II

103D CONGRESS

1ST SESSION S. 1315

To establish a national policy respecting medical residency training programs

and the health care workforce, and for other purposes.

IN THE SENATE OF THE UNITED STATES

JULY 29 (legislative day, JUNE 30), 1993

Mr. ROCKEFELLER (for himself, Mr. DURENBERGER, and Mr. PRYOR) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To establish a national policy respecting medical residency

training programs and the health care workforce, 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 ‘‘Primary Care

5 Workforce Act of 1993’’.

6 SEC. 2. DEFINITIONS.

7 In this Act, the following definitions shall apply:
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1 (1) The term ‘‘approved medical residency

2 training program’’ has the meaning given such term

3 in section 1886(h)(5)(A) of the Social Security Act.

4 (2) The term ‘‘entry position’’ means, with re5 spect to a medical residency training program, a po6 sition as a resident in the initial year of study in the

7 program.

8 (3) The term ‘‘primary care resident’’ means

9 (in accordance with criteria established by the Sec10 retary) a resident being trained in a distinct pro11 gram of primary health care (as defined in section

12 723(d)(5) of the Public Health Service Act).

13 (4) The term ‘‘resident’’ has the meaning given

14 such term in section 1886(h)(5)(H) of the Social Se15 curity Act.

16 (5) The term ‘‘Secretary’’ means the Secretary

17 of Health and Human Services.

18 (6) The term ‘‘State’’ has the meaning given

19 such term under section 799(9) of the Public Health

20 Service Act.

21 (7) The term ‘‘United States medical graduate’’

22 means a resident who is a graduate of—

23 (A) a school of medicine accredited by the

24 Liaison Committee on Medical Education of the

25 American Medical Association and the Associa-
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1 tion of American Medical colleges (or approved

2 by such Committee as meeting the standards

3 necessary for such accreditation); or

4 (B) a school of osteopathy accredited by

5 the American Osteopathic Association, or ap6 proved by such Association as meeting the

7 standards necessary for such accreditation.

8 SEC. 3. ESTABLISHMENT AND ENFORCEMENT OF NA9 TIONAL POLICY FOR APPROVED MEDICAL

10 RESIDENCY TRAINING PROGRAMS.

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

12 Human Services shall establish a national policy respect13 ing the number of positions in each State in each approved

14 medical residency training program of the different medi15 cal specialties conducted in the State.

16 (b) SPECIFIC DISTRIBUTION RULES.—

17 (1) LIMIT ON TOTAL NUMBER OF POSITIONS.—

18 The national policy established under subsection (a)

19 shall provide that, with respect to residents who

20 begin an initial residency period on or after June 1,

21 1998, the total number of entry positions in ap22 proved medical residency training programs in the

23 United States in which residents may enroll without

24 having previously completed another medical resi25 dency training program may not for any fiscal year
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1 exceed 110 percent of the number of United States

2 medical graduates.

3 (2) DISTRIBUTION OF PRIMARY CARE AND NON4 PRIMARY CARE POSITIONS.—

5 (A) GENERAL RULE.—The national policy

6 established under subsection (a) shall provide

7 that, after a 3-year transition period beginning

8 on June 1, 1995, the number of entry positions

9 in all approved medical residency training pro10 grams in a State for residents who begin an ini11 tial residency period on or after June 1, 1998,

12 who are not primary care residents may not ex13 ceed 50 percent of the total number of entry

14 positions in all such programs in a State for all

15 residents who are United States medical grad16 uates.

17 (B) WAIVER FOR CERTAIN STATES.—The

18 Secretary may waive the application of the gen19 eral rule described in subparagraph (A) to a

20 State if the Secretary finds that the application

21 of the rule to the State is not practicable.

22 (c) TIMETABLE.—

23 (1) PUBLICATION OF INTERIM FINAL REGULA24 TION.—The Secretary shall publish an interim final

25 regulation carrying out the national policy referred
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1 to in subsection (a) not later than 60 days after the

2 National Health Professional Workforce Advisory

3 Board submits its recommendations to the Secretary

4 regarding such national policy pursuant to section

5 3(b).

