II

103D CONGRESS

1ST SESSION S. 1473

To encourage an appropriate mixture of different specialties of physicians

and other health care providers to meet national needs, and for other

purposes.

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 20 (legislative day, SEPTEMBER 7), 1993

Mr. BAUCUS introduced the following bill; which was read twice and referred

to the Committee on Finance

A BILL

To encourage an appropriate mixture of different specialties

of physicians and other health care providers to meet

national needs, 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 Health Care

5 Support Act of 1993’’.

6 SEC. 2. FINDINGS AND PURPOSE.

7 (a) FINDINGS.—The Congress finds that:

8 (1) Primary care physicians, including family

9 physicians, general internists, and general pediatri-
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1 cians, provide health care services that are essential

2 to the well-being of all Americans.

3 (2) There is a shortage of primary care physi4 cians in many areas of the United States.

5 (3) A large majority of recent graduates of

6 medical schools located in the United States are en7 tering non-primary care specialty practices.

8 (4) There is an oversupply of non-primary care

9 specialists in the practice of medicine in the United

10 States.

11 (5) An appropriate mix of physicians in the

12 United States is approximately one-half primary

13 care physicians and one-half physicians in other spe14 cialties.

15 (6) The oversupply of non-primary care special16 ists has helped to drive up health care costs through

17 high fees and high utilization of diagnostic tests and

18 procedures.

19 (7) The shortage of primary care physicians has

20 affected medical service quality because these physi21 cians furnish excellent continuity of care, are expert

22 in diagnosing medical problems, and can effectively

23 deal with the interaction of comorbid conditions.

24 (8) The shortage of primary care physicians has

25 amplified the problems of access to medical care in
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1 areas with health care professional shortages, espe2 cially inner city and rural areas.

3 (b) PURPOSES.—The purposes of this Act are to—

4 (1) increase the relative income of primary care

5 physicians as compared to physicians in other spe6 cialties;

7 (2) reform the system for payment of direct

8 graduate medical education costs to operators of

9 graduate medical education programs under the

10 medicare program;

11 (3) establish the National Physician Work

12 Force Commission to study and recommend national

13 physician work force goals;

14 (4) establish a program to designate physician

15 residency programs and the number of positions in

16 those programs based on national needs; and

17 (5) increase the number of primary care physi18 cians trained and employed with the help of govern19 ment programs.

20 SEC. 3. RESOURCE-BASED PRACTICE EXPENSE RELATIVE

21 VALUE UNITS.

22 (a) RESOURCE-BASED PRACTICE EXPENSES.—Not

23 later than October 1, 1996, the Secretary of Health and

24 Human Services (referred to in this section as the ‘‘Sec25 retary’’) shall develop resource-based expenses for the de-
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1 termination of average practice expense relative value

2 units to be utilized in determining payment for each physi3 cian service under part B of title XVIII of the Social Secu4 rity Act.

5 (b) IMPLEMENTATION.—

6 (1) COMPUTATION OF PRACTICE EXPENSE REL7 ATIVE VALUE UNITS.—Section 1848(c)(2)(C)(ii) of

8 the Social Security Act (42 U.S.C. 1395w–

9 4(c)(2)(C)(ii)) is amended to read as follows:

10 ‘‘(ii) PRACTICE EXPENSE RELATIVE

11 VALUE UNITS.—The Secretary shall deter12 mine a number of practice expense relative

13 value units equal to the product of—

14 ‘‘(I) the resource-based expenses

15 (as defined in subparagraph (E)) for

16 the service, and

17 ‘‘(II) the practice expense per18 centage for the service (as determined

19 under paragraph (3)(C)(ii)).’’.

20 (2) RESOURCE-BASED EXPENSES.—Subpara21 graph (E) of section 1848(c)(2) of the Social Secu22 rity Act (42 U.S.C. 1395w–4(c)(2)), as added by

23 section 13513 of the Omnibus Budget Reconciliation

24 Act of 1993, is amended to read as follows:
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1 ‘‘(E) RESOURCE-BASED EXPENSES DE2 FINED.—In this paragraph, the term ‘resource3 based expenses’ means, with respect to a physi4 cian’s service, the direct and indirect costs of

5 the resources needed to furnish the service, as

6 estimated by the Secretary using the most re7 cent data available. The resources shall be esti8 mated using accounting methods to measure di9 rect and indirect costs. The Secretary may use

10 extrapolation and other techniques to determine

11 resource-based expenses for services for which

12 adequate data is not available.’’.

13 (c) BUDGET NEUTRALITY.—The Secretary shall pro14 vide that in carrying out the amendments made by sub15 section (b) that payments under section 1848 of the Social

16 Security Act are equal to what such payments would have

17 been if such amendments had not been enacted.

