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[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 1978 Introduced in Senate (IS)]

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.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Increasing Primary 
Care Access Act of 2014''.
    (b) Table of Contents.--The table of contents of 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.
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.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) A well prepared, effective primary care workforce can 
        reduce health care costs and play a large role in the 
        prevention and management of illness. A one-unit increase in 
        primary care physicians per 10,000 population is associated 
        with improved health outcomes such as all-cause, cancer, heart 
        disease, and stroke mortality, as well as increased life 
        expectancy.
            (2) Primary care physicians include those trained in family 
        medicine, general internal medicine, general pediatrics, and in 
        some cases, gynecology. One primary care physician will 
        generate 6 to 23 jobs in the community served by such 
        physician, $900,000 to $1,200,000 in wages, salaries, and 
        benefits, and nearly $100,000 in State and local taxes.
            (3) As of 2011, only 32 percent of the physician workforce 
        is comprised of primary care and only between 16 to 18 percent 
        of graduates of allopathic medical schools are likely to pursue 
        a career in primary care.
            (4) Primary care supply has a positive effect on the entire 
        population, but the effect is greater in areas with higher 
        income inequality and poverty, such as rural areas. Only about 
        10 percent of physicians in America practice in rural areas 
        while 20 percent of the United States population is located in 
        rural areas.
            (5) Geographic areas with more general and family 
        physicians per population have lower rates of mortality and 
        hospitalization for conditions that should be preventable or 
        detected early, such as diabetes, congestive heart failure, and 
        hypertension.
            (6) As of May 2011, there were 6,419 primary care health 
        professional shortage areas, comprised of 66,300,000 
        individuals. It would take 17,636 practitioners to meet such 
        individuals' need for primary care providers.

SEC. 3. CENTERS OF EXCELLENCE IN PRIMARY CARE.

    Part C of title VII of the Public Health Service Act (42 U.S.C. 
293k) is amended by adding at the end the following:

          ``Subpart III--Centers of Excellence in Primary Care

``SEC. 749C. CENTERS OF EXCELLENCE IN PRIMARY CARE.

    ``(a) In General.--The Secretary shall make grants to, and enter 
into contracts with, schools of medicine and osteopathic medicine for 
the purpose of assisting the schools in supporting programs of 
excellence in primary care.
    ``(b) Eligible Schools.--To be eligible to receive a grant under 
subsection (a), a school of medicine or osteopathic medicine shall 
submit an application at such time, in such manner, and containing such 
information as the Secretary may require, including a description of 
innovative ideas that applicants propose to increase recruitment and 
retention in primary care, including pipeline, admissions, curriculum, 
mentoring, preparation for residency, and related purposes.
    ``(c) Selection of Recipients.--
            ``(1) In general.--The Secretary shall award a grant under 
        this section to not less than 6 and not more than 10 eligible 
        schools of medicine and osteopathic medicine. Such selected 
        schools shall be designated as Centers of Excellence in Primary 
        Care.
            ``(2) Requirements relating to rural and underserved 
        areas.--Of the schools designated under paragraph (1)--
                    ``(A) not less than 4 and not more than 7 shall be 
                located in a rural area; and
                    ``(B) not less than 2 and not more than 3 shall be 
                located in a medically underserved area.
    ``(d) Use of Funds.--A school of medicine or osteopathic medicine 
designated as a Center of Excellence under this section shall, in using 
funds provided under the grant, give funding priority to--
            ``(1) making medical school affordable for each admitted 
        and graduated student, including through significant tuition 
        scholarships, tuition remissions, and stipends, especially for 
        low-income students, and other provisions, such as loan 
        forgiveness for graduates who practice primary care for a 
        specified duration of time;
            ``(2) conducting admissions processes that favor students 
        who will work in rural and medically underserved areas, and 
        consider factors such as rural birth, minority status or 
        upbringing, and desire to serve rural and medically underserved 
        populations;
            ``(3) developing curricula models and innovations that 
        expedite medical school training, build needed skills for 
        modern medical practice, and enhance affinity of graduates for 
        practice in rural and medically underserved areas (which may 
        include 3-year undergraduate medical education models, rural 
        and inner city rotations, and mentoring with rural physicians);
            ``(4) research whether students completing a service 
        requirement in a rural or underserved area as part of the 
        criteria for graduation improves access to care in such area;
            ``(5) implement tracking systems that--
                    ``(A) assess practice patterns of medical school 
                graduates and require annual reports on this 
                information for the duration of the grant program; and
                    ``(B) track all loan repayment and scholarship 
                disbursements to assure that program goals are being 
                met with regard to recipients serving in desired 
                locations with expected populations of need for a 
                minimum required amount of time; and
            ``(6) having interprofessional primary care health 
        professions community-based service learning models for primary 
        care residents, and include clerkships and continuity clinic 
        experiences for medical, nurse practitioner, and physician 
        assistant students interested in primary care.''.

