I 

111TH CONGRESS 

1ST SESSION H. R. 2350 

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 purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 12, 2009 

Ms. SCHWARTZ (for herself, Mr. ABERCROMBIE, Ms. BERKLEY, Mr. BERMAN, 

Mr. BISHOP of New York, Mr. BLUMENAUER, Mr. BOSWELL, Mr. BRADY

of Pennsylvania, Mrs. CAPPS, Mr. CARNAHAN, Ms. CASTOR of Florida, 

Mrs. CHRISTENSEN, Ms. CLARKE, Mr. CLEAVER, Mr. COHEN, Mr. 

CONNOLLY of Virginia, Mr. COURTNEY, Mr. CROWLEY, Mr. CUELLAR, 

Mr. DAVIS of Illinois, Ms. DELAURO, Mr. DOGGETT, Mr. DRIEHAUS, Mr. 

EDWARDS of Texas, Mr. ELLISON, Mr. FARR, Mr. FATTAH, Ms. GIFFORDS, Mr. GUTIERREZ, Mrs. HALVORSON, Mr. HARE, Mr. HASTINGS of 

Florida, Mr. HIGGINS, Mr. HINCHEY, Ms. HIRONO, Mr. HOLT, Mr. 

ISRAEL, Ms. JACKSON-LEE of Texas, Ms. KAPTUR, Mr. KENNEDY, Ms. 

KILROY, Mr. KIND, Mr. KUCINICH, Ms. LEE of California, Mr. LEVIN, 

Mr. LEWIS of Georgia, Mr. LOEBSACK, Mr. MAFFEI, Ms. MATSUI, Ms. 

MCCOLLUM, Mr. MCDERMOTT, Mr. MCGOVERN, Ms. MOORE of Wisconsin, Mr. MORAN of Virginia, Mr. PATRICK J. MURPHY of Pennsylvania, Mr. MURTHA, Mrs. NAPOLITANO, Mr. NEAL of Massachusetts, Mr. 

OLVER, Mr. PERLMUTTER, Mr. PETERS, Ms. PINGREE of Maine, Mr. 

SALAZAR, Mr. SCHRADER, Mr. SCOTT of Virginia, Mr. SCOTT of Georgia, 

Ms. SHEA-PORTER, Mr. SIRES, Mr. SNYDER, Mr. VAN HOLLEN, Ms. WATERS, Ms. WATSON, Mr. WEINER, Mr. WILSON of Ohio, Mr. YARMUTH, 

Mr. MEEKS of New York, Ms. LINDA T. SA ́NCHEZ of California, Mr. 

HONDA, Mr. ETHERIDGE, Ms. SUTTON, Mr. HOLDEN, Mr. KANJORSKI, 

Mr. LANGEVIN, Mr. LARSON of Connecticut, Mr. DOYLE, Mr. WEXLER, 

and Ms. DEGETTE) introduced the following bill; which was referred to 

the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means and Education and Labor, for a period to be 

subsequently determined by the Speaker, in each case for consideration 

of such provisions as fall within the jurisdiction of the committee concerned 


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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 

purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Preserving Patient Access to Primary Care Act of 2009’’. 

6 (b) TABLE OF CONTENTS.—The table of contents is 

7 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 assistance, 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. 


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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. 

1 SEC. 2. FINDINGS. 

2 Congress makes the following findings: 

3 (1) Approximately 21 percent of physicians who 

4 were board certified in general internal medicine 

5 during the early 1990s have left internal medicine, 


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1 compared to a 5 percent departure rate for those 

2 who were certified in subspecialties of internal medi3 cine. 

4 (2) The number of United States medical grad5 uates going into family medicine has fallen by more 

6 than 50 percent from 1997 to 2005. 

7 (3) In 2007, only 88 percent of the available 

8 medicine residency positions were filled and only 42 

9 percent of those were filled by United States medical 

10 school graduates. 

11 (4) In 2006, only 24 percent of third-year inter12 nal medicine resident intended to pursue careers in 

13 general internal medicine, down from 54 percent in 

14 1998. 

15 (5) Primary care physicians and primary care 

16 providers serve as the point of first contact for most 

17 patients and are able to coordinate the care of the 

18 whole person, reducing unnecessary care and dupli19 cative testing. 

20 (6) Primary care physicians and primary care 

21 providers practicing preventive care, including 

22 screening for illness and treating diseases, can help 

23 prevent complications that result in more costly 

24 care. 


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1 (7) Patients with primary care physicians or 

2 primary care providers have lower health care ex3 penditures and primary care is correlated with better 

4 health status, lower overall mortality, and longer life 

5 expectancy. 

6 (8) Higher proportions of primary care physi7 cians are associated with significantly reduced utili8 zation. 

9 (9) The United States has a higher ratio of spe10 cialists to primary care physicians than other indus11 trialized nations and the population of the United 

12 States is growing faster than the expected rate of 

13 growth in the supply of primary care physicians. 

14 (10) The number of Americans age 65 and 

15 older, those eligible for Medicare and who use far 

16 more ambulatory care visits per person as those 

17 under age 65, is expected to double from 2000 to 

18 2030. 

19 (11) A decrease in Federal spending to carry 

20 out programs authorized by title VII of the Public 

21 Health Service Act threatens the viability of one of 

22 the programs used to solve the problem of inad23 equate access to primary care. 

24 (12) The National Health Service Corps pro25 gram has a proven record of supplying physicians to 


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1 underserved areas, and has played an important role 

2 in expanding access for underserved populations in 

3 rural and inner city communities. 

4 (13) Individuals in many geographic areas, es5 pecially rural areas, lack adequate access to high 

6 quality preventive, primary health care, contributing 

7 to significant health disparities that impair Amer8 ica’s public health and economic productivity. 

9 (14) About 20 percent of the population of the 

10 United States resides in primary medical care 

11 Health Professional Shortage Areas. 

12 SEC. 3. DEFINITIONS. 

13 (a) GENERAL DEFINITIONS.—In this Act: 

14 (1) CHRONIC CARE COORDINATION.—The term 

15 ‘‘chronic care coordination’’ means the coordination 

16 of services that is based on the Chronic Care Model 

17 that provides on-going health care to patients with 

18 chronic diseases that may include any of the fol19 lowing services: 

20 (A) The development of an initial plan of 

21 care, and subsequent appropriate revisions to 

22 such plan of care. 

23 (B) The management of, and referral for, 

24 medical and other health services, including 


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1 interdisciplinary care conferences and manage2 ment with other providers. 

3 (C) The monitoring and management of 

4 medications. 

5 (D) Patient education and counseling serv6 ices. 

7 (E) Family caregiver education and coun8 seling services. 

9 (F) Self-management services, including 

10 health education and risk appraisal to identify 

11 behavioral risk factors through self-assessment. 

12 (G) Providing access by telephone with 

13 physicians and other appropriate health care 

14 professionals, including 24-hour availability of 

15 such professionals for emergencies. 

16 (H) Management with the principal non17 professional caregiver in the home. 

18 (I) Managing and facilitating transitions 

19 among health care professionals and across set20 tings of care, including the following: 

21 (i) Pursuing the treatment option 

22 elected by the individual. 

23 (ii) Including any advance directive 

24 executed by the individual in the medical 

25 file of the individual. 


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1 (J) Information about, and referral to, 

2 hospice care, including patient and family care3 giver education and counseling about hospice 

4 care, and facilitating transition to hospice care 

5 when elected. 

6 (K) Information about, referral to, and 

7 management with, community services. 

8 (2) CRITICAL SHORTAGE HEALTH FACILITY.— 

9 The term ‘‘critical shortage health facility’’ means a 

10 public or private nonprofit health facility that does 

11 not serve a health professional shortage area (as 

12 designated under section 332 of the Public Health 

13 Service Act), but that has a critical shortage of phy14 sicians (as determined by the Secretary) in a pri15 mary care field. 

16 (3) PHYSICIAN.—The term physician has the 

17 meaning given such term in section 1861(r)(1) of 

18 the Social Security Act. 

19 (4) PRIMARY CARE.—The term ‘‘primary care’’ 

20 means the provision of integrated, high-quality, ac21 cessible health care services by health care providers 

22 who are accountable for addressing a full range of 

23 personal health and health care needs, developing a 

24 sustained partnership with patients, practicing in 


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1 the context of family and community, and working 

2 to minimize disparities across population subgroups. 

3 (5) PRIMARY CARE FIELD.—The term ‘‘primary 

4 care field’’ means any of the following fields: 

5 (A) The field of family medicine. 

6 (B) The field of general internal medicine. 

7 (C) The field of geriatric medicine. 

8 (D) The field of pediatric medicine 

9 (6) PRIMARY CARE PHYSICIAN.—The term ‘‘pri10 mary care physician’’ means a physician who is 

11 trained in a primary care field who provides first 

12 contact, continuous, and comprehensive care to pa13 tients. 

14 (7) PRIMARY CARE PROVIDER.—The term ‘‘pri15 mary care provider’’ means— 

16 (A) a nurse practitioner; or 

17 (B) a physician assistant practicing as a 

18 member of a physician-directed or nurse-practi19 tioner-directed team; 

20 who provides first contact, continuous, and com21 prehensive care to patients. 

22 (8) PRINCIPAL CARE.—The term ‘‘principal 

23 care’’ means integrated, accessible health care that 

24 is provided by a physician who is a medical sub25 specialist that addresses the majority of the personal 


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1 health care needs of patients with chronic conditions 

2 requiring the subspecialist’s expertise, and for whom 

3 the subspecialist assumes care management, devel4 oping a sustained physician-patient partnership and 

5 practicing within the context of family and commu6 nity. 

7 (9) SECRETARY.—The term ‘‘Secretary’’ means 

8 the Secretary of Health and Human Services. 

9 (b) PRIMARY MEDICAL CARE SHORTAGE AREA.— 

10 (1) IN GENERAL.—In this Act, the term ‘‘pri11 mary medical care shortage area’’ or ‘‘PMCSA’’ 

12 means a geographic area with a shortage of physi13 cians (as designated by the Secretary) in a primary 

14 care field, as designated in accordance with para15 graph (2). 

16 (2) DESIGNATION.—To be designated by the 

17 Secretary as a PMCSA, the Secretary must find 

18 that the geographic area involved has an established 

19 shortage of primary care physicians for the popu20 lation served. The Secretary shall make such a des21 ignation with respect to an urban or rural geo22 graphic area if the following criteria are met: 

23 (A) The area is a rational area for the de24 livery of primary care services. 


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1 (B) One of the following conditions pre2 vails within the area: 

3 (i) The area has a population to full4 time-equivalent primary care physician 

5 ratio of at least 3,500 to 1. 

6 (ii) The area has a population to full7 time-equivalent primary care physician 

8 ratio of less than 3,500 to 1 and has un9 usually high needs for primary care serv10 ices or insufficient capacity of existing pri11 mary care providers. 

12 (C) Primary care providers in contiguous 

13 geographic areas are overutilized. 

14 (c) MEDICALLY UNDERSERVED AREA.— 

15 (1) IN GENERAL.—In this Act, the term ‘‘medi16 cally underserved area’’ or ‘‘MUA’’ means a rational 

17 service area with a demonstrable shortage of pri18 mary health care resources relative to the needs of 

19 the entire population within the service area as de20 termined in accordance with paragraph (2) through 

21 the use of the Index of Medical Underservice (re22 ferred to in this subsection as the ‘‘IMU’’) with re23 spect to data on a service area. 

24 (2) DETERMINATIONS.—Under criteria to be 

25 established by the Secretary with respect to the 


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1 IMU, if a service area is determined by the Sec2 retary to have a score of 62.0 or less, such area shall 

3 be eligible to be designated as a MUA. 

4 (3) IMU VARIABLES.—In establishing criteria 

5 under paragraph (2), the Secretary shall ensure that 

6 the following variables are utilized: 

7 (A) The ratio of primary medical care phy8 sicians per 1,000 individuals in the population 

9 of the area involved. 

10 (B) The infant mortality rate in the area 

11 involved. 

12 (C) The percentage of the population in13 volved with incomes below the poverty level. 

14 (D) The percentage of the population in15 volved age 65 or over. 

16 The value of each of such variables for the service 

17 area involved shall be converted by the Secretary to 

18 a weighted value, according to established criteria, 

19 and added together to obtain the area’s IMU score. 