18 (d) EFFECTIVE DATE.—The amendments made by

19 subsection (b) shall apply to services furnished on or after

20 January 1, 1997.

21 SEC. 4. PAYMENTS FOR DIRECT GRADUATE MEDICAL EDU22 CATION COSTS.

23 (a) IN GENERAL.—

24 (1) DETERMINING PER RESIDENT STANDARD

25 AMOUNT.—Section 1886(h) of the Social Security
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1 Act (42 U.S.C. 1395ww(h)), as amended by section

2 13563 of the Omnibus Budget Reconciliation Act of

3 1993, is amended by redesignating paragraphs (3),

4 (4), (5), and (6) as paragraphs (4), (5), (6), and

5 (7), respectively and by inserting after paragraph

6 (2) the following new paragraph:

7 ‘‘(3) DETERMINATION OF PER RESIDENT

8 STANDARD AMOUNT.—The Secretary shall determine

9 a national per resident standard amount for each

10 fiscal year beginning on or after October 1, 1994, as

11 follows:

12 ‘‘(A) BASE AMOUNT.—The Secretary shall

13 determine the weighted national mean of all

14 FTE resident amounts calculated under para15 graph (2) and updated in accordance with para16 graph (2)(D) to the midpoint of fiscal year

17 1994 for the most recent cost reporting periods

18 for which data are available.

19 ‘‘(B) INFLATION ADJUSTMENT TO BASE

20 AMOUNT.—

21 ‘‘(i) FISCAL YEAR 1995.—For fiscal

22 year 1995, the per resident standard

23 amount is the amount determined under

24 subparagraph (A) updated in accordance
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1 with paragraph (2)(D) through the mid2 point of fiscal year 1995.

3 ‘‘(ii) SUBSEQUENT FISCAL YEARS.—

4 For fiscal year 1996 and any subsequent

5 fiscal year, the per resident standard

6 amount is equal to the amount determined

7 under this paragraph for the previous fis8 cal year updated, through the midpoint of

9 the fiscal year, by projecting the estimated

10 percentage change in the Consumer Price

11 Index during the 12-month period ending

12 at that midpoint, with appropriate adjust13 ments to reflect previous underestimations

14 or overestimations under this subpara15 graph in the projected percentage change

16 in the Consumer Price Index.

17 ‘‘(C) SPECIAL RULE.—In the case of a

18 hospital that received payment under this sub19 section prior to October 1, 1994, the per resi20 dent standard amount for such hospital for fis21 cal year 1995 shall be equal to the sum of—

22 ‘‘(i) 50 percent of the hospital specific

23 approved FTE resident amount determined

24 under paragraph (2) for such hospital; and
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1 ‘‘(ii) 50 percent of the per resident

2 standard amount determined under sub3 paragraph (B)(i).’’.

4 (2) PAYMENT AMOUNT PER RESIDENT.—Para5 graph (4) of section 1886(h) of such Act (42 U.S.C.

6 1395ww(h)), as redesignated by paragraph (1), is

7 amended to read as follows:

8 ‘‘(4) GME OPERATOR PAYMENT AMOUNT PER

9 RESIDENT.—

10 ‘‘(A) IN GENERAL.—The payment amount,

11 for a GME operator cost reporting period be12 ginning on or after October 1, 1994, is equal to

13 the product of—

14 ‘‘(i) the aggregate approved amount

15 (as defined in subparagraph (B)) for that

16 period, and

17 ‘‘(ii) the GME operator’s medicare pa18 tient load (as determined by the Secretary)

19 for that period.

20 ‘‘(B) AGGREGATE APPROVED AMOUNT.—

21 As used in subparagraph (A), the term ‘aggre22 gate approved amount’ means, for a GME oper23 ator cost reporting period, the product of—
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1 ‘‘(i) the per resident standard amount

2 determined under paragraph (3) for that

3 period, and

4 ‘‘(ii) the weighted average number of

5 full-time-equivalent residents (as deter6 mined under paragraph (5)) in the GME

7 operator’s approved medical residency

8 training programs in that period.’’.

