II 

113TH CONGRESS 

2D SESSION S. 1978 

To increase access to primary care services through training and 

accountability improvements. 

IN THE SENATE OF THE UNITED STATES 

JANUARY 30, 2014 

Mr. UDALL of New Mexico introduced the following bill; which was read twice 

and referred to the Committee on Finance 

A BILL 

To increase access to primary care services through training 

and accountability improvements. 

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 ‘‘Increasing Primary Care Access Act of 2014’’. 

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. Centers of Excellence in Primary Care. 

Sec. 4. Medicare Indirect Medical Education (IME) performance adjustment 

and primary care training bonus. 

Sec. 5. Increasing Medicare graduate medical education transparency. 


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Sec. 6. Ensuring appropriate representation of primary care physicians on 

groups making recommendations regarding relative values 

under the Medicare physician fee schedule. 

Sec. 7. Primary care project. 

Sec. 8. Regional centers for health workforce analysis. 

Sec. 9. Payments for graduate medical education under the Medicaid program. 

Sec. 10. National Center for Health Care Workforce Analysis. 

Sec. 11. Teaching health center reauthorization. 

Sec. 12. GAO studies on graduate medical education. 

1 SEC. 2. FINDINGS. 

2 Congress makes the following findings: 

3 (1) A well prepared, effective primary care 

4 workforce can reduce health care costs and play a 

5 large role in the prevention and management of ill6 ness. A one-unit increase in primary care physicians 

7 per 10,000 population is associated with improved 

8 health outcomes such as all-cause, cancer, heart dis9 ease, and stroke mortality, as well as increased life 

10 expectancy. 

11 (2) Primary care physicians include those 

12 trained in family medicine, general internal medi13 cine, general pediatrics, and in some cases, gyne14 cology. One primary care physician will generate 6 

15 to 23 jobs in the community served by such physi16 cian, $900,000 to $1,200,000 in wages, salaries, and 

17 benefits, and nearly $100,000 in State and local 

18 taxes. 

19 (3) As of 2011, only 32 percent of the physician 

20 workforce is comprised of primary care and only be21 tween 16 to 18 percent of graduates of allopathic 


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1 medical schools are likely to pursue a career in pri2 mary care. 

3 (4) Primary care supply has a positive effect on 

4 the entire population, but the effect is greater in 

5 areas with higher income inequality and poverty, 

6 such as rural areas. Only about 10 percent of physi7 cians in America practice in rural areas while 20 

8 percent of the United States population is located in 

9 rural areas. 

10 (5) Geographic areas with more general and 

11 family physicians per population have lower rates of 

12 mortality and hospitalization for conditions that 

13 should be preventable or detected early, such as dia14 betes, congestive heart failure, and hypertension. 

15 (6) As of May 2011, there were 6,419 primary 

16 care health professional shortage areas, comprised of 

17 66,300,000 individuals. It would take 17,636 practi18 tioners to meet such individuals’ need for primary 

19 care providers. 

20 SEC. 3. CENTERS OF EXCELLENCE IN PRIMARY CARE. 

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

22 (42 U.S.C. 293k) is amended by adding at the end the 

23 following: 


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1 ‘‘Subpart III—Centers of Excellence in Primary Care 

2 ‘‘SEC. 749C. CENTERS OF EXCELLENCE IN PRIMARY CARE. 

3 ‘‘(a) IN GENERAL.—The Secretary shall make grants 

4 to, and enter into contracts with, schools of medicine and 

5 osteopathic medicine for the purpose of assisting the 

6 schools in supporting programs of excellence in primary 

7 care. 

8 ‘‘(b) ELIGIBLE SCHOOLS.—To be eligible to receive 

9 a grant under subsection (a), a school of medicine or os10 teopathic medicine shall submit an application at such 

11 time, in such manner, and containing such information as 

12 the Secretary may require, including a description of inno13 vative ideas that applicants propose to increase recruit14 ment and retention in primary care, including pipeline, ad15 missions, curriculum, mentoring, preparation for resi16 dency, and related purposes. 