20 (d) PATIENT CENTERED MEDICAL HOME.— 

21 (1) IN GENERAL.—In this Act, the term ‘‘pa22 tient centered medical home’’ means a physician-di23 rected practice (or a nurse-practitioner-directed 

24 practice in those States in which such functions are 

25 included in the scope of practice of licensed nurse 


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1 practitioners) that has been certified by an organiza2 tion under paragraph (3) as meeting the following 

3 standards: 

4 (A) The practice provides patients who 

5 elect to obtain care through a patient centered 

6 medical home (referred to as ‘‘participating pa7 tients’’) with direct and ongoing access to a pri8 mary or principal care physician or nurse prac9 titioner who accepts responsibility for providing 

10 first contact, continuous, and comprehensive 

11 care to the whole person, in collaboration with 

12 teams of other health professionals, including 

13 nurses and specialist physicians, as needed and 

14 appropriate. 

15 (B) The practice applies standards for ac16 cess to care and communication with partici17 pating beneficiaries. 

18 (C) The practice has readily accessible, 

19 clinically useful information on participating pa20 tients that enables the practice to treat such 

21 patients comprehensively and systematically. 

22 (D) The practice maintains continuous re23 lationships with participating patients by imple24 menting evidence-based guidelines and applying 

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1 vidual beneficiaries over time and with the in2 tensity needed by such beneficiaries. 

3 (2) RECOGNITION OF NCQA APPROVAL.—Such 

4 term also includes a physician-directed (or nurse5 practitioner-directed) practice that has been recog6 nized as a medical home through the Physician 

7 Practice Connections—patient centered Medical 

8 Home (‘‘PPC–PCMH’’) voluntary recognition proc9 ess of the National Committee for Quality Assur10 ance. 

11 (3) STANDARD SETTING AND QUALIFICATION

12 PROCESS FOR MEDICAL HOMES.—The Secretary 

13 shall establish a process for the selection of a quali14 fied standard setting and certification organiza15 tion— 

16 (A) to establish standards, consistent with 

17 this subsection, to enable medical practices to 

18 qualify as patient centered medical homes; and 

19 (B) to provide for the review and certifi20 cation of medical practices as meeting such 

21 standards. 

22 (4) TREATMENT OF CERTAIN PRACTICES.— 

23 Nothing in this section shall be construed as pre24 venting a nurse practitioner from leading a patient 

25 centered medical home so long as— 


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1 (A) all of the requirements of this section 

2 are met; and 

3 (B) the nurse practitioner is acting con4 sistently with State law. 

5 (e) APPLICATION UNDER MEDICARE, MEDICAID, 

6 PHSA, ETC.—Unless otherwise provided, the provisions of 

7 the previous subsections shall apply for purposes of provi8 sions of the Social Security Act, the Public Health Service 

9 Act, and any other Act amended by this Act. 

10 TITLE I—MEDICAL EDUCATION 

11 SEC. 101. RECRUITMENT INCENTIVES. 

12 Title VII of the Higher Education Act of 1965 (20 

13 U.S.C. 1133 et seq.) is amended by adding at the end 

14 the following: 

15 ‘‘PART F—MEDICAL EDUCATION RECRUITMENT 

16 INCENTIVES 

17 ‘‘SEC. 786. MEDICAL EDUCATION RECRUITMENT INCEN18 TIVES. 

19 ‘‘(a) IN GENERAL.—The Secretary is authorized to 

20 award grants or contracts to institutions of higher edu21 cation that are graduate medical schools, to enable the 

22 graduate medical schools to improve primary care edu23 cation and training for medical students. 

24 ‘‘(b) APPLICATION.—A graduate medical school that 

25 desires to receive a grant under this section shall submit 


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1 to the Secretary an application at such time, in such man2 ner, and containing such information as the Secretary may 

3 require. 

4 ‘‘(c) USES OF FUNDS.—A graduate medical school 

5 that receives a grant under this section shall use such 

6 grant funds to carry out 1 or more of the following: 

7 ‘‘(1) The creation of primary care mentorship 

8 programs. 

9 ‘‘(2) Curriculum development for population10 based primary care models of care, such as the pa11 tient centered medical home. 

12 ‘‘(3) Increased opportunities for ambulatory, 

13 community-based training. 

14 ‘‘(4) Development of generalist curriculum to 

15 enhance care for rural and underserved populations 

16 in primary care or general surgery. 

17 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

18 is authorized to be appropriated to carry out this section 

19 $50,000,000 for each of the fiscal years 2010 through 

20 2012.’’. 

21 SEC. 102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERV22 ICE OBLIGATIONS. 

23 (a) PURPOSE.—It is the purpose of this section to 

24 encourage individuals to enter and continue in primary 

25 care physician careers. 


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1 (b) AMENDMENT TO THE PUBLIC HEALTH SERVICE

2 ACT.—Part D of title III of the Public Health Service Act 

3 (42 U.S.C. 254b et seq.) is amended by adding at the end 

4 the following: 

5 ‘‘Subpart XI—Primary Care Medical Education 

6 ‘‘SEC. 340I. SCHOLARSHIPS. 

7 ‘‘(a) IN GENERAL.—The Secretary, acting through 

8 the Administrator of the Health Resources and Services 

9 Administration, shall award grants to critical shortage 

10 health facilities to enable such facilities to provide scholar11 ships to individuals who agree to serve as physicians at 

12 such facilities after completing a residency in a primary 

13 care field (as defined in section 3(a)(5) of the Preserving 

14 Patient Access to Primary Care Act of 2009). 

15 ‘‘(b) SCHOLARSHIPS.—A health facility shall use 

16 amounts received under a grant under this section to enter 

17 into contracts with eligible individuals under which— 

18 ‘‘(1) the facility agrees to provide the individual 

19 with a scholarship for each school year (not to ex20 ceed 4 school years) in which the individual is en21 rolled as a full-time student in a school of medicine 

22 or a school of osteopathic medicine; and 

23 ‘‘(2) the individual agrees— 

24 ‘‘(A) to maintain an acceptable level of 

25 academic standing; 


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1 ‘‘(B) to complete a residency in a primary 

2 care field; and 

3 ‘‘(C) after completing the residency, to 

4 serve as a primary care physician at such facil5 ity in such field for a time period equal to the 

6 greater of— 

7 ‘‘(i) one year for each school year for 

8 which the individual was provided a schol9 arship under this section; or 

10 ‘‘(ii) two years. 

11 ‘‘(c) AMOUNT.— 

12 ‘‘(1) IN GENERAL.—The amount paid by a 

13 health facility to an individual under a scholarship 

14 under this section shall not exceed $35,000 for any 

15 school year. 

16 ‘‘(2) CONSIDERATIONS.—In determining the 

17 amount of a scholarship to be provided to an indi18 vidual under this section, a health facility may take 

19 into consideration the individual’s financial need, ge20 ographic differences, and educational costs. 

21 ‘‘(3) EXCLUSION FROM GROSS INCOME.—For 

22 purposes of the Internal Revenue Code of 1986, 

23 gross income shall not include any amount received 

24 as a scholarship under this section. 


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1 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

2 provisions of subpart III of part D shall, except as incon3 sistent with this section, apply to the program established 

4 in subsection (a) in the same manner and to the same 

5 extent as such provisions apply to the National Health 

6 Service Corps Scholarship Program established in such 

7 subpart. 

8 ‘‘(e) DEFINITIONS.—In this section: 

9 ‘‘(1) CRITICAL SHORTAGE HEALTH FACILITY.— 

10 The term ‘critical shortage health facility’ means a 

11 public or private nonprofit health facility that does 

12 not serve a health professional shortage area (as 

13 designated under section 332), but has a critical 

14 shortage of physicians (as determined by the Sec15 retary) in a primary care field. 

16 ‘‘(2) ELIGIBLE INDIVIDUAL.—The term ‘eligible 

17 individual’ means an individual who is enrolled, or 

18 accepted for enrollment, as a full-time student in an 

19 accredited school of medicine or school of osteo20 pathic medicine. 

21 ‘‘SEC. 340J. LOAN REPAYMENT PROGRAM. 

22 ‘‘(a) PURPOSE.—It is the purpose of this section to 

23 alleviate critical shortages of primary care physicians and 

24 primary care providers. 


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1 ‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 

2 through the Administrator of the Health Resources and 

3 Services Administration, shall establish a program of en4 tering into contracts with eligible individuals under 

5 which— 

6 ‘‘(1) the individual agrees to serve— 

7 ‘‘(A) as a primary care physician or pri8 mary care provider in a primary care field; and 

9 ‘‘(B) in an area that is not a health profes10 sional shortage area (as designated under sec11 tion 332), but has a critical shortage of primary 

12 care physicians and primary care providers (as 

13 determined by the Secretary) in such field; and 

14 ‘‘(2) the Secretary agrees to pay, for each year 

15 of such service, not more than $35,000 of the prin16 cipal and interest of the undergraduate or graduate 

17 educational loans of the individual. 

18 ‘‘(c) SERVICE REQUIREMENT.—A contract entered 

19 into under this section shall allow the individual receiving 

20 the loan repayment to satisfy the service requirement de21 scribed in subsection (a)(1) through employment in a solo 

22 or group practice, a clinic, a public or private nonprofit 

23 hospital, or any other appropriate health care entity. 

24 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

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1 sistent with this section, apply to the program established 

2 in subsection (a) in the same manner and to the same 

3 extent as such provisions apply to the National Health 

4 Service Corps Scholarship Program established in such 

5 subpart. 

6 ‘‘(e) DEFINITION.—In this section, the term ‘eligible 

7 individual’ means— 

8 ‘‘(1) an individual with a degree in medicine or 

9 osteopathic medicine; or 

10 ‘‘(2) a nurse practitioner. 

11 ‘‘SEC. 340K. LOAN REPAYMENTS FOR PHYSICIANS IN THE 

12 FIELDS OF OBSTETRICS AND GYNECOLOGY 

13 AND CERTIFIED NURSE MIDWIVES. 

14 ‘‘(a) PURPOSE.—It is the purpose of this section to 

15 alleviate critical shortages of physicians in the fields of 

16 obstetrics and gynecology and certified nurse midwives. 

17 ‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 

18 through the Administrator of the Health Resources and 

19 Services Administration, shall establish a program of en20 tering into contracts with eligible individuals under 

21 which— 

22 ‘‘(1) the individual agrees to serve— 

23 ‘‘(A) as a physician in the field of obstet24 rics and gynecology or as a certified nurse mid25 wife; and 


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1 ‘‘(B) in an area that is not a health profes2 sional shortage area (as designated under sec3 tion 332), but has a critical shortage of physi4 cians in the fields of obstetrics and gynecology 

5 or certified nurse midwives (as determined by 

6 the Secretary), respectively; and 

7 ‘‘(2) the Secretary agrees to pay, for each year 

8 of such service, not more than $35,000 of the prin9 cipal and interest of the undergraduate or graduate 

10 educational loans of the individual. 

11 ‘‘(c) SERVICE REQUIREMENT.—A contract entered 

12 into under this section shall allow the individual receiving 

13 the loan repayment to satisfy the service requirement de14 scribed in subsection (a)(1) through employment in a solo 

15 or group practice, a clinic, a public or private nonprofit 

16 hospital, or any other appropriate health care entity. 

17 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

18 provisions of subpart III of part D shall, except as incon19 sistent with this section, apply to the program established 

20 in subsection (a) in the same manner and to the same 

21 extent as such provisions apply to the National Health 

22 Service Corps Scholarship Program established in such 

23 subpart. 

24 ‘‘(e) DEFINITION.—In this section, the term ‘eligible 

25 individual’ means— 


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1 ‘‘(1) a physician in the field of obstetrics and 

2 gynecology; or 

3 ‘‘(2) a certified nurse midwife. 

4 ‘‘SEC. 340L. REPORTS. 

5 ‘‘Not later than 18 months after the date of enact6 ment of this section, and annually thereafter, the Sec7 retary shall submit to Congress a report that describes 

8 the programs carried out under this subpart, including 

9 statements concerning— 

10 ‘‘(1) the number of enrollees, scholarships, loan 

11 repayments, and grant recipients; 

12 ‘‘(2) the number of graduates; 

13 ‘‘(3) the amount of scholarship payments and 

14 loan repayments made; 

15 ‘‘(4) which educational institution the recipients 

16 attended; 

17 ‘‘(5) the number and placement location of the 

18 scholarship and loan repayment recipients at health 

19 care facilities with a critical shortage of primary 

20 care physicians; 

21 ‘‘(6) the default rate and actions required; 

22 ‘‘(7) the amount of outstanding default funds of 

23 both the scholarship and loan repayment programs; 

24 ‘‘(8) to the extent that it can be determined, 

25 the reason for the default; 


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1 ‘‘(9) the demographics of the individuals par2 ticipating in the scholarship and loan repayment 

3 programs; 

4 ‘‘(10) the justification for the allocation of 

5 funds between the scholarship and loan repayment 

6 programs; and 

7 ‘‘(11) an evaluation of the overall costs and 

8 benefits of the programs. 