9 (3) WEIGHTING FACTORS.—Subparagraph (C)

10 of paragraph (5) of section 1886(h) of such Act (42

11 U.S.C. 1395ww(h)), as redesignated by paragraph

12 (1), is amended to read as follows:

13 ‘‘(C) WEIGHTING FACTORS FOR CERTAIN

14 RESIDENTS.—Subject to subparagraph (D),

15 such rules shall provide, in calculating the num16 ber of full-time-equivalent residents in an ap17 proved medical residency training program—

18 ‘‘(i) for a resident who is in the resi19 dent’s initial residency period, the

20 weighting factor is 0.80 (1.20, in the case

21 of a resident who is a primary care resi22 dent), and

23 ‘‘(ii) for a resident who is not in the

24 resident’s initial residency period, the

25 weighting factor is 0.50.’’.
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1 (4) DEFINITIONS.—Paragraph (6) of section

2 1886(h) of such Act (42 U.S.C. 1395ww(h)), as re3 designated by paragraph (1), is amended by adding

4 at the end the following new subparagraph:

5 ‘‘(K) GME OPERATOR.—The term ‘GME

6 operator’ means a hospital, rural health clinic,

7 health maintenance organization, medical

8 school, group practice, physician’s office, area

9 health education center, community health cen10 ter, or consortium of institutional providers or

11 health professionals that has an approved medi12 cal residency training program.’’.

13 (5) CONFORMING AMENDMENTS.—Section

14 1886(h) of such Act (42 U.S.C. 1395ww(h)) is

15 amended—

16 (A) in paragraph (1)—

17 (i) by striking ‘‘hospitals’’ each place

18 it appears and inserting ‘‘GME operators’’;

19 and

20 (ii) by striking ‘‘paragraph (3)’’ and

21 inserting ‘‘paragraph (4)’’;

22 (B) in paragraph (2), in the matter pre23 ceding subparagraph (A), by inserting ‘‘and

24 ending on or before September 30, 1995,’’ after

25 ‘‘1985,’’; and
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1 (C) in paragraph (5), as redesignated by

2 subsection (a)—

3 (i) by adding at the end of subpara4 graph (A) the following new sentence:

5 ‘‘Such rules shall provide that only time

6 spent in activities relating to patient care

7 shall be counted and that all the time so

8 spent by a resident under an approved

9 medical residency training program spon10 sored by a GME operator shall be counted

11 toward the determination of full-time12 equivalency, without regard to the setting

13 in which the activities are performed.’’;

14 (ii) in subparagraph (B), by striking

15 ‘‘hospital’’ each place it appears and in16 serting ‘‘GME operator’’; and

17 (iii) by striking subparagraph (E).

18 (b) BUDGET NEUTRALITY.—Through fiscal year

19 1998, the Secretary of Health and Human Services shall

20 provide that in carrying out the amendments made by sub21 section (a), payments under section 1886(h) of the Social

22 Security Act shall be equal to what such payments would

23 have been if such amendments had not been enacted.

24 (c) CONFORMING AMENDMENT.—Section 1861(u) of

25 the Social Security Act (42 U.S.C. 1395x(u)) is amended
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1 by striking ‘‘hospice program,’’ and inserting ‘‘hospice

2 program, GME operator (as defined in section

3 1886(h)(6)(K)),’’.

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

5 this section shall be effective for cost reporting periods be6 ginning on or after October 1, 1994.

7 SEC. 5. NATIONAL PHYSICIAN WORK FORCE COMMISSION.

8 (a) ESTABLISHMENT OF COMMISSION.—

9 (1) ESTABLISHMENT.—There is established a

10 commission to be known as the National Physician

11 Work Force Commission (referred to in this section

12 as the ‘‘Commission’’) which shall be composed of

13 the Secretary of Health and Human Services (re14 ferred to in this section as the ‘‘Secretary’’) and 10

15 other members to be appointed by the Director of

16 the Congressional Office of Technology Assessment

17 (referred to in this section as the ‘‘Director’’), on or

18 before the date that is 60 days after the date of the

19 enactment of this Act.

20 (2) MEMBERSHIP.—The members of the Com21 mission appointed under paragraph (1) shall include

22 individuals with national recognition for expertise in

23 health service delivery, research, health economics,

24 physician medical education, and physician work

25 force issues. The professions of members of the
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1 Commission shall include physicians, mid-level

2 health professionals, employers, third party payers,

3 and health research experts. In appointing individ4 uals, the Director shall assure representation of var5 ious professions, different geographic regions, and

6 urban and rural regions.

7 (3) TERMS.—The members of the Commission

8 appointed under paragraph (1) shall be appointed to

9 serve for terms of 3 years, except that the terms of

10 the members first appointed may be staggered so

11 that the terms of no more than 4 members expire

12 in any 1 year. Any individual appointed to fill a va13 cancy created in the Commission shall be appointed

14 for the remainder of the term of such individual’s

15 predecessor.

16 (4) CHAIRMAN AND VICE CHAIRMAN.—The Di17 rector shall select the Chairman and Vice Chairman

18 of the Commission.