17 ‘‘(c) SELECTION OF RECIPIENTS.— 

18 ‘‘(1) IN GENERAL.—The Secretary shall award 

19 a grant under this section to not less than 6 and not 

20 more than 10 eligible schools of medicine and osteo21 pathic medicine. Such selected schools shall be des22 ignated as Centers of Excellence in Primary Care. 

23 ‘‘(2) REQUIREMENTS RELATING TO RURAL AND

24 UNDERSERVED AREAS.—Of the schools designated 

25 under paragraph (1)— 


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1 ‘‘(A) not less than 4 and not more than 7 

2 shall be located in a rural area; and 

3 ‘‘(B) not less than 2 and not more than 3 

4 shall be located in a medically underserved 

5 area. 

6 ‘‘(d) USE OF FUNDS.—A school of medicine or osteo7 pathic medicine designated as a Center of Excellence 

8 under this section shall, in using funds provided under the 

9 grant, give funding priority to— 

10 ‘‘(1) making medical school affordable for each 

11 admitted and graduated student, including through 

12 significant tuition scholarships, tuition remissions, 

13 and stipends, especially for low-income students, and 

14 other provisions, such as loan forgiveness for grad15 uates who practice primary care for a specified dura16 tion of time; 

17 ‘‘(2) conducting admissions processes that favor 

18 students who will work in rural and medically under19 served areas, and consider factors such as rural 

20 birth, minority status or upbringing, and desire to 

21 serve rural and medically underserved populations; 

22 ‘‘(3) developing curricula models and innova23 tions that expedite medical school training, build 

24 needed skills for modern medical practice, and en25 hance affinity of graduates for practice in rural and 


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1 medically underserved areas (which may include 3- 

2 year undergraduate medical education models, rural 

3 and inner city rotations, and mentoring with rural 

4 physicians); 

5 ‘‘(4) research whether students completing a 

6 service requirement in a rural or underserved area 

7 as part of the criteria for graduation improves ac8 cess to care in such area; 

9 ‘‘(5) implement tracking systems that— 

10 ‘‘(A) assess practice patterns of medical 

11 school graduates and require annual reports on 

12 this information for the duration of the grant 

13 program; and 

14 ‘‘(B) track all loan repayment and scholar15 ship disbursements to assure that program 

16 goals are being met with regard to recipients 

17 serving in desired locations with expected popu18 lations of need for a minimum required amount 

19 of time; and 

20 ‘‘(6) having interprofessional primary care 

21 health professions community-based service learning 

22 models for primary care residents, and include clerk23 ships and continuity clinic experiences for medical, 

24 nurse practitioner, and physician assistant students 

25 interested in primary care.’’. 


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1 SEC. 4. MEDICARE INDIRECT MEDICAL EDUCATION (IME) 

2 PERFORMANCE ADJUSTMENT AND PRIMARY 

3 CARE TRAINING BONUS. 

4 (a) IN GENERAL.—Section 1886(d)(5)(B) of the So5 cial Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amend6 ed— 

7 (1) by redesignating the clause (x) as added by 

8 section 5505(b) of the Patient Protection and Af9 fordable Care Act as clause (xi); and 

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

11 clauses: 

12 ‘‘(xii) ADJUSTMENT FOR PERFORMANCE.— 

13 ‘‘(I) IN GENERAL.—The Secretary, in con14 sultation with the advisory body under clause 

15 (xiii), shall establish and implement procedures 

16 under which the amount of payments that a 

17 hospital would otherwise receive for indirect 

18 medical education costs under this subpara19 graph for discharges occurring during an appli20 cable period is adjusted based on the perform21 ance of the hospital on measures specified by 

22 the Secretary. 

23 ‘‘(II) MEASURES.—The measures specified 

24 by the Secretary under this clause shall include 

25 measures on quality measurement and improve26 ment, evidence-based medicine, interprofessional 


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1 teamwork, multidisciplinary teamwork, care co2 ordination, and health information technology. 