SEC. 4. MEDICARE INDIRECT MEDICAL EDUCATION (IME) PERFORMANCE 
              ADJUSTMENT AND PRIMARY CARE TRAINING BONUS.

    (a) In General.--Section 1886(d)(5)(B) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)(B)) is amended--
            (1) by redesignating the clause (x) as added by section 
        5505(b) of the Patient Protection and Affordable Care Act as 
        clause (xi); and
            (2) by adding at the end the following new clauses:
            ``(xii) Adjustment for performance.--
                    ``(I) In general.--The Secretary, in consultation 
                with the advisory body under clause (xiii), shall 
                establish and implement procedures under which the 
                amount of payments that a hospital would otherwise 
                receive for indirect medical education costs under this 
                subparagraph for discharges occurring during an 
                applicable period is adjusted based on the performance 
                of the hospital on measures specified by the Secretary.
                    ``(II) Measures.--The measures specified by the 
                Secretary under this clause shall include measures on 
                quality measurement and improvement, evidence-based 
                medicine, interprofessional teamwork, multidisciplinary 
                teamwork, care coordination, and health information 
                technology. Such measures shall include factors that 
                promote training in primary care, such as--
                            ``(aa) resident training in outpatient and 
                        community settings, including Federally 
                        qualified health centers, rural health clinics, 
                        teaching health centers, rural medical 
                        practices, facilities operated by the Veterans 
                        Administration, Indian Health Service 
                        facilities, including primary care training 
                        sites that are carried out through self 
                        determination contracts and are located in a 
                        rural or primary care health professional 
                        shortage area;
                            ``(bb) salary and loan conditions for 
                        primary care residents;
                            ``(cc) the percentage of all graduates 
                        practicing primary care 5 years after 
                        graduation;
                            ``(dd) the percentage of all graduates 
                        practicing primary care in health professional 
                        shortage areas 5 years after graduation;
                            ``(ee) the percentage of all primary care 
                        graduates from underrepresented minority 
                        groups, including African-Americans, Hispanic-
                        Americans, and Native Americans, as well as 
                        other underserved populations;
                            ``(ff) how the residency is responding to 
                        the workforce needs identified by State and 
                        regional centers for workforce analysis 
                        established under the National Center for 
                        Health Care Workforce Analysis or the National 
                        Health Care Workforce Commission;
                            ``(gg) the provision of service to all 
                        socioeconomic levels of patients, including but 
                        not limited to Medicaid program populations;
                            ``(hh) mentoring curriculum in primary 
                        care;
                            ``(ii) systems-based practice, including 
                        training in new forms of delivery system 
                        models, such as care coordination, accountable 
                        care organizations, and patient-centered 
                        medical homes; and
                            ``(jj) training in preventive care, chronic 
                        disease management, and population health and 
                        public health.
                    ``(III) Initial measure development timeline.--
                            ``(aa) Proposed set of measures.--Not later 
                        than January 1, 2016, the Secretary shall 
                        publish in the Federal Register a proposed set 
                        of measures for use under this clause. The 
                        Secretary shall provide for a period of public 
                        comment on such measures.
                            ``(bb) Final set of measures.--Not later 
                        than June 30, 2016, the Secretary shall publish 
                        in the Federal Register the final set of 
                        measures to be specified by the Secretary for 
                        use under this clause.
                    ``(IV) Adjustment.--Subject to subclause (V), the 
                Secretary shall determine the amount of any adjustment 
                under this clause to payments to a hospital under this 
                subparagraph in an applicable period.
                    ``(V) Budget-neutral with respect to payments that 
                would otherwise be made.--In making adjustments under 
                this clause, the Secretary shall ensure that the total 
                amount of payments made to all hospitals under this 
                subparagraph for an applicable period is equal to the 
                total amount of payments that would have been made to 
                such hospitals under this subparagraph in such period 
                if this clause had not been enacted.
                    ``(VI) Primary care defined.--In this clause, the 
                term `primary care' means family medicine, general 
                internal medicine, general pediatrics, preventive 
                medicine, obstetrics and gynecology, psychiatry, and 
                any other specialty which provides integrated, 
                accessible health care services and is accountable for 
                addressing a large majority of health care needs, 
                developing a sustained partnership with patients, and 
                practicing in the context of family and community.
                    ``(VII) Applicable period defined.--In this clause, 
                the term `applicable period' means the 12-month period 
                beginning on July 1 of each year (beginning with 2015).
            ``(xiii) Use of advisory body.--
                    ``(I) In general.--Subject to subclause (III), the 
                Secretary shall establish an advisory group to advise 
                the Secretary on the application of clause (xii), 
                including the development of the measures to be used, 
                how data on the measures may be collected, which 
                measures will be required in any given reporting 
                period, the applicable thresholds for the measures, and 
                the mechanisms to be used in order to determine whether 
                a hospital has met a threshold.
                    ``(II) Make-up of group.--The advisory group 
                established under subclause (I) shall include--
                            ``(aa) representatives of accrediting and 
                        certifying organizations;
                            ``(bb) representatives of facilities that 
                        receive payments under this subparagraph;
                            ``(cc) representatives of specialty boards 
                        and primary care boards;
                            ``(dd) representatives of high-performing 
                        health care systems;
                            ``(ee) experts in family medicine, primary 
                        care, and preventive medicine;
                            ``(ff) representatives of public and 
                        private purchasers;
                            ``(gg) representatives of consumer and 
                        patient organizations, especially those from 
                        rural areas; and
                            ``(hh) other entities and individuals as 
                        determined by the Secretary of Health and Human 
                        Services.
                    ``(III) Use of existing entity.--If the Secretary 
                determines that an existing entity is comprised of the 
                individuals described in subclause (II) and that such 
                entity has the expertise to advise the Secretary on the 
                matters described in subclause (I), the Secretary may 
                enter into an arrangement with such entity to advise 
                the Secretary on such matters rather than establishing 
                a new advisory group under subclause (I).''.
    (b) GAO Study and Report.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on the application of clause (xii) of 
        section 1886(d)(5)(B) of the Social Security Act, as added by 
        subsection (a), including an analysis of any changes in 
        workforce patterns as a result of the application of such 
        clause.
            (2) Report.--Not later than January 1, 2018, the 
        Comptroller General of the United States shall submit to 
        Congress a report on the study conducted under paragraph (1), 
        together with recommendations for such legislation and 
        administrative action as the Comptroller General determines to 
        be appropriate.