19 (5) MEETINGS.—

20 (A) IN GENERAL.—The Commission shall

21 meet at the call of the Chairman.

22 (B) INITIAL MEETING.—No later than 30

23 days after the date on which all members of the

24 Commission have been appointed, the Commis25 sion shall hold its first meeting.
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1 (C) QUORUM.—A majority of the members

2 of the Commission shall constitute a quorum,

3 but a lesser number of members may hold hear4 ings.

5 (b) POWERS OF THE COMMISSION.—

6 (1) HEARINGS.—The Commission may hold

7 such hearings, sit and act at such times and places,

8 take such testimony, and receive such evidence as

9 the Commission considers advisable to carry out the

10 purposes of this section.

11 (2) INFORMATION FROM FEDERAL AGENCIES.—

12 The Commission may secure directly from any Fed13 eral department or agency such information as the

14 Commission considers necessary to carry out the

15 provisions of this Act. Upon request of the Chair16 man of the Commission, the head of such depart17 ment or agency shall furnish such information to the

18 Commission.

19 (3) POSTAL SERVICES.—The Commission may

20 use the United States mails in the same manner and

21 under the same conditions as other departments and

22 agencies of the Federal Government.

23 (4) GIFTS.—The Commission may accept, use,

24 and dispose of gifts or donations of services or prop25 erty.
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1 (c) COMMISSION PERSONNEL MATTERS.—

2 (1) COMPENSATION OF MEMBERS.—Each mem3 ber of the Commission who is not an officer or em4 ployee of the Federal Government shall be com5 pensated at a rate equal to the daily equivalent of

6 the annual rate of basic pay prescribed for level IV

7 of the Executive Schedule under section 5315 of title

8 5, United States Code, for each day (including travel

9 time) during which such member is engaged in the

10 performance of the duties of the Commission. All

11 members of the Commission who are officers or em12 ployees of the United States shall serve without com13 pensation in addition to that received for their serv14 ices as officers or employees of the United States.

15 (2) TRAVEL EXPENSES.—The members of the

16 Commission shall be allowed travel expenses, includ17 ing per diem in lieu of subsistence, at rates author18 ized for employees of agencies under subchapter I of

19 chapter 57 of title 5, United States Code, while

20 away from their homes or regular places of business

21 in the performance of services for the Commission.

22 (3) STAFF.—

23 (A) IN GENERAL.—The Chairman of the

24 Commission may, without regard to the civil

25 service laws and regulations, appoint and termi-
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1 nate an executive director and such other addi2 tional personnel as may be necessary to enable

3 the Commission to perform its duties. The em4 ployment of an executive director shall be sub5 ject to confirmation by the Commission.

6 (B) COMPENSATION.—The Chairman of

7 the Commission may fix the compensation of

8 the executive director and other personnel with9 out regard to the provisions of chapter 51 and

10 subchapter III of chapter 53 of title 5, United

11 States Code, relating to classification of posi12 tions and General Schedule pay rates, except

13 that the rate of pay for the executive director

14 and other personnel may not exceed the rate

15 payable for level V of the Executive Schedule

16 under section 5316 of such title.

17 (4) DETAIL OF GOVERNMENT EMPLOYEES.—

18 Any Federal Government employee may be detailed

19 to the Commission without reimbursement, and such

20 detail shall be without interruption or loss of civil

21 service status or privilege.

22 (5) PROCUREMENT OF TEMPORARY AND INTER23 MITTENT SERVICES.—The Chairman of the Commis24 sion may procure temporary and intermittent serv25 ices under section 3109(b) of title 5, United States
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1 Code, at rates for individuals which do not exceed

2 the daily equivalent of the annual rate of basic pay

3 prescribed for level V of the Executive Schedule

4 under section 5316 of such title.

5 (d) STUDIES AND REPORTS.—

6 (1) GENERAL STUDIES AND RECOMMENDA7 TIONS.—

8 (A) IN GENERAL.—The Commission shall

9 conduct a thorough study of all matters relating

10 to physician work force goals and issues.

11 (B) MATTERS STUDIED.—The matters

12 studied by the Commission shall include—

13 (i) national physician supply, composi14 tion, and trends;

15 (ii) national physician work force

16 goals;

17 (iii) policies to attain national physi18 cian work force goals;

19 (iv) the desirable number of medical

20 residents by specialty;

21 (v) the designation of appropriate op22 erators of graduate medical education pro23 grams in each specialty;

24 (vi) the designation of the appropriate

25 number of positions allocated to the grad-
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1 uate medical education programs at each

2 program operator and its affiliated institu3 tions;

4 (vii) the match of residents and grad5 uate medical education positions;

6 (viii) means of implementing policies

7 related to physician work force issues; and

8 (ix) the effects of the physician work

9 force composition, supply and trends of the

10 health care system in the United States,

11 including issues of access to care, quality

12 of care, and cost of health care.