6 (2) USE OF BOARD’S RECOMMENDATIONS AS

7 DEFAULT POLICY.—If the Secretary does not meet

8 the requirements of paragraph (1), the recommenda9 tions of the National Health Professional Workforce

10 Advisory Board submitted to the Secretary pursuant

11 to section 3(b) shall, for purposes of this Act and

12 the amendments made by this Act, be deemed to be

13 the national policy established by the Secretary

14 under subsection (a) respecting the number of posi15 tions in each State in the approved medical resi16 dency training programs of the different medical

17 specialties conducted in the State.

18 (d) ASSURING CONFORMITY OF MEDICARE PAY19 MENTS FOR MEDICAL EDUCATION WITH NATIONAL POL20 ICY.—

21 (1) PAYMENT FOR DIRECT MEDICAL EDU22 CATION.—Section 1886(h)(5)(A) of the Social Secu23 rity Act (42 U.S.C. 1395ww(h)(5)(A)) is amended—

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

25 ‘‘means, with respect to a hospital,’’; and
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1 (B) by striking the period at the end and

2 inserting the following: ‘‘, but only if (with re3 spect to residents who begin an initial residency

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

5 in each such program of the hospital are in ac6 cordance with the national policy established by

7 the Secretary under section 3(a) of the Primary

8 Care Workforce Act of 1993 respecting the

9 number of positions in such program.’’.

10 (2) PAYMENT FOR INDIRECT MEDICAL EDU11 CATION.—Section 1886(d)(5)(B) of such Act (42

12 U.S.C. 1395ww(d)(5)(B)) is amended by adding at

13 the end the following new clauses:

14 ‘‘(v) In determining such adjustment, the Sec15 retary may not take into account the services of any

16 interns and residents in a medical residency training

17 program for a specialty or subspecialty unless, with

18 respect to interns and residents who begin an initial

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

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

21 such program of the hospital are in accordance with

22 the national policy established by the Secretary

23 under section 3(a) of the Primary Care Workforce

24 Act of 1993 respecting the number of positions in

25 such program.
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1 ‘‘(vi) With respect to payments during each of

2 the first 5 fiscal years for which clause (v) is in ef3 fect, the application of such clause may not result in

4 a reduction of the additional payment amount made

5 to the hospital under this subparagraph during the

6 fiscal year to an amount that is less than—

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

8 additional payment amount under subpara9 graph (F) during the fiscal year that is com10 puted under clause (vii)(I) of such subpara11 graph, 95 percent of the additional payment

12 amount made to the hospital under this sub13 paragraph during the previous fiscal year; or

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

15 percent of the additional payment amount made

16 to the hospital under this subparagraph during

17 the previous fiscal year.’’.

18 SEC. 4. NATIONAL HEALTH PROFESSIONAL WORKFORCE

19 ADVISORY BOARD.

20 (a) ESTABLISHMENT; COMPOSITION.—There is here21 by established the National Health Professional Workforce

22 Advisory Board (hereafter in this section referred to as

23 the ‘‘Board’’), to be composed of the Secretary of Health

24 and Human Services, the Secretary of Veterans’ Affairs,

25 and 7 other members appointed by the President not later
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1 than 3 months after the date of the enactment of this Act,

2 of whom—

3 (1) at least 1 shall be a dean of a school of

4 medicine;

5 (2) at least 1 shall be a health care professional

6 who is not a physician;

7 (3) at least 1 shall be the program director of

8 an approved medical residency training program;

9 (4) at least 1 shall be the chief executive officer

10 of a hospital that operates an approved medical resi11 dency training program;

12 (5) at least 1 shall be the vice-president or vice13 chancellor for health affairs of a multi-disciplinary

14 academic health center; and

15 (6) at least 1 shall represent the general public.

