Rockefeller. This Act would 
create a demonstration program to show that physician shortage, 
recruitment, and retention problems may be ameliorated in demonstration 
States by developing a training program and loan repayment program that 
will result in statewide physician population growth.
  The problem of recruiting and retaining physicians, particularly in 
some specialties, has reached crisis proportions in my State. There are 
very few small town residents who don't have a story to tell about 
losing a cherished doctor or traveling vast distances to see a 
specialist. And even in New Mexico's most populous city, Albuquerque, 
the number of practicing neurosurgeons can be counted on one hand. Not 
so long ago there were 11 of them practicing there. We know that the 
surgeons in Santa Fe are struggling to recruit a new general surgeon, 
as are many other communities throughout the State. We know that the 
thought of having an additional psychiatrist in Las Cruces would be 
considered by many to be an unrealistic fantasy. I am certain that many 
Senators from States that are demographically more similar to New 
Mexico than they are to Washington, D.C. can truly understand the 
discrepancy in physician recruitment and retention.
  Anyone representing a rural State knows that a certain amount of 
physician turn over is inevitable and understandable. It is very 
important, however, to anticipate how we can ensure an adequate supply 
of physicians in the future. Payment for Graduate Medical Education 
slots has been frozen at the number of physicians who were being 
trained in 1996. Within the past six months we have been told that the 
funding for training family physicians, general internists, 
pediatricians, dentists, nurse practitioners, physician assistants, and 
other health professionals should be drastically cut because ``today a 
physician shortage no longer exists''. Although aggregate data appears 
to support the notion that we need not be concerned about a physician 
shortage, this does not reflect what is happening at home.
  Health professional shortages continue to exist in geographically 
isolated and economically disadvantaged areas. This maldistribution 
problem is exacerbated by market forces that often entice physicians to 
urban or suburban areas where higher income levels can be achieved. The 
Medicare payment formula further contributes to the problem by 
assessing a lower cost of living adjustment in rural areas and, 
accordingly, decreasing the Medicare payment rate in the very area 
where the physician shortage exists in the first place. Fortunately we 
know that economics is only one of the many factors that physicians 
consider when they are choosing a place to practice. Family 
considerations and lifestyle issues also play a vital role in this 
important decision. One of the best predictors of where a physician 
will practice is directly related to the location of their post-
graduate medical education--they are likely to stay within a sixty-mile 
radius of where they did their residency training. This fact, provides 
us with a focus for this demonstration project.

  This particular piece of legislation creates a demonstration program 
in nine States that will correct the flaws in the system in two ways, 
and then will track health professionals in each demonstration State 
through a state-specific health professions database. Demonstration 
States would be identified using three criteria including an uninsured 
rate above the U.S. average, lack of primary care access above the U.S. 
average, and a combined Medicare and Medicaid population above 20 
percent.
  The first flaw in the system is the capitation limit placed on all 
residency graduate medical education positions in 1996. Whereas this 
action may have been appropriate for some States, maybe even most 
States, it has been extremely damaging to rural States where we know 
physicians are in short supply. This bill allows a sponsoring 
institution to increase the number of residency and fellowship 
positions by up to 50 percent if the sponsoring institution agrees to 
require that each resident or fellow in the affected training programs 
would spend an aggregate of 10 percent of their time during training 
providing supervised specialty services to underserved and rural 
community populations outside of their training institution. A waiver 
from this rural outreach requirement can be granted by the Secretary 
for certain hospital-based subspecialists, like neurosurgeons, if the 
demonstration State can demonstrate a shortage of physicians in that 
specialty statewide.
  The second flaw in the system revolves around the debt load carried 
by many physicians when they finish their training program. Currently 
there are several Federal and State programs that will help repay 
education loans. The problem lies in the fact that only primary care 
specialties currently qualify for these loan repayment programs. This 
legislation creates a similar loan repayment program for underserved 
specialists who agree to practice for one year in the demonstration 
State for each year of education loans that are repaid.
  Thus, this demonstration project does two critical things for 
recruitment and retention in rural States. It exposes to underserved 
areas that they may never have otherwise been exposed to, which 
increases the possibility that they will stay and practice there. It 
also relieves some of their economic burden from loans which may help 
to moderate the effect of lower Medicare reimbursement rates in rural 
areas.
  I request unanimous consent that the text of this bill be printed in 
the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

[[Page S8962]]

