I

103D CONGRESS

1ST SESSION H. R. 3089

To provide for programs and activities regarding primary health care.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 15, 1993

Mr. KLUG introduced the following bill; which was referred jointly to the Committees on Energy and Commerce, Ways and Means, and Education and

Labor

A BILL

To provide for programs and activities regarding primary

health care.

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.

4 This Act may be cited as the ‘‘Family Medicine and

5 Primary Care Research Act of 1993’’.
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1 TITLE I—OFFICE OF FAMILY

2 MEDICINE AND PRIMARY

3 CARE RESEARCH

4 SEC. 101. ESTABLISHMENT OF OFFICE OF FAMILY MEDI5 CINE AND PRIMARY CARE RESEARCH.

6 Subpart A of title IV of the Public Health Service

7 Act (42 U.S.C. 281 et seq.), as amended by section 209

8 of Public Law 103–43 (107 Stat. 149), is amended by

9 adding at the end the following section:

10 ‘‘OFFICE OF FAMILY MEDICINE AND PRIMARY CARE

11 RESEARCH

12 ‘‘SEC. 404F. (a) IN GENERAL.—There is established

13 within the Office of the Director of NIH an office to be

14 known as the Office on Family Medicine and Primary

15 Care Research (in this section referred to as the ‘Office’),

16 which shall be headed by a director appointed by the Di17 rector of NIH.

18 ‘‘(b) DUTIES.—

19 ‘‘(1) IN GENERAL.—With respect to the field of

20 family medicine and other primary medical care dis21 ciplines, the Director of the Office shall monitor and

22 coordinate all activities of the National Institutes of

23 Health, including biomedical, social, and behavioral

24 research and activities regarding training and the

25 dissemination of health information.
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1 ‘‘(2) PRIORITIES.—In carrying out paragraph

2 (1), the Director of the Office shall give priority—

3 ‘‘(A) to activities regarding the prevention,

4 diagnosis, and treatment of medical illness in

5 the primary medical practice setting, and dur6 ing early stages of the development of the dis7 ease processes; and

8 ‘‘(B) to conducting research on the capac9 ity of physicians in the disciplines of family

10 medicine and other primary care medical spe11 cialties to provide an integrated set of preven12 tive and curative services addressing the broad13 est scope of disease presentations.

14 ‘‘(c) PLAN.—The Director of the Office shall prepare

15 and transmit to the Director of NIH a plan for a national

16 family medicine and primary care research program to es17 tablish, expand, intensify, and coordinate the activities of

18 the Institute respecting family medicine and primary care

19 research.

20 ‘‘(d) ACADEMIC HEALTH CENTERS.—The Director of

21 NIH, in collaboration with the Director of the Office, shall

22 in carrying out subsection (a) provide for the development,

23 modernization, and operation (including staffing and other

24 operating costs such as the costs of patient care required
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1 for research) of new and existing centers for research in

2 family care medicine and primary care.

3 ‘‘(e) ADVISORY COUNCIL.—The Secretary shall ap4 point an advisory council for the Office to advise, assist,

5 consult with, and make recommendations to the Secretary

6 and the Director of the Office on matters related to the

7 activities carried out under this section.

8 ‘‘(f) BIENNIAL REPORT.—The Director of the Office,

9 after consultation with the advisory council established

10 under subsection (e), shall prepare for inclusion in the bi11 ennial report made under section 403 a biennial report

12 which shall consist of a description of the activities of the

13 Office and program policies of the Director of the Office

14 in the fiscal years respecting which the report is prepared,

15 including the program required under subsection (c).’’.

16 TITLE II—INCENTIVES FOR

17 RURAL PHYSICIANS REGARD18 ING PRIMARY CARE

19 SEC. 201. DEDUCTION FOR MEDICAL SCHOOL EDUCATION

20 LOAN INTEREST INCURRED BY DOCTORS

21 SERVING IN MEDICALLY UNDERSERVED

22 RURAL AREAS.

23 (a) IN GENERAL.—Paragraph (1) of section 163(h)

24 of the Internal Revenue Code of 1986 (relating to dis25 allowance of deduction for personal interest) is amended
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1 by striking ‘‘and’’ at the end of subparagraph (D), by re2 designating subparagraph (E) as subparagraph (F), and

3 by inserting after subparagraph (D) the following new

4 subparagraph:

5 ‘‘(E) any qualified medical education loan

6 interest (within the meaning of paragraph (5)),

7 and’’.

