I 

114TH CONGRESS 

2D SESSION H. R. 4774 

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

of additional residency positions, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 17, 2016 

Ms. CASTOR of Florida introduced the following bill; which was referred to the 

Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Training Tomorrow’s Doctors Today Act’’. 

6 (b) TABLE OF CONTENTS.—The table of contents for 

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Distribution of additional residency positions. 


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Sec. 3. Additional rules relating to application of 3-year rolling average for redistributed residency positions. 

Sec. 4. Rules for determining full-time equivalent residents. 

Sec. 5. Medicare GME treatment of hospitals establishing new medical residency training programs after hosting medical resident rotators 

for short durations. 

Sec. 6. Aggregation rules relating to applying limitation on number of residents. 

Sec. 7. Period of board eligibility for residents who change programs. 

Sec. 8. Medicare indirect medical education performance adjustment. 

Sec. 9. Increasing graduate medical education transparency. 

Sec. 10. GAO studies and reports. 

1 SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI2 TIONS. 

3 (a) DGME.—Section 1886(h) of the Social Security 

4 Act (42 U.S.C. 1395ww(h)) is amended— 

5 (1) in paragraph (4)(F)(i), by striking ‘‘para6 graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 

7 (8), and (9)’’; 

8 (2) in paragraph (4)(H)(i), by striking ‘‘para9 graphs (7) and (8)’’ and inserting ‘‘paragraphs (7), 

10 (8), and (9)’’; 

11 (3) in paragraph (7)(E), by inserting ‘‘para12 graph (9),’’ after ‘‘paragraph (8),’’; and 

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

14 paragraph: 

15 ‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY

16 POSITIONS.— 

17 ‘‘(A) ADDITIONAL RESIDENCY POSI18 TIONS.— 

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

20 years 2017 through 2021 (and succeeding 


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1 fiscal years if the Secretary determines 

2 that there are additional residency posi3 tions available to distribute under clause 

4 (iv)(II)), the Secretary shall, subject to 

5 clause (ii) and subparagraph (D), increase 

6 the otherwise applicable resident limit for 

7 each qualifying hospital that submits a 

8 timely application under this subparagraph 

9 by such number as the Secretary may ap10 prove for portions of cost reporting periods 

11 occurring on or after July 1 of the fiscal 

12 year of the increase. 

13 ‘‘(ii) NUMBER AVAILABLE FOR DIS14 TRIBUTION.—For each such fiscal year, 

15 the Secretary shall determine the total 

16 number of additional residency positions 

17 available for distribution under clause (i) 

18 in accordance with the following: 

19 ‘‘(I) ALLOCATION TO HOSPITALS

20 ALREADY OPERATING OVER RESIDENT

21 LIMIT.—One-third of such number 

22 shall be available for distribution only 

23 to hospitals described in subparagraph 

24 (B). 


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1 ‘‘(II) AGGREGATE LIMITATION.— 

2 Except as provided in clause (iv)(I), 

3 the aggregate number of increases in 

4 the otherwise applicable resident limit 

5 under this subparagraph shall be 

6 equal to 3,000 in each such year. 

7 ‘‘(iii) PROCESS FOR DISTRIBUTING

8 POSITIONS.— 

9 ‘‘(I) ROUNDS OF APPLICA10 TIONS.—The Secretary shall initiate 5 

11 separate rounds of applications for an 

12 increase under clause (i), 1 round 

13 with respect to each of fiscal years 

14 2017 through 2021. 

15 ‘‘(II) NUMBER AVAILABLE.—In 

16 each of such rounds, the aggregate 

17 number of positions available for dis18 tribution in the fiscal year under 

19 clause (ii) shall be distributed, plus 

20 any additional positions available 

21 under clause (iv). 

22 ‘‘(III) TIMING.—The Secretary 

23 shall notify hospitals of the number of 

24 positions distributed to the hospital 

25 under this paragraph as a result of an 


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1 increase in the otherwise applicable 

2 resident limit by January 1 of the fis3 cal year of the increase. Such increase 

4 shall be effective for portions of cost 

5 reporting periods beginning on or 

6 after July 1 of that fiscal year. 

7 ‘‘(iv) POSITIONS NOT DISTRIBUTED

8 DURING THE FISCAL YEAR.— 

9 ‘‘(I) IN GENERAL.—If the num10 ber of resident full-time equivalent po11 sitions distributed under this para12 graph in a fiscal year is less than the 

13 aggregate number of positions avail14 able for distribution in the fiscal year 

15 (as described in clause (ii), including 

16 after application of this subclause), 

17 the difference between such number 

18 distributed and such number available 

19 for distribution shall be added to the 

20 aggregate number of positions avail21 able for distribution in the following 

22 fiscal year. 

23 ‘‘(II) EXCEPTION IF POSITIONS

24 NOT DISTRIBUTED BY END OF FISCAL

25 YEAR 2021.—If the aggregate number 


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1 of positions distributed under this 

2 paragraph during the 5-year period of 

3 fiscal years 2017 through 2021 is less 

4 than 15,000, the Secretary shall, in 

5 accordance with the provisions of 

6 clause (ii) and subparagraph (D) and 

7 the considerations and priority de8 scribed in subparagraph (C), conduct 

9 an application and distribution proc10 ess in each subsequent fiscal year 

11 until such time as the aggregate 

12 amount of positions distributed under 

13 this paragraph is equal to 15,000. 

14 ‘‘(B) ALLOCATION OF DISTRIBUTION FOR

15 POSITIONS TO HOSPITALS ALREADY OPERATING

16 OVER RESIDENT LIMIT.— 

17 ‘‘(i) IN GENERAL.—Subject to clauses 

18 (ii) and (iii), in the case of a hospital in 

19 which the reference resident level of the 

20 hospital (as specified in subparagraph 

21 (G)(iii)) is greater than the otherwise ap22 plicable resident limit, the increase in the 

23 otherwise applicable resident limit under 

24 subparagraph (A) for a fiscal year de25 scribed in such subparagraph shall be an 


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1 amount equal to the product of the total 

2 number of additional residency positions 

3 available for distribution under subpara4 graph (A)(ii)(I) for such fiscal year and 

5 the quotient of— 

6 ‘‘(I) the number of resident posi7 tions by which the reference resident 

8 level of the hospital exceeds the other9 wise applicable resident limit for the 

10 hospital; and 

11 ‘‘(II) the number of resident po12 sitions by which the reference resident 

13 level of all such hospitals with respect 

14 to which an application is approved 

15 under this paragraph exceeds the oth16 erwise applicable resident limit for 

17 such hospitals. 

18 ‘‘(ii) REQUIREMENTS.—A hospital de19 scribed in clause (i)— 

20 ‘‘(I) is not eligible for an increase 

21 in the otherwise applicable resident 

22 limit under this subparagraph unless 

23 the amount by which the reference 

24 resident level of the hospital exceeds 

25 the otherwise applicable resident limit 


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1 is not less than 10 and the hospital 

2 trains at least 30 percent of the full3 time equivalent residents of the hos4 pital in primary care and general sur5 gery (as of the date of enactment of 

6 this paragraph); and 

7 ‘‘(II) shall continue to train at 

8 least 30 percent of the full-time equiv9 alent residents of the hospital in pri10 mary care and general surgery for the 

11 5-year period beginning on such date. 

12 In the case where the Secretary determines 

13 