                                S. 1387

       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 ``Rural 
     States Physician Recruitment and Retention Demonstration Act 
     of 2001''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
Sec. 3. Rural States Physician Recruitment and Retention Demonstration 
              Program.
Sec. 4. Establishment of the Health Professions Database.
Sec. 5. Evaluation and reports.
Sec. 6. Contracting flexibility.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) COGME.--The term ``COGME'' means the Council on 
     Graduate Medical Education established under section 762 of 
     the Public Health Service Act (42 U.S.C. 294o).
       (2) Demonstration program.--The term ``demonstration 
     program'' means the Rural States Physician Recruitment and 
     Retention Demonstration Program established by the Secretary 
     under section 3(a).
       (3) Demonstration states.--The term ``demonstration 
     States'' means each State identified by the Secretary, based 
     upon data from the most recent year for which data are 
     available--
       (A) that has an uninsured population above 16 percent (as 
     determined by the Bureau of the Census);
       (B) for which the sum of the number of individuals who are 
     entitled to benefits under the medicare program and the 
     number of individuals who are eligible for medical assistance 
     under the medicaid program under title XIX of the Social 
     Security Act (42 U.S.C. 1396 et seq.) equals or exceeds 20 
     percent of the total population of the State (as determined 
     by the Centers for Medicare & Medicaid Services); and
       (C) that has an estimated number of individuals in the 
     State without access to a primary care provider of at least 
     17 percent (as published in ``HRSA's Bureau of Primary Health 
     Care: BPHC State Profiles'').
       (4) Eligible residency or fellowship graduate.--The term 
     ``eligible residency or fellowship graduate'' means a 
     graduate of an approved medical residency training program 
     (as defined in section 1886(h)(5)(A) of the Social Security 
     Act (42 U.S.C. 1395ww(h)(5)(A))) in a shortage physician 
     specialty.
       (5) Health professions database.--The term ``Health 
     Professions Database'' means the database established under 
     section 4(a).
       (6) Medicare program.--The term ``medicare program'' means 
     the health benefits program under title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.).
       (7) MedPAC.--The term ``MedPAC'' means the Medicare Payment 
     Advisory Commission established under section 1805 of the 
     Social Security Act (42 U.S.C. 1395b-6).
       (8) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (9) Shortage physician specialty.--The term ``shortage 
     physician specialty'' means a medical or surgical specialty 
     identified in a demonstration State by the Secretary based 
     on--
       (A) an analysis and comparison of national data and 
     demonstration State data; and
       (B) recommendations from appropriate Federal, State, and 
     private commissions, centers, councils, medical and surgical 
     physician specialty boards, and medical societies or 
     associations involved in physician workforce, education and 
     training, and payment issues.

     SEC. 3. RURAL STATES PHYSICIAN RECRUITMENT AND RETENTION 
                   DEMONSTRATION PROGRAM.

       (a) Establishment.--
       (1) In general.--The Secretary shall establish a Rural 
     States Physician Recruitment and Retention Demonstration 
     Program for the purpose of ameliorating physician shortage, 
     recruitment, and retention problems in rural States in 
     accordance with the requirements of this section.
       (2) Consultation.--For purposes of establishing the 
     demonstration program, the Secretary shall consult with--
       (A) COGME;
       (B) MedPAC;
       (C) a representative of each demonstration State medical 
     society or association;
       (D) the health workforce planning and physician training 
     authority of each demonstration State; and
       (E) any other entity described in section 2(9)(B).
       (b) Duration.--The Secretary shall conduct the 
     demonstration program for a period of 10 years.
       (c) Conduct of Program.--
       (1) Funding of additional residency and fellowship 
     positions.--
       (A) In general.--As part of the demonstration program, the 
     Secretary (acting through the Administrator of the Centers 
     for Medicare & Medicaid Services) shall--
       (i) notwithstanding section 1886(h)(4)(F) of the Social 
     Security Act (42 U.S.C. 1395ww(h)(4)(F)) increase, by up to 
     50 percent of the total number of residency and fellowship 
     positions approved at each medical residency training program 
     in each demonstration State, the number of residency and 
     fellowship positions in each shortage physician specialty; 
     and
       (ii) subject to subparagraph (C), provide funding under 
     subsections (d)(5)(B) and (h) of section 1886 of the Social 
     Security Act (42 U.S.C. 1395ww) for each position added under 
     clause (i).
       (B) Establishment of additional positions.--
       (i) Identification.--The Secretary shall identify each 
     additional residency and fellowship position created as a 
     result of the application of subparagraph (A).
       (ii) Negotiation and consultation.--The Secretary shall 
     negotiate and consult with representatives of each approved 
     medical residency training program in a demonstration State 
     at which a position identified under clause (i) is created 
     for purposes of supporting such position.
       (C) Contracts with sponsoring institutions.--
       (i) In general.--The Secretary shall condition the 
     availability of funding for each residency and fellowship 
     position identified under subparagraph (B)(i) on the 
     execution of a contract containing such provisions as the 
     Secretary determines are appropriate, including the provision 
     described in clause (ii) by each sponsoring institution.
       (ii) Provision described.--

