[Congressional Record Volume 155, Number 82 (Wednesday, June 3, 2009)]
[Senate]
[Pages S6035-S6046]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

  By Ms. CANTWELL (for herself, Ms. Collins, and Mr. Whitehouse):
  S. 1174. A bill to amend the Public Health Service Act and the Social 
Security Act to increase the number of primary care physicians and 
primary care providers and to improve patient access to primary care 
services, and for other services; to the Committee on Finance.
  Ms. CANTWELL. Mr. President, I rise today to introduce the Preserving 
Patient Access to Primary Care Act of 2009, together with my colleagues 
from Maine, Senator Susan Collins, and from Rhode Island, Senator 
Sheldon Whitehouse. As we set about the urgently important business of 
health care reform, we will be hearing a lot about the uninsured. But 
there is another urgent problem in our health care system: the 
underserved. We must address both problems as we set about reforming 
the health care system.
  It does you little good to have health care insurance if the nearest 
primary care physician is hundreds of miles away.
  This bipartisan proposal sets out a multifaceted approach to 
supporting and expanding our primary care workforce as well as 
enhancing the coordination of care within our health care system. I am 
grateful for the input and collaboration of key health-care 
stakeholders in Washington state that has helped make this legislation 
possible. In my state, we know it is possible to both increase health 
care quality while also lowering costs, all within an integrated system 
that places a priority on expanding our primary care workforce and 
protecting patients' relationships with their doctors.
  A dramatic increase in the primary care physician workforce will be 
needed. My legislation not only addresses the needs of those 
individuals to whom health insurance coverage will be extended but also 
of those who are currently insured but who live in areas underserved by 
our current health care system.
  I believe we can address this problem by adopting long overdue 
reforms to improve pay levels for primary care providers while also 
taking measures to ensure an adequate primary care workforce, 
particularly in rural areas. As more Americans gain health care 
coverage, the experts estimate there will be a shortage of 46,000 
primary care physicians available to care for the influx of patients by 
the year 2025. As the need grows, the number of medical students 
choosing primary care is rapidly dwindling.
  Detailed studies from the Center for Evaluative Clinical Sciences at 
Dartmouth and the Commonwealth Fund found that populations with ready 
access to primary care physicians realize improved health outcomes, 
reduced mortality, lower utilization of health care resources, and 
lower overall costs of care. Yet despite what we know, all across this 
country, we are failing to realize the benefits of primary care and

[[Page S6036]]

a system of having a primary care physician coordinate a patient's 
health care needs. This bill includes several key provisions aimed at 
achieving a high quality, more comprehensive integrated health system.
  Specific provisions include: scholarship and loan repayment 
opportunities for primary care providers who serve in areas with 
critical shortages of primary care services. New residency positions 
for primary care with a focus on more opportunities to train in 
ambulatory care settings--including community in health centers. 
Increased reimbursements for primary care providers. Medicare payments 
for care coordination services, and bonus payments to providers who 
serve as integrated patient-centered medical homes. Improved access to 
primary care for seniors by eliminating copayments for preventives care 
services in Medicare.
  I look forward to working with my colleagues in the Senate to ensure 
we make the necessary investments in our primary care workforce. Mr. 
President, I ask unanimous consent that the text of the bill and 
letters of support be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1174

       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 of 2009''.
       (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. Educating medical students about primary care careers.
Sec. 105. Training in a family medicine, general internal medicine, 
              general geriatrics, general pediatrics, physician 
              assistant education, general dentistry, and pediatric 
              dentistry.
Sec. 106. Increased funding for National Health Service Corps 
              Scholarship and Loan Repayment Programs.

                 TITLE II--MEDICAID RELATED PROVISIONS

Sec. 201. Transformation grants to support patient centered medical 
              homes under Medicaid and CHIP.

                     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 
              and primary care providers to assist Medicare 
              beneficiaries in obtaining needed prescriptions under 
              Medicare part D.
Sec. 322. HHS study and report on improved patient care through 
              increased caregiver and physician interaction.
Sec. 323. Improved patient care through expanded support for limited 
              English proficiency (LEP) services.
Sec. 324. HHS study and report on use of real-time Medicare claims 
              adjudication.
Sec. 325. Ongoing assessment by MedPAC of the impact of medicare 
              payments on primary care access and equity.
Sec. 326. Distribution of additional residency positions.
Sec. 327. Counting resident time in outpatient settings.
Sec. 328. Rules for counting resident time for didactic and scholarly 
              activities and other activities.
Sec. 329. Preservation of resident cap positions from closed and 
              acquired hospitals.
Sec. 330. Quality improvement organization assistance for physician 
              practices seeking to be patient centered medical home 
              practices.

                           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 and primary care providers 
     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 or primary care 
     providers 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.--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.

[[Page S6037]]