16 (b) DUTIES.—

17 (1) IN GENERAL.—The Board shall—

18 (A) prepare initial recommendations re19 garding the national policy referred to in sec20 tion 3(a) for the number of positions in ap21 proved medical residency training programs of

22 the different medical specialties (subject to the

23 requirements of section 3(b) regarding the total

24 number of entry positions in such programs and

25 the distribution of such positions under such
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1 programs among primary care and non-primary

2 care residents at various sites), and submit

3 such recommendations to the Secretary not

4 later than 1 year after the date of the enact5 ment of this Act;

6 (B) submit recommendations to the Sec7 retary regarding the supply and role of provid8 ers of primary care services who are not physi9 cians;

10 (C) with respect to funds available pursu11 ant to title XVIII of the Social Security Act for

12 direct graduate medical education for the clini13 cal training of physicians and nurses, study the

14 appropriateness of expending such funds to

15 make reimbursements under such title for the

16 clinical training in primary care of additional

17 practitioners;

18 (D) submit annual reports to Congress and

19 the Secretary on the implementation of such

20 national policy; and

21 (E) provide the Secretary with such tech22 nical and other assistance regarding such na23 tional policy as the Secretary may request.
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1 (2) CRITERIA FOR RECOMMENDATIONS.—In

2 preparing its recommendations under paragraph (1),

3 the Board shall take into consideration—

4 (A) the quality of graduate medical resi5 dency training programs;

6 (B) the need to maintain the operation of

7 such programs that have demonstrated success

8 in recruiting, retaining, and promoting minority

9 practitioners;

10 (C) the need to assure that the distribution

11 of entry positions in such programs is not in12 equitable in relation to the States and hospitals

13 in urban and rural areas that are qualified to

14 offer such programs;

15 (D) the need to assure the provision of pri16 mary care and other health care services to

17 medically underserved communities; and

18 (E) such other criteria as the Board (in

19 consultation with the accrediting bodies referred

20 to in subsection (c)) considers appropriate.

21 (c) ROLE OF ACCREDITING BODIES AND CERTIFYING

22 BOARDS.—In preparing its recommendations regarding

23 the national policy referred to in section 3(a), the Board

24 shall—
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1 (1) request each accrediting body for approved

2 medical residency training programs for a specialty

3 or subspecialty, and each certification board for such

4 specialty or subspecialty, to prepare and submit a

5 plan that provides for the achievement of such na6 tional policy with respect to approved medical resi7 dency training programs for such specialty or sub8 specialty;

9 (2) analyze the extent to which the Board may

10 adopt such plans as the basis for its recommenda11 tions; and

12 (3) maintain close consultation with such bodies

13 and boards throughout the process of preparing its

14 recommendations.

15 (d) CHAIRPERSON; ADDITIONAL DUTIES.—The

16 President shall designate a Chairperson from among the

17 members, who (subject to the approval of the Board)

18 may—

19 (1) employ and fix the compensation of an Ex20 ecutive Director and such other personnel (not to ex21 ceed 25) as may be necessary to carry out the

22 Board’s duties;

23 (2) seek such assistance and support as may be

24 required in the performance of the Board’s duties

25 from appropriate Federal departments and agencies;
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1 (3) enter into contracts or make other arrange2 ments, as may be necessary for the conduct of the

3 work of the Board (without regard to section 3709

4 of the Revised Statutes (41 U.S.C. 5));

5 (4) make advance, progress, and other pay6 ments which relate to the work of the Commission;

7 (5) provide transportation and subsistence for

8 persons serving without compensation; and

9 (6) prescribe such rules and regulations as the

10 Board deems necessary with respect to its internal

11 organization and operation.