       (I) In general.--Except as provided in subclause (II), the 
     provision described in this clause is a provision that 
     provides that, during the residency or fellowship, the 
     resident or fellow shall spend not less than 10 percent of 
     the training time providing specialty services to underserved 
     and rural community populations other than an underserved 
     population of the sponsoring institution.
       (II) Exceptions.--The Secretary, in consultation with 
     COGME, shall identify shortage physician specialties and 
     subspecialties for which the application of the provision 
     described in subclause (I) would be inappropriate and the 
     Secretary may waive the requirement under clause (i) that 
     such provision be included in the contract of a resident or 
     fellow with such a specialty or subspecialty.

       (D) Limitations.--
       (i) Period of payment.--The Secretary may not fund any 
     residency or fellowship position identified under 
     subparagraph (B)(i) for a period of more than 5 years.
       (ii) Reassessment of need.--The Secretary shall reassess 
     the status of the shortage physician specialty in the 
     demonstration State prior to entering into any contract under 
     subparagraph (C) after the date that is 5 years after the 
     date on which the Secretary establishes the demonstration 
     program.
       (2) Loan repayment and forgiveness program.--
       (A) In general.--As part of the demonstration program, the 
     Secretary (acting through the Administrator of the Health 
     Resources and Services Administration) shall establish a loan 
     repayment and forgiveness program, through the holder of the 
     loan, under which the Secretary assumes the obligation to 
     repay a qualified loan amount for an educational loan of an 
     eligible residency or fellowship graduate--
       (i) for whom the Secretary has approved an application 
     submitted under subparagraph (D); and
       (ii) with whom the Secretary has entered into a contract 
     under subparagraph (C).
       (B) Qualified loan amount.--
       (i) In general.--Subject to clause (ii), the Secretary 
     shall repay the lesser of--

       (I) 25 percent of the loan obligation of a graduate on a 
     loan that is outstanding during the period that the eligible 
     residency or fellowship graduate practices in the area 
     designated by the contract entered into under subparagraph 
     (C); or
       (II) $25,000 per graduate per year of such obligation 
     during such period.

       (ii) Limitation.--The aggregate amount under this 
     subparagraph may not exceed $125,000 for any graduate and the 
     Secretary may not repay or forgive more than 30 loans per 
     year in each demonstration State under this paragraph.
       (C) Contracts with residents and fellows.--
       (i) In general.--Each eligible residency or fellowship 
     graduate desiring repayment of a loan under this paragraph 
     shall execute a contract containing the provisions described 
     in clause (ii).
       (ii) Provisions.--The provisions described in this clause 
     are provisions that require the eligible residency or 
     fellowship graduate--

       (I) to practice in a health professional shortage area of a 
     demonstration State during the period in which a loan is 
     being repaid or forgiven under this section; and
       (II) to provide health services relating to the shortage 
     physician specialty of the graduate that was funded with the 
     loan being repaid or forgiven under this section during such 
     period.

       (D) Application.--
       (i) In general.--Each eligible residency or fellowship 
     graduate desiring repayment of a loan under this paragraph 
     shall submit an application to the Secretary at such time, in 
     such manner, and accompanied by such information as the 
     Secretary may reasonably require.
       (ii) Reassessment of need.--The Secretary shall reassess 
     the shortage physician specialty in the demonstration State 
     prior to accepting an application for repayment of any loan 
     under this paragraph after the date that is 5 years after the 
     date on which the demonstration program is established.
       (E) Construction.--Nothing in the section shall be 
     construed to authorize any refunding of any repayment of a 
     loan.