8 (b) QUALIFIED MEDICAL EDUCATION LOAN INTER9 EST DEFINED.—Subsection (h) of section 163 of such

10 Code is amended by redesignating paragraph (5) as para11 graph (6) and by inserting after paragraph (4) the follow12 ing new paragraph:

13 ‘‘(5) QUALIFIED MEDICAL EDUCATION LOAN IN14 TEREST.—

15 ‘‘(A) IN GENERAL.—The term ‘qualified

16 medical education loan interest’ means inter17 est—

18 ‘‘(i) which is on a medical education

19 loan of a physician,

20 ‘‘(ii) which is paid or accrued by such

21 physician, and

22 ‘‘(iii) which accrues during the pe23 riod—

24 ‘‘(I) such physician is providing

25 primary care (including general inter-
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1 nal medicine, general pediatrics, fam2 ily medicine, and osteopathy), or ob3 stetrical and gynecology services, to

4 residents of a medically underserved

5 rural area, and

6 ‘‘(II) such physician’s principal

7 place of abode is in such area.

8 ‘‘(B) MEDICAL EDUCATION LOAN.—The

9 term ‘medical education loan’ means indebted10 ness incurred to pay the individual’s—

11 ‘‘(i) qualified tuition and related ex12 penses (as defined in section 117(b)) in13 curred for the medical education of such

14 individual, or

15 ‘‘(ii) reasonable living expenses while

16 away from home in order to attend an edu17 cational institution described in section

18 170(b)(1)(A)(ii) for the medical education

19 of such individual.

20 ‘‘(C) PHYSICIAN.—For purposes of sub21 paragraph (A), the term ‘physician’ has the

22 meaning given such term by section 1861(r)(1)

23 of the Social Security Act.

24 ‘‘(D) MEDICALLY UNDERSERVED RURAL

25 AREA.—The term ‘medically underserved rural
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1 area’ means any rural area which is a medically

2 underserved area (as defined in section 330(b)

3 or 1302(7) of the Public Health Service Act).’’.

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

5 this section shall apply to taxable years ending after the

6 date of the enactment of this Act.

7 SEC. 202. EXTENSION OF DEFERMENTS.

8 (a) STAFFORD LOANS.—

9 (1) GSL LOANS.—Section 428(b)(1)(M) of the

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

11 1078(b)(1)(M)) is amended—

12 (A) by striking ‘‘or’’ at the end of clause

13 (ii);

14 (B) by inserting ‘‘or’’ after the semicolon

15 at the end of clause (iii); and

16 (C) by adding at the end thereof the fol17 lowing new clause:

18 ‘‘(iv) during which the borrower is

19 serving in an internship or residency pro20 gram in preparation for practice in an area

21 of primary care (including general internal

22 medicine, general pediatrics, family medi23 cine, and osteopathy) or in obstetrics and

24 gynecology;’’.
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1 (2) FISL LOANS.—Section 427(a)(2)(C) of

2 such Act (20 U.S.C. 1077(a)(2)(C)) is amended—

3 (A) by striking ‘‘or’’ at the end of clause

4 (ii);

5 (B) by inserting ‘‘or’’ after the semicolon

6 at the end of clause (iii); and

7 (C) by adding at the end thereof the fol8 lowing new clause:

9 ‘‘(iv) during which the borrower is

10 serving in an internship or residency pro11 gram in preparation for practice in an area

12 of primary care (including general internal

13 medicine, general pediatrics, family medi14 cine, and osteopathy) or in obstetrics and

15 gynecology;’’.

16 (b) PERKINS LOANS.—Section 464(c)(2)(A) of such

17 Act (20 U.S.C. 1087dd(c)(2)(A)) is amended—

18 (1) by striking ‘‘or’’ at the end of clause (iii);

19 (2) by inserting ‘‘or’’ after the semicolon at the

20 end of clause (iv); and

21 (3) by adding at the end thereof the following

22 new clause:

23 ‘‘(v) during which the borrower is

24 serving in an internship or residency pro25 gram in preparation for practice in an area
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1 of primary care (including general internal

2 medicine, general pediatrics, family medi3 cine, and osteopathy) or in obstetrics and

4 gynecology;’’.

5 (c) EFFECTIVE DATE.—The amendments made by

6 this section shall apply to on and after the date of the

7 enactment of this Act with respect to loans made under

8 the Higher Education Act of 1965 before, on, or after that

9 date.

10 SEC. 203. CLARIFICATION OF PERMISSIBLE SUBSTITUTE

11 BILLING ARRANGEMENTS FOR PHYSICIANS’

12 SERVICES UNDER THE MEDICARE AND MED13 ICAID PROGRAMS.

14 (a) MEDICARE PROGRAM.—

15 (1) IN GENERAL.—Clause (D) of section

16 1842(b)(6) of the Social Security Act (42 U.S.C.