3 Such measures shall include factors that pro4 mote training in primary care, such as— 

5 ‘‘(aa) resident training in outpatient 

6 and community settings, including Feder7 ally qualified health centers, rural health 

8 clinics, teaching health centers, rural med9 ical practices, facilities operated by the 

10 Veterans Administration, Indian Health 

11 Service facilities, including primary care 

12 training sites that are carried out through 

13 self determination contracts and are lo14 cated in a rural or primary care health 

15 professional shortage area; 

16 ‘‘(bb) salary and loan conditions for 

17 primary care residents; 

18 ‘‘(cc) the percentage of all graduates 

19 practicing primary care 5 years after grad20 uation; 

21 ‘‘(dd) the percentage of all graduates 

22 practicing primary care in health profes23 sional shortage areas 5 years after gradua24 tion; 


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1 ‘‘(ee) the percentage of all primary 

2 care graduates from underrepresented mi3 nority groups, including African-Ameri4 cans, Hispanic-Americans, and Native 

5 Americans, as well as other underserved 

6 populations; 

7 ‘‘(ff) how the residency is responding 

8 to the workforce needs identified by State 

9 and regional centers for workforce analysis 

10 established under the National Center for 

11 Health Care Workforce Analysis or the 

12 National Health Care Workforce Commis13 sion; 

14 ‘‘(gg) the provision of service to all so15 cioeconomic levels of patients, including 

16 but not limited to Medicaid program popu17 lations; 

18 ‘‘(hh) mentoring curriculum in pri19 mary care; 

20 ‘‘(ii) systems-based practice, including 

21 training in new forms of delivery system 

22 models, such as care coordination, account23 able care organizations, and patient-cen24 tered medical homes; and 


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1 ‘‘(jj) training in preventive care, 

2 chronic disease management, and popu3 lation health and public health. 

4 ‘‘(III) INITIAL MEASURE DEVELOPMENT

5 TIMELINE.— 

6 ‘‘(aa) PROPOSED SET OF MEAS7 URES.—Not later than January 1, 2016, 

8 the Secretary shall publish in the Federal 

9 Register a proposed set of measures for 

10 use under this clause. The Secretary shall 

11 provide for a period of public comment on 

12 such measures. 

13 ‘‘(bb) FINAL SET OF MEASURES.— 

14 Not later than June 30, 2016, the Sec15 retary shall publish in the Federal Register 

16 the final set of measures to be specified by 

17 the Secretary for use under this clause. 

18 ‘‘(IV) ADJUSTMENT.—Subject to subclause 

19 (V), the Secretary shall determine the amount 

20 of any adjustment under this clause to pay21 ments to a hospital under this subparagraph in 

22 an applicable period. 

23 ‘‘(V) BUDGET-NEUTRAL WITH RESPECT TO

24 PAYMENTS THAT WOULD OTHERWISE BE

25 MADE.—In making adjustments under this 


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1 clause, the Secretary shall ensure that the total 

2 amount of payments made to all hospitals 

3 under this subparagraph for an applicable pe4 riod is equal to the total amount of payments 

5 that would have been made to such hospitals 

6 under this subparagraph in such period if this 

7 clause had not been enacted. 

8 ‘‘(VI) PRIMARY CARE DEFINED.—In this 

9 clause, the term ‘primary care’ means family 

10 medicine, general internal medicine, general pe11 diatrics, preventive medicine, obstetrics and 

12 gynecology, psychiatry, and any other specialty 

13 which provides integrated, accessible health care 

14 services and is accountable for addressing a 

15 large majority of health care needs, developing 

16 a sustained partnership with patients, and prac17 ticing in the context of family and community. 

18 ‘‘(VII) APPLICABLE PERIOD DEFINED.—In 

19 this clause, the term ‘applicable period’ means 

20 the 12-month period beginning on July 1 of 

21 each year (beginning with 2015). 