SEC. 5. INCREASING MEDICARE GRADUATE MEDICAL EDUCATION TRANSPARENCY.

    (a) In General.--Not later than 2 years after the date of the 
enactment of this Act, and annually thereafter, the Secretary of Health 
and Human Services shall submit to Congress a report on the graduate 
medical education payments that hospitals and other facilities receive 
under the Medicare program. The report shall include the following 
information with respect to each hospital or facility that receives 
such payments:
            (1) The direct graduate medical education payments made to 
        the hospital or other facility under section 1886(h) of the 
        Social Security Act (42 U.S.C. 1395ww(h)).
            (2) The indirect medical education payments made to the 
        hospital or other facility under section 1886(d)(5)(B) of such 
        Act (42 U.S.C. 1395ww(d)(1)(B)).
            (3) The number of residents counted for purposes of making 
        the payments described in paragraph (1).
            (4) The number of residents counted for purposes of making 
        the payments described in paragraph (2).
            (5) The number of residents, if any, that are not counted 
        for purposes of making payments described in paragraph (1).
            (6) The number of residents, if any, that are not counted 
        for purposes of making payments described in paragraph (2).
            (7) The percent that the payments described in paragraphs 
        (1) and (2) that are made to the hospital or other facility 
        make up of the total costs that the hospital or other facility 
        incurs in providing graduate medical education, including 
        salaries, benefits, operational expenses, and all other patient 
        care costs.
            (8) The number of residents training in each specialty.
            (9) A list that identifies any training partners and the 
        sponsoring institutions for each residency program.