       (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.
       (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 a 
     primary care field.
       (3) Physician.--The term physician has the meaning given 
     such term in section 1861(r)(1) of the Social Security Act.
       (4) 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.
       (5) Primary care field.--The term ``primary care field'' 
     means any of the following fields:
       (A) The field of family medicine.
       (B) The field of general internal medicine.
       (C) The field of geriatric medicine.
       (D) The field of pediatric medicine
       (6) Primary care physician.--The term ``primary care 
     physician'' means a physician who is trained in a primary 
     care field who provides first contact, continuous, and 
     comprehensive care to patients.
       (7) Primary care provider.--The term ``primary care 
     provider'' means--
       (A) a nurse practitioner; or
       (B) a physician assistant practicing as a member of a 
     physician-directed team;
     who provides first contact, continuous, and comprehensive 
     care to patients.
       (8) Principal care.--The term ``principal care'' means 
     integrated, accessible health care that is provided by a 
     physician who is a medical subspecialist 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.
       (9) 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 a primary care field, 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 
     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.
       (ii) The area has a population to full-time-equivalent 
     primary care physician ratio of less than 3,500 to 1 and has 
     unusually high needs for primary care services or 
     insufficient capacity of existing primary care providers.
       (C) Primary care providers in contiguous geographic areas 
     are overutilized.
       (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 
     variables 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 (or a 
     nurse practitioner directed practice in those States in which 
     such functions are included in the scope of practice of 
     licensed nurse practitioners) that has been certified by an 
     organization under paragraph (3) 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 or a primary care 
     provider 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.
       (2) Recognition of ncqa approval.--Such term also includes 
     a physician-directed (or nurse-practitioner-directed) 
     practice that has been recognized as a medical home through 
     the Physician Practice Connections--patient centered Medical 
     Home (``PPC-PCMH'') voluntary recognition process of the 
     National Committee for Quality Assurance.
       (3) 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.
       (4) Treatment of certain practices.--Nothing in this 
     section shall be construed as preventing a nurse practitioner 
     from leading a patient-centered medical home so long as--
       (A) all of the requirements of this section are met; and
       (B) the nurse practitioner is acting consistently with 
     State law.
       (e) Application Under Medicare, Medicaid, PHSA, etc.--
     Unless otherwise provided, the provisions of the previous 
     subsections shall apply for purposes of provisions of the 
     Social Security Act, the Public Health Service Act, and any 
     other Act amended by this Act.

                       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.
       ``(4) Development of generalist curriculum to enhance care 
     for rural and underserved populations in primary care or 
     general surgery.
       ``(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

[[Page S6038]]

     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 a primary care field (as defined in 
     section 3(a)(5) of the Preserving Patient Access to Primary 
     Care Act of 2009).
       ``(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 a primary care field; 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 $35,000 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 a primary care field.
       ``(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.

     ``SEC. 340J. LOAN REPAYMENT PROGRAM.

       ``(a) Purpose.--It is the purpose of this section to 
     alleviate critical shortages of primary care physicians and 
     primary care providers.
       ``(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 or primary care provider 
     in a primary care field; and
       ``(B) in an area that is not a health professional shortage 
     area (as designated under section 332), but has a critical 
     shortage of primary care physicians and primary care 
     providers (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--
       ``(1) an individual with a degree in medicine or 
     osteopathic medicine; or
       ``(2) a primary care provider (as defined in section 
     3(a)(7) of the Preserving Patient Access to Primary Care Act 
     of 2009).

     ``SEC. 340K. LOAN REPAYMENTS FOR PHYSICIANS IN THE FIELDS OF 
                   OBSTETRICS AND GYNECOLOGY AND CERTIFIED NURSE 
                   MIDWIVES.

       ``(a) Purpose.--It is the purpose of this section to 
     alleviate critical shortages of physicians in the fields of 
     obstetrics and gynecology and certified nurse midwives.
       ``(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 physician in the field of obstetrics and 
     gynecology or as a certified nurse midwife; 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 in the fields of obstetrics and 
     gynecology or certified nurse midwives (as determined by the 
     Secretary), respectively; 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--
       ``(1) a physician in the field of obstetrics and 
     gynecology; or
       ``(2) a certified nurse midwife.

     ``SEC. 340L. REPORTS.

       ``Not later than 18 months after the date of enactment of 
     this section, 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. 340M. AUTHORIZATION OF APPROPRIATIONS.

       ``To carry out sections 340I, 340J, and 340K there are 
     authorized to be appropriated $55,000,000 for fiscal year 
     2010, $90,000,000 for fiscal year 2011, and $125,000,000 for 
     fiscal year 2012, to be used solely for scholarships and loan 
     repayment awards for primary care physicians and primary care 
     providers.''.

     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 a primary care field (as defined in 
     section 3(a)(5) of the Preserving Patient Access to Primary 
     Care Act of 2009)'' 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 a primary care field (as defined in section 
     3(a)(5) of the Preserving Patient Access to Primary Care Act 
     of 2009)'' 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 a primary care field (as defined in 
     section 3(a)(5) of the Preserving Patient Access to Primary 
     Care Act of 2009)'' 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 a primary care field (as defined in 
     section 3(a)(5) of the Preserving Patient Access to Primary 
     Care Act of 2009)'' after ``residency program''.

     SEC. 104. 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

[[Page S6039]]

     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; 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 2010 through 
     2013.''.

     SEC. 105. TRAINING IN A FAMILY MEDICINE, GENERAL INTERNAL 
                   MEDICINE, GENERAL GERIATRICS, GENERAL 
                   PEDIATRICS, PHYSICIAN ASSISTANT EDUCATION, 
                   GENERAL DENTISTRY, AND PEDIATRIC DENTISTRY.

       Section 747(e) of the Public Health Service Act (42 U.S.C. 
     293k) is amended by striking paragraph (1) and inserting the 
     following:
       ``(1) Authorization of appropriations.--For the purpose of 
     carrying out this section, there is authorized to be 
     appropriated $198,000,000 for each of fiscal years 2010 
     through 2012.''.

     SEC. 106. INCREASED FUNDING FOR NATIONAL HEALTH SERVICE CORPS 
                   SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS.

       (a) In General.--There is authorized to be appropriated 
     $332,000,000 for the period of fiscal years 2010 through 2012 
     for the purpose of carrying out subpart III of part D of 
     title III of the Public Health Service Act (42 U.S.C. 254l et 
     seq.). Such authorization of appropriations is in addition to 
     the authorization of appropriations in section 338H of such 
     Act (42 U.S.C. 254q) and any other authorization of 
     appropriations for such purpose.
       (b) Allocation.--Of the amounts appropriated under 
     subsection (a) for the period of fiscal years 2010 through 
     2012, the Secretary shall obligate $96,000,000 for the 
     purpose of providing contracts for scholarships and loan 
     repayments to individuals who--
       (1) are primary care physicians or primary care providers; 
     and
       (2) have not previously received a scholarship or loan 
     repayment under subpart III of part D of title III of the 
     Public Health Service Act (42 U.S.C. 254l et seq.).