17 1395u(b)(6)) is amended to read as follows: ‘‘(D)(i)

18 payment may be made to a physician for physicians’

19 services (and services incident to such services) to be

20 provided by a second physician on a reciprocal basis

21 to individuals who are patients of the first physician

22 if (I) the first physician is unavailable to provide the

23 services, (II) the services are not provided by the

24 second physician over a continuous period of longer

25 than 60 days, and (III) the claim form submitted to
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1 the carrier includes the second physician’s unique

2 identifier (provided under the system established

3 under subsection (r)) and indicates that the claim

4 meets the requirements of this clause for payment to

5 the first physician; and (ii) payment may be made

6 to a physician for physicians’ services (and services

7 incident to such services) which that physician pays

8 a second physician on a per diem or other fee-for9 time basis to provide to individuals who are patients

10 of the first physician if (I) the first physician is un11 available to provide the services, (II) the services are

12 not provided by the second physician over a continu13 ous period of longer than 90 days (or such longer

14 period as the Secretary may provide), and (III) the

15 claim form submitted to the carrier includes the sec16 ond physician’s unique identifier (provided under the

17 system established under subsection (r)) and indi18 cates that the claim meets the requirements of this

19 clause for payment to the first physician’’.

20 (2) EFFECTIVE DATE.—The amendment made

21 by paragraph (1) shall apply to services furnished on

22 or after the first day of the first month beginning

23 more than 60 days after the date of the enactment

24 of this Act.

25 (b) MEDICAID PROGRAM.—
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1 (1) IN GENERAL.—Section 1902(a)(32)(C) of

2 the Social Security Act (42 U.S.C. 1396a(a)(32)(C))

3 is amended to read as follows:

4 ‘‘(C) payment may be made to a physician

5 for services furnished by a substitute physician

6 under the circumstances described in subpara7 graph (D) of section 1842(b)(6), except that,

8 for purposes of this subparagraph, any ref9 erence in such subparagraph to ‘a carrier’ or

10 ‘the system established under subsection (r)’ is

11 deemed a reference to the State (or other fiscal

12 agent under the State plan) and to the system

13 established under subsection (x) of this section,

14 respectively.’’.

15 (2) EFFECTIVE DATE.—(A) The amendment

16 made by paragraph (1) shall apply to services fur17 nished on or after the date of the enactment of this

18 Act.

19 (B) Until the first day of the first calendar

20 quarter beginning more than 60 days after the date

21 the Secretary of Health and Human Services estab22 lishes the physician identifier system under section

23 1902(x) of the Social Security Act, the requirement

24 under section 1902(a)(32)(C) of such Act that a

25 claim form submitted must include the second physi-
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1 cian’s unique identifier is deemed to be satisfied if

2 the claim form identifies (in a manner specified by

3 the Secretary of Health and Human Services) the

4 second physician.

5 TITLE III—PRIMARY CARE PHY6 SICIANS UNDER APPROVED

7 MEDICAL RESIDENCY TRAIN8 ING PROGRAMS

9 SEC. 301. DISTRIBUTION OF PRIMARY CARE PHYSICIANS

10 UNDER APPROVED MEDICAL RESIDENCY

11 TRAINING PROGRAMS.

12 (a) ESTABLISHMENT OF 50/50 RULE AS NATIONAL

13 POLICY.—

14 (1) IN GENERAL.—The Secretary of Health and

15 Human Services shall establish a national policy pro16 viding that, after a 3-year transition period begin17 ning on June 1, 1995, the number of entry positions

18 in all approved medical residency training programs

19 in a State or region for residents who begin an ini20 tial residency period on or after June 1, 1998, who

21 are not primary care residents may not exceed 50

22 percent of the total number of entry positions in all

23 such programs in a State for all residents who are

24 medical graduates.
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1 (2) WAIVER FOR CERTAIN STATES.—The Sec2 retary may waive the application of the general rule

3 described in paragraph (1) to a State if the Sec4 retary finds that the application of the rule to the

5 State is not practicable.

6 (3) TIMETABLE.—

7 (A) PUBLICATION OF INTERIM FINAL REG8 ULATION.—The Secretary shall publish an in9 terim final regulation carrying out the national

10 policy referred to in paragraph (1) not later

11 than 60 days after the National Health Profes12 sional Workforce Advisory Board submits its

13 recommendations to the Secretary regarding

14 such national policy pursuant to subsection

15 (c)(2).