9 ‘‘SEC. 340M. AUTHORIZATION OF APPROPRIATIONS. 

10 ‘‘To carry out sections 340I, 340J, and 340K there 

11 are authorized to be appropriated $55,000,000 for fiscal 

12 year 2010, $90,000,000 for fiscal year 2011, and 

13 $125,000,000 for fiscal year 2012, to be used solely for 

14 scholarships and loan repayment awards for primary care 

15 physicians and primary care providers.’’. 

16 SEC. 103. DEFERMENT OF LOANS DURING RESIDENCY AND 

17 INTERNSHIPS. 

18 (a) LOAN REQUIREMENTS.—Section 427(a)(2)(C)(i) 

19 of the Higher Education Act of 1965 (20 U.S.C. 

20 1077(a)(2)(C)(i)) is amended by inserting ‘‘unless the 

21 medical internship or residency program is in a primary 

22 care field (as defined in section 3(a)(5) of the Preserving 

23 Patient Access to Primary Care Act of 2009)’’ after ‘‘resi24 dency program’’. 


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1 (b) FFEL LOANS.—Section 428(b)(1)(M)(i) of the 

2 Higher Education Act of 1965 (20 U.S.C. 

3 1078(b)(1)(M)(i)) is amended by inserting ‘‘unless the 

4 medical internship or residency program is in a primary 

5 care field (as defined in section 3(a)(5) of the Preserving 

6 Patient Access to Primary Care Act of 2009)’’ after ‘‘resi7 dency program’’. 

8 (c) FEDERAL DIRECT LOANS.—Section 455(f)(2)(A) 

9 of the Higher Education Act of 1965 (20 U.S.C. 

10 1087e(f)(2)(A)) is amended by inserting ‘‘unless the med11 ical internship or residency program is in a primary care 

12 field (as defined in section 3(a)(5) of the Preserving Pa13 tient Access to Primary Care Act of 2009)’’ after ‘‘resi14 dency program’’. 

15 (d) FEDERAL PERKINS LOANS.—Section 

16 464(c)(2)(A)(i) of the Higher Education Act of 1965 (20 

17 U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting ‘‘un18 less the medical internship or residency program is in a 

19 primary care field (as defined in section 3(a)(5) of the 

20 Preserving Patient Access to Primary Care Act of 2009)’’ 

21 after ‘‘residency program’’. 


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1 SEC. 104. EDUCATING MEDICAL STUDENTS ABOUT PRI2 MARY CARE CAREERS. 

3 Part C of title VII of the Public Health Service Act 

4 (42 U.S.C. 293k) is amended by adding at the end the 

5 following: 

6 ‘‘SEC. 749. EDUCATING MEDICAL STUDENTS ABOUT PRI7 MARY CARE CAREERS. 

8 ‘‘(a) IN GENERAL.—The Secretary shall award 

9 grants to eligible State and local government entities for 

10 the development of informational materials that promote 

11 careers in primary care by highlighting the advantages 

12 and rewards of primary care, and that encourage medical 

13 students, particularly students from disadvantaged back14 grounds, to become primary care physicians. 

15 ‘‘(b) ANNOUNCEMENT.—The grants described in sub16 section (a) shall be announced through a publication in 

17 the Federal Register and through appropriate media out18 lets in a manner intended to reach medical education insti19 tutions, associations, physician groups, and others who 

20 communicate with medical students. 

21 ‘‘(c) ELIGIBILITY.—To be eligible to receive a grant 

22 under this section an entity shall— 

23 ‘‘(1) be a State or local entity; and 

24 ‘‘(2) submit to the Secretary an application at 

25 such time, in such manner, and containing such in26 formation as the Secretary may require. 


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1 ‘‘(d) USE OF FUNDS.— 

2 ‘‘(1) IN GENERAL.—An entity shall use 

3 amounts received under a grant under this section to 

4 support State and local campaigns through appro5 priate media outlets to promote careers in primary 

6 care and to encourage individuals from disadvan7 taged backgrounds to enter and pursue careers in 

8 primary care. 

9 ‘‘(2) SPECIFIC USES.—In carrying out activities 

10 under paragraph (1), an entity shall use grants 

11 funds to develop informational materials in a man12 ner intended to reach as wide and diverse an audi13 ence of medical students as possible, in order to— 

14 ‘‘(A) advertise and promote careers in pri15 mary care; 

16 ‘‘(B) promote primary care medical edu17 cation programs; 

18 ‘‘(C) inform the public of financial assist19 ance regarding such education programs; 

20 ‘‘(D) highlight individuals in the commu21 nity who are practicing primary care physicians; 

22 or 

23 ‘‘(E) provide any other information to re24 cruit individuals for careers in primary care. 


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1 ‘‘(e) LIMITATION.—An entity shall not use amounts 

2 received under a grant under this section to advertise par3 ticular employment opportunities. 

4 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

5 is authorized to be appropriated to carry out this section, 

6 such sums as may be necessary for each of fiscal years 

7 2010 through 2013.’’. 

8 SEC. 105. TRAINING IN A FAMILY MEDICINE, GENERAL IN9 TERNAL MEDICINE, GENERAL GERIATRICS, 

10 GENERAL PEDIATRICS, PHYSICIAN ASSIST11 ANCE, GENERAL DENTISTRY, AND PEDIATRIC 

12 DENTISTRY. 

13 Section 747(e) of the Public Health Service Act (42 

14 U.S.C. 293k) is amended by striking paragraph (1) and 

15 inserting the following: 

16 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

17 For the purpose of carrying out this section, there 

18 is authorized to be appropriated $198,000,000 for 

19 each of fiscal years 2010 through 2012.’’. 

20 SEC. 106. INCREASED FUNDING FOR NATIONAL HEALTH 

21 SERVICE CORPS SCHOLARSHIP AND LOAN 

22 REPAYMENT PROGRAMS. 

23 (a) IN GENERAL.—There is authorized to be appro24 priated $332,000,000 for the period of fiscal years 2010 

25 through 2012 for the purpose of carrying out subpart III 


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1 of part D of title III of the Public Health Service Act 

2 (42 U.S.C. 254l et seq.). Such authorization of appropria3 tions is in addition to the authorization of appropriations 

4 in section 338H of such Act (42 U.S.C. 254q) and any 

5 other authorization of appropriations for such purpose. 

6 (b) ALLOCATION.—Of the amounts appropriated 

7 under subsection (a) for the period of fiscal years 2010 

8 through 2012, the Secretary shall obligate $96,000,000 

9 for the purpose of providing contracts for scholarships and 

10 loan repayments to individuals who— 

11 (1) are primary care physicians or primary care 

12 providers; and 

13 (2) have not previously received a scholarship or 

14 loan repayment under subpart III of part D of title 

15 III of the Public Health Service Act (42 U.S.C. 254l 

16 et seq.). 

17 TITLE II—MEDICAID RELATED 

18 PROVISIONS 

19 SEC. 201. TRANSFORMATION GRANTS TO SUPPORT PA20 TIENT CENTERED MEDICAL HOMES UNDER 

21 MEDICAID AND CHIP. 

22 (a) IN GENERAL.—Section 1903(z) of the Social Se23 curity Act (42 U.S.C. 1396b(z)) is amended— 

24 (1) in paragraph (2), by adding at the end the 

25 following new subparagraph: 


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1 ‘‘(G) Methods for improving the effective2 ness and efficiency of medical assistance pro3 vided under this title and child health assist4 ance provided under title XXI by encouraging 

5 the adoption of medical practices that satisfy 

6 the standards established by the Secretary 

7 under paragraph (2) of section 3(d) of the Pre8 serving Patient Access to Primary Care Act of 

9 2009 for medical practices to qualify as patient 

10 centered medical homes (as defined in para11 graph (1) of such section).’’; and 

12 (2) in paragraph (4)— 

13 (A) in subparagraph (A)— 

14 (i) in clause (i), by striking ‘‘and’’ at 

15 the end; 

16 (ii) in clause (ii), by striking the pe17 riod at the end and inserting ‘‘; and’’; and 

18 (iii) by inserting after clause (ii), the 

19 following new clause: 

20 ‘‘(iii) $25,000,000 for each of fiscal 

21 years 2010, 2011, and 2012.’’; and 

22 (B) in subparagraph (B), by striking the 

23 second and third sentences and inserting the 

24 following: ‘‘Such method shall provide that 100 

25 percent of such funds for each of fiscal years 


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1 2010, 2011, and 2012 shall be allocated among 

2 States that design programs to adopt the inno3 vative methods described in paragraph (2)(G), 

4 with preference given to States that design pro5 grams involving multipayers (including under 

6 title XVIII and private health plans) test 

7 projects for implementation of the elements nec8 essary to be recognized as a patient centered 

9 medical home practice under the National Com10 mittee for Quality Assurance Physicians Prac11 tice Connection—PCMH module (or any other 

12 equivalent process, as determined by the Sec13 retary).’’. 

14 (b) EFFECTIVE DATE.—The amendments made by 

15 this section take effect on October 1, 2010. 

16 TITLE III—MEDICARE 

17 PROVISIONS 

18 Subtitle A—Primary Care 

19 SEC. 301. REFORMING PAYMENT SYSTEMS UNDER MEDI20 CARE TO SUPPORT PRIMARY CARE. 

21 (a) INCREASING BUDGET NEUTRALITY LIMITS

22 UNDER THE PHYSICIAN FEE SCHEDULE TO ACCOUNT

23 FOR ANTICIPATED SAVINGS RESULTING FROM PAYMENTS

24 FOR CERTAIN SERVICES AND THE COORDINATION OF


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1 BENEFICIARY CARE.—Section 1848(c)(2)(B) of the Social 

2 Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended— 

3 (1) in clause (ii)(II), by striking ‘‘(iv) and (v)’’ 

4 and inserting ‘‘(iv), (v), and (vii)’’; and 

5 (2) by adding at the end the following new 

6 clause: 

7 ‘‘(vii) INCREASE IN LIMITATION TO

8 ACCOUNT FOR CERTAIN ANTICIPATED SAV9 INGS.— 

10 ‘‘(I) IN GENERAL.—Effective for 

11 fee schedules established beginning 

12 with 2010, the Secretary shall in13 crease the limitation on annual ad14 justments under clause (ii)(II) by an 

15 amount equal to the anticipated sav16 ings under parts A, B, and D (includ17 ing any savings with respect to items 

18 and services for which payment is not 

19 made under this section) which are a 

20 result of payments for designated pri21 mary care services and comprehensive 

22 care coordination services under sec23 tion 1834(m) and the coverage of pa24 tient centered medical home services 


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1 under section 1861(s)(2)(FF) (as de2 termined by the Secretary). 

3 ‘‘(II) MECHANISM TO DETER4 MINE APPLICATION OF INCREASE.— 

5 The Secretary shall establish a mecha6 nism for determining which relative 

7 value units established under this 

8 paragraph for physicians’ services 

9 shall be subject to an adjustment 

10 under clause (ii)(I) as a result of the 

11 increase under subclause (I). 

12 ‘‘(III) ADDITIONAL FUNDING AS

13 DETERMINED NECESSARY BY THE

14 SECRETARY.—In addition to any 

15 funding that may be made available 

16 as a result of an increase in the limi17 tation on annual adjustments under 

18 subclause (I), there shall also be avail19 able to the Secretary, for purposes of 

20 making payments under this title for 

21 new services and capabilities to im22 prove care provided to individuals 

23 under this title and to generate effi24 ciencies under this title, such addiVerDate Nov 24 2008 06:45 May 14, 2009 Jkt 079200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\H2350.IH H2350

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1 tional funds as the Secretary deter2 mines are necessary.’’. 

3 (b) SEPARATE MEDICARE PAYMENT FOR DES4 IGNATED PRIMARY CARE SERVICES AND COMPREHENSIVE

5 CARE COORDINATION SERVICES.— 

6 (1) IN GENERAL.—Section 1834 of the Social 

7 Security Act (42 U.S.C. 1395m) is amended by add8 ing at the end the following new subsection: 

9 ‘‘(n) PAYMENT FOR DESIGNATED PRIMARY CARE

10 SERVICES AND COMPREHENSIVE CARE COORDINATION

11 SERVICES.— 

12 ‘‘(1) IN GENERAL.—The Secretary shall pay for 

13 designated primary care services and comprehensive 

14 care coordination services furnished to an individual 

15 enrolled under this part. 