13 (C) RECOMMENDATIONS.—The Commis14 sion shall develop recommendations on each of

15 the matters studied under subparagraph (B).

16 (D) ANNUAL REPORT.—Not later than Oc17 tober 1, 1994, and annually thereafter, the

18 Commission shall deliver a report to Congress

19 and the Secretary which shall contain the find20 ings and conclusions of the Commission, to21 gether with its recommendations on each of the

22 matters studied under subparagraph (B).

23 (2) MEDICAL EDUCATION STUDY.—

24 (A) IN GENERAL.—The Commission shall

25 evaluate the undergraduate medical education
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1 programs operated by medical schools and

2 graduate medical education programs located in

3 the United States, including an evaluation of

4 whether such programs are properly designed to

5 train generalist physicians prepared to practice

6 and whether such programs are adequately

7 training physicians to treat the nonacute care

8 needs of patients.

9 (B) REPORT.—Not later than 18 months

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

11 Commission shall deliver a report to Congress

12 and the Secretary which shall contain the eval13 uation required by subparagraph (A).

14 (3) DIRECT MEDICAL EDUCATION FUNDING.—

15 (A) IN GENERAL.—The Commission shall

16 perform a study of the sources of available

17 funds for graduate medical education other

18 than funding available under title XVIII of the

19 Social Security Act, and whether it is desirable

20 for all medical service payers to contribute to

21 funding for graduate medical education. The

22 Commission shall determine the amount of

23 funds that would be needed in a system in

24 which all medical service payers, other than the

25 medicare program under title XVIII of the So-
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1 cial Security Act, paid a portion of the funds

2 necessary for graduate medical education, the

3 assessments to be imposed on such payers in

4 order to obtain the necessary funds, policies

5 necessary to implement such a program, and

6 the probable effects of such a program.

7 (B) REPORT.—Not later than 1 year after

8 the date of the enactment of this Act, the Com9 mission shall deliver a report to Congress and

10 the Secretary which shall contain the evaluation

11 required by subparagraph (A).

12 (e) IMPLEMENTING BILL ON NUMBER OF RESI13 DENCY POSITIONS AND ALLOCATION OF RESIDENCY PO14 SITIONS.—

15 (1) IN GENERAL.—

16 (A) IMPLEMENTING BILL.—Not later than

17 15 months after the date of the enactment of

18 this Act, the Commission shall submit to Con19 gress an implementing bill with respect to the

20 legislative proposal developed under paragraph

21 (2) which contains such provisions necessary or

22 appropriate to implement such proposal either

23 repealing or amending existing laws or provid24 ing new statutory authority.
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1 (B) CONSIDERATION OF IMPLEMENTING

2 BILL.—The implementing bill described in sub3 paragraph (A) shall be considered by Congress

4 under the procedures for consideration de5 scribed in paragraph (3).

6 (2) LEGISLATIVE PROPOSAL.—

7 (A) IN GENERAL.—The Commission shall

8 develop a legislative proposal that—

9 (i) specifies, by specialty and sub10 specialty, the total number of first-year

11 residency positions for which payment will

12 be available under section 1886(h) of the

13 Social Security Act for each year of the

14 initial 4-year period and allocates to GME

15 operators such first-year residency posi16 tions;

17 (ii) for each 4-year period subsequent

18 to the initial 4-year period, directs the Sec19 retary to determine, by specialty and sub20 specialty, the appropriate number of first21 year residency positions for which payment

22 will be available under section 1886(h) of

23 such Act and allocate to GME operators

24 such first-year residency positions taking

25 into consideration the recommendations of
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1 the Commission contained in the report

2 submitted to the Secretary under sub3 section (d)(1)(D);

4 (iii) requires the Secretary to deny

5 payment under subsections (d)(5)(B) and

6 (h) of section 1886 of the Social Security

7 Act to a GME operator or any of its affili8 ated institutions which provide for any

9 residency position in addition to the resi10 dency positions allocated to such GME op11 erator;

12 (iv) provides that the Secretary shall

13 have the authority to increase or decrease

14 the number of residency training positions

15 allotted in a specialty or subspecialty area

16 to a GME operator during any 4-year pe17 riod by up to 10 percent of the original al18 lotment if the aggregate number of all resi19 dency positions allotted to GME operators

20 is not altered; and

21 (v) provides that a resident who is en22 rolled in an approved medical residency

23 training program prior to the date on

24 which the initial 4-year period begins shall

25 not be restricted from completing such pro-
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1 gram due to the enactment of any imple2 menting bill described in paragraph (1) if

3 such resident does not change specialties

4 or start a subspecialty program after such

5 date.

