II 

114TH CONGRESS 

1ST SESSION S. 1148 

To amend title XVIII of the Social Security Act to provide for the distribution 

of additional residency positions, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 30, 2015 

Mr. NELSON (for himself, Mr. REID, and Mr. SCHUMER) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for the distribution of additional residency positions, and 

for other purposes. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Resident Physician 

5 Shortage Reduction Act of 2015’’. 

6 SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI7 TIONS. 

8 (a) IN GENERAL.—Section 1886(h) of the Social Se9 curity Act (42 U.S.C. 1395ww(h)) is amended— 


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1 (1) in paragraph (4)(F)(i), by striking ‘‘para2 graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 

3 (8), and (9)’’; 

4 (2) in paragraph (4)(H)(i), by striking ‘‘para5 graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 

6 (8), and (9)’’; 

7 (3) in paragraph (7)(E), by inserting ‘‘para8 graph (9),’’ after ‘‘paragraph (8),’’; and 

9 (4) by adding at the end the following new 

10 paragraph: 

11 ‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY

12 POSITIONS.— 

13 ‘‘(A) ADDITIONAL RESIDENCY POSI14 TIONS.— 

15 ‘‘(i) IN GENERAL.—For each of fiscal 

16 years 2017 through 2021 (and succeeding 

17 fiscal years if the Secretary determines 

18 that there are additional residency posi19 tions available to distribute under clause 

20 (iii)(II)), the Secretary shall increase the 

21 otherwise applicable resident limit for each 

22 qualifying hospital that submits a timely 

23 application under this subparagraph by 

24 such number as the Secretary may approve 

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1 curring on or after July 1 of the fiscal year 

2 of the increase. Except as provided in 

3 clause (iii), the aggregate number of in4 creases in the otherwise applicable resident 

5 limit under this subparagraph shall be 

6 equal to 3,000 in each of fiscal years 2017 

7 through 2021, of which at least 1,500 in 

8 each such fiscal year shall be used for full9 time equivalent residents training in a 

10 shortage specialty residency program (as 

11 defined in subparagraph (F)(iii)). 

12 ‘‘(ii) PROCESS FOR DISTRIBUTING PO13 SITIONS.— 

14 ‘‘(I) ROUNDS OF APPLICA15 TIONS.—The Secretary shall initiate 5 

16 separate rounds of applications for an 

17 increase under clause (i), 1 round 

18 with respect to each of fiscal years 

19 2017 through 2021. 

20 ‘‘(II) NUMBER AVAILABLE.—In 

21 each of such rounds, the aggregate 

22 number of positions available for dis23 tribution in the fiscal year as a result 

24 of an increase in the otherwise appli25 cable resident limit (as described in 


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1 clause (i)) shall be distributed, plus 

2 any additional positions available 

3 under clause (iii). 

4 ‘‘(III) TIMING.—The Secretary 

5 shall notify hospitals of the number of 

6 positions distributed to the hospital 

7 under this paragraph as result of an 

8 increase in the otherwise applicable 

9 resident limit by January 1 of the fis10 cal year of the increase. Such increase 

11 shall be effective for portions of cost 

12 reporting periods beginning on or 

13 after July 1 of that fiscal year. 

14 ‘‘(iii) POSITIONS NOT DISTRIBUTED

15 DURING THE FISCAL YEAR.— 

16 ‘‘(I) IN GENERAL.—If the num17 ber of resident full-time equivalent po18 sitions distributed under this para19 graph in a fiscal year is less than the 

20 aggregate number of positions avail21 able for distribution in the fiscal year 

22 (as described in clause (i), including 

23 after application of this subclause), 

24 the difference between such number 

25 distributed and such number available 


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1 for distribution shall be added to the 

2 aggregate number of positions avail3 able for distribution in the following 

4 fiscal year. 