22 ‘‘(xiii) USE OF ADVISORY BODY.— 

23 ‘‘(I) IN GENERAL.—Subject to subclause 

24 (III), the Secretary shall establish an advisory 

25 group to advise the Secretary on the application 


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1 of clause (xii), including the development of the 

2 measures to be used, how data on the measures 

3 may be collected, which measures will be re4 quired in any given reporting period, the appli5 cable thresholds for the measures, and the 

6 mechanisms to be used in order to determine 

7 whether a hospital has met a threshold. 

8 ‘‘(II) MAKE-UP OF GROUP.—The advisory 

9 group established under subclause (I) shall in10 clude— 

11 ‘‘(aa) representatives of accrediting 

12 and certifying organizations; 

13 ‘‘(bb) representatives of facilities that 

14 receive payments under this subparagraph; 

15 ‘‘(cc) representatives of specialty 

16 boards and primary care boards; 

17 ‘‘(dd) representatives of high-per18 forming health care systems; 

19 ‘‘(ee) experts in family medicine, pri20 mary care, and preventive medicine; 

21 ‘‘(ff) representatives of public and pri22 vate purchasers; 

23 ‘‘(gg) representatives of consumer and 

24 patient organizations, especially those from 

25 rural areas; and 


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1 ‘‘(hh) other entities and individuals as 

2 determined by the Secretary of Health and 

3 Human Services. 

4 ‘‘(III) USE OF EXISTING ENTITY.—If the 

5 Secretary determines that an existing entity is 

6 comprised of the individuals described in sub7 clause (II) and that such entity has the exper8 tise to advise the Secretary on the matters de9 scribed in subclause (I), the Secretary may 

10 enter into an arrangement with such entity to 

11 advise the Secretary on such matters rather 

12 than establishing a new advisory group under 

13 subclause (I).’’. 

14 (b) GAO STUDY AND REPORT.— 

15 (1) STUDY.—The Comptroller General of the 

16 United States shall conduct a study on the applica17 tion of clause (xii) of section 1886(d)(5)(B) of the 

18 Social Security Act, as added by subsection (a), in19 cluding an analysis of any changes in workforce pat20 terns as a result of the application of such clause. 

21 (2) REPORT.—Not later than January 1, 2018, 

22 the Comptroller General of the United States shall 

23 submit to Congress a report on the study conducted 

24 under paragraph (1), together with recommenda25 tions for such legislation and administrative action 


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1 as the Comptroller General determines to be appro2 priate. 

3 SEC. 5. INCREASING MEDICARE GRADUATE MEDICAL EDU4 CATION TRANSPARENCY. 

5 (a) IN GENERAL.—Not later than 2 years after the 

6 date of the enactment of this Act, and annually thereafter, 

7 the Secretary of Health and Human Services shall submit 

8 to Congress a report on the graduate medical education 

9 payments that hospitals and other facilities receive under 

10 the Medicare program. The report shall include the fol11 lowing information with respect to each hospital or facility 

12 that receives such payments: 

13 (1) The direct graduate medical education pay14 ments made to the hospital or other facility under 

15 section 1886(h) of the Social Security Act (42 

16 U.S.C. 1395ww(h)). 

17 (2) The indirect medical education payments 

18 made to the hospital or other facility under section 

19 1886(d)(5)(B) of such Act (42 U.S.C. 

20 1395ww(d)(1)(B)). 

21 (3) The number of residents counted for pur22 poses of making the payments described in para23 graph (1). 


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1 (4) The number of residents counted for pur2 poses of making the payments described in para3 graph (2). 

4 (5) The number of residents, if any, that are 

5 not counted for purposes of making payments de6 scribed in paragraph (1). 

7 (6) The number of residents, if any, that are 

8 not counted for purposes of making payments de9 scribed in paragraph (2). 