SEC. 6. ENSURING APPROPRIATE REPRESENTATION OF PRIMARY CARE PHYSICIANS 
              ON GROUPS MAKING RECOMMENDATIONS REGARDING RELATIVE 
              VALUES UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

    Section 1848(c)(2)(B)(iii) of the Social Security Act (42 U.S.C. 
1395w-4(c)(2)(B)(iii)) is amended by adding at the end the following 
new sentence: ``The Secretary may not consult with an organization 
representing physicians if the organization uses a group to formulate 
recommendations regarding adjustments under clause (i) unless at least 
40 percent of the members of the group are physicians who are board 
certified and actively practicing in family medicine, general internal 
medicine, general pediatrics, preventive medicine, obstetrics and 
gynecology, or psychiatry.''.

SEC. 7. PRIMARY CARE PROJECT.

    (a) In General.--The Secretary of Health and Human Services 
(referred to in this section as the ``Secretary'') shall establish a 
pilot program to provide funding for graduate medical residency 
training programs in primary care.
    (b) Application and Selection of Sites.--
            (1) In general.--An entity shall be eligible to participate 
        in the project under this section if such entity--
                    (A) is--
                            (i) a community-based corporate entity 
                        collaborating with 1 or more hospitals to 
                        operate a primary care residency program;
                            (ii) a medical education entity established 
                        by 1 or more hospitals to operate a primary 
                        care residency program;
                            (iii) a hospital subsidiary or independent 
                        corporation operating a primary care residency 
                        program;
                            (iv) a medical education entity, 
                        independent of a hospital, collaborating with a 
                        primary care residency program; or
                            (v) another type of entity as determined 
                        appropriate by the Secretary; and
                    (B) submits an application at such time, in such 
                manner, and containing such information as the 
                Secretary may require.
            (2) Selection of participants.--The Secretary shall select, 
        from the eligible entities under paragraph (1), 4 entities to 
        participate in the project. Not less than 1 selected entity 
        shall be an entity that is not a hospital.
    (c) Activities Under the Project.--In carrying out the project, the 
Secretary shall--
            (1) structure the funding of the project such that payments 
        are made directly to the entity participating in the project;
            (2) support primary care training in all sites where care 
        is delivered, including non-hospital settings such as Federally 
        qualified health centers (as defined in section 1861(aa) of the 
        Social Security Act (42 U.S.C. 1395x(aa)));
            (3)(A) increase funding for the primary care residency 
        programs of the participating entities such that those primary 
        care residency programs are funded at the 90th percentile of 
        all residency programs nationally and are funded at levels that 
        equal at least $100,000 per resident involved; and
            (B) ensure that entities participating in the project use 
        the funding under the project to provide infrastructure support 
        and recruitment and retention support for faculty and residents 
        of the primary care residency program, including loan repayment 
        for such residents;
            (4) require training in rural and medically underserved 
        areas, and with medically underserved populations (as defined 
        in section 330(b) of the Public Health Service Act (42 U.S.C. 
        254b(b))) and service in such areas for a minimum of two 
        rotations of not less than four weeks each year; and
            (5) permit the primary care residency program of the 
        participating entities to qualify for payment under section 
        1886(d)(5)(B)(xii) of the Social Security Act (as added by 
        section 4) if such entities receive an appropriate score (as 
        determined by the Secretary) on the measures specified by the 
        Secretary under such section.
    (d) Term of Project.--The Secretary shall carry out the project 
under this section for a term of at least 6 years.
    (e) Evaluation.--
            (1) In general.--Not later than 1 year after the 
        commencement of the project, and each year thereafter, the 
        Secretary shall conduct an of evaluation the project.
            (2) Content.--The Secretary shall conduct the evaluation 
        under paragraph (1) using the following criteria:
                    (A) The percentage of graduates from the primary 
                care residency programs of the participating entities 
                that are practicing primary care 2 years after 
                graduation, and longer.
                    (B) The percentage of graduates from the primary 
                care residency programs of the participating entities 
                that are practicing in a health professional shortage 
                area (as defined in section 332 of the Public Health 
                Service Act (42 U.S.C. 254e)) 2 years after graduation, 
                and longer.
                    (C) Other criteria as determined appropriate by the 
                Secretary.
    (f) Authorization of Appropriation.--There are authorized to be 
appropriated to carry out this section $3,600,000 for each of fiscal 
years 2015 through 2019.