12 (e) COMPENSATION.—Members of the Board who are

13 full-time officers or employees of the United States may

14 not receive additional pay, allowances, or benefits by rea15 son of their service on the Board, but may receive travel

16 expenses, including per diem in lieu of subsistence, in ac17 cordance with sections 5702 and 5703 of title 5, United

18 States Code.

19 (f) TERMINATION.—The Board shall terminate upon

20 the expiration of the 6-year period that begins on the date

21 of the enactment of this Act. Section 14(a) of the Federal

22 Advisory Committee Act (5 U.S.C. App.; relating to the

23 termination of advisory committees) shall not apply to the

24 Board.
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1 (g) CONFORMING AMENDMENT REPEALING COUNCIL

2 ON GRADUATE MEDICAL EDUCATION.—Effective on the

3 date of the enactment of this Act, section 301 of the

4 Health Professions Education Extension Amendments of

5 1992 (Public Law 102–408) is repealed.

6 SEC. 5. REVISIONS TO MEDICARE METHODOLOGY FOR DE7 TERMINING PAYMENTS FOR MEDICAL RESI8 DENCY.

9 (a) PAYMENTS FOR DIRECT MEDICAL EDUCATION

10 COSTS OF NON-HOSPITAL PROVIDERS.—Title XVIII of

11 the Social Security Act (42 U.S.C. 1395 et seq.) is amend12 ed by inserting after section 1889 the following new sec13 tion:

14 ‘‘GRADUATE MEDICAL EDUCATION PAYMENTS FOR NON15 HOSPITAL PROVIDERS

16 ‘‘SEC. 1890. (a) IN GENERAL.—Notwithstanding any

17 other provision of this title, in the case of any entity (other

18 than a hospital) eligible to receive payments under this

19 title that operates an approved medical residency training

20 program, in addition to any other payments that may be

21 made to the entity under this title, the Secretary shall pro22 vide for payment to the entity for direct graduate medical

23 education costs in accordance with subsection (b).

24 ‘‘(b) DETERMINATION OF AMOUNT OF PAYMENT.—

25 ‘‘(1) IN GENERAL.—The amount of payment

26 made to an entity under this section for direct medi-
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1 cal education for a fiscal year is equal to the product

2 of—

3 ‘‘(A) the aggregate approved amount (as

4 defined in paragraph (2)) for the year; and

5 ‘‘(B) the entity’s medicare patient load (as

6 defined in subsection (d)(2)) for the year.

7 ‘‘(2) AGGREGATE APPROVED AMOUNT.—In

8 paragraph (1), the term ‘aggregate approved

9 amount’ means, for a fiscal year, the product of—

10 ‘‘(A) the approved FTE resident amount

11 (determined under paragraph (3)) for the year;

12 and

13 ‘‘(B) the weighted average number of full14 time equivalent residents (as determined by the

15 Secretary in a manner similar to the manner

16 used to determine the number of such residents

17 under section 1886(h)(4)) in the entity’s ap18 proved medical residency training programs in

19 the year.

20 ‘‘(3) DETERMINATION OF APPROVED FTE RESI21 DENT AMOUNT.—

22 ‘‘(A) IN GENERAL.—For each approved

23 medical residency training program, the Sec24 retary shall determine an approved FTE resi25 dent amount for each fiscal year (beginning
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1 with fiscal year 1995) equal to the applicable

2 percentage (as defined in subparagraph (C)) of

3 the national average salary for the year (as de4 fined in subparagraph (B)(ii)).

5 ‘‘(B) DETERMINATION OF NATIONAL AV6 ERAGE SALARY.—

7 ‘‘(i) DETERMINATION OF BASE

8 AMOUNT.—The Secretary shall determine a

9 base salary amount equal to the Sec10 retary’s estimate (using the most recent

11 available audited cost reports) of the na12 tional average salary, including fringe ben13 efits, for a full-time-equivalent resident in

14 an approved medical residency training

15 program during fiscal year 1990, increased

16 (in a compounded manner) by the sum of

17 the estimated percentage changes in the

18 consumer price index during the 12-month

19 periods between the midpoint of fiscal year

20 1990 and the midpoint of fiscal year 1994.