6 (B) GUIDELINES FOR LEGISLATIVE PRO7 POSAL.—

8 (i) NUMBER OF RESIDENTS.—In de9 veloping the legislative proposal under this

10 paragraph, the Commission shall—

11 (I) work toward achieving the

12 ideal distribution of the Nation’s phy13 sicians by specialty and subspecialty

14 through the allocation of residency po15 sitions;

16 (II) work toward a goal of devel17 oping a physician workforce made up

18 of one-half generalists and primary19 care physicians and one-half other

20 specialists and subspecialists; and

21 (III) propose a total number of

22 first-year residency positions for the

23 fourth year of the initial 4-year period

24 equal to 110 percent of the total num25 ber of graduates of United States
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1 medical schools for the calendar year

2 immediately preceding the calendar

3 year in which the legislative proposal

4 is submitted to Congress.

5 (ii) ALLOCATION OF RESIDENTS.—In

6 developing the legislative proposal under

7 this paragraph, the Commission shall allot

8 first-year residency positions to individual

9 GME operators based on the following se10 lection factors:

11 (I) The academic quality of the

12 approved medical training program,

13 including evidence of whether the pro14 gram provides an appropriate amount

15 of ambulatory and subacute training

16 for the residents in the specialty or

17 subspecialty area under consideration.

18 (II) The equitable distribution of

19 the programs in different regions of

20 the United States and in rural and

21 urban areas.

22 (III) The structure of the GME

23 operator, including whether the GME

24 operator is a consortium made up of
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1 medical schools, hospitals, and ambu2 latory care sites.

3 (IV) Medical services delivered by

4 the GME operator to medically under5 served areas in the specialty under

6 consideration.

7 (V) The resources devoted by the

8 GME operator to the program and the

9 equity of the GME operator’s financ10 ing arrangements with its affiliated

11 institutions.

12 (VI) Any other factors that the

13 Commission may determine appro14 priate.

15 (C) INITIAL 4-YEAR PERIOD.—The term

16 ‘‘initial 4-year period’’ means the 4-year period

17 beginning on July 1 of the calendar year follow18 ing the calendar year in which the implement19 ing bill described in paragraph (1) is submitted.

20 (3) CONGRESSIONAL CONSIDERATION.—

21 (A) RULES OF HOUSE OF REPRESENTA22 TIVES AND SENATE.—This paragraph is en23 acted by Congress—

24 (i) as an exercise of the rulemaking

25 power of the House of Representatives and
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1 the Senate, respectively, and as such is

2 deemed a part of the rules of each House,

3 respectively, but applicable only with re4 spect to the procedure to be followed in

5 that House in the case of an implementing

6 bill described in paragraph (1)(A), and su7 persedes other rules only to the extent that

8 such rules are inconsistent therewith; and

9 (ii) with full recognition of the con10 stitutional right of either House to change

11 the rules (so far as relating to the proce12 dure of that House) at any time, in the

13 same manner and to the same extent as in

14 the case of any other rule of that House.

15 (B) INTRODUCTION AND REFERRAL.—On

16 the day on which the implementing bill de17 scribed in paragraph (1)(A) is transmitted to

18 the House of Representatives and the Senate,

19 such bill shall be introduced (by request) in the

20 House of Representatives by the Majority Lead21 er of the House, for himself and the Minority

22 Leader of the House, or by Members of the

23 House designated by the Majority Leader and

24 Minority Leader of the House and shall be in25 troduced (by request) in the Senate by the Ma-
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1 jority Leader of the Senate, for himself and the

2 Minority Leader of the Senate, or by Members

3 of the Senate designated by the Majority Lead4 er and Minority Leader of the Senate. If either

5 House is not in session on the day on which the

6 implementing bill is transmitted, the bill shall

7 be introduced in the House, as provided in the

8 preceding sentence, on the first day thereafter

9 on which the House is in session. The imple10 menting bill introduced in the House of Rep11 resentatives and the Senate shall be referred to

12 the appropriate committees of each House.

13 (C) AMENDMENTS PROHIBITED.—No

14 amendment to an implementing bill shall be in

15 order in either the House of Representatives or

16 the Senate and no motion to suspend the appli17 cation of this paragraph shall be in order in ei18 ther House, nor shall it be in order in either

19 House for the Presiding Officer to entertain a

20 request to suspend the application of this para21 graph by unanimous consent.