5 ‘‘(II) EXCEPTION IF POSITIONS

6 NOT DISTRIBUTED BY END OF FISCAL

7 YEAR 2021.—If the aggregate number 

8 of positions distributed under this 

9 paragraph during the 5-year period of 

10 fiscal years 2017 through 2021 is less 

11 than 15,000, the Secretary shall, in 

12 accordance with the considerations de13 scribed in subparagraph (B)(i) and 

14 the priority described in subparagraph 

15 (B)(ii), conduct an application and 

16 distribution process in each subse17 quent fiscal year until such time as 

18 the aggregate amount of positions dis19 tributed under this paragraph is equal 

20 to 15,000. 

21 ‘‘(B) DISTRIBUTION TO CERTAIN HOS22 PITALS.— 

23 ‘‘(i) CONSIDERATION IN DISTRIBU24 TION.—In determining for which hospitals 

25 the increase in the otherwise applicable 


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1 resident limit is provided under subpara2 graph (A), the Secretary shall take into ac3 count the demonstrated likelihood of the 

4 hospital filling the positions made available 

5 under this paragraph within the first 5 

6 cost reporting periods beginning after the 

7 date the increase would be effective, as de8 termined by the Secretary. 

9 ‘‘(ii) PRIORITY FOR CERTAIN HOS10 PITALS.—Subject to clause (iii), in deter11 mining for which hospitals the increase in 

12 the otherwise applicable resident limit is 

13 provided under subparagraph (A), the Sec14 retary shall distribute the increase in the 

15 following priority order: 

16 ‘‘(I) First, to hospitals in States 

17 with (aa) new medical schools that re18 ceived ‘Candidate School’ status from 

19 the Liaison Committee on Medical 

20 Education or that received ‘Pre-Ac21 creditation’ status from the American 

22 Osteopathic Association Commission 

23 on Osteopathic College Accreditation 

24 on or after January 1, 2000, and that 

25 have achieved or continue to progress 


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1 toward ‘Full Accreditation’ status (as 

2 such term is defined by the Liaison 

3 Committee on Medical Education) or 

4 toward ‘Accreditation’ status (as such 

5 term is defined by the American Os6 teopathic Association Commission on 

7 Osteopathic College Accreditation), or 

8 (bb) additional locations and branch 

9 campuses established on or after Jan10 uary 1, 2000, by medical schools with 

11 ‘Full Accreditation’ status (as such 

12 term is defined by the Liaison Com13 mittee on Medical Education) or ‘Ac14 creditation’ status (as such term is 

15 defined by the American Osteopathic 

16 Association Commission on Osteo17 pathic College Accreditation). 

18 ‘‘(II) Second, to hospitals in 

19 which the resident level of the hospital 

20 is greater than the otherwise applica21 ble resident limit during the most re22 cent cost reporting period ending on 

23 or before the date of enactment of 

24 this paragraph. 


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1 ‘‘(III) Third, to hospitals with 

2 which the Secretary cooperates under 

3 section 7302(d) of title 38, United 

4 States Code; 

5 ‘‘(IV) Fourth, to hospitals that 

6 emphasize training in community7 based settings or in hospital out8 patient departments. 

9 ‘‘(V) Fifth, to hospitals that are 

10 meaningful EHR users (as defined in 

11 subsection (n)(3)) for the fiscal year 

12 which includes the date the hospital 

13 submits an application for such in14 crease under subparagraph (A). 

15 ‘‘(VI) Sixth, to all other hos16 pitals. 

17 ‘‘(iii) DISTRIBUTION TO HOSPITALS IN

18 HIGHER PRIORITY GROUP PRIOR TO DIS19 TRIBUTION IN LOWER PRIORITY GROUPS.— 

20 The Secretary may only distribute an in21 crease under subparagraph (A) to a lower 

22 priority group under clause (ii) if all quali23 fying hospitals in the higher priority group 

24 or groups have received the maximum 

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1 graph that the hospital is eligible for under 

2 this paragraph for the fiscal year. 