[[Page S8963]]

       (F) Prevention of double benefits.--No borrower may, for 
     the same service, receive a benefit under both this paragraph 
     and any loan repayment or forgiveness program under title VII 
     of the Public Health Service Act (42 U.S.C. 292 et seq.).
       (d) Waiver of Medicare Requirements.--The Secretary is 
     authorized to waive any requirement of the medicare program, 
     or approve equivalent or alternative ways of meeting such a 
     requirement, if such waiver is necessary to carry out the 
     demonstration program, including the waiver of any limitation 
     on the amount of payment or number of residents under section 
     1886 of the Social Security Act (42 U.S.C. 1395ww).
       (e) Appropriations.--
       (1) Funding of additional residency and fellowship 
     positions.--Any expenditures resulting from the establishment 
     of the funding of additional residency and fellowship 
     positions under subsection (c)(1) shall be made from the 
     Federal Hospital Insurance Trust Fund under section 1817 of 
     the Social Security Act (42 U.S.C. 1395i).
       (2) Loan repayment and forgiveness program.--There are 
     authorized to be appropriated such sums as may be necessary 
     to carry out the loan repayment and forgiveness program 
     established under subsection (c)(2).

     SEC. 4. ESTABLISHMENT OF THE HEALTH PROFESSIONS DATABASE.

       (a) Establishment of the Health Professions Database.--
       (1) In general.--Not later than 7 months after the date of 
     enactment of this Act, the Secretary (acting through the 
     Administrator of the Health Resources and Services 
     Administration) shall establish a State-specific health 
     professions database to track health professionals in each 
     demonstration State with respect to specialty certifications, 
     practice characteristics, professional licensure, practice 
     types, locations, education, and training, as well as 
     obligations under the demonstration program as a result of 
     the execution of a contract under paragraph (1)(C) or (2)(C) 
     of section 3(c).
       (2) Data sources.--In establishing the Health Professions 
     Database, the Secretary shall use the latest available data 
     from existing health workforce files, including the AMA 
     Master File, State databases, specialty medical society data 
     sources and information, and such other data points as may be 
     recommended by COGME, MedPAC, the National Center for 
     Workforce Information and Analysis, or the medical society of 
     the respective demonstration State.
       (b) Availability.--
       (1) During the program.--During the demonstration program, 
     data from the Health Professions Database shall be made 
     available to the Secretary, each demonstration State, and the 
     public for the purposes of--
       (A) developing a baseline with respect to a State's health 
     professions workforce and to track changes in a demonstration 
     State's health professions workforce;
       (B) tracking direct and indirect graduate medical education 
     payments to hospitals;
       (C) tracking the forgiveness and repayment of loans for 
     educating physicians; and
       (D) tracking commitments by physicians under the 
     demonstration program.
       (2) Following the program.--Following the termination of 
     the demonstration program, a demonstration State may elect to 
     maintain the Health Professions Database for such State at 
     its expense.
       (c) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary for the 
     purpose of carrying out this section.

     SEC. 5. EVALUATION AND REPORTS.

       (a) Evaluation.--
       (1) In general.--COGME and MedPAC shall jointly conduct a 
     comprehensive evaluation of the demonstration program.
       (2) Matters evaluated.--The evaluation conducted under 
     paragraph (1) shall include an analysis of the effectiveness 
     of the funding of additional residency and fellowship 
     positions and the loan repayment and forgiveness program on 
     physician recruitment, retention, and specialty mix in each 
     demonstration State.
       (b) Progress Reports.--
       (1) COGME.--Not later than 1 year after the date on which 
     the Secretary establishes the demonstration program, 5 years 
     after such date, and 10 years after such date, COGME shall 
     submit a report on the progress of the demonstration program 
     to the Secretary and Congress.
       (2) MedPAC.--MedPAC shall submit biennial reports on the 
     progress of the demonstration program to the Secretary and 
     Congress.
       (c) Final Report.--Not later than 1 year after the date on 
     which the demonstration program terminates, COGME and MedPAC 
     shall submit a final report to the President, Congress, and 
     the Secretary which shall contain a detailed statement of the 
     findings and conclusions of COGME and MedPAC, together with 
     such recommendations for legislation and administrative 
     actions as COGME and MedPAC consider appropriate.
       (d) Authorization of Appropriations.--There are authorized 
     to be appropriated to COGME such sums as may be necessary for 
     the purpose of carrying out this section.

     SEC. 6. CONTRACTING FLEXIBILITY.

       For purposes of conducting the demonstration program and 
     establishing and administering the Health Professions 
     Database, the Secretary may procure temporary and 
     intermittent services under section 3109(b) of title 5, 
     United States Code.
                                 ______