16 ‘‘(2) PAYMENT AMOUNT.—The Secretary shall 

17 determine the amount of payment for designated 

18 primary care services and comprehensive care co19 ordination services under this subsection. 

20 ‘‘(3) DOCUMENTATION REQUIREMENTS.—The 

21 Secretary shall propose appropriate documentation 

22 requirements to justify payments for designated pri23 mary care services and comprehensive care coordina24 tion services under this subsection. 

25 ‘‘(4) DEFINITIONS.— 


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1 ‘‘(A) COMPREHENSIVE CARE COORDINA2 TION SERVICES.—The term ‘comprehensive care 

3 coordination services’ means care coordination 

4 services with procedure codes established by the 

5 Secretary (as appropriate) which are furnished 

6 to an individual enrolled under this part by a 

7 primary care provider or principal care physi8 cian. 

9 ‘‘(B) DESIGNATED PRIMARY CARE SERV10 ICES.—The term ‘designated primary care serv11 ice’ means a service which the Secretary deter12 mines has a procedure code which involves a 

13 clinical interaction with an individual enrolled 

14 under this part that is inherent to care coordi15 nation, including interactions outside of a face16 to-face encounter. Such term includes the fol17 lowing: 

18 ‘‘(i) Care plan oversight. 

19 ‘‘(ii) Evaluation and management pro20 vided by phone. 

21 ‘‘(iii) Evaluation and management 

22 provided using internet resources. 

23 ‘‘(iv) Collection and review of physio24 logic data, such as from a remote moni25 toring device. 


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1 ‘‘(v) Education and training for pa2 tient self management. 

3 ‘‘(vi) Anticoagulation management 

4 services. 

5 ‘‘(vii) Any other service determined 

6 appropriate by the Secretary.’’. 

7 (2) EFFECTIVE DATE.—The amendment made 

8 by this section shall apply to items and services fur9 nished on or after January 1, 2010. 

10 SEC. 302. COVERAGE OF PATIENT CENTERED MEDICAL 

11 HOME SERVICES. 

12 (a) IN GENERAL.—Section 1861(s)(2) of the Social 

13 Security Act (42 U.S.C. 1395x(s)(2)) is amended— 

14 (1) in subparagraph (DD), by striking ‘‘and’’ at 

15 the end; 

16 (2) in subparagraph (EE), by inserting ‘‘and’’ 

17 at the end; and 

18 (3) by adding at the end the following new sub19 paragraph: 

20 ‘‘(FF) patient centered medical home services 

21 (as defined in subsection (hhh)(1));’’. 

22 (b) DEFINITION OF PATIENT CENTERED MEDICAL

23 HOME SERVICES.—Section 1861 of the Social Security 

24 Act (42 U.S.C. 1395x) is amended by adding at the end 

25 the following new subsection: 


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1 ‘‘Patient Centered Medical Home Services 

2 ‘‘(hhh)(1) The term ‘patient centered medical home 

3 services’ means care coordination services furnished by a 

4 qualified patient centered medical home. 

5 ‘‘(2) The term ‘qualified patient centered medical 

6 home’ means a patient centered medical home (as defined 

7 in section 3(d) of the Preserving Patient Access to Pri8 mary Care Act of 2009).’’. 

9 (c) MONTHLY FEE FOR PATIENT CENTERED MED10 ICAL HOME SERVICES.—Section 1848 of the Social Secu11 rity Act (42 U.S.C. 1395w–4) is amended by adding at 

12 the end the following new subsection: 

13 ‘‘(p) MONTHLY FEE FOR PATIENT CENTERED MED14 ICAL HOME SERVICES.— 

15 ‘‘(1) MONTHLY FEE.— 

16 ‘‘(A) IN GENERAL.—Not later than Janu17 ary 1, 2012, the Secretary shall establish a pay18 ment methodology for patient centered medical 

19 home services (as defined in paragraph (1) of 

20 section 1861(hhh)). Under such payment meth21 odology, the Secretary shall pay qualified pa22 tient centered medical homes (as defined in 

23 paragraph (2) of such section) a monthly fee 

24 for each individual who elects to receive patient 

25 centered medical home services at that medical 


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1 home. Such fee shall be paid on a prospective 

2 basis. 

3 ‘‘(B) CONSIDERATIONS.—The Secretary 

4 shall take into account the results of the Medi5 care medical home demonstration project under 

6 section 204 of the Medicare Improvement and 

7 Extension Act of 2006 (42 U.S.C. 1395b–1 

8 note; division B of Public Law 109–432) in es9 tablishing the payment methodology under sub10 paragraph (A). 

11 ‘‘(2) AMOUNT OF PAYMENT.— 

12 ‘‘(A) CONSIDERATIONS.—In determining 

13 the amount of such fee, subject to paragraph 

14 (3), the Secretary shall consider the following: 

15 ‘‘(i) The clinical work and practice ex16 penses involved in providing care coordina17 tion services consistent with the patient 

18 centered medical home model (such as pro19 viding increased access, care coordination, 

20 disease population management, and edu21 cation) for which payment is not made 

22 under this section as of the date of enact23 ment of this subsection. 

24 ‘‘(ii) Ensuring that the amount of 

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1 sition, use, and maintenance of clinical in2 formation systems which— 

3 ‘‘(I) are needed by a qualified pa4 tient centered medical home; and 

5 ‘‘(II) have been shown to facili6 tate improved outcomes through care 

7 coordination. 

8 ‘‘(iii) The establishment of a tiered 

9 monthly care management fee that pro10 vides for a range of payment depending on 

11 how advanced the capabilities of a qualified 

12 patient centered medical home are in hav13 ing the information systems needed to sup14 port care coordination. 

15 ‘‘(B) RISK-ADJUSTMENT.—The Secretary 

16 shall use appropriate risk-adjustment in deter17 mining the amount of the monthly fee under 

18 this paragraph. 

19 ‘‘(3) FUNDING.— 

20 ‘‘(A) IN GENERAL.—The Secretary shall 

21 determine the aggregate estimated savings for a 

22 calendar year as a result of the implementation 

23 of this subsection on reducing preventable hos24 pital admissions, duplicate testing, medication 

25 errors and drug interactions, and other savings 


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1 under this part and part A (including any sav2 ings with respect to items and services for 

3 which payment is not made under this section). 

4 ‘‘(B) FUNDING.—Subject to subparagraph 

5 (C), the aggregate amount available for pay6 ment of the monthly fee under this subsection 

7 during a calendar year shall be equal to the ag8 gregate estimated savings (as determined under 

9 subparagraph (A)) for the calendar year (as de10 termined by the Secretary). 

11 ‘‘(C) ADDITIONAL FUNDING.—In the case 

12 where the amount of the aggregate actual sav13 ings during the preceding 3 years exceeds the 

14 amount of the aggregate estimated savings (as 

15 determined under subparagraph (A)) during 

16 such period, the aggregate amount available for 

17 payment of the monthly fee under this sub18 section during the calendar year (as determined 

19 under subparagraph (B)) shall be increased by 

20 the amount of such excess. 

21 ‘‘(D) ADDITIONAL FUNDING AS DETER22 MINED NECESSARY BY THE SECRETARY.—In 

23 addition to any funding made available under 

24 subparagraphs (B) and (C), there shall also be 

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1 tively implementing this subsection, such addi2 tional funds as the Secretary determines are 

3 necessary. 

4 ‘‘(4) PERFORMANCE-BASED BONUS PAY5 MENTS.—The Secretary shall establish a process for 

6 paying a performance-based bonus to qualified pa7 tient centered medical homes which meet or achieve 

8 substantial improvements in performance (as speci9 fied under clinical, patient satisfaction, and effi10 ciency benchmarks established by the Secretary). 

11 Such bonus shall be in an amount determined appro12 priate by the Secretary. 

13 ‘‘(5) NO EFFECT ON PAYMENTS FOR EVALUA14 TION AND MANAGEMENT SERVICES.—The monthly 

15 fee under this subsection shall have no effect on the 

16 amount of payment for evaluation and management 

17 services under this title.’’. 

18 (d) COINSURANCE.—Section 1833(a)(1) of the Social 

19 Security Act (42 U.S.C. 1395l(a)(1)) is amended— 

20 (1) by striking ‘‘and’’ before ‘‘(W)’’; and 

21 (2) by inserting before the semicolon at the end 

22 the following: ‘‘, and (X) with respect to patient cen23 tered medical home services (as defined in section 

24 1861(hhh)(1)), the amount paid shall be (i) in the 

25 case of such services which are physicians’ services, 


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1 the amount determined under subparagraph (N), 

2 and (ii) in the case of all other such services, 80 per3 cent of the lesser of the actual charge for the service 

4 or the amount determined under a fee schedule es5 tablished by the Secretary for purposes of this sub6 paragraph’’. 

7 (e) EFFECTIVE DATE.—The amendments made by 

8 this section shall apply to services furnished on or after 

9 January 1, 2012. 

10 SEC. 303. MEDICARE PRIMARY CARE PAYMENT EQUITY AND 

11 ACCESS PROVISION. 

12 (a) IN GENERAL.—Section 1848 of the Social Secu13 rity Act (42 U.S.C. 1395w–4), as amended by section 

14 302(c), is amended by adding at the end the following new 

15 subsection: 

16 ‘‘(q) PRIMARY CARE PAYMENT EQUITY AND AC17 CESS.— 

18 ‘‘(1) IN GENERAL.—Not later than January 1, 

19 2010, the Secretary shall develop a methodology, in 

20 consultation with primary care physician organiza21 tions and primary care provider organizations, the 

22 Medicare Payment Advisory Commission, and other 

23 experts, to increase payments under this section for 

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1 viders, and principal care providers through 1 or 

2 more of the following: 

3 ‘‘(A) A service-specific modifier to the rel4 ative value units established for such services. 

5 ‘‘(B) Service-specific bonus payments. 

6 ‘‘(C) Any other methodology determined 

7 appropriate by the Secretary. 

8 ‘‘(2) INCLUSION OF PROPOSED CRITERIA.—The 

9 methodology developed under paragraph (1) shall in10 clude proposed criteria for providers to qualify for 

11 such increased payments, including consideration 

12 of— 

13 ‘‘(A) the type of service being rendered; 

14 ‘‘(B) the specialty of the provider providing 

15 the service; and 

16 ‘‘(C) demonstration by the provider of vol17 untary participation in programs to improve 

18 quality, such as participation in the Physician 

19 Quality Reporting Initiative (as determined by 

20 the Secretary) or practice-level qualification as 

21 a patient centered medical home. 

22 ‘‘(3) FUNDING.— 

23 ‘‘(A) DETERMINATION.—The Secretary 

24 shall determine the aggregate estimated savings 

25 for a calendar year as a result of such increased 


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1 payments on reducing preventable hospital ad2 missions, duplicate testing, medication errors 

3 and drug interactions, Intensive Care Unit ad4 missions, per capita health care expenditures, 

5 and other savings under this part and part A 

6 (including any savings with respect to items 

7 and services for which payment is not made 

8 under this section). 

9 ‘‘(B) FUNDING.—The aggregate amount 

10 available for such increased payments during a 

11 calendar year shall be equal to the aggregate 

12 estimated savings (as determined under sub13 paragraph (A)) for the calendar year (as deter14 mined by the Secretary). 

15 ‘‘(C) ADDITIONAL FUNDING AS DETER16 MINED NECESSARY BY THE SECRETARY.—In 

17 addition to any funding made available under 

18 subparagraph (B), there shall also be available 

19 to the Secretary, for purposes of effectively im20 plementing this subsection, such additional 

21 funds as the Secretary determines are nec22 essary.’’. 

23 (b) EFFECTIVE DATE.—The amendment made by 

24 this section shall apply to services furnished on or after 

25 January 1, 2010. 


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1 SEC. 304. ADDITIONAL INCENTIVE PAYMENT PROGRAM 

2 FOR PRIMARY CARE SERVICES FURNISHED 

3 IN HEALTH PROFESSIONAL SHORTAGE 

4 AREAS. 

5 (a) IN GENERAL.—Section 1833 of the Social Secu6 rity Act (42 U.S.C. 1395l) is amended by adding at the 

7 end the following new subsection: 

8 ‘‘(x) ADDITIONAL INCENTIVE PAYMENTS FOR PRI9 MARY CARE SERVICES FURNISHED IN HEALTH PROFES10 SIONAL SHORTAGE AREAS.— 

11 ‘‘(1) IN GENERAL.—In the case of primary care 

12 services furnished on or after January 1, 2010, by 

13 a primary care physician or primary care provider in 

14 an area that is designated (under section 

15 332(a)(1)(A) of the Public Health Service Act) as a 

16 health professional shortage area as identified by the 

17 Secretary prior to the beginning of the year involved, 

18 in addition to the amount of payment that would 

19 otherwise be made for such services under this part, 

20 there also shall be paid (on a monthly or quarterly 

21 basis) an amount equal to 10 percent of the pay22 ment amount for the service under this part. 