SEC. 8. REGIONAL CENTERS FOR HEALTH WORKFORCE ANALYSIS.

    (a) In General.--Section 761(c) of the Public Health Service Act 
(42 U.S.C. 294n(c)) is amended by adding at the end the following--
            ``(3) Establishment of new centers and funding to primary 
        care residency programs.--
                    ``(A) Establishment of new centers.--
                            ``(i) In general.--Not later than 1 year 
                        after the date of enactment of the Increasing 
                        Primary Care Access Act of 2014, the Secretary 
                        shall award grants to, or enter into contracts 
                        with, not less than 6 and not more than 8 
                        additional eligible entities, as described in 
                        paragraph (1).
                            ``(ii) Requirements.--In awarding grants or 
                        entering into contracts under clause (i), the 
                        Secretary shall--
                                    ``(I) ensure that each Regional 
                                Center for Health Workforce Analysis 
                                established under this paragraph is 
                                located in the geographic region that 
                                the Center covers; and
                                    ``(II) seek to award such grants or 
                                enter into contracts with eligible 
                                entities that are multi-State 
                                consortia.
                    ``(B) Distribution of funding to primary care 
                residency programs.--
                            ``(i) In general.--Each Regional Center for 
                        Health Workforce Analysis established pursuant 
                        to a grant or contract under subparagraph (A) 
                        shall, from the funds described in subparagraph 
                        (D), allocate funding to primary care residency 
                        programs--
                                    ``(I) within the region served by 
                                the Regional Center for Health 
                                Workforce Analysis; and
                                    ``(II) that the Center has 
                                identified as a primary care residency 
                                program in need.
                    ``(C) Consultation.--Each Regional Center for 
                Health Workforce Analysis established pursuant to a 
                grant or contract under this subsection shall establish 
                a consortium of academic institutions with which the 
                Center shall consult in determining allocations under 
                subparagraph (B).
                    ``(D) Funding.--
                            ``(i) Authorization of appropriations.--For 
                        each fiscal year, there is authorized to be 
                        appropriated to carry out this paragraph 
                        $4,000,000, of which not less than $500,000 
                        shall be allocated to each Regional Center for 
                        Health Workforce Analysis established under 
                        this paragraph.
                            ``(ii) Use of funds to establish new 
                        centers.--Each entity receiving funds under 
                        this paragraph may use a portion of such 
                        funding to establish the Regional Center for 
                        Health Workforce Analysis.''.
    (b) Conforming Amendment.--Section 761(e)(2) of the Public Health 
Service Act (42 U.S.C. 294n(e)(2)) is amended by striking ``subsection 
(c)'' and inserting ``paragraphs (1) and (2) of subsection (c)''.

SEC. 9. PAYMENTS FOR GRADUATE MEDICAL EDUCATION UNDER THE MEDICAID 
              PROGRAM.