10 (7) The percent that the payments described in 

11 paragraphs (1) and (2) that are made to the hos12 pital or other facility make up of the total costs that 

13 the hospital or other facility incurs in providing 

14 graduate medical education, including salaries, bene15 fits, operational expenses, and all other patient care 

16 costs. 

17 (8) The number of residents training in each 

18 specialty. 

19 (9) A list that identifies any training partners 

20 and the sponsoring institutions for each residency 

21 program. 


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1 SEC. 6. ENSURING APPROPRIATE REPRESENTATION OF 

2 PRIMARY CARE PHYSICIANS ON GROUPS 

3 MAKING RECOMMENDATIONS REGARDING 

4 RELATIVE VALUES UNDER THE MEDICARE 

5 PHYSICIAN FEE SCHEDULE. 

6 Section 1848(c)(2)(B)(iii) of the Social Security Act 

7 (42 U.S.C. 1395w–4(c)(2)(B)(iii)) is amended by adding 

8 at the end the following new sentence: ‘‘The Secretary may 

9 not consult with an organization representing physicians 

10 if the organization uses a group to formulate recommenda11 tions regarding adjustments under clause (i) unless at 

12 least 40 percent of the members of the group are physi13 cians who are board certified and actively practicing in 

14 family medicine, general internal medicine, general pediat15 rics, preventive medicine, obstetrics and gynecology, or 

16 psychiatry.’’. 

17 SEC. 7. PRIMARY CARE PROJECT. 

18 (a) IN GENERAL.—The Secretary of Health and 

19 Human Services (referred to in this section as the ‘‘Sec20 retary’’) shall establish a pilot program to provide funding 

21 for graduate medical residency training programs in pri22 mary care. 

23 (b) APPLICATION AND SELECTION OF SITES.— 

24 (1) IN GENERAL.—An entity shall be eligible to 

25 participate in the project under this section if such 

26 entity— 


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1 (A) is— 

2 (i) a community-based corporate enti3 ty collaborating with 1 or more hospitals to 

4 operate a primary care residency program; 

5 (ii) a medical education entity estab6 lished by 1 or more hospitals to operate a 

7 primary care residency program; 

8 (iii) a hospital subsidiary or inde9 pendent corporation operating a primary 

10 care residency program; 

11 (iv) a medical education entity, inde12 pendent of a hospital, collaborating with a 

13 primary care residency program; or 

14 (v) another type of entity as deter15 mined appropriate by the Secretary; and 

16 (B) submits an application at such time, in 

17 such manner, and containing such information 

18 as the Secretary may require. 

19 (2) SELECTION OF PARTICIPANTS.—The Sec20 retary shall select, from the eligible entities under 

21 paragraph (1), 4 entities to participate in the 

22 project. Not less than 1 selected entity shall be an 

23 entity that is not a hospital. 

24 (c) ACTIVITIES UNDER THE PROJECT.—In carrying 

25 out the project, the Secretary shall— 


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1 (1) structure the funding of the project such 

2 that payments are made directly to the entity par3 ticipating in the project; 

4 (2) support primary care training in all sites 

5 where care is delivered, including non-hospital set6 tings such as Federally qualified health centers (as 

7 defined in section 1861(aa) of the Social Security 

8 Act (42 U.S.C. 1395x(aa))); 

9 (3)(A) increase funding for the primary care 

10 residency programs of the participating entities such 

11 that those primary care residency programs are 

12 funded at the 90th percentile of all residency pro13 grams nationally and are funded at levels that equal 

14 at least $100,000 per resident involved; and 

15 (B) ensure that entities participating in the 

16 project use the funding under the project to provide 

17 infrastructure support and recruitment and reten18 tion support for faculty and residents of the primary 

19 care residency program, including loan repayment 

20 for such residents; 

21 (4) require training in rural and medically un22 derserved areas, and with medically underserved 

23 populations (as defined in section 330(b) of the Pub24 lic Health Service Act (42 U.S.C. 254b(b))) and 


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1 service in such areas for a minimum of two rotations 

2 of not less than four weeks each year; and 

3 (5) permit the primary care residency program 

4 of the participating entities to qualify for payment 

5 under section 1886(d)(5)(B)(xii) of the Social Secu6 rity Act (as added by section 4) if such entities re7 ceive an appropriate score (as determined by the 

8 Secretary) on the measures specified by the Sec9 retary under such section. 

10 (d) TERM OF PROJECT.—The Secretary shall carry 

11 out the project under this section for a term of at least 

12 6 years. 