21 ‘‘(ii) NATIONAL AVERAGE SALARY DE22 FINED.—In this paragraph, the ‘national

23 average salary’ for a fiscal year is equal

24 to—
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1 ‘‘(I) for fiscal year 1995, the

2 base amount determined under clause

3 (i) updated through the midpoint of

4 the year by projecting the estimated

5 percentage change in the consumer

6 price index during the 12-month pe7 riod ending at that midpoint (with ap8 propriate adjustments to reflect pre9 vious under- or over-estimations under

10 this subparagraph in the projected

11 percentage change in the consumer

12 price index); and

13 ‘‘(II) for a subsequent fiscal year,

14 the amount determined under this

15 clause for the previous fiscal year up16 dated through the midpoint of the

17 year by projecting the estimated per18 centage change in the consumer price

19 index during the 12-month period

20 ending at that midpoint (with appro21 priate adjustments to reflect previous

22 under- or over-estimations under this

23 subparagraph in the projected per24 centage change in the consumer price

25 index).
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1 ‘‘(C) APPLICABLE PERCENTAGE.—In sub2 paragraph (A), the ‘applicable percentage’ is—

3 ‘‘(i) in the case of a primary care resi4 dency training program, 200 percent; or

5 ‘‘(ii) in the case of medical residency

6 training program that is not a primary

7 care residency training program, 150 per8 cent.

9 ‘‘(c) ALLOCATION OF PAYMENTS AMONG TRUST

10 FUNDS.—In providing for payments under this section,

11 the Secretary shall provide for an allocation of such pay12 ments between part A and part B (and the trust funds

13 established under the respective parts) as reasonably re14 flects the proportion of direct graduate medical costs of

15 entities associated with the provision of services under

16 each respective part.

17 ‘‘(d) DEFINITIONS.—In this section:

18 ‘‘(1) The terms ‘approved medical residency

19 training program’, ‘consumer price index’, ‘direct

20 graduate medical education costs’, and ‘resident’

21 have the meaning given such terms under section

22 1886(h)(5).

23 ‘‘(2) The term ‘medicare patient load’ means,

24 with respect to an entity for a year, the fraction of

25 the entity’s services during the year which are at-
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1 tributable to individuals entitled to benefits under

2 this title (based on such measure of services as the

3 Secretary determines to be appropriate for purposes

4 of this section).

5 ‘‘(3) The term ‘primary care medical residency

6 training program’ means an approved medical resi7 dency training program consisting of a distinct pro8 gram of primary health care (as defined in section

9 723(d)(5) of the Public Health Service Act).’’.

10 (b) PAYMENT FOR HOSPITAL COSTS OF INDIRECT

11 MEDICAL EDUCATION PROVIDED OFF-SITE.—Section

12 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C.

13 1395ww(d)(5)(B)(iv)) is amended by inserting by striking

14 the period at the end and inserting the following: ‘‘, with15 out regard to the setting in which the services are fur16 nished (if the hospital incurs all, or substantially all, of

17 the costs of the services furnished to the hospital by such

18 interns and residents).’’.

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

20 this section shall apply to cost reporting periods (or por21 tions thereof) beginning on or after October 1, 1994.

22 SEC. 6. CERTAIN PRIMARY CARE PROGRAMS UNDER PUB23 LIC HEALTH SERVICE ACT.

24 (a) INCREASE IN FUNDING FOR SCHOLARSHIP AND

25 LOAN REPAYMENT PROGRAMS OF NATIONAL HEALTH
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1 SERVICE CORPS.—Section 338H(b)(1) of the Public

2 Health Service Act (42 U.S.C. 254q(b)(1)) is amended—

3 (1) by striking ‘‘and’’ after ‘‘1991,’’;

4 (2) by striking ‘‘through 2000’’ and inserting

5 ‘‘and 1993’’; and

6 (3) by inserting before the period the following:

7 ‘‘, $226,000,000 for fiscal year 1994, $294,000,000

8 for fiscal year 1995, $381,000,000 for fiscal year

9 1996, $496,000,000 for fiscal year 1997,

10 $644,000,000 for fiscal year 1998, $837,000,000 for

11 fiscal year 1999, and $1,089,000,000 for fiscal year

12 2000’’.