23 ‘‘(2) DEFINITIONS.—In this subsection: 

24 ‘‘(A) PRIMARY CARE PHYSICIAN; PRIMARY

25 CARE PROVIDER.—The terms ‘primary care 

26 physician’ and ‘primary care provider’ have the 


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1 meaning given such terms in paragraphs (6) 

2 and (7), respectively, of section 3(a) of the Pre3 serving Patient Access to Primary Care Act of 

4 2009. 

5 ‘‘(B) PRIMARY CARE SERVICES.—The term 

6 ‘primary care services’ means procedure codes 

7 for services in the category of the Healthcare 

8 Common Procedure Coding System, as estab9 lished by the Secretary under section 

10 1848(c)(5) (as of December 31, 2008, and as 

11 subsequently modified by the Secretary) con12 sisting of evaluation and management services, 

13 but limited to such procedure codes in the cat14 egory of office or other outpatient services, and 

15 consisting of subcategories of such procedure 

16 codes for services for both new and established 

17 patients. 

18 ‘‘(3) JUDICIAL REVIEW.—There shall be no ad19 ministrative or judicial review under section 1869, 

20 1878, or otherwise, respecting the identification of 

21 primary care physicians, primary care providers, or 

22 primary care services under this subsection.’’. 

23 (b) CONFORMING AMENDMENT.—Section 

24 1834(g)(2)(B) of the Social Security Act (42 U.S.C. 

25 1395m(g)(2)(B)) is amended by adding at the end the folVerDate Nov 24 2008 23:59 May 14, 2009 Jkt 079200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\H2350.IH H2350

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1 lowing sentence: ‘‘Section 1833(x) shall not be taken into 

2 account in determining the amounts that would otherwise 

3 be paid pursuant to the preceding sentence.’’. 

4 SEC. 305. PERMANENT EXTENSION OF FLOOR ON MEDI5 CARE WORK GEOGRAPHIC ADJUSTMENT 

6 UNDER THE MEDICARE PHYSICIAN FEE 

7 SCHEDULE. 

8 Section 1848(e)(1)(E) of the Social Security Act (42 

9 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘and 

10 before January 1, 2010,’’. 

11 SEC. 306. PERMANENT EXTENSION OF MEDICARE INCEN12 TIVE PAYMENT PROGRAM FOR PHYSICIAN 

13 SCARCITY AREAS. 

14 Section 1833(u) of the Social Security Act (42 U.S.C. 

15 1395l(u)) is amended— 

16 (1) in paragraph (1)— 

17 (A) by inserting ‘‘or on or after July 1, 

18 2009’’ after ‘‘before July 1, 2008’’; and 

19 (B) by inserting ‘‘(or, in the case of serv20 ices furnished on or after July 1, 2009, 10 per21 cent)’’ after ‘‘5 percent’’; and 

22 (2) in paragraph (4)(D), by striking ‘‘before 

23 July 1, 2008’’ and inserting ‘‘before January 1, 

24 2010’’. 


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1 SEC. 307. HHS STUDY AND REPORT ON THE PROCESS FOR 

2 DETERMINING RELATIVE VALUE UNDER THE 

3 MEDICARE PHYSICIAN FEE SCHEDULE. 

4 (a) STUDY.—The Secretary shall conduct a study on 

5 the process used by the Secretary for determining relative 

6 value under the Medicare physician fee schedule under 

7 section 1848(c) of the Social Security Act (42 U.S.C. 

8 1395w–4(c)). Such study shall include an analysis of the 

9 following: 

10 (1)(A) Whether the existing process includes 

11 equitable representation of primary care physicians 

12 (as defined in section 3(a)(6)); and 

13 (B) any changes that may be necessary to en14 sure such equitable representation. 

15 (2)(A) Whether the existing process provides 

16 the Secretary with expert and impartial input from 

17 physicians in medical specialties that provide pri18 mary care to patients with multiple chronic diseases, 

19 the fastest growing part of the Medicare population; 

20 and 

21 (B) any changes that may be necessary to en22 sure such input. 

23 (3)(A) Whether the existing process includes 

24 equitable representation of physician medical special25 ties in proportion to their relative contributions to26 ward caring for Medicare beneficiaries, as deterVerDate Nov 24 2008 06:45 May 14, 2009 Jkt 079200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\H2350.IH H2350

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1 mined by the percentage of Medicare billings per 

2 specialty, percentage of Medicare encounters by spe3 cialty, or such other measures of relative contribu4 tions to patient care as determined by the Secretary; 

5 and 

6 (B) any changes that may be necessary to re7 flect such equitable representation. 

8 (4)(A) Whether the existing process, including 

9 the application of budget neutrality rules, unfairly 

10 disadvantages primary care physicians, primary care 

11 providers, or other physicians who principally pro12 vide evaluation and management services; and 

13 (B) any changes that may be necessary to 

14 eliminate such disadvantages. 

15 (b) REPORT.—Not later than 12 months after the 

16 date of enactment of this Act, the Secretary shall submit 

17 to Congress a report containing the results of the study 

18 conducted under subsection (a), together with rec19 ommendations for such legislation and administrative ac20 tion as the Secretary determines appropriate. 

21 Subtitle B—Preventive Services 

22 SEC. 311. ELIMINATING TIME RESTRICTION FOR INITIAL 

23 PREVENTIVE PHYSICAL EXAMINATION. 

24 (a) IN GENERAL.—Section 1862(a)(1)(K) of the So25 cial Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended 


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1 by striking ‘‘more than’’ and all that follows before the 

2 comma at the end and inserting ‘‘more than one time dur3 ing the lifetime of the individual’’. 

4 (b) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to services furnished on or after 

6 January 1, 2010. 

7 SEC. 312. ELIMINATION OF COST-SHARING FOR PREVEN8 TIVE BENEFITS UNDER THE MEDICARE PRO9 GRAM. 

10 (a) DEFINITION OF PREVENTIVE SERVICES.—Sec11 tion 1861(ddd) of the Social Security Act (42 U.S.C. 

12 1395w(dd)) is amended— 

13 (1) in the heading, by inserting ‘‘; Preventive 

14 Services’’ after ‘‘Services’’; 

15 (2) in paragraph (1), by striking ‘‘not otherwise 

16 described in this title’’ and inserting ‘‘not described 

17 in subparagraphs (A) through (N) of paragraph 

18 (3)’’; and 

19 (3) by adding at the end the following new 

20 paragraph: 

21 ‘‘(3) The term ‘preventive services’ means the fol22 lowing: 

23 ‘‘(A) Prostate cancer screening tests (as defined 

24 in subsection (oo)). 


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1 ‘‘(B) Colorectal cancer screening tests (as de2 fined in subsection (pp)). 

3 ‘‘(C) Diabetes outpatient self-management 

4 training services (as defined in subsection (qq)). 

5 ‘‘(D) Screening for glaucoma for certain indi6 viduals (as described in subsection (s)(2)(U)). 

7 ‘‘(E) Medical nutrition therapy services for cer8 tain individuals (as described in subsection 

9 (s)(2)(V)). 

10 ‘‘(F) An initial preventive physical examination 

11 (as defined in subsection (ww)). 

12 ‘‘(G) Cardiovascular screening blood tests (as 

13 defined in subsection (xx)(1)). 

14 ‘‘(H) Diabetes screening tests (as defined in 

15 subsection (yy)). 

16 ‘‘(I) Ultrasound screening for abdominal aortic 

17 aneurysm for certain individuals (as described in 

18 subsection (s)(2)(AA)). 

19 ‘‘(J) Pneumococcal and influenza vaccine and 

20 their administration (as described in subsection 

21 (s)(10)(A)). 

22 ‘‘(K) Hepatitis B vaccine and its administration 

23 for certain individuals (as described in subsection 

24 (s)(10)(B)). 


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1 ‘‘(L) Screening mammography (as defined in 

2 subsection (jj)). 

3 ‘‘(M) Screening pap smear and screening pelvic 

4 exam (as described in subsection (s)(14)). 

5 ‘‘(N) Bone mass measurement (as defined in 

6 subsection (rr)). 

7 ‘‘(O) Additional preventive services (as deter8 mined under paragraph (1)).’’. 

9 (b) COINSURANCE.— 

10 (1) GENERAL APPLICATION.— 

11 (A) IN GENERAL.—Section 1833(a)(1) of 

12 the Social Security Act (42 U.S.C. 

13 1395l(a)(1)), as amended by section 302, is 

14 amended— 

15 (i) in subparagraph (T), by striking 

16 ‘‘80 percent’’ and inserting ‘‘100 percent’’; 

17 (ii) in subparagraph (W), by striking 

18 ‘‘80 percent’’ and inserting ‘‘100 percent’’; 

19 (iii) by striking ‘‘and’’ before ‘‘(X)’’; 

20 and 

21 (iv) by inserting before the semicolon 

22 at the end the following: ‘‘, and (Y) with 

23 respect to preventive services described in 

24 subparagraphs (A) through (O) of section 

25 1861(ddd)(3), the amount paid shall be 


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1 100 percent of the lesser of the actual 

2 charge for the services or the amount de3 termined under the fee schedule that ap4 plies to such services under this part’’. 

5 (2) ELIMINATION OF COINSURANCE FOR

6 SCREENING SIGMOIDOSCOPIES AND

7 COLONOSCOPIES.—Section 1834(d) of the Social Se8 curity Act (42 U.S.C. 1395m(d)) is amended— 

9 (A) in paragraph (2)— 

10 (i) in subparagraph (A), by inserting 

11 ‘‘, except that payment for such tests 

12 under such section shall be 100 percent of 

13 the payment determined under such sec14 tion for such tests’’ before the period at 

15 the end; and 

16 (ii) in subparagraph (C)— 

17 (I) by striking clause (ii); and 

18 (II) in clause (i)— 

19 (aa) by striking ‘‘(i) IN GEN20 ERAL.—Notwithstanding’’ and 

21 inserting ‘‘Notwithstanding’’; 

22 (bb) by redesignating sub23 clauses (I) and (II) as clauses (i) 

24 and (ii), respectively, and moving 


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1 such clauses 2 ems to the left; 

2 and 

3 (cc) in the flush matter fol4 lowing clause (ii), as so redesig5 nated, by inserting ‘‘100 percent 

6 of’’ after ‘‘based on’’; and 

7 (B) in paragraph (3)— 

8 (i) in subparagraph (A), by inserting 

9 ‘‘, except that payment for such tests 

10 under such section shall be 100 percent of 

11 the payment determined under such sec12 tion for such tests’’ before the period at 

13 the end; and 

14 (ii) in subparagraph (C)— 

15 (I) by striking clause (ii); and 

16 (II) in clause (i)— 

17 (aa) by striking ‘‘(i) IN GEN18 ERAL.—Notwithstanding’’ and 

19 inserting ‘‘Notwithstanding’’; and 

20 (bb) by inserting ‘‘100 per21 cent of’’ after ‘‘based on’’. 

22 (3) ELIMINATION OF COINSURANCE IN OUT23 PATIENT HOSPITAL SETTINGS.— 

24 (A) EXCLUSION FROM OPD FEE SCHED25 ULE.—Section 1833(t)(1)(B)(iv) of the Social 


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1 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 

2 amended by striking ‘‘and diagnostic mammog3 raphy’’ and inserting ‘‘, diagnostic mammog4 raphy, and preventive services (as defined in 

5 section 1861(ddd)(3))’’. 

6 (B) CONFORMING AMENDMENTS.—Section 

7 1833(a)(2) of the Social Security Act (42 

8 U.S.C. 1395l(a)(2)) is amended— 

9 (i) in subparagraph (F), by striking 

10 ‘‘and’’ after the semicolon at the end; 

11 (ii) in subparagraph (G)(ii), by adding 

12 ‘‘and’’ at the end; and 

13 (iii) by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(H) with respect to preventive services (as 

16 defined in section 1861(ddd)(3)) furnished by 

17 an outpatient department of a hospital, the 

18 amount determined under paragraph (1)(W) or 

19 (1)(X), as applicable;’’. 