16 (B) USE OF BOARD’S RECOMMENDATIONS

17 AS DEFAULT POLICY.—If the Secretary does

18 not meet the requirements of subparagraph (A),

19 the recommendations of the National Health

20 Professional Workforce Advisory Board submit21 ted to the Secretary pursuant to subsection

22 (c)(2) shall, for purposes of this section and the

23 amendments made by this section, be deemed to

24 be the national policy established by the Sec25 retary under paragraph (1) respecting the num-
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1 ber of positions in each State or region in the

2 approved medical residency training programs

3 of the different medical specialties conducted in

4 the State.

5 (b) ASSURING CONFORMITY OF MEDICARE PAY6 MENTS FOR MEDICAL EDUCATION WITH NATIONAL POL7 ICY.—

8 (1) PAYMENT FOR DIRECT MEDICAL EDU9 CATION.—Section 1886(h)(5)(A) of the Social Secu10 rity Act (42 U.S.C. 1395ww(h)(5)(A)) is amended—

11 (A) by striking ‘‘means’’ and inserting

12 ‘‘means, with respect to a hospital,’’; and

13 (B) by striking the period at the end and

14 inserting the following: ‘‘, but only if (with re15 spect to residents who begin an initial residency

16 period on or after June 1, 1995) entry positions

17 in each such program of the hospital are in ac18 cordance with the national policy established by

19 the Secretary under section 301(a) of the Fam20 ily Medicine and Primary Care Research Act of

21 1993 respecting the number of positions in such

22 program.’’.

23 (2) PAYMENT FOR INDIRECT MEDICAL EDU24 CATION.—Section 1886(d)(5)(B) of such Act (42
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1 U.S.C. 1395ww(d)(5)(B)) is amended by adding at

2 the end the following new clauses:

3 ‘‘(v) In determining such adjustment, the Sec4 retary may not take into account the services of any

5 interns and residents in a medical residency training

6 program for a specialty or subspecialty unless, with

7 respect to interns and residents who begin an initial

8 residency period (as defined in subsection (h)(5)(F))

9 on or after June 1, 1995, entry positions in each

10 such program of the hospital are in accordance with

11 the national policy established by the Secretary

12 under section 301(a) of the Family Medicine and

13 Primary Care Research Act of 1993 respecting the

14 number of positions in such program.

15 ‘‘(vi) With respect to payments during each of

16 the first 5 fiscal years for which clause (v) is in ef17 fect, the application of such clause may not result in

18 a reduction of the additional payment amount made

19 to the hospital under this subparagraph during the

20 fiscal year to an amount that is less than—

21 ‘‘(I) in the case of a hospital receiving an

22 additional payment amount under subpara23 graph (F) during the fiscal year that is com24 puted under clause (vii)(I) of such subpara25 graph, 95 percent of the additional payment
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1 amount made to the hospital under this sub2 paragraph during the previous fiscal year; or

3 ‘‘(II) in the case of any other hospital, 90

4 percent of the additional payment amount made

5 to the hospital under this subparagraph during

6 the previous fiscal year.’’.

7 (c) NATIONAL HEALTH PROFESSIONAL WORKFORCE

8 ADVISORY BOARD.—

9 (1) ESTABLISHMENT; COMPOSITION.—There is

10 hereby established the National Health Professional

11 Workforce Advisory Board (hereafter in this sub12 section referred to as the ‘‘Board’’), to be composed

13 of the Secretary of Health and Human Services, the

14 Secretary of Veterans’ Affairs, and 7 other members

15 appointed by the President not later than 3 months

16 after the date of the enactment of this Act, of

17 whom—

18 (A) at least 1 shall be a dean of a school

19 of medicine;

20 (B) at least 1 shall be a health care profes21 sional who is not a physician;

22 (C) at least 3 shall be the program direc23 tors of approved medical residency training pro24 grams in each of the 3 primary care disciplines;
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1 (D) at least 1 shall be the chief executive

2 officer of a hospital that operates an approved

3 medical residency training program;

4 (E) at least 1 shall be the vice-president or

5 vice-chancellor for health affairs of a multi-dis6 ciplinary academic health center; and

7 (F) at least 1 shall represent the general

8 public.