22 (D) PERIOD FOR COMMITTEE AND FLOOR

23 CONSIDERATION.—

24 (i) IN GENERAL.—Except as provided

25 in clause (ii), if the committee or commit-
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1 tees of either House to which an imple2 menting bill has been referred have not re3 ported it at the close of the 45th day after

4 its introduction, such committee or com5 mittees shall be automatically discharged

6 from further consideration of the imple7 menting bill and it shall be placed on the

8 appropriate calendar. A vote on final pas9 sage of the implementing bill shall be

10 taken in each House on or before the close

11 of the 45th day after the implementing bill

12 is reported by the committees or committee

13 of that House to which it was referred, or

14 after such committee or committees have

15 been discharged from further consideration

16 of the implementing bill. If prior to the

17 passage by 1 House of an implementing

18 bill of that House, that House receives the

19 same implementing bill from the other

20 House then—

21 (I) the procedure in that House

22 shall be the same as if no implement23 ing bill had been received from the

24 other House; but
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1 (II) the vote on final passage

2 shall be on the implementing bill of

3 the other House.

4 (ii) COMPUTATION OF DAYS.—For

5 purposes of clause (i), in computing a

6 number of days in either House, there

7 shall be excluded—

8 (I) the days on which either

9 House is not in session because of an

10 adjournment of more than 3 days to

11 a day certain, or an adjournment of

12 the Congress sine die, and

13 (II) any Saturday and Sunday

14 not excluded under subclause (I) when

15 either House is not in session.

16 (E) FLOOR CONSIDERATION IN THE

17 HOUSE OF REPRESENTATIVES.—

18 (i) MOTION TO PROCEED.—A motion

19 in the House of Representatives to proceed

20 to the consideration of an implementing

21 bill shall be highly privileged and not de22 batable. An amendment to the motion shall

23 not be in order, nor shall it be in order to

24 move to reconsider the vote by which the

25 motion is agreed to or disagreed to.
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1 (ii) DEBATE.—Debate in the House of

2 Representatives on an implementing bill

3 shall be limited to not more than 20 hours,

4 which shall be divided equally between

5 those favoring and those opposing the bill.

6 A motion further to limit debate shall not

7 be debatable. It shall not be in order to

8 move to recommit an implementing bill or

9 to move to reconsider the vote by which an

10 implementing bill is agreed to or disagreed

11 to.

12 (iii) MOTION TO POSTPONE.—Motions

13 to postpone, made in the House of Rep14 resentatives with respect to the consider15 ation of an implementing bill, and motions

16 to proceed to the consideration of other

17 business, shall be decided without debate.

18 (iv) APPEALS.—All appeals from the

19 decisions of the Chair relating to the appli20 cation of the Rules of the House of Rep21 resentatives to the procedure relating to an

22 implementing bill shall be decided without

23 debate.

24 (v) GENERAL RULES APPLY.—Except

25 to the extent specifically provided in the
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1 preceding provisions of this subparagraph,

2 consideration of an implementing bill shall

3 be governed by the Rules of the House of

4 Representatives applicable to other bills

5 and resolutions in similar circumstances.

6 (F) FLOOR CONSIDERATION IN THE SEN7 ATE.—

8 (i) MOTION TO PROCEED.—A motion in

9 the Senate to proceed to the consideration

10 of an implementing bill shall be privileged

11 and not debatable. An amendment to the

12 motion shall not be in order, nor shall it be

13 in order to move to reconsider the vote by

14 which the motion is agreed to or disagreed

15 to.

16 (ii) GENERAL DEBATE.—Debate in

17 the Senate on an implementing bill, and all

18 debatable motions and appeals in connec19 tion therewith, shall be limited to not more

20 than 20 hours. The time shall be equally

21 divided between, and controlled by, the

22 Majority Leader and the Minority Leader

23 or their designees.

24 (iii) DEBATE OF MOTIONS AND AP25 PEALS.—Debate in the Senate on any de-
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1 batable motion or appeal in connection

2 with an implementing bill shall be limited

3 to not more than 1 hour, to be equally di4 vided between, and controlled by, the

5 mover and the manager of the implement6 ing bill, except that in the event the man7 ager of the implementing bill is in favor of

8 any such motion or appeal, the time in op9 position thereto, shall be controlled by the

10 Minority Leader or his designee. Such

11 leaders, or either of them, may, from time

12 under their control on the passage of an

13 implementing bill, allot additional time to

14 any Senator during the consideration of

15 any debatable motion or appeal.

16 (iv) OTHER MOTIONS.—A motion in

17 the Senate to further limit debate is not

18 debatable. A motion to recommit an imple19 menting bill is not in order.