20 (c) WAIVER OF APPLICATION OF DEDUCTIBLE.—The 

21 first sentence of section 1833(b) of the Social Security Act 

22 (42 U.S.C. 1395l(b)) is amended— 

23 (1) in clause (1), by striking ‘‘items and serv24 ices described in section 1861(s)(10)(A)’’ and insertVerDate Nov 24 2008 06:45 May 14, 2009 Jkt 079200 PO 00000 Frm 00055 Fmt 6652 Sfmt 6201 E:\BILLS\H2350.IH H2350

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1 ing ‘‘preventive services (as defined in section 

2 1861(ddd)(3))’’; 

3 (2) by inserting ‘‘and’’ before ‘‘(4)’’; and 

4 (3) by striking ‘‘, (5)’’ and all that follows up 

5 to the period at the end. 

6 SEC. 313. HHS STUDY AND REPORT ON FACILITATING THE 

7 RECEIPT OF MEDICARE PREVENTIVE SERV8 ICES BY MEDICARE BENEFICIARIES. 

9 (a) STUDY.—The Secretary, in consultation with pro10 vider organizations and other appropriate stakeholders, 

11 shall conduct a study on— 

12 (1) ways to assist primary care physicians and 

13 primary care providers (as defined in section 3(a)) 

14 in— 

15 (A) furnishing appropriate preventive serv16 ices (as defined in section 1861(ddd)(3) of the 

17 Social Security Act, as added by section 312) to 

18 individuals enrolled under part B of title XVIII 

19 of such Act; and 

20 (B) referring such individuals for other 

21 items and services furnished by other physicians 

22 and health care providers; and 

23 (2) the advisability and feasability of making 

24 additional payments under the Medicare program to 

25 physicians and primary care providers for— 


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1 (A) the work involved in ensuring that 

2 such individuals receive appropriate preventive 

3 services furnished by other physicians and 

4 health care providers; and 

5 (B) incorporating the resulting clinical in6 formation into the treatment plan for the indi7 vidual. 

8 (b) REPORT.—Not later than 12 months after the 

9 date of enactment of this Act, the Secretary shall submit 

10 to Congress a report containing the results of the study 

11 conducted under subsection (a), together with rec12 ommendations for such legislation and administrative ac13 tion as the Secretary determines appropriate. 

14 Subtitle C—Other Provisions 

15 SEC. 321. HHS STUDY AND REPORT ON IMPROVING THE 

16 ABILITY OF PHYSICIANS AND PRIMARY CARE 

17 PROVIDERS TO ASSIST MEDICARE BENE18 FICIARIES IN OBTAINING NEEDED PRESCRIP19 TIONS UNDER MEDICARE PART D. 

20 (a) STUDY.—The Secretary, in consultation with phy21 sician organizations and other appropriate stakeholders, 

22 shall conduct a study on the development and implementa23 tion of mechanisms to facilitate increased efficiency relat24 ing to the role of physicians and primary care providers 

25 in Medicare beneficiaries obtaining needed prescription 


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1 drugs under the Medicare prescription drug program 

2 under part D of title XVIII of the Social Security Act. 

3 Such study shall include an analysis of ways to— 

4 (1) improve the accessibility of formulary infor5 mation; 

6 (2) streamline the prior authorization, excep7 tion, and appeals processes, through, at a minimum, 

8 standardizing formats and allowing electronic ex9 change of information; and 

10 (3) recognize the work of the physician and pri11 mary care provider involved in the prescribing proc12 ess, especially work that may extend beyond the 

13 amount considered to be bundled into payment for 

14 evaluation and management services. 

15 (b) REPORT.—Not later than 12 months after the 

16 date of enactment of this Act, the Secretary shall submit 

17 to Congress a report containing the results of the study 

18 conducted under subsection (a), together with rec19 ommendations for such legislation and administrative ac20 tion as the Secretary determines appropriate. 

21 SEC. 322. HHS STUDY AND REPORT ON IMPROVED PATIENT 

22 CARE THROUGH INCREASED CAREGIVER AND 

23 PHYSICIAN INTERACTION. 

24 (a) STUDY.—The Secretary, in consultation with ap25 propriate stakeholders, shall conduct a study on the develVerDate Nov 24 2008 06:45 May 14, 2009 Jkt 079200 PO 00000 Frm 00058 Fmt 6652 Sfmt 6201 E:\BILLS\H2350.IH H2350

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1 opment and implementation of mechanisms to promote 

2 and increase interaction between physicians or primary 

3 care providers and the families of Medicare beneficiaries, 

4 as well as other caregivers who support such beneficiaries, 

5 for the purpose of improving patient care under the Medi6 care program. Such study shall include an analysis of— 

7 (1) ways to recognize the work of physicians 

8 and primary care providers involved in discussing 

9 clinical issues with caregivers that relate to the care 

10 of the beneficiary; and 

11 (2) regulations under the Medicare program 

12 that are barriers to interactions between caregivers 

13 and physicians or primary care providers and how 

14 such regulations should be revised to eliminate such 

15 barriers. 

16 (b) REPORT.—Not later than 12 months after the 

17 date of enactment of this Act, the Secretary shall submit 

18 to Congress a report containing the results of the study 

19 conducted under subsection (a), together with rec20 ommendations for such legislation and administrative ac21 tion as the Secretary determines appropriate. 


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1 SEC. 323. IMPROVED PATIENT CARE THROUGH EXPANDED 

2 SUPPORT FOR LIMITED ENGLISH PRO3 FICIENCY (LEP) SERVICES. 

4 (a) ADDITIONAL PAYMENTS FOR PRIMARY CARE

5 PHYSICIANS AND PRIMARY CARE PROVIDERS.—Section 

6 1833 of the Social Security Act (42 U.S.C. 1395l), as 

7 amended by section 304, is amended by adding at the end 

8 the following new subsection: 

9 ‘‘(y) ADDITIONAL PAYMENTS FOR PROVIDING SERV10 ICES TO INDIVIDUALS WITH LIMITED ENGLISH PRO11 FICIENCY.— 

12 ‘‘(1) IN GENERAL.—In the case of primary care 

13 physicians and primary care providers’ services fur14 nished on or after January 1, 2010, to an individual 

15 with limited English proficiency by a provider, in ad16 dition to the amount of payment that would other17 wise be made for such services under this part, there 

18 shall also be paid an appropriate amount (as deter19 mined by the Secretary) in order to recognize the 

20 additional time involved in furnishing the service to 

21 such individual. 

22 ‘‘(2) JUDICIAL REVIEW.—There shall be no ad23 ministrative or judicial review under section 1869, 

24 1878, or otherwise, respecting the determination of 

25 the amount of additional payment under this sub26 section.’’. 


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1 (b) NATIONAL CLEARINGHOUSE.—Not later than 

2 180 days after the date of enactment of this Act, the Sec3 retary shall establish a national clearinghouse to make 

4 available to the primary care physicians, primary care pro5 viders, patients, and States translated documents regard6 ing patient care and education under the Medicare pro7 gram, the Medicaid program, and the State Children’s 

8 Health Insurance Program under titles XVIII, XIX, and 

9 XXI, respectively, of the Social Security Act. 

10 (c) GRANTS TO SUPPORT LANGUAGE TRANSLATION

11 SERVICES IN UNDERSERVED COMMUNITIES.— 

12 (1) AUTHORITY TO AWARD GRANTS.—The Sec13 retary shall award grants to support language trans14 lation services for primary care physicians and pri15 mary care providers in medically underserved areas 

16 (as defined in section 3(c)). 

17 (2) AUTHORIZATION OF APPROPRIATIONS.— 

18 There are authorized to be appropriated to the Sec19 retary to award grants under this subsection, such 

20 sums as are necessary for fiscal years beginning with 

21 fiscal year 2010. 

22 SEC. 324. HHS STUDY AND REPORT ON USE OF REAL-TIME 

23 MEDICARE CLAIMS ADJUDICATION. 

24 (a) STUDY.—The Secretary shall conduct a study to 

25 assess the ability of the Medicare program under title 


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1 XVIII of the Social Security Act to engage in real-time 

2 claims adjudication for items and services furnished to 

3 Medicare beneficiaries. 

4 (b) CONSULTATION.—In conducting the study under 

5 subsection (a), the Secretary consult with stakeholders in 

6 the private sector, including stakeholders who are using 

7 or are testing real-time claims adjudication systems. 

8 (c) REPORT.—Not later than January 1, 2011, the 

9 Secretary shall submit to Congress a report containing the 

10 results of the study conducted under subsection (a), to11 gether with recommendations for such legislation and ad12 ministrative action as the Secretary determines appro13 priate. 

14 SEC. 325. ONGOING ASSESSMENT BY MEDPAC OF THE IM15 PACT OF MEDICARE PAYMENTS ON PRIMARY 

16 CARE ACCESS AND EQUITY. 

17 The Medicare Payment Advisory Commission, begin18 ning in 2010 and in each of its subsequent annual reports 

19 to Congress on Medicare physician payment policies, shall 

20 provide an assessment of the impact of changes in Medi21 care payment policies in improving access to and equity 

22 of payments to primary care physicians and primary care 

23 providers. Such assessment shall include an assessment of 

24 the effectiveness, once implemented, of the Medicare pay25 ment-related reforms required by this Act to support priVerDate Nov 24 2008 06:45 May 14, 2009 Jkt 079200 PO 00000 Frm 00062 Fmt 6652 Sfmt 6201 E:\BILLS\H2350.IH H2350

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1 mary care as well as any other payment changes that may 

2 be required by Congress to improve access to and equity 

3 of payments to primary care physicians and primary care 

4 providers. 

5 SEC. 326. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI6 TIONS. 

7 (a) IN GENERAL.—Section 1886(h) of the Social Se8 curity Act (42 U.S.C. 1395ww(h)) is amended— 

9 (1) in paragraph (4)(F)(i), by striking ‘‘para10 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

11 (2) in paragraph (4)(H)(i), by striking ‘‘para12 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

13 and 

14 (3) by adding at the end the following new 

15 paragraph: 

16 ‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY

17 POSITIONS.— 

18 ‘‘(A) ADDITIONAL RESIDENCY POSI19 TIONS.— 

20 ‘‘(i) REDUCTION IN LIMIT BASED ON

21 UNUSED POSITIONS.— 

22 ‘‘(I) IN GENERAL.—The Sec23 retary shall reduce the otherwise ap24 plicable resident limit for a hospital 

25 that the Secretary determines had 


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1 residency positions that were unused 

2 for all 5 of the most recent cost re3 porting periods ending prior to the 

4 date of enactment of this paragraph 

5 by an amount that is equal to the 

6 number of such unused residency po7 sitions. 

8 ‘‘(II) EXCEPTION FOR RURAL

9 HOSPITALS AND CERTAIN OTHER HOS10 PITALS.—This subparagraph shall not 

11 apply to a hospital— 

12 ‘‘(aa) located in a rural area 

13 (as defined in subsection 

14 (d)(2)(D)(ii)); 

15 ‘‘(bb) that has participated 

16 in a voluntary reduction plan 

17 under paragraph (6); or 

18 ‘‘(cc) that has participated 

19 in a demonstration project ap20 proved as of October 31, 2003, 

21 under the authority of section 

22 402 of Public Law 90–248. 

23 ‘‘(ii) NUMBER AVAILABLE FOR DIS24 TRIBUTION.—The number of additional 

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1 tion under subparagraph (B) shall be an 

2 amount that the Secretary determines 

3 would result in a 15 percent increase in 

4 the aggregate number of full-time equiva5 lent residents in approved medical training 

6 programs (as determined based on the 

7 most recent cost reports available at the 

8 time of distribution). One-third of such 

9 number shall only be available for distribu10 tion to hospitals described in subclause (I) 

11 of subparagraph (B)(ii) under such sub12 paragraph. 

13 ‘‘(B) DISTRIBUTION.— 

14 ‘‘(i) IN GENERAL.—The Secretary 

15 shall increase the otherwise applicable resi16 dent limit for each qualifying hospital that 

17 submits an application under this subpara18 graph by such number as the Secretary 

19 may approve for portions of cost reporting 

20 periods occurring on or after the date of 

21 enactment of this paragraph. The aggre22 gate number of increases in the otherwise 

23 applicable resident limit under this sub24 paragraph shall be equal to the number of 


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1 additional residency positions available for 

2 distribution under subparagraph (A)(ii). 