9 (2) DUTIES.—

10 (A) IN GENERAL.—The Board shall—

11 (i) prepare initial recommendations

12 regarding the national policy referred to in

13 subsection (a)(1) regarding the distribution

14 of entry positions in approved medical resi15 dency training programs of the different

16 medical specialties among primary care

17 and non-primary care residents at various

18 sites, and submit such recommendations to

19 the Secretary not later than 1 year after

20 the date of the enactment of this Act;

21 (ii) submit recommendations to the

22 Secretary regarding the supply and role of

23 providers of primary care services who are

24 not physicians;
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1 (iii) with respect to funds available

2 pursuant to title XVIII of the Social Secu3 rity Act for direct graduate medical edu4 cation for the clinical training of physi5 cians and nurses, study the appropriate6 ness of expending such funds to make re7 imbursements under such title for the clin8 ical training in primary care of additional

9 practitioners;

10 (iv) submit annual reports to Con11 gress and the Secretary on the implemen12 tation of such national policy; and

13 (v) provide the Secretary with such

14 technical and other assistance regarding

15 such national policy as the Secretary may

16 request.

17 (B) CRITERIA FOR RECOMMENDATIONS.—

18 In preparing its recommendations under sub19 paragraph (A), the Board shall take into con20 sideration—

21 (i) the quality of graduate medical

22 residency training programs;

23 (ii) the need to maintain the operation

24 of such programs that have demonstrated
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1 success in recruiting, retaining, and pro2 moting minority practitioners;

3 (iii) the need to assure that the dis4 tribution of entry positions in such pro5 grams is not inequitable in relation to the

6 States and hospitals in urban and rural

7 areas that are qualified to offer such pro8 grams;

9 (iv) the need to assure the provision

10 of primary care and other health care serv11 ices to medically underserved communities;

12 and

13 (v) such other criteria as the Board

14 (in consultation with the accrediting bodies

15 referred to in paragraph (3)) considers ap16 propriate.

17 (3) ROLE OF ACCREDITING BODIES AND CER18 TIFYING BOARDS.—In preparing its recommenda19 tions regarding the national policy referred to in

20 subsection (a)(1), the Board shall—

21 (A) request each accrediting body for ap22 proved medical residency training programs for

23 a specialty or subspecialty, and each certifi24 cation board for such specialty or subspecialty,

25 to prepare and submit a plan that provides for
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1 the achievement of such national policy with re2 spect to approved medical residency training

3 programs for such specialty or subspecialty;

4 (B) analyze the extent to which the Board

5 may adopt such plans as the basis for its rec6 ommendations; and

7 (C) maintain close consultation with such

8 bodies and boards throughout the process of

9 preparing its recommendations.

10 (4) CHAIRPERSON; ADDITIONAL DUTIES.—The

11 President shall designate a Chairperson from among

12 the members, who (subject to the approval of the

13 Board) may—

14 (A) employ and fix the compensation of an

15 Executive Director and such other personnel

16 (not to exceed 25) as may be necessary to carry

17 out the Board’s duties;

18 (B) seek such assistance and support as

19 may be required in the performance of the

20 Board’s duties from appropriate Federal de21 partments and agencies;

22 (C) enter into contracts or make other ar23 rangements, as may be necessary for the con24 duct of the work of the Board (without regard
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1 to section 3709 of the Revised Statutes (41

2 U.S.C. 5));

3 (D) make advance, progress, and other

4 payments which relate to the work of the Com5 mission;

6 (E) provide transportation and subsistence

7 for persons serving without compensation; and

8 (F) prescribe such rules and regulations as

9 the Board deems necessary with respect to its

10 internal organization and operation.

11 (5) COMPENSATION.—Members of the Board

12 who are full-time officers or employees of the United

13 States may not receive additional pay, allowances, or

14 benefits by reason of their service on the Board, but

15 may receive travel expenses, including per diem in

16 lieu of subsistence, in accordance with sections 5702

17 and 5703 of title 5, United States Code.

18 (6) TERMINATION.—The Board shall terminate

19 upon the expiration of the 6-year period that begins

20 on the date of the enactment of this act. Section

21 14(a) of the Federal Advisory Committee Act (5

22 U.S.C. App.; relating to the termination of advisory

23 committees) shall not apply to the Board.

24 (7) CONFORMING AMENDMENT REPEALING

25 COUNCIL ON GRADUATE MEDICAL EDUCATION.—Ef-
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1 fective on the date of the enactment of this Act, sec2 tion 301 of the Health Professions Education Exten3 sion Amendments of 1992 (Public Law 102–408) is

4 repealed.

5 (d) ANNUAL PUBLICATION OF MEDICARE PAYMENTS

6 FOR DIRECT GRADUATE MEDICAL EDUCATION COSTS.—

7 Not later than March of each year (beginning with 1994),

8 the Secretary of Health and Human Services shall publish

9 in the Federal Register a list of the total amount of pay10 ments made to each hospital in the United States during

11 the previous year under section 1886(h) of the Social Se12 curity Act for the direct costs of graduate medical edu13 cation.

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