                 TITLE II--MEDICAID RELATED PROVISIONS

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

       (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 of 2009 for medical practices to qualify as 
     patient centered medical homes (as defined in paragraph (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, 2010.

                     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)) 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 2010, 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:
       ``(n) 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 care 
     provider 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, 2010.

     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)) is amended--
       (1) in subparagraph (DD), by striking ``and'' at the end;
       (2) in subparagraph (EE), by inserting ``and'' at the end; 
     and

[[Page S6040]]

       (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) 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 (as defined in section 
     3(d) of the Preserving Patient Access to Primary Care Act of 
     2009).''.
       (c) Monthly Fee for Patient Centered Medical Home 
     Services.--Section 1848 of the Social Security Act (42 U.S.C. 
     1395w-4) is amended by adding at the end the following new 
     subsection:
       ``(p) 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 the Medicare 
     Improvement and Extension Act of 2006 (42 U.S.C. 1395b-1 
     note; division B of Public Law 109-432) 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; 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 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 302(c), is amended 
     by adding at the end the following new subsection:
       ``(q) 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 and primary care 
     provider organizations, the Medicare Payment Advisory 
     Commission, and other experts, to increase payments under 
     this section for designated evaluation and management 
     services provided by primary care physicians, primary care 
     providers, and principal care providers 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 providers to qualify for such increased payments, 
     including consideration of--
       ``(A) the type of service being rendered;
       ``(B) the specialty of the provider providing the service; 
     and
       ``(C) demonstration by the provider 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:
       ``(x) 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, 2010, by a primary care 
     physician or primary care provider 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; primary care provider.--The 
     terms `primary care physician' and `primary care provider' 
     have the meaning given such terms in paragraphs (6) and (7), 
     respectively, of section 3(a) of the Preserving Patient 
     Access to Primary Care Act of 2009.
       ``(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

[[Page S6041]]

     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, 
     primary care providers, 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(x) 
     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)) 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)) is amended--
       (1) in paragraph (1)--
       (A) by inserting ``or on or after July 1, 2009'' after 
     ``before July 1, 2008''; and
       (B) by inserting ``(or, in the case of services furnished 
     on or after July 1, 2009, 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)(6)); 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, primary care 
     providers, or 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)) 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, 
     2010.

     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 (42 U.S.C. 1395w(dd)) 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 302, 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)(3), 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)) 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 ``, (5)'' and all that follows up to the 
     period at the end.

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

       (a) Study.--The Secretary, in consultation with provider 
     organizations and other appropriate stakeholders, shall 
     conduct a study on--
       (1) ways to assist primary care physicians and primary care 
     providers (as defined in section 3(a)) in--
       (A) furnishing appropriate preventive services (as defined 
     in section 1861(ddd)(3) of the Social Security Act, as added 
     by section 312) to individuals enrolled under part B of title 
     XVIII of such Act; and

[[Page S6042]]

       (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 and primary 
     care providers 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 AND PRIMARY CARE PROVIDERS 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 
     role of physicians and primary care providers 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 work of the physician and primary care 
     provider 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. 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 or primary care providers 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 work of physicians and primary 
     care providers 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 caregivers and physicians or 
     primary care providers 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. 323. IMPROVED PATIENT CARE THROUGH EXPANDED SUPPORT FOR 
                   LIMITED ENGLISH PROFICIENCY (LEP) SERVICES.

       (a) Additional Payments for Primary Care Physicians and 
     Primary Care Providers.--Section 1833 of the Social Security 
     Act (42 U.S.C. 1395l), as amended by section 304, is amended 
     by adding at the end the following new subsection:
       ``(y) Additional Payments for Providing Services to 
     Individuals With Limited English Proficiency.--
       ``(1) In general.--In the case of primary care providers' 
     services furnished on or after January 1, 2010, to an 
     individual with limited English proficiency by a provider, 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 
     primary care physicians, primary care 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 physicians and primary care providers 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 2010.

     SEC. 324. HHS STUDY AND REPORT ON USE OF REAL-TIME MEDICARE 
                   CLAIMS ADJUDICATION.

       (a) Study.--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, 2011, 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. 325. ONGOING ASSESSMENT BY MEDPAC OF THE IMPACT OF 
                   MEDICARE PAYMENTS ON PRIMARY CARE ACCESS AND 
                   EQUITY.

       The Medicare Payment Advisory Commission, beginning in 2010 
     and in each of its subsequent annual reports to Congress on 
     Medicare physician payment policies, shall provide an 
     assessment of the impact of changes in Medicare payment 
     policies in improving access to and equity of payments to 
     primary care physicians and primary care providers. Such 
     assessment shall include an assessment of the effectiveness, 
     once implemented, of the Medicare payment-related reforms 
     required by this Act to support primary care as well as any 
     other payment changes that may be required by Congress to 
     improve access to and equity of payments to primary care 
     physicians and primary care providers.

     SEC. 326. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.