3 ‘‘(ii) DISTRIBUTION TO HOSPITALS

4 ALREADY OPERATING OVER RESIDENT

5 LIMIT.— 

6 ‘‘(I) IN GENERAL.—Subject to 

7 subclause (II), in the case of a hos8 pital in which the reference resident 

9 level of the hospital (as defined in 

10 clause (ii)) is greater than the other11 wise applicable resident limit, the in12 crease in the otherwise applicable resi13 dent limit under this subparagraph 

14 shall be an amount equal to the prod15 uct of the total number of additional 

16 residency positions available for dis17 tribution under subparagraph (A)(ii) 

18 and the quotient of— 

19 ‘‘(aa) the number of resident 

20 positions by which the reference 

21 resident level of the hospital ex22 ceeds the otherwise applicable 

23 resident limit for the hospital; 

24 and 


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1 ‘‘(bb) the number of resident 

2 positions by which the reference 

3 resident level of all such hospitals 

4 with respect to which an applica5 tion is approved under this sub6 paragraph exceeds the otherwise 

7 applicable resident limit for such 

8 hospitals. 

9 ‘‘(II) REQUIREMENTS.—A hos10 pital described in subclause (I)— 

11 ‘‘(aa) is not eligible for an 

12 increase in the otherwise applica13 ble resident limit under this sub14 paragraph unless the amount by 

15 which the reference resident level 

16 of the hospital exceeds the other17 wise applicable resident limit is 

18 not less than 10 and the hospital 

19 trains at least 25 percent of the 

20 full-time equivalent residents of 

21 the hospital in primary care and 

22 general surgery (as of the date of 

23 enactment of this paragraph); 

24 and 


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1 ‘‘(bb) shall continue to train 

2 at least 25 percent of the full3 time equivalent residents of the 

4 hospital in primary care and gen5 eral surgery for the 10-year pe6 riod beginning on such date. 

7 In the case where the Secretary deter8 mines that a hospital no longer meets 

9 the requirement of item (bb), the Sec10 retary may reduce the otherwise appli11 cable resident limit of the hospital by 

12 the amount by which such limit was 

13 increased under this clause. 

14 ‘‘(III) CLARIFICATION REGARD15 ING ELIGIBILITY FOR OTHER ADDI16 TIONAL RESIDENCY POSITIONS.— 

17 Nothing in this clause shall be con18 strued as preventing a hospital de19 scribed in subclause (I) from applying 

20 for additional residency positions 

21 under this paragraph that are not re22 served for distribution under this 

23 clause. 

24 ‘‘(iii) REFERENCE RESIDENT

25 LEVEL.— 


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1 ‘‘(I) IN GENERAL.—Except as 

2 otherwise provided in subclause (II), 

3 the reference resident level specified in 

4 this clause for a hospital is the resi5 dent level for the most recent cost re6 porting period of the hospital ending 

7 on or before the date of enactment of 

8 this paragraph, for which a cost re9 port has been settled (or, if not, sub10 mitted (subject to audit)), as deter11 mined by the Secretary. 

12 ‘‘(II) USE OF MOST RECENT AC13 COUNTING PERIOD TO RECOGNIZE EX14 PANSION OF EXISTING PROGRAM OR

15 ESTABLISHMENT OF NEW PRO16 GRAM.—If a hospital submits a timely 

17 request to increase its resident level 

18 due to an expansion of an existing 

19 residency training program or the es20 tablishment of a new residency train21 ing program that is not reflected on 

22 the most recent cost report that has 

23 been settled (or, if not, submitted 

24 (subject to audit)), after audit and 

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1 retary, the reference resident level for 

2 such hospital is the resident level for 

3 the cost reporting period that includes 

4 the additional residents attributable to 

5 such expansion or establishment, as 

6 determined by the Secretary. 

7 ‘‘(C) CONSIDERATIONS IN REDISTRIBU8 TION.—In determining for which hospitals the 

9 increase in the otherwise applicable resident 

10 limit is provided under subparagraph (B) (other 

11 than an increase under subparagraph (B)(ii)), 

12 the Secretary shall take into account the dem13 onstrated likelihood of the hospital filling the 

14 positions within the first 3 cost reporting peri15 ods beginning on or after July 1, 2010, made 

16 available under this paragraph, as determined 

17 by the Secretary. 

18 ‘‘(D) PRIORITY FOR CERTAIN AREAS.—In 

19 determining for which hospitals the increase in 

20 the otherwise applicable resident limit is pro21 vided under subparagraph (B) (other than an 

22 increase under subparagraph (B)(ii)), the Sec23 retary shall distribute the increase to hospitals 

24 based on the following criteria: 


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1 ‘‘(i) The Secretary shall give pref2 erence to hospitals that submit applica3 tions for new primary care and general 

4 surgery residency positions. In the case of 

5 any increase based on such preference, a 

6 hospital shall ensure that— 

7 ‘‘(I) the position made available 

8 as a result of such increase remains a 

9 primary care or general surgery resi10 dency position for not less than 10 

11 years after the date on which the posi12 tion is filled; and 

13 ‘‘(II) the total number of primary 

14 care and general surgery residency po15 sitions in the hospital (determined 

16 based on the number of such positions 

17 as of the date of such increase, includ18 ing any position added as a result of 

19 such increase) is not decreased during 

20 such 10-year period. 

21 In the case where the Secretary determines 

22 that a hospital no longer meets the re23 quirement of subclause (II), the Secretary 

24 may reduce the otherwise applicable resi25 dent limit of the hospital by the amount by 


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1 which such limit was increased under this 

2 paragraph. 

3 ‘‘(ii) The Secretary shall give pref4 erence to hospitals that emphasizes train5 ing in community health centers and other 

6 community-based clinical settings. 

7 ‘‘(iii) The Secretary shall give pref8 erence to hospitals in States that have 

9 more medical students than residency posi10 tions available (including a greater pref11 erence for those States with smaller resi12 dent-to-medical-student ratios). In deter13 mining the number of medical students in 

14 a State for purposes of the preceding sen15 tence, the Secretary shall include planned 

16 students at medical schools which have 

17 provisional accreditation by the Liaison 

18 Committee on Medical Education or the 

19 American Osteopathic Association. 

20 ‘‘(iv) The Secretary shall give pref21 erence to hospitals in States that have low 

22 resident-to-population ratios (including a 

23 greater preference for those States with 

24 lower resident-to-population ratios). 

25 ‘‘(E) LIMITATION.— 


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1 ‘‘(i) IN GENERAL.—Except as pro2 vided in clause (ii), in no case may a hos3 pital (other than a hospital described in 

4 subparagraph (B)(ii)(I), subject to the lim5 itation under subparagraph (B)(ii)(III)) 

6 apply for more than 50 full-time equivalent 

7 additional residency positions under this 

8 paragraph. 

9 ‘‘(ii) INCREASE IN NUMBER OF ADDI10 TIONAL POSITIONS AVAILABLE FOR DIS11 TRIBUTION.—The Secretary shall increase 

12 the number of full-time equivalent addi13 tional residency positions a hospital may 

14 apply for under this paragraph if the Sec15 retary determines that the number of addi16 tional residency positions available for dis17 tribution under subparagraph (A)(ii) ex18 ceeds the number of such applications ap19 proved. 

20 ‘‘(F) APPLICATION OF PER RESIDENT

21 AMOUNTS FOR PRIMARY CARE AND NONPRI22 MARY CARE.—With respect to additional resi23 dency positions in a hospital attributable to the 

24 increase provided under this paragraph, the ap25 proved FTE resident amounts are deemed to be 


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1 equal to the hospital per resident amounts for 

2 primary care and nonprimary care computed 

3 under paragraph (2)(D) for that hospital. 

4 ‘‘(G) DISTRIBUTION.—The Secretary shall 

5 distribute the increase to hospitals under this 

6 paragraph not later than 2 years after the date 

7 of enactment of this paragraph.’’. 

8 (b) IME.— 

9 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of 

10 the Social Security Act (42 U.S.C. 

11 1395ww(d)(5)(B)(v)), in the second sentence, is 

12 amended— 

13 (A) by striking ‘‘subsection (h)(7)’’ and in14 serting ‘‘subsections (h)(7) and (h)(8)’’; and 

15 (B) by striking ‘‘it applies’’ and inserting 

16 ‘‘they apply’’. 

17 (2) CONFORMING PROVISION.—Section 

18 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

19 1395ww(d)(5)(B)) is amended by adding at the end 

20 the following clause: 

21 ‘‘(x) For discharges occurring on or after the 

22 date of enactment of this clause, insofar as an addi23 tional payment amount under this subparagraph is 

24 attributable to resident positions distributed to a 

25 hospital under subsection (h)(8)(B), the indirect 


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1 teaching adjustment factor shall be computed in the 

2 same manner as provided under clause (ii) with re3 spect to such resident positions.’’. 

4 SEC. 327. COUNTING RESIDENT TIME IN OUTPATIENT SET5 TINGS. 

6 (a) D–GME.—Section 1886(h)(4)(E) of the Social 

7 Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amended— 

8 (1) by striking ‘‘under an approved medical 

9 residency training program’’; and 

10 (2) by striking ‘‘if the hospital incurs all, or 

11 substantially all, of the costs for the training pro12 gram in that setting’’ and inserting ‘‘if the hospital 

13 continues to incur the costs of the stipends and 

14 fringe benefits of the resident during the time the 

15 resident spends in that setting’’. 

16 (b) IME.—Section 1886(d)(5)(B)(iv) of the Social 

17 Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend18 ed— 

19 (1) by striking ‘‘under an approved medical 

20 residency training program’’; and 

21 (2) by striking ‘‘if the hospital incurs all, or 

22 substantially all, of the costs for the training pro23 gram in that setting’’ and inserting ‘‘if the hospital 

24 continues to incur the costs of the stipends and 


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1 fringe benefits of the intern or resident during the 

2 time the intern or resident spends in that setting’’. 

3 (c) EFFECTIVE DATES; APPLICATION.— 

4 (1) IN GENERAL.—Effective for cost reporting 

5 periods beginning on or after July 1, 2009, the Sec6 retary of Health and Human Services shall imple7 ment the amendments made by this section in a 

8 manner so as to apply to cost reporting periods be9 ginning on or after July 1, 2009. 

10 (2) APPLICATION.—The amendments made by 

11 this section shall not be applied in a manner that re12 quires reopening of any settled hospital cost reports 

13 as to which there is not a jurisdictionally proper ap14 peal pending as of the date of the enactment of this 

15 Act on the issue of payment for indirect costs of 

16 medical education under section 1886(d)(5)(B) of 

17 the Social Security Act (42 U.S.C. 

18 1395ww(d)(5)(B)) or for direct graduate medical 

19 education costs under section 1886(h) of such Act 

20 (42 U.S.C. 1395ww(h)). 


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1 SEC. 328. RULES FOR COUNTING RESIDENT TIME FOR DI2 DACTIC AND SCHOLARLY ACTIVITIES AND 

3 OTHER ACTIVITIES. 

4 (a) GME.—Section 1886(h) of the Social Security 

5 Act (42 U.S.C. 1395ww(h)), as amended by section 

6 327(a), is amended— 

7 (1) in paragraph (4)(E)— 

8 (A) by designating the first sentence as a 

9 clause (i) with the heading ‘‘IN GENERAL’’ and 

10 appropriate indentation and by striking ‘‘Such 

11 rules’’ and inserting ‘‘Subject to clause (ii), 

12 such rules’’; and 

13 (B) by adding at the end the following new 

14 clause: 

15 ‘‘(ii) TREATMENT OF CERTAIN NON16 HOSPITAL AND DIDACTIC ACTIVITIES.— 

17 Such rules shall provide that all time spent 

18 by an intern or resident in an approved 

19 medical residency training program in a 

20 nonhospital setting that is primarily en21 gaged in furnishing patient care (as de22 fined in paragraph (5)(K)) in non-patient 

23 care activities, such as didactic conferences 

24 and seminars, but not including research 

25 not associated with the treatment or diag26 nosis of a particular patient, as such time 


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1 and activities are defined by the Secretary, 

2 shall be counted toward the determination 

3 of full-time equivalency.’’; 

4 (2) in paragraph (4), by adding at the end the 

5 following new subparagraph: 

6 ‘‘(I) In determining the hospital’s number 

7 of full-time equivalent residents for purposes of 

8 this subsection, all the time that is spent by an 

9 intern or resident in an approved medical resi10 dency training program on vacation, sick leave, 

11 or other approved leave, as such time is defined 

12 by the Secretary, and that does not prolong the 

13 total time the resident is participating in the 

14 approved program beyond the normal duration 

15 of the program shall be counted toward the de16 termination of full-time equivalency.’’; and 

17 (3) in paragraph (5), by adding at the end the 

18 following new subparagraph: 

19 ‘‘(M) NONHOSPITAL SETTING THAT IS PRI20 MARILY ENGAGED IN FURNISHING PATIENT

21 CARE.—The term ‘nonhospital setting that is 

22 primarily engaged in furnishing patient care’ 

23 means a nonhospital setting in which the pri24 mary activity is the care and treatment of pa25 tients, as defined by the Secretary.’’. 