13 (e) EVALUATION.— 

14 (1) IN GENERAL.—Not later than 1 year after 

15 the commencement of the project, and each year 

16 thereafter, the Secretary shall conduct an of evalua17 tion the project. 

18 (2) CONTENT.—The Secretary shall conduct 

19 the evaluation under paragraph (1) using the fol20 lowing criteria: 

21 (A) The percentage of graduates from the 

22 primary care residency programs of the partici23 pating entities that are practicing primary care 

24 2 years after graduation, and longer. 


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1 (B) The percentage of graduates from the 

2 primary care residency programs of the partici3 pating entities that are practicing in a health 

4 professional shortage area (as defined in section 

5 332 of the Public Health Service Act (42 

6 U.S.C. 254e)) 2 years after graduation, and 

7 longer. 

8 (C) Other criteria as determined appro9 priate by the Secretary. 

10 (f) AUTHORIZATION OF APPROPRIATION.—There are 

11 authorized to be appropriated to carry out this section 

12 $3,600,000 for each of fiscal years 2015 through 2019. 

13 SEC. 8. REGIONAL CENTERS FOR HEALTH WORKFORCE 

14 ANALYSIS. 

15 (a) IN GENERAL.—Section 761(c) of the Public 

16 Health Service Act (42 U.S.C. 294n(c)) is amended by 

17 adding at the end the following— 

18 ‘‘(3) ESTABLISHMENT OF NEW CENTERS AND

19 FUNDING TO PRIMARY CARE RESIDENCY PRO20 GRAMS.— 

21 ‘‘(A) ESTABLISHMENT OF NEW CEN22 TERS.— 

23 ‘‘(i) IN GENERAL.—Not later than 1 

24 year after the date of enactment of the In25 creasing Primary Care Access Act of 2014, 


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1 the Secretary shall award grants to, or 

2 enter into contracts with, not less than 6 

3 and not more than 8 additional eligible en4 tities, as described in paragraph (1). 

5 ‘‘(ii) REQUIREMENTS.—In awarding 

6 grants or entering into contracts under 

7 clause (i), the Secretary shall— 

8 ‘‘(I) ensure that each Regional 

9 Center for Health Workforce Analysis 

10 established under this paragraph is lo11 cated in the geographic region that 

12 the Center covers; and 

13 ‘‘(II) seek to award such grants 

14 or enter into contracts with eligible 

15 entities that are multi-State consortia. 

16 ‘‘(B) DISTRIBUTION OF FUNDING TO PRI17 MARY CARE RESIDENCY PROGRAMS.— 

18 ‘‘(i) IN GENERAL.—Each Regional 

19 Center for Health Workforce Analysis es20 tablished pursuant to a grant or contract 

21 under subparagraph (A) shall, from the 

22 funds described in subparagraph (D), allo23 cate funding to primary care residency 

24 programs— 


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1 ‘‘(I) within the region served by 

2 the Regional Center for Health Work3 force Analysis; and 

4 ‘‘(II) that the Center has identi5 fied as a primary care residency pro6 gram in need. 

7 ‘‘(C) CONSULTATION.—Each Regional 

8 Center for Health Workforce Analysis estab9 lished pursuant to a grant or contract under 

10 this subsection shall establish a consortium of 

11 academic institutions with which the Center 

12 shall consult in determining allocations under 

13 subparagraph (B). 