       (a) In General.--Section 1886(h) of the Social Security Act 
     (42 U.S.C. 1395ww(h)) is amended--
       (1) in paragraph (4)(F)(i), by striking ``paragraph (7)'' 
     and inserting ``paragraphs (7) and (8)'';
       (2) in paragraph (4)(H)(i), by striking ``paragraph (7)'' 
     and inserting ``paragraphs (7) and (8)''; and
       (3) by adding at the end the following new paragraph:
       ``(8) Distribution of additional residency positions.--
       ``(A) Additional residency positions.--
       ``(i) Reduction in limit based on unused positions.--

       ``(I) In general.--The Secretary shall reduce the otherwise 
     applicable resident limit for a hospital that the Secretary 
     determines had residency positions that were unused for all 5 
     of the most recent cost reporting periods ending prior to the 
     date of enactment of this paragraph by an amount that is 
     equal to the number of such unused residency positions.
       ``(II) Exception for rural hospitals and certain other 
     hospitals.--This subparagraph shall not apply to a hospital--

       ``(aa) located in a rural area (as defined in subsection 
     (d)(2)(D)(ii));
       ``(bb) that has participated in a voluntary reduction plan 
     under paragraph (6); or
       ``(cc) that has participated in a demonstration project 
     approved as of October 31, 2003, under the authority of 
     section 402 of Public Law 90-248.
       ``(ii) Number available for distribution.--The number of 
     additional residency positions available for distribution 
     under subparagraph (B) shall be an amount that the Secretary 
     determines would result in a 15 percent increase in the 
     aggregate number of full-time equivalent residents in 
     approved medical training programs (as determined based on 
     the most recent cost reports available at the time of 
     distribution). One-third of such number shall only be 
     available for distribution to hospitals described in 
     subclause (I) of subparagraph (B)(ii) under such 
     subparagraph.
       ``(B) Distribution.--
       ``(i) In general.--The Secretary shall increase the 
     otherwise applicable resident limit for each qualifying 
     hospital that submits an application under this subparagraph 
     by such number as the Secretary may approve for portions of 
     cost reporting periods occurring on or after the date of 
     enactment of this paragraph. The aggregate number of 
     increases in the otherwise applicable resident limit under 
     this subparagraph shall be equal to the number of additional 
     residency positions available for distribution under 
     subparagraph (A)(ii).
       ``(ii) Distribution to hospitals already operating over 
     resident limit.--

       ``(I) In general.--Subject to subclause (II), in the case 
     of a hospital in which the reference resident level of the 
     hospital (as defined in clause (ii)) is greater than the 
     otherwise applicable resident limit, the increase in the 
     otherwise applicable resident limit

[[Page S6043]]

     under this subparagraph shall be an amount equal to the 
     product of the total number of additional residency positions 
     available for distribution under subparagraph (A)(ii) and the 
     quotient of--

       ``(aa) the number of resident positions by which the 
     reference resident level of the hospital exceeds the 
     otherwise applicable resident limit for the hospital; and
       ``(bb) the number of resident positions by which the 
     reference resident level of all such hospitals with respect 
     to which an application is approved under this subparagraph 
     exceeds the otherwise applicable resident limit for such 
     hospitals.

       ``(II) Requirements.--A hospital described in subclause 
     (I)--

       ``(aa) is not eligible for an increase in the otherwise 
     applicable resident limit under this subparagraph unless the 
     amount by which the reference resident level of the hospital 
     exceeds the otherwise applicable resident limit is not less 
     than 10 and the hospital trains at least 25 percent of the 
     full-time equivalent residents of the hospital in primary 
     care and general surgery (as of the date of enactment of this 
     paragraph); and
       ``(bb) shall continue to train at least 25 percent of the 
     full-time equivalent residents of the hospital in primary 
     care and general surgery for the 10-year period beginning on 
     such date.

     In the case where the Secretary determines that a hospital no 
     longer meets the requirement of item (bb), the Secretary may 
     reduce the otherwise applicable resident limit of the 
     hospital by the amount by which such limit was increased 
     under this clause.
       ``(III) Clarification regarding eligibility for other 
     additional residency positions.--Nothing in this clause shall 
     be construed as preventing a hospital described in subclause 
     (I) from applying for additional residency positions under 
     this paragraph that are not reserved for distribution under 
     this clause.

       ``(iii) Reference resident level.--

       ``(I) In general.--Except as otherwise provided in 
     subclause (II), the reference resident level specified in 
     this clause for a hospital is the resident level for the most 
     recent cost reporting period of the hospital ending on or 
     before the date of enactment of this paragraph, for which a 
     cost report has been settled (or, if not, submitted (subject 
     to audit)), as determined by the Secretary.
       ``(II) Use of most recent accounting period to recognize 
     expansion of existing program or establishment of new 
     program.--If a hospital submits a timely request to increase 
     its resident level due to an expansion of an existing 
     residency training program or the establishment of a new 
     residency training program that is not reflected on the most 
     recent cost report that has been settled (or, if not, 
     submitted (subject to audit)), after audit and subject to the 
     discretion of the Secretary, the reference resident level for 
     such hospital is the resident level for the cost reporting 
     period that includes the additional residents attributable to 
     such expansion or establishment, as determined by the 
     Secretary.

       ``(C) Considerations in redistribution.--In determining for 
     which hospitals the increase in the otherwise applicable 
     resident limit is provided under subparagraph (B) (other than 
     an increase under subparagraph (B)(ii)), the Secretary shall 
     take into account the demonstrated likelihood of the hospital 
     filling the positions within the first 3 cost reporting 
     periods beginning on or after July 1, 2010, made available 
     under this paragraph, as determined by the Secretary.
       ``(D) Priority for certain areas.--In determining for which 
     hospitals the increase in the otherwise applicable resident 
     limit is provided under subparagraph (B) (other than an 
     increase under subparagraph (B)(ii)), the Secretary shall 
     distribute the increase to hospitals based on the following 
     criteria:
       ``(i) The Secretary shall give preference to hospitals that 
     submit applications for new primary care and general surgery 
     residency positions. In the case of any increase based on 
     such preference, a hospital shall ensure that--

       ``(I) the position made available as a result of such 
     increase remains a primary care or general surgery residency 
     position for not less than 10 years after the date on which 
     the position is filled; and
       ``(II) the total number of primary care and general surgery 
     residency positions in the hospital (determined based on the 
     number of such positions as of the date of such increase, 
     including any position added as a result of such increase) is 
     not decreased during such 10-year period.