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1 (b) IME DETERMINATIONS.—Section 1886(d)(5)(B) 

2 of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by 

3 section 326(b), is amended by adding at the end the fol4 lowing new clause: 

5 ‘‘(xi)(I) The provisions of subparagraph (I) of 

6 subsection (h)(4) shall apply under this subpara7 graph in the same manner as they apply under such 

8 subsection. 

9 ‘‘(II) In determining the hospital’s number of 

10 full-time equivalent residents for purposes of this 

11 subparagraph, all the time spent by an intern or 

12 resident in an approved medical residency training 

13 program in non-patient care activities, such as di14 dactic conferences and seminars, as such time and 

15 activities are defined by the Secretary, that occurs in 

16 the hospital shall be counted toward the determina17 tion of full-time equivalency if the hospital— 

18 ‘‘(aa) is recognized as a subsection (d) hos19 pital; 

20 ‘‘(bb) is recognized as a subsection (d) 

21 Puerto Rico hospital; 

22 ‘‘(cc) is reimbursed under a reimbursement 

23 system authorized under section 1814(b)(3); or 

24 ‘‘(dd) is a provider-based hospital out25 patient department. 


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1 ‘‘(III) In determining the hospital’s number of 

2 full-time equivalent residents for purposes of this 

3 subparagraph, all the time spent by an intern or 

4 resident in an approved medical residency training 

5 program in research activities that are not associ6 ated with the treatment or diagnosis of a particular 

7 patient, as such time and activities are defined by 

8 the Secretary, shall not be counted toward the deter9 mination of full-time equivalency.’’. 

10 (c) EFFECTIVE DATES; APPLICATION.— 

11 (1) IN GENERAL.—Except as otherwise pro12 vided, the Secretary of Health and Human Services 

13 shall implement the amendments made by this sec14 tion in a manner so as to apply to cost reporting pe15 riods beginning on or after January 1, 1983. 

16 (2) DIRECT GME.—Section 1886(h)(4)(E)(ii) of 

17 the Social Security Act, as added by subsection 

18 (a)(1)(B), shall apply to cost reporting periods be19 ginning on or after July 1, 2009. 

20 (3) IME.—Section 1886(d)(5)(B)(xi)(III) of 

21 the Social Security Act, as added by subsection (b), 

22 shall apply to cost reporting periods beginning on or 

23 after October 1, 2001. Such section, as so added, 

24 shall not give rise to any inference on how the law 

25 in effect prior to such date should be interpreted. 


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1 (4) APPLICATION.—The amendments made by 

2 this section shall not be applied in a manner that re3 quires reopening of any settled hospital cost reports 

4 as to which there is not a jurisdictionally proper ap5 peal pending as of the date of the enactment of this 

6 Act on the issue of payment for indirect costs of 

7 medical education under section 1886(d)(5)(B) of 

8 the Social Security Act or for direct graduate med9 ical education costs under section 1886(h) of such 

10 Act. 

11 SEC. 329. PRESERVATION OF RESIDENT CAP POSITIONS 

12 FROM CLOSED AND ACQUIRED HOSPITALS. 

13 (a) GME.—Section 1886(h)(4)(H) of the Social Se14 curity Act (42 U.S.C. Section 1395ww(h)(4)(H)) is 

15 amended by adding at the end the following new clauses: 

16 ‘‘(vi) REDISTRIBUTION OF RESIDENCY

17 SLOTS AFTER A HOSPITAL CLOSES.— 

18 ‘‘(I) IN GENERAL.—Subject to 

19 the succeeding provisions of this 

20 clause, the Secretary shall, by regula21 tion, establish a process under which, 

22 in the case where a hospital with an 

23 approved medical residency program 

24 closes on or after the date of enact25 ment of the Balanced Budget Act of 


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1 1997, the Secretary shall increase the 

2 otherwise applicable resident limit 

3 under this paragraph for other hos4 pitals in accordance with this clause. 

5 ‘‘(II) PRIORITY FOR HOSPITALS

6 IN CERTAIN AREAS.—Subject to the 

7 succeeding provisions of this clause, in 

8 determining for which hospitals the 

9 increase in the otherwise applicable 

10 resident limit is provided under such 

11 process, the Secretary shall distribute 

12 the increase to hospitals located in the 

13 following priority order (with pref14 erence given within each category to 

15 hospitals that are members of the 

16 same affiliated group (as defined by 

17 the Secretary under clause (ii)) as the 

18 closed hospital): 

19 ‘‘(aa) First, to hospitals lo20 cated in the same core-based sta21 tistical area as, or a core-based 

22 statistical area contiguous to, the 

23 hospital that closed. 


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1 ‘‘(bb) Second, to hospitals 

2 located in the same State as the 

3 hospital that closed. 

4 ‘‘(cc) Third, to hospitals lo5 cated in the same region of the 

6 country as the hospital that 

7 closed. 

8 ‘‘(dd) Fourth, to all other 

9 hospitals. 

10 ‘‘(III) REQUIREMENT HOSPITAL

11 LIKELY TO FILL POSITION WITHIN

12 CERTAIN TIME PERIOD.—The Sec13 retary may only increase the otherwise 

14 applicable resident limit of a hospital 

15 under such process if the Secretary 

16 determines the hospital has dem17 onstrated a likelihood of filling the po18 sitions made available under this 

19 clause within 3 years. 

20 ‘‘(IV) LIMITATION.—The aggre21 gate number of increases in the other22 wise applicable resident limits for hos23 pitals under this clause shall be equal 

24 to the number of resident positions in 

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1 grams that closed on or after the date 

2 described in subclause (I). 

3 ‘‘(vii) SPECIAL RULE FOR ACQUIRED

4 HOSPITALS.— 

5 ‘‘(I) IN GENERAL.—In the case 

6 of a hospital that is acquired (through 

7 any mechanism) by another entity 

8 with the approval of a bankruptcy 

9 court, during a period determined by 

10 the Secretary (but not less than 3 

11 years), the applicable resident limit of 

12 the acquired hospital shall, except as 

13 provided in subclause (II), be the ap14 plicable resident limit of the hospital 

15 that was acquired (as of the date im16 mediately before the acquisition), 

17 without regard to whether the acquir18 ing entity accepts assignment of the 

19 Medicare provider agreement of the 

20 hospital that was acquired, so long as 

21 the acquiring entity continues to oper22 ate the hospital that was acquired and 

23 to furnish services, medical residency 

24 programs, and volume of patients 

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1 dency programs, and volume of pa2 tients of the hospital that was ac3 quired (as determined by the Sec4 retary) during such period. 

5 ‘‘(II) LIMITATION.—Subclause 

6 (I) shall only apply in the case where 

7 an acquiring entity waives the right as 

8 a new provider under the program 

9 under this title to have the otherwise 

10 applicable resident limit of the ac11 quired hospital re-established or in12 creased.’’. 

13 (b) IME.—Section 1886(d)(5)(B)(v) of the Social Se14 curity Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 

15 sentence, as amended by section 326(b), is amended by 

16 striking ‘‘subsections (h)(7) and (h)(8)’’ and inserting 

17 ‘‘subsections (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and 

18 (h)(8)’’. 

19 (c) APPLICATION.—The amendments made by this 

20 section shall not be applied in a manner that requires re21 opening of any settled hospital cost reports as to which 

22 there is not a jurisdictionally proper appeal pending as 

23 of the date of the enactment of this Act on the issue of 

24 payment for indirect costs of medical education under sec25 tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 


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1 1395ww(d)(5)(B)) or for direct graduate medical edu2 cation costs under section 1886(h) of such Act (42 U.S.C. 

3 1395ww(h)). 

4 (d) NO AFFECT ON TEMPORARY FTE CAP ADJUST5 MENTS.—The amendments made by this section shall not 

6 affect any temporary adjustment to a hospital’s FTE cap 

7 under section 413.79(h) of title 42, Code of Federal Regu8 lations (as in effect on the date of enactment of this Act). 

9 SEC. 330. QUALITY IMPROVEMENT ORGANIZATION ASSIST10 ANCE FOR PHYSICIAN PRACTICES SEEKING 

11 TO BE PATIENT CENTERED MEDICAL HOME 

12 PRACTICES. 

13 Not later than 90 days after the date of enactment 

14 of this Act, the Secretary of Health and Human Services 

15 shall revise the 9th Statement of Work under the Quality 

16 Improvement Program under part B of title XI of the So17 cial Security Act to include a requirement that, in order 

18 to be an eligible Quality Improvement Organization (in 

19 this section referred to as a ‘‘QIO’’) for the 9th Statement 

20 of Work contract cycle, a QIO shall provide assistance, 

21 including technical assistance, to physicians under the 

22 Medicare program under title XVIII of the Social Security 

23 Act that seek to acquire the elements necessary to be rec24 ognized as a patient centered medical home practice under 

25 the National Committee for Quality Assurance’s Physician 


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1 Practice Connections—PCMH module (or any successor 

2 module issued by such Committee). 

3 TITLE IV—STUDIES 

4 SEC. 401. STUDY CONCERNING THE DESIGNATION OF PRI5 MARY CARE AS A SHORTAGE PROFESSION. 

6 (a) IN GENERAL.—Not later than June 30, 2010, the 

7 Secretary of Labor shall conduct a study and submit to 

8 the Committee on Education and Labor of the House of 

9 Representatives and the Committee on Health, Education, 

10 Labor, and Pensions a report that contains— 

11 (1) a description of the criteria for the designa12 tion of primary care physicians as professions in 

13 shortage as defined by the Secretary under section 

14 212(a)(5)(A) of the Immigration and Nationality 

15 Act; 

16 (2) the findings of the Secretary on whether 

17 primary care physician professions will, on the date 

18 on which the report is submitted, or within the 5- 

19 year period beginning on such date, satisfy the cri20 teria referred to in paragraph (1); and 

21 (3) if the Secretary finds that such professions 

22 will not satisfy such criteria, recommendations for 

23 modifications to such criteria to enable primary care 

24 physicians to be so designated as a profession in 

25 shortage. 


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1 (b) REQUIREMENTS.—In conducting the study under 

2 subsection (a), the Secretary of Labor shall consider work3 force data from the Health Resources and Services Admin4 istration, the Council on Graduate Medical Education, the 

5 Association of American Medical Colleges, and input from 

6 physician membership organizations that represent pri7 mary care physicians. 

8 SEC. 402. STUDY CONCERNING THE EDUCATION DEBT OF 

9 MEDICAL SCHOOL GRADUATES. 

10 (a) STUDY.—The Comptroller General of the United 

11 States shall conduct a study to evaluate the higher edu12 cation-related indebtedness of medical school graduates in 

13 the United States at the time of graduation from medical 

14 school, and the impact of such indebtedness on specialty 

15 choice, including the impact on the field of primary care. 

16 (b) REPORT.— 

17 (1) SUBMISSION AND DISSEMINATION OF RE18 PORT.—Not later than 1 year after the date of en19 actment of this Act, the Comptroller General shall 

20 submit a report on the study required by subsection 

21 (a) to the Committee on Health, Education, Labor, 

22 and Pensions of the Senate and the Committee on 

23 Education and Labor of the House of Representa24 tives, and shall make such report widely available to 

25 the public. 


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1 (2) ADDITIONAL REPORTS.—The Comptroller 

2 General may periodically prepare and release as nec3 essary additional reports on the topic described in 

4 subsection (a). 

5 SEC. 403. STUDY ON MINORITY REPRESENTATION IN PRI6 MARY CARE. 

7 (a) STUDY.—The Secretary of Health and Human 

8 Services, acting through the Administrator of the Health 

9 Resources and Services Administration, shall conduct a 

10 study of minority representation in training, and in prac11 tice, in primary care specialties. 

12 (b) REPORT.—Not later than 1 year after the date 

13 of enactment of this Act, the Secretary of Health and 

14 Human Services, acting through the Administrator of the 

15 Health Resources and Services Administration, shall sub16 mit to the appropriate committees of Congress a report 

17 concerning the study conducted under subsection (a), in18 cluding recommendations for achieving a primary care 

19 workforce that is more representative of the population of 

20 the United States. 

Æ 


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