20 (4) RESUBMISSIONS.—If an implementing bill

21 of the Commission is not approved by Congress or

22 is vetoed by the President (and such veto is not

23 overridden by the Congress), the Commission shall

24 resubmit a new implementing bill not later than 90

25 days after Congress failed to approve such bill or
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1 failed to override the President’s veto, and such new

2 implementing bill shall be subject to congressional

3 consideration as provided in paragraph (3).

4 (f) AUTHORIZATION OF APPROPRIATIONS.—There

5 are authorized to be appropriated such sums as may be

6 necessary to carry out the purposes of this section.

7 SEC. 6. COUNCIL ON GRADUATE MEDICAL EDUCATION.

8 (a) COUNCIL ABOLISHED.—Section 301 of the

9 Health Professions Education Extension Amendments of

10 1992 is repealed.

11 (b) EFFECTIVE DATE.—Subsection (a) shall become

12 effective upon the appointment of the initial 11 members

13 of the National Physician Work Force Commission under

14 section 5(a).

15 SEC. 7. STUDY OF EFFECT OF RESEARCH GRANTS ON PRI16 MARY CARE MEDICAL TRAINING.

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

18 Human Services (referred to in this section as the ‘‘Sec19 retary’’) shall conduct research on the effect of United

20 States Government research grants and contracts (includ21 ing research grants and contracts from the National Insti22 tutes of Health, the Agency for Health Care Policy Re23 search, and other organizations administered by the Sec24 retary). The Secretary shall evaluate whether there are

25 policy changes that should be made in order to alter the
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1 medical school environment to encourage medical students

2 to seek careers in generalist primary care medicine.

3 (b) REPORT.—Not later than 18 months after the

4 date of the enactment of this Act, the Secretary shall de5 liver a report to Congress containing the results of the

6 research and evaluation required by subsection (a).

7 SEC. 8. PAYMENTS FOR SERVICES FURNISHED IN HEALTH

8 PROFESSIONAL SHORTAGE AREAS.

9 Section 1833(m) of the Social Security Act (42

10 U.S.C. 1395l(m)) is amended to read as follows:

11 ‘‘(m)(1) If a physician furnishes a qualified physi12 cians’ service in an area that is designated as a health

13 professional shortage area under section 332(a)(1)(A) of

14 the Public Health Service Act, in addition to the payment

15 amount for such service determined without regard to this

16 subsection, the physician shall be paid an amount equal

17 to 20 percent of such payment amount.

18 ‘‘(2) If an area that is designated as a health profes19 sional shortage area under such section ceases to be so

20 designated, any physician who furnished qualified

21 physicians’s services in such area and received payments

22 under paragraph (1) shall continue to be eligible to receive

23 payments under such paragraph for qualified physicians’

24 services furnished in such area during the 10-consecutive-
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1 year period beginning on the date the area ceases to be

2 designated as a health professional shortage area.

3 ‘‘(3) Any amount paid under paragraph (1) shall be

4 paid on a monthly or quarterly basis from the Federal

5 Supplementary Medical Insurance Trust Fund to the phy6 sician furnishing the service (or to an employer or facility

7 in cases described in section 1842(b)(6)(A)).

8 ‘‘(4) For purposes of determining the payment

9 amount for a qualified physicians’ service under para10 graph (1), if the index established under paragraph

11 (1)(A)(i) or (1)(B) of section 1848(e) for the area in which

12 such service is furnished is less than 1, the geographic

13 cost-of-practice index value under paragraph (3)(B) of

14 such section 1848(e) for such area shall be 1.

15 ‘‘(5) For purposes of this subsection, the term ‘quali16 fied physician’s service’ means any physicians’ service pro17 vided to an individual who is covered under the insurance

18 program under this part, except that, in the case of an

19 urban area, such term shall only include primary care

20 services.’’.

21 SEC. 9. PAYMENT FOR INDIRECT COSTS OF MEDICAL EDU22 CATION.

23 Section 1886(d)(5)(B)(ii) of the Social Security Act

24 (42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended to read as

25 follows:
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1 ‘‘(ii) For purposes of clause (i)(II), the indirect

2 teaching adjustment factor is equal to c × (((1+r)

3 to the nth power) –1), where ‘r’ is the ratio of the

4 hospital’s full-time equivalent interns and residents

5 to beds and ‘n’ equals .405. For discharges occur6 ring on or after—

7 ‘‘(I) May 1, 1986, and before January 1,

8 1994, ‘c’ is equal to 1.89,

9 ‘‘(II) January 1, 1994, and before January

10 1, 1996, ‘c’ is equal to 1.728, and

11 ‘‘(III) January 1, 1996, ‘c’ is equal to

12 1.605.’’.

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