     In the case where the Secretary determines that a hospital no 
     longer meets the requirement of subclause (II), the Secretary 
     may reduce the otherwise applicable resident limit of the 
     hospital by the amount by which such limit was increased 
     under this paragraph.
       ``(ii) The Secretary shall give preference to hospitals 
     that emphasizes training in community health centers and 
     other community-based clinical settings.
       ``(iii) The Secretary shall give preference to hospitals in 
     States that have more medical students than residency 
     positions available (including a greater preference for those 
     States with smaller resident-to-medical-student ratios). In 
     determining the number of medical students in a State for 
     purposes of the preceding sentence, the Secretary shall 
     include planned students at medical schools which have 
     provisional accreditation by the Liaison Committee on Medical 
     Education or the American Osteopathic Association.
       ``(iv) The Secretary shall give preference to hospitals in 
     States that have low resident-to-population ratios (including 
     a greater preference for those States with lower resident-to-
     population ratios).
       ``(E) Limitation.--
       ``(i) In general.--Except as provided in clause (ii), in no 
     case may a hospital (other than a hospital described in 
     subparagraph (B)(ii)(I), subject to the limitation under 
     subparagraph (B)(ii)(III)) apply for more than 50 full-time 
     equivalent additional residency positions under this 
     paragraph.
       ``(ii) Increase in number of additional positions available 
     for distribution.--The Secretary shall increase the number of 
     full-time equivalent additional residency positions a 
     hospital may apply for under this paragraph if the Secretary 
     determines that the number of additional residency positions 
     available for distribution under subparagraph (A)(ii) exceeds 
     the number of such applications approved.
       ``(F) Application of per resident amounts for primary care 
     and nonprimary care.--With respect to additional residency 
     positions in a hospital attributable to the increase provided 
     under this paragraph, the approved FTE resident amounts are 
     deemed to be equal to the hospital per resident amounts for 
     primary care and nonprimary care computed under paragraph 
     (2)(D) for that hospital.
       ``(G) Distribution.--The Secretary shall distribute the 
     increase to hospitals under this paragraph not later than 2 
     years after the date of enactment of this paragraph.''.
       (b) IME.--
       (1) In general.--Section 1886(d)(5)(B)(v) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 
     sentence, is amended--
       (A) by striking ``subsection (h)(7)'' and inserting 
     ``subsections (h)(7) and (h)(8)''; and
       (B) by striking ``it applies'' and inserting ``they 
     apply''.
       (2) Conforming provision.--Section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 
     adding at the end the following clause:
       ``(x) For discharges occurring on or after the date of 
     enactment of this clause, insofar as an additional payment 
     amount under this subparagraph is attributable to resident 
     positions distributed to a hospital under subsection 
     (h)(8)(B), the indirect teaching adjustment factor shall be 
     computed in the same manner as provided under clause (ii) 
     with respect to such resident positions.''.

     SEC. 327. COUNTING RESIDENT TIME IN OUTPATIENT SETTINGS.

       (a) D-GME.--Section 1886(h)(4)(E) of the Social Security 
     Act (42 U.S.C. 1395ww(h)(4)(E)) is amended--
       (1) by striking ``under an approved medical residency 
     training program''; and
       (2) by striking ``if the hospital incurs all, or 
     substantially all, of the costs for the training program in 
     that setting'' and inserting ``if the hospital continues to 
     incur the costs of the stipends and fringe benefits of the 
     resident during the time the resident spends in that 
     setting''.
       (b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended--
       (1) by striking ``under an approved medical residency 
     training program''; and
       (2) by striking ``if the hospital incurs all, or 
     substantially all, of the costs for the training program in 
     that setting'' and inserting ``if the hospital continues to 
     incur the costs of the stipends and fringe benefits of the 
     intern or resident during the time the intern or resident 
     spends in that setting''.
       (c) Effective Dates; Application.--
       (1) In general.--Effective for cost reporting periods 
     beginning on or after July 1, 2009, the Secretary of Health 
     and Human Services shall implement the amendments made by 
     this section in a manner so as to apply to cost reporting 
     periods beginning on or after July 1, 2009.
       (2) Application.--The amendments made by this section shall 
     not be applied in a manner that requires reopening of any 
     settled hospital cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security (42 U.S.C. 1395ww(d)(5)(B))Act or for direct 
     graduate medical education costs under section 1886(h) of 
     such Act (42 U.S.C. 1395ww(h)).

     SEC. 328. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND 
                   SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.

       (a) GME.--Section 1886(h) of the Social Security Act (42 
     U.S.C. 1395ww(h)), as amended by section 327(a), is amended--
       (1) in paragraph (4)(E)--
       (A) by designating the first sentence as a clause (i) with 
     the heading ``In general'' and appropriate indentation and by 
     striking ``Such rules'' and inserting ``Subject to clause 
     (ii), such rules''; and
       (B) by adding at the end the following new clause:
       ``(ii) Treatment of certain nonhospital and didactic 
     activities.--Such rules shall provide that all time spent by 
     an intern or resident in an approved medical residency 
     training program in a nonhospital setting that is primarily 
     engaged in furnishing patient care (as defined in paragraph 
     (5)(K)) in non-patient care activities, such as didactic 
     conferences and seminars, but not including research not 
     associated with the treatment or diagnosis of a particular 
     patient, as such