3 ‘‘(C) REQUIREMENTS FOR USE OF ADDI4 TIONAL POSITIONS.— 

5 ‘‘(i) IN GENERAL.—Subject to clause 

6 (ii), a hospital that receives an increase in 

7 the otherwise applicable resident limit 

8 under subparagraph (A) shall ensure, dur9 ing the 5-year period beginning on the ef10 fective date of such increase, that— 

11 ‘‘(I) not less than 50 percent of 

12 the positions attributable to such in13 crease are used to train full-time 

14 equivalent residents in a shortage spe15 cialty residency program (as defined 

16 in subclause (F)(iii)), as determined 

17 by the Secretary at the end of such 5- 

18 year period; 

19 ‘‘(II) the total number of full20 time equivalent residents, excluding 

21 any additional positions attributable 

22 to such increase, is not less than the 

23 average number of full-time equivalent 

24 residents during the 3 most recent 

25 cost reporting periods ending on or 


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1 before the effective date of such in2 crease; and 

3 ‘‘(III) the ratio of full-time equiv4 alent residents in a shortage specialty 

5 residency program (as so defined) is 

6 not less than the average ratio of full7 time equivalent residents in such a 

8 program during the 3 most recent 

9 cost reporting periods ending on or 

10 before the effective date of such in11 crease. 

12 ‘‘(ii) REDISTRIBUTION OF POSITIONS

13 IF HOSPITAL NO LONGER MEETS CERTAIN

14 REQUIREMENTS.—In the case where the 

15 Secretary determines that a hospital de16 scribed in clause (i) does not meet the re17 quirements of such clause, the Secretary 

18 shall— 

19 ‘‘(I) reduce the otherwise applica20 ble resident limit of the hospital by 

21 the amount by which such limit was 

22 increased under this paragraph; and 

23 ‘‘(II) provide for the distribution 

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1 duction in accordance with the re2 quirements of this paragraph. 

3 ‘‘(D) LIMITATION.— 

4 ‘‘(i) IN GENERAL.—Except as pro5 vided in clause (ii), a hospital may not re6 ceive more than 75 full-time equivalent ad7 ditional residency positions in the aggre8 gate under this paragraph over the period 

9 of fiscal years 2017 through 2021. 

10 ‘‘(ii) INCREASE IN NUMBER OF ADDI11 TIONAL POSITIONS A HOSPITAL MAY RE12 CEIVE.—The Secretary shall increase the 

13 aggregate number of full-time equivalent 

14 additional residency positions a hospital 

15 may receive under this paragraph over 

16 such period if the Secretary estimates that 

17 the number of positions available for dis18 tribution under subparagraph (A) exceeds 

19 the number of applications approved under 

20 such subparagraph over such period. 

21 ‘‘(E) APPLICATION OF PER RESIDENT

22 AMOUNTS FOR PRIMARY CARE AND NONPRI23 MARY CARE.—With respect to additional resi24 dency positions in a hospital attributable to the 

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1 proved FTE per resident amounts are deemed 

2 to be equal to the hospital per resident amounts 

3 for primary care and nonprimary care com4 puted under paragraph (2)(D) for that hospital. 

5 ‘‘(F) DEFINITIONS.—In this paragraph: 

6 ‘‘(i) OTHERWISE APPLICABLE RESI7 DENT LIMIT.—The term ‘otherwise appli8 cable resident limit’ means, with respect to 

9 a hospital, the limit otherwise applicable 

10 under subparagraphs (F)(i) and (H) of 

11 paragraph (4) on the resident level for the 

12 hospital determined without regard to this 

13 paragraph but taking into account para14 graphs (7)(A), (7)(B), (8)(A), and (8)(B). 

15 ‘‘(ii) RESIDENT LEVEL.—The term 

16 ‘resident level’ has the meaning given such 

17 term in paragraph (7)(C)(i). 