13 (b) DEMONSTRATION GRANTS TO STATES FOR COM14 MUNITY SCHOLARSHIP PROGRAMS.—Section 338L(l)(1)

15 of the Public Health Service Act (42 U.S.C. 254t(l)(1))

16 is amended—

17 (1) by striking ‘‘and’’ after ‘‘1992,’’; and

18 (2) by inserting before the period the following:

19 ‘‘, and $5,000,000 for each of the fiscal years 1994

20 through 2000’’.

21 (c) NATIONAL RESEARCH SERVICE AWARDS.—Sec22 tion 487(d)(3) of the Public Health Service Act (42 U.S.C.

23 288(d)(3)), as amended by section 1641(2) of Public Law

24 103–43, is amended—
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1 (1) by striking ‘‘1 percent’’ the first place such

2 terms appears and inserting ‘‘2 percent’’; and

3 (2) by striking ‘‘Awards which (A) are made’’

4 and all that follows through ‘‘(B) are for research in

5 primary medical care;’’ and inserting the following:

6 ‘‘Awards made for research in primary medical

7 care;’’.

8 (d) HEALTH CARE POLICY AND RESEARCH.—

9 (1) FUNDING.—Section 926 of the Public

10 Health Service Act (42 U.S.C. 299c–5), as amended

11 by section 10 of Public Law 102–410 (106 Stat.

12 2101), is amended by adding at the end the follow13 ing subsection:

14 ‘‘(f) ALLOCATION REGARDING PRIMARY CARE.—Of

15 the amounts made available for a fiscal year for carrying

16 out this title, the Secretary shall obligate not less than

17 15 percent for carrying out section 902 with respect to

18 primary care.’’.

19 (2) RETRAINING PROGRAMS.—Section 902 of

20 the Public Health Service Act (42 U.S.C. 299a), as

21 amended by section 2 of Public Law 102–410 (106

22 Stat. 2094), is amended by adding at the end the

23 following subsection:

24 ‘‘(f) RETRAINING OF SPECIALISTS.—With respect to

25 physicians who are in a specialty, the Administrator shall,
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1 in carrying out subsection (a), conduct or support pro2 grams for training such physicians in primary care.’’.

3 (e) COMMISSION ON OBLIGATED SERVICE.—

4 (1) IN GENERAL.—Not later than 180 days

5 after the date of the enactment of this Act, there

6 shall be established in accordance with this sub7 section an advisory commission to carry out the du8 ties described in paragraph (2).

9 (2) DUTIES.—The duties referred to in para10 graph (1) are making recommendations to the Presi11 dent and the Secretary on Health and Human Serv12 ices on whether and to what extent students attend13 ing health professions schools pursuant to direct or

14 indirect federal financial assistance (for the students

15 or for the schools, or both) should, as a condition of

16 such attendance, be contractually required to com17 plete a period of providing health services to medi18 cally underserved individuals. Recommendations

19 under the preceding sentence shall include rec20 ommendations with respect to establishing such a re21 quirement for each student who attends a health

22 professions school pursuant to such assistance.

23 (3) MEMBERSHIP.—The advisory commission

24 established under paragraph (1) shall be comprised

25 of five individuals appointed by the President.
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1 (4) ADMINISTRATIVE PROVISIONS.—The advi2 sory commission established under paragraph (1)

3 shall be established within the Department of Health

4 and Human Services. The Secretary shall provide to

5 the commission such staff, quarters, information,

6 and other assistance as may be necessary for the

7 commission to carry out paragraph (2).

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