[[Page S6044]]

     time and activities are defined by the Secretary, shall be 
     counted toward the determination of full-time equivalency.'';
       (2) in paragraph (4), by adding at the end the following 
     new subparagraph:
       ``(I) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subsection, all the 
     time that is spent by an intern or resident in an approved 
     medical residency training program on vacation, sick leave, 
     or other approved leave, as such time is defined by the 
     Secretary, and that does not prolong the total time the 
     resident is participating in the approved program beyond the 
     normal duration of the program shall be counted toward the 
     determination of full-time equivalency.''; and
       (3) in paragraph (5), by adding at the end the following 
     new subparagraph:
       ``(M) Nonhospital setting that is primarily engaged in 
     furnishing patient care.--The term `nonhospital setting that 
     is primarily engaged in furnishing patient care' means a 
     nonhospital setting in which the primary activity is the care 
     and treatment of patients, as defined by the Secretary.''.
       (b) IME Determinations.--Section 1886(d)(5)(B) of such Act 
     (42 U.S.C. 1395ww(d)(5)(B)), as amended by section 326(b), is 
     amended by adding at the end the following new clause:
       ``(xi)(I) The provisions of subparagraph (I) of subsection 
     (h)(4) shall apply under this subparagraph in the same manner 
     as they apply under such subsection.
       ``(II) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subparagraph, all 
     the time spent by an intern or resident in an approved 
     medical residency training program in non-patient care 
     activities, such as didactic conferences and seminars, as 
     such time and activities are defined by the Secretary, that 
     occurs in the hospital shall be counted toward the 
     determination of full-time equivalency if the hospital--
       ``(aa) is recognized as a subsection (d) hospital;
       ``(bb) is recognized as a subsection (d) Puerto Rico 
     hospital;
       ``(cc) is reimbursed under a reimbursement system 
     authorized under section 1814(b)(3); or
       ``(dd) is a provider-based hospital outpatient department.
       ``(III) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subparagraph, all 
     the time spent by an intern or resident in an approved 
     medical residency training program in research activities 
     that are not associated with the treatment or diagnosis of a 
     particular patient, as such time and activities are defined 
     by the Secretary, shall not be counted toward the 
     determination of full-time equivalency.''.
       (c) Effective Dates; Application.--
       (1) In general.--Except as otherwise provided, the 
     Secretary of Health and Human Services shall implement the 
     amendments made by this section in a manner so as to apply to 
     cost reporting periods beginning on or after January 1, 1983.
       (2) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social 
     Security Act, as added by subsection (a)(1)(B), shall apply 
     to cost reporting periods beginning on or after July 1, 2009.
       (3) IME.--Section 1886(d)(5)(B)(xi)(III) of the Social 
     Security Act, as added by subsection (b), shall apply to cost 
     reporting periods beginning on or after October 1, 2001. Such 
     section, as so added, shall not give rise to any inference on 
     how the law in effect prior to such date should be 
     interpreted.
       (4) Application.--The amendments made by this section shall 
     not be applied in a manner that requires reopening of any 
     settled hospital cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security Act or for direct graduate medical education 
     costs under section 1886(h) of such Act.

     SEC. 329. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED 
                   AND ACQUIRED HOSPITALS.

       (a) GME.--Section 1886(h)(4)(H) of the Social Security Act 
     (42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at 
     the end the following new clauses:
       ``(vi) Redistribution of residency slots after a hospital 
     closes.--

       ``(I) In general.--Subject to the succeeding provisions of 
     this clause, the Secretary shall, by regulation, establish a 
     process under which, in the case where a hospital with an 
     approved medical residency program closes on or after the 
     date of enactment of the Balanced Budget Act of 1997, the 
     Secretary shall increase the otherwise applicable resident 
     limit under this paragraph for other hospitals in accordance 
     with this clause.
       ``(II) Priority for hospitals in certain areas.--Subject to 
     the succeeding provisions of this clause, in determining for 
     which hospitals the increase in the otherwise applicable 
     resident limit is provided under such process, the Secretary 
     shall distribute the increase to hospitals located in the 
     following priority order (with preference given within each 
     category to hospitals that are members of the same affiliated 
     group (as defined by the Secretary under clause (ii)) as the 
     closed hospital):

       ``(aa) First, to hospitals located in the same core-based 
     statistical area as, or a core-based statistical area 
     contiguous to, the hospital that closed.
       ``(bb) Second, to hospitals located in the same State as 
     the hospital that closed.
       ``(cc) Third, to hospitals located in the same region of 
     the country as the hospital that closed.
       ``(dd) Fourth, to all other hospitals.

       ``(III) Requirement hospital likely to fill position within 
     certain time period.--The Secretary may only increase the 
     otherwise applicable resident limit of a hospital under such 
     process if the Secretary determines the hospital has 
     demonstrated a likelihood of filling the positions made 
     available under this clause within 3 years.
       ``(IV) Limitation.--The aggregate number of increases in 
     the otherwise applicable resident limits for hospitals under 
     this clause shall be equal to the number of resident 
     positions in the approved medical residency programs that 
     closed on or after the date described in subclause (I).

       ``(vii) Special rule for acquired hospitals.--

       ``(I) In general.--In the case of a hospital that is 
     acquired (through any mechanism) by another entity with the 
     approval of a bankruptcy court, during a period determined by 
     the Secretary (but not less than 3 years), the applicable 
     resident limit of the acquired hospital shall, except as 
     provided in subclause (II), be the applicable resident limit 
     of the hospital that was acquired (as of the date immediately 
     before the acquisition), without regard to whether the 
     acquiring entity accepts assignment of the Medicare provider 
     agreement of the hospital that was acquired, so long as the 
     acquiring entity continues to operate the hospital that was 
     acquired and to furnish services, medical residency programs, 
     and volume of patients similar to the services, medical 
     residency programs, and volume of patients of the hospital 
     that was acquired (as determined by the Secretary) during 
     such period.
       ``(II) Limitation.--Subclause (I) shall only apply in the 
     case where an acquiring entity waives the right as a new 
     provider under the program under this title to have the 
     otherwise applicable resident limit of the acquired hospital 
     re-established or increased.''.