    (a) In General.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d), is amended by adding at the end the following new subsection:
    ``(ee) Increased FMAP for Targeted Graduate Medical Education in 
Expansion States.--
            ``(1) In general.--The term `medical assistance' includes 
        payment for costs of graduate medical education consistent with 
        this subsection, whether provided in or outside of a hospital.
            ``(2) Increased fmap for expansion states that expand 
        targeted graduate medical education.--Notwithstanding 
        subsection (b), with respect to amounts expended by an 
        Expansion State for medical assistance for targeted graduate 
        medical education that is above the level of expenditures made 
        by the Expansion State for such graduate medical education for 
        2014, the Federal medical assistance percentage shall be equal 
        to--
                    ``(A) 100 percent for amounts expended in calendar 
                quarters in 2015, 2016, or 2017;
                    ``(B) 95 percent for amounts expended in calendar 
                quarters in 2018;
                    ``(C) 94 percent for amounts expended in calendar 
                quarters in 2019;
                    ``(D) 93 percent for amounts expended in calendar 
                quarters in 2020; and
                    ``(E) 90 percent for amounts expended in calendar 
                quarters in 2021 or in each year thereafter.
            ``(3) Definitions.--In this subsection:
                    ``(A) Expansion state.--The term `Expansion State' 
                means a State that elects in accordance with the 
                amendments made by the Patient Protection and 
                Affordable Care Act (Public Law 111-148) to this title 
                to provide medical assistance to individuals described 
                in subclause (VIII) of section 1902(a)(10)(A)(i).
                    ``(B) Targeted graduate medical education.--The 
                term `targeted graduate medical education' means 
                graduate medical education for community-based, 
                interprofessional primary care residents and other 
                health care students, located in a rural area or an 
                area that is designated (under section 332(a)(1)(A) of 
                the Public Health Service Act) as a health professional 
                shortage area, or for other workforce needs identified 
                by State and regional centers for workforce analysis 
                established under the National Center for Health 
                Workforce Analysis.
                    ``(C) Primary care.--The term `primary care' means 
                family medicine, general internal medicine, general 
                pediatrics, preventive medicine, obstetrics and 
                gynecology, psychiatry, and any other specialty which 
                provides integrated, accessible health care services 
                and is accountable for addressing a large majority of 
                health care needs, developing a sustained partnership 
                with patients, and practicing in the context of family 
                and community.''.
    (b) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2015. Nothing in this section shall be construed 
as affecting payments made before such date under a State plan under 
title XIX of the Social Security Act for graduate medical education.

SEC. 10. NATIONAL CENTER FOR HEALTH CARE WORKFORCE ANALYSIS.

    Section 761(b)(2)(A) of the Public Health Service Act (42 U.S.C. 
294n(b)(2)(A)) is amended by inserting before the semicolon, the 
following: ``, including national and regional workforce issues related 
to spending under the Medicaid program under title XIX of the Social 
Security Act''.

SEC. 11. TEACHING HEALTH CENTER REAUTHORIZATION.

    (a) Reauthorization of the Teaching Health Centers Program.--
Section 340H of the Public Health Service Act (42 U.S.C. 256h) is 
amended--
            (1) in subsection (g)--
                    (A) by inserting before the period the following: 
                ``, and not to exceed $800,000,000, for the period of 
                fiscal years 2016 through 2020''; and
                    (B) by adding at the end the following: ``Any 
                amounts appropriated under this subsection for any of 
                fiscal years 2011 through 2020 and remaining unexpended 
                at the end of the fiscal year involved may be used in 
                subsequent fiscal years to carry out this section.'';
            (2) in subsection (h)(2)--
                    (A) in the paragraph heading, by adding at the end 
                the following: ``; submission to congress''; and
                    (B) by adding at the end the following:
                    ``(C) Submission to congress.--The Secretary shall 
                annually submit to Congress a report that contains a 
                compilation of the data submitted to the Secretary 
                under paragraph (1) for the year involved.'';
            (3) by redesignating subsections (h) through (j) as 
        subsections (i) through (k), respectively; and
            (4) by inserting after subsection (g), the following:
    ``(h) Limitation.--The Secretary shall establish a minimum per 
resident per year payment amount for funding of all approved teaching 
health center graduate medical education positions under this section 
that shall be not less than the per resident per year payment amount as 
of January 1, 2013, and ensure that not less than such amount is 
provided to all teaching health center graduate medical education 
programs for all approved positions.''.
    (b) Teaching Health Centers Development Grants.--Section 749A(g) of 
the Public Health Service Act (42 U.S.C. 293l-1(g)) is amended by 
striking ``each fiscal year thereafter'' and inserting ``each of fiscal 
years 2013 through 2020 and each fiscal year thereafter''.

SEC. 12. GAO STUDIES ON GRADUATE MEDICAL EDUCATION.

    (a) Study.--The Comptroller General of the United States shall 
conduct a study on each of the following:
            (1) The potential of making graduate medical education 
        payments under the Medicare program for mid-level health 
        providers (such as physician assistants and nurse 
        practitioners) in order to allow physicians and other health 
        care providers to perform to their full scope of practice.
            (2) The actual costs involved in training residents in 
        different residency specialty types.
    (b) Report.--Not later than one year after the date of the 
enactment of this Act, the Comptroller General of the United States 
shall submit to Congress a report on each of the studies conducted 
under subsection (a), together with recommendations for such 
legislation and administrative action as the Comptroller General 
determines to be appropriate.
                                 <all>
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