14 ‘‘(D) FUNDING.— 

15 ‘‘(i) AUTHORIZATION OF APPROPRIA16 TIONS.—For each fiscal year, there is au17 thorized to be appropriated to carry out 

18 this paragraph $4,000,000, of which not 

19 less than $500,000 shall be allocated to 

20 each Regional Center for Health Work21 force Analysis established under this para22 graph. 

23 ‘‘(ii) USE OF FUNDS TO ESTABLISH

24 NEW CENTERS.—Each entity receiving 

25 funds under this paragraph may use a porVerDate Mar 15 2010 04:12 Feb 01, 2014 Jkt 039200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\S1978.IS S1978

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1 tion of such funding to establish the Re2 gional Center for Health Workforce Anal3 ysis.’’. 

4 (b) CONFORMING AMENDMENT.—Section 761(e)(2) 

5 of the Public Health Service Act (42 U.S.C. 294n(e)(2)) 

6 is amended by striking ‘‘subsection (c)’’ and inserting 

7 ‘‘paragraphs (1) and (2) of subsection (c)’’. 

8 SEC. 9. PAYMENTS FOR GRADUATE MEDICAL EDUCATION 

9 UNDER THE MEDICAID PROGRAM. 

10 (a) IN GENERAL.—Section 1905 of the Social Secu11 rity Act (42 U.S.C. 1396d), is amended by adding at the 

12 end the following new subsection: 

13 ‘‘(ee) INCREASED FMAP FOR TARGETED GRADUATE

14 MEDICAL EDUCATION IN EXPANSION STATES.— 

15 ‘‘(1) IN GENERAL.—The term ‘medical assist16 ance’ includes payment for costs of graduate medical 

17 education consistent with this subsection, whether 

18 provided in or outside of a hospital. 

19 ‘‘(2) INCREASED FMAP FOR EXPANSION STATES

20 THAT EXPAND TARGETED GRADUATE MEDICAL EDU21 CATION.—Notwithstanding subsection (b), with re22 spect to amounts expended by an Expansion State 

23 for medical assistance for targeted graduate medical 

24 education that is above the level of expenditures 

25 made by the Expansion State for such graduate 


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1 medical education for 2014, the Federal medical as2 sistance percentage shall be equal to— 

3 ‘‘(A) 100 percent for amounts expended in 

4 calendar quarters in 2015, 2016, or 2017; 

5 ‘‘(B) 95 percent for amounts expended in 

6 calendar quarters in 2018; 

7 ‘‘(C) 94 percent for amounts expended in 

8 calendar quarters in 2019; 

9 ‘‘(D) 93 percent for amounts expended in 

10 calendar quarters in 2020; and 

11 ‘‘(E) 90 percent for amounts expended in 

12 calendar quarters in 2021 or in each year 

13 thereafter. 

14 ‘‘(3) DEFINITIONS.—In this subsection: 

15 ‘‘(A) EXPANSION STATE.—The term ‘Ex16 pansion State’ means a State that elects in ac17 cordance with the amendments made by the Pa18 tient Protection and Affordable Care Act (Pub19 lic Law 111–148) to this title to provide med20 ical assistance to individuals described in sub21 clause (VIII) of section 1902(a)(10)(A)(i). 

22 ‘‘(B) TARGETED GRADUATE MEDICAL EDU23 CATION.—The term ‘targeted graduate medical 

24 education’ means graduate medical education 

25 for community-based, interprofessional primary 


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1 care residents and other health care students, 

2 located in a rural area or an area that is des3 ignated (under section 332(a)(1)(A) of the Pub4 lic Health Service Act) as a health professional 

5 shortage area, or for other workforce needs 

6 identified by State and regional centers for 

7 workforce analysis established under the Na8 tional Center for Health Workforce Analysis. 