       (b) IME.--Section 1886(d)(5)(B)(v) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, 
     as amended by section 326(b), is amended by striking 
     ``subsections (h)(7) and (h)(8)'' and inserting ``subsections 
     (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and (h)(8)''.
       (c) Application.--The amendments made by this section shall 
     not be applied in a manner that requires reopening of any 
     settled hospital cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B))or for direct 
     graduate medical education costs under section 1886(h) of 
     such Act (42 U.S.C. 1395ww(h)).
       (d) No Affect on Temporary FTE Cap Adjustments.--The 
     amendments made by this section shall not affect any 
     temporary adjustment to a hospital's FTE cap under section 
     413.79(h) of title 42, Code of Federal Regulations (as in 
     effect on the date of enactment of this Act).

     SEC. 330. 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 of Health and Human Services shall revise 
     the 9th Statement of Work under the Quality Improvement 
     Program under part B of title XI of the Social Security Act 
     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).

                           TITLE IV--STUDIES

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

       (a) In General.--Not later than June 30, 2010, 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

[[Page S6045]]

     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.
                                  ____

                                               American College of


                                Osteopathic Family Physicians,

                              Arlington Heights, IL, May 21, 2009.
     Hon. Maria Cantwell,
     U.S. Senate,
     Washington, DC.
       Dear Senator Cantwell: On behalf of the American College of 
     Osteopathic Family Physicians (ACOFP), I am pleased to offer 
     you our strong support for the ``Preserving Patient Access to 
     Primary Care Act''. This legislation lays the groundwork for 
     a much needed boost to the primary care physician workforce 
     through reforms of both the Medicare payment system and the 
     graduate medical education (GME) system. The ACOFP lauds your 
     ambitious leadership on these important issues and looks 
     forward to helping you secure enactment of this legislation.
       As you are well aware, the current Medicare physician 
     payment system neglects to recognize the value of primary 
     care services in the health care delivery system. Studies 
     show that access to primary health care is associated with 
     better health outcomes and lower health care costs. We 
     commend you on the emphasis your legislation places on 
     addressing payment equity among physicians by increasing 
     payments for evaluation and management services and providing 
     bonus payments for care coordination and other tenets central 
     to the delivery of primary care.
       The ACOFP applauds the provisions included in the 
     ``Preserving Patient Access to Primary Care Act'' to expand 
     the Patient Centered Medical Home (PCMH). Building upon the 
     progress made in the current Medicare demonstration projects, 
     your legislation would require that Medicare transition to a 
     new payment methodology to provide monthly payments to PCMH 
     practices that provide care coordination to Medicare 
     beneficiaries. Additionally, grants to states for inclusion 
     of the PCMH into Medicaid and SCHIP programs will further 
     provide patients with on-going access to coordinated care by 
     a physician.
       Over the last decade, the population of our country has 
     increased and grown older. Increasing access to health care 
     coverage for all Americans is at the center of the health 
     care reform debate. We must work to ensure that our nation's 
     physician workforce is capable of meeting future increased 
     demand. Central to achieving this is a strong GME system.
       The current Medicare payment system in the United States 
     neglects the value of didactic experiences, training 
     opportunities in non-hospital settings, and voluntary 
     physician supervision of medical residents within the GME 
     system. The ACOFP is supportive of your efforts to create new 
     training opportunities in non-hospital settings as well as 
     those seeking to clarify existing regulations governing non-
     hospital training. Recent statistics associated with career 
     choices of medical school graduates reveal the acute need to 
     increase our nation's supply of family physicians. The ACOFP 
     strongly believes that by providing experiences in non-
     hospital settings for resident physicians, especially those 
     in primary care specialties, increases the likelihood that 
     they will seek practice opportunities in those settings.
       Finally, the ACOFP supports your efforts to increase the 
     number of primary care physicians through new scholarship and 
     loan forgiveness programs. We recognize that the education 
     debt burden carried by medical school graduates discourages 
     students from seeking careers in public health service, 
     seeking careers in family practice or practicing in 
     underserved areas. According to the American Association of 
     Colleges of Osteopathic Medicine (AACOM), the average 
     osteopathic medical school graduate has a debt load of 
     $168,031. Further, the average first year medical resident 
     stipend is $44,747. Scholarships and loan forgiveness for 
     physicians who agree to practice primary care medicine in 
     underserved areas would allow medical school graduates to 
     pursue careers in medical specialties based upon their 
     individual career interests rather than their financial 
     obligations, while additionally addressing geographic 
     disparities in access to care.
       Again, thank you for your leadership on this important 
     legislation. The ACOFP and our members stand ready to assist 
     you in securing enactment of this important legislation.
           Respectfully,
                                                    Jan D. Zieren,
     ACOFP President.
                                  ____