18 ‘‘(iii) SHORTAGE SPECIALTY RESI19 DENCY PROGRAM.—The term ‘shortage 

20 specialty residency program’ means the fol21 lowing: 

22 ‘‘(I) PRIOR TO REPORT ON

23 SHORTAGE SPECIALTIES.—Prior to 

24 the date on which the report of the 

25 National Health Care Workforce 


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1 Commission is submitted under sec2 tion 3 of the Resident Physician 

3 Shortage Reduction Act of 2015, any 

4 approved residency training program 

5 in a specialty identified in the report 

6 entitled ‘The Physician Workforce: 

7 Projections and Research into Current 

8 Issues Affecting Supply and Demand’, 

9 issued in December 2008 by the 

10 Health Resources and Services Ad11 ministration, as a specialty whose 

12 baseline physician requirements pro13 jections exceed the projected supply of 

14 total active physicians for the period 

15 of 2005 through 2020. 

16 ‘‘(II) AFTER REPORT ON SHORT17 AGE SPECIALTIES.—On or after the 

18 date on which the report of the Na19 tional Health Care Workforce Com20 mission is submitted under such sec21 tion, any approved residency training 

22 program in a physician specialty iden23 tified in such report as a specialty for 

24 which there is a shortage.’’. 

25 (b) IME.— 


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

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

3 1395ww(d)(5)(B)(v)), in the third sentence, is 

4 amended by striking ‘‘and (h)(8)’’ and inserting 

5 ‘‘(h)(8), and (h)(9)’’. 

6 (2) CONFORMING PROVISION.—Section 

7 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

8 1395ww(d)(5)(B)) is amended— 

9 (A) by redesignating clause (x), as added 

10 by section 5505(b) of the Patient Protection 

11 and Affordable Care Act (Public Law 111– 

12 148), as clause (xi) and moving such clause 4 

13 ems to the left; and 

14 (B) by adding after clause (xi), as redesig15 nated by subparagraph (A), the following new 

16 clause: 

17 ‘‘(xii) For discharges occurring on or after July 

18 1, 2017, insofar as an additional payment amount 

19 under this subparagraph is attributable to resident 

20 positions distributed to a hospital under subsection 

21 (h)(9), the indirect teaching adjustment factor shall 

22 be computed in the same manner as provided under 

23 clause (ii) with respect to such resident positions.’’. 


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1 SEC. 3. STUDY AND REPORT BY NATIONAL HEALTH CARE 

2 WORKFORCE COMMISSION. 

3 (a) STUDY.—The National Health Care Workforce 

4 Commission established under section 5101 of the Patient 

5 Protection and Affordable Care Act (Public Law 111– 

6 148) shall conduct a study of the physician workforce. 

7 Such study shall include the identification of physician 

8 specialties for which there is a shortage, as defined by the 

9 Commission. 

10 (b) REPORT.—Not later than January 1, 2018, the 

11 National Health Care Workforce Commission shall submit 

12 to Congress a report on the study conducted under sub13 section (a), together with recommendations for such legis14 lation and administrative action as the Commission deter15 mines appropriate. 

16 SEC. 4. STUDY AND REPORT ON STRATEGIES FOR INCREAS17 ING DIVERSITY. 

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

19 States (in this section referred to as the ‘‘Comptroller 

20 General’’) shall conduct a study on strategies for increas21 ing the diversity of the health professional workforce. Such 

22 study shall include an analysis of strategies for increasing 

23 the number of health professionals from rural, lower in24 come, and underrepresented minority communities, includ25 ing which strategies are most effective for achieving such 

26 goal. 


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1 (b) REPORT.—Not later than 2 years after the date 

2 of the enactment of this Act, the Comptroller General shall 

3 submit to Congress a report on the study conducted under 

4 subsection (a), together with recommendations for such 

5 legislation and administrative action as the Comptroller 

6 General determines appropriate. 

Æ 


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