9 ‘‘(C) PRIMARY CARE.—The term ‘primary 

10 care’ means family medicine, general internal 

11 medicine, general pediatrics, preventive medi12 cine, obstetrics and gynecology, psychiatry, and 

13 any other specialty which provides integrated, 

14 accessible health care services and is account15 able for addressing a large majority of health 

16 care needs, developing a sustained partnership 

17 with patients, and practicing in the context of 

18 family and community.’’. 

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

20 this section shall take effect on January 1, 2015. Nothing 

21 in this section shall be construed as affecting payments 

22 made before such date under a State plan under title XIX 

23 of the Social Security Act for graduate medical education. 


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1 SEC. 10. NATIONAL CENTER FOR HEALTH CARE WORK2 FORCE ANALYSIS. 

3 Section 761(b)(2)(A) of the Public Health Service 

4 Act (42 U.S.C. 294n(b)(2)(A)) is amended by inserting 

5 before the semicolon, the following: ‘‘, including national 

6 and regional workforce issues related to spending under 

7 the Medicaid program under title XIX of the Social Secu8 rity Act’’. 

9 SEC. 11. TEACHING HEALTH CENTER REAUTHORIZATION. 

10 (a) REAUTHORIZATION OF THE TEACHING HEALTH

11 CENTERS PROGRAM.—Section 340H of the Public Health 

12 Service Act (42 U.S.C. 256h) is amended— 

13 (1) in subsection (g)— 

14 (A) by inserting before the period the fol15 lowing: ‘‘, and not to exceed $800,000,000, for 

16 the period of fiscal years 2016 through 2020’’; 

17 and 

18 (B) by adding at the end the following: 

19 ‘‘Any amounts appropriated under this sub20 section for any of fiscal years 2011 through 

21 2020 and remaining unexpended at the end of 

22 the fiscal year involved may be used in subse23 quent fiscal years to carry out this section.’’; 

24 (2) in subsection (h)(2)— 


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1 (A) in the paragraph heading, by adding at 

2 the end the following: ‘‘; SUBMISSION TO CON3 GRESS’’; and 

4 (B) by adding at the end the following: 

5 ‘‘(C) SUBMISSION TO CONGRESS.—The 

6 Secretary shall annually submit to Congress a 

7 report that contains a compilation of the data 

8 submitted to the Secretary under paragraph (1) 

9 for the year involved.’’; 

10 (3) by redesignating subsections (h) through (j) 

11 as subsections (i) through (k), respectively; and 

12 (4) by inserting after subsection (g), the fol13 lowing: 

14 ‘‘(h) LIMITATION.—The Secretary shall establish a 

15 minimum per resident per year payment amount for fund16 ing of all approved teaching health center graduate med17 ical education positions under this section that shall be 

18 not less than the per resident per year payment amount 

19 as of January 1, 2013, and ensure that not less than such 

20 amount is provided to all teaching health center graduate 

21 medical education programs for all approved positions.’’. 

22 (b) TEACHING HEALTH CENTERS DEVELOPMENT

23 GRANTS.—Section 749A(g) of the Public Health Service 

24 Act (42 U.S.C. 293l–1(g)) is amended by striking ‘‘each 


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1 fiscal year thereafter’’ and inserting ‘‘each of fiscal years 

2 2013 through 2020 and each fiscal year thereafter’’. 

3 SEC. 12. GAO STUDIES ON GRADUATE MEDICAL EDU4 CATION. 

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

6 States shall conduct a study on each of the following: 

7 (1) The potential of making graduate medical 

8 education payments under the Medicare program for 

9 mid-level health providers (such as physician assist10 ants and nurse practitioners) in order to allow physi11 cians and other health care providers to perform to 

12 their full scope of practice. 

13 (2) The actual costs involved in training resi14 dents in different residency specialty types. 

15 (b) REPORT.—Not later than one year after the date 

16 of the enactment of this Act, the Comptroller General of 

17 the United States shall submit to Congress a report on 

18 each of the studies conducted under subsection (a), to19 gether with recommendations for such legislation and ad20 ministrative action as the Comptroller General determines 

21 to be appropriate. 

Æ 


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