                                                     May 20, 2009.
     Hon. Maria Cantwell,
     U.S. Senate,
     Washington, DC.
       Dear Senator Cantwell: I am writing on behalf of the 
     American Nurses Association (ANA) to applaud your efforts to 
     address the shortage of primary care providers by introducing 
     the Preserving Patient Access to Primary Care Act of 2009. 
     ANA strongly supports this legislation because it recognizes 
     the integral role nurses and nurse practitioners play in the 
     delivery of primary care and helps bring the focus of our 
     health care system back where it belongs--on the patient and 
     the community.
       The American Nurses Association is the only full-service 
     national association representing the interests of 2.9 
     million registered nurses (RNs). Through our 51 constituent 
     nursing associations, we represent RNs across the nation in 
     all educational and practice settings. ANA believes that a 
     health care system that is patient-centered, comprehensive, 
     accessible, and delivers quality care for all is something 
     that should not be a partisan or political issue.
       The Preserving Patient Access to Primary Care Act of 2009 
     would provide scholarship and loan repayment opportunities 
     for primary care providers who serve in areas with critical 
     shortages of primary care services. Secondly, the bill would 
     increase Medicare reimbursements for primary care providers, 
     and provide Medicare payments for care coordination services, 
     and monthly payments to practices which serve as patient 
     centered medical homes. Moreover, the Preserving Patient 
     Access to Primary Care Act of 2009 aims to support an 
     interdisciplinary model in which providers, physicians and 
     nurses, are able to practice collaboratively and to the full 
     extent of their education and licensure on behalf of the 
     patient.
       The American Nurses Association is proud to support this 
     legislation and we look forward to working with you and 
     others in the health care community to ensure that your 
     vision of strengthening primary care becomes reality.
           Sincerely,

                                                Rose Gonzalez,

                                     Director, Government Affairs,
     American Nurses Association.
                                  ____



                             American Osteopathic Association,

                                     Washington, DC, May 20, 2009.
     Hon. Maria Cantwell,
     U.S. Senate,
     Washington, DC.
     Hon. Susan Collins,
     U.S. Senate,
     Washington, DC.
       Dear Senators Cantwell and Collins: On behalf of the 
     American Osteopathic Association (AOA) and the 64,000 
     osteopathic physicians it represents, I am pleased to inform 
     you of our strong support for the ``Preserving Patient Access 
     to Primary Care Act.'' We believe your legislation would 
     provide a critical boost to the primary care physician 
     workforce through innovative changes to the Medicare payment 
     structure and graduate medical education system, among other 
     reforms. The AOA commends your leadership on these important 
     issues and we are committed to assisting you in securing 
     enactment of this legislation.
       We applaud the emphasis your legislation places upon 
     improving primary care through alternative payment 
     mechanisms. As you know, the Medicare physician payment 
     system is fundamentally flawed and fails to recognize the 
     value of primary care services in achieving savings through 
     prevention and care coordination. Studies indicate that 
     income disparities have a significant negative impact on the 
     choice of primary care as a career. The ``Preserving Patient 
     Access to Primary Care Act'' would promote payment equity for 
     primary care physicians by increasing payments for evaluation 
     and management services and providing bonus payments for 
     other important primary services. The AOA appreciates your 
     foresight and recognition of the long-term savings that will 
     be realized through increased access to primary care.
       The AOA strongly supports an expansion of the Patient 
     Centered Medical Home (PCMH) through the Medicare 
     demonstration project and grants to states for inclusion of 
     PCMH models in their Medicaid and SCHIP programs. Your 
     legislation provides a monthly primary care management fee 
     for physicians who are designated the health home of a 
     Medicare beneficiary and provide continuous

[[Page S6046]]

     medical care. This policy is consistent with the principles 
     of the patient-centered medical home as envisioned by the 
     AOA. The PCMH payment policy contained in this legislation 
     accounts for the considerable practice expenses involved in 
     comprehensive care coordination and facilitates widespread 
     adoption of the medical home. The AOA strongly supports this 
     move toward a model of health care delivery that is based on 
     an ongoing personal relationship with a physician.
       Over the past 10 years our population has increased and 
     aged, and to ensure that our nation's physician workforce is 
     capable of meeting increased demand, we must begin to educate 
     and train a larger cadre of physicians now. A strong graduate 
     medical education (GME) system capable of providing training 
     opportunities across specialties and geographic regions is 
     central to building the physician workforce. However, these 
     institutions are currently confronted with fierce competition 
     from private markets, increasing costs and shrinking federal 
     support. In addition to increasing residency training 
     programs to meet the needs of our growing population, this 
     legislation would appropriately permit Direct Graduate 
     Medical Education (DGME) and Indirect Medical Education (IME) 
     reimbursement for didactic educational activities and allow 
     hospitals to count the time residents spend providing patient 
     care in outpatient settings. The AOA strongly supports these 
     provisions.
       Finally, the AOA strongly supports your efforts to address 
     the burden of the educational debt carried by many young 
     physicians that may discourage them from seeking careers in 
     public health service, practicing in underserved areas, or 
     seeking careers in primary care specialties. The average 
     osteopathic medical school graduate has a debt load of 
     $168,031 and the average first year medical resident stipend 
     is $44,747, making student debt a significant hardship 
     throughout a physician's training. By providing scholarships 
     and loan forgiveness for primary care physicians who agree to 
     practice in underserved areas, this legislation would address 
     geographic disparities in access to care and allow medical 
     school graduates to pursue training opportunities in medical 
     specialties based upon their individual career interests and 
     talents versus their financial obligations.
       Today, one in five medical students in the United States is 
     enrolled in a college of osteopathic medicine. The current 
     colleges of osteopathic medicine, and those set to open in 
     the future, are located in regions that historically have had 
     limited access to physician services. The location of current 
     and future colleges of osteopathic medicine reflects the 
     osteopathic profession's commitment to rural and underserved 
     communities. We believe that our graduates and their patients 
     will benefit greatly from the primary care policies and 
     programs in this legislation.
       Again, thank you for introducing this important 
     legislation. The AOA and our members stand ready to assist 
     you in promoting primary care and securing enactment of the 
     ``Preserving Patient Access to Primary Care Act.''
           Sincerely,
                                                 Carlo J. DiMarco,
                                                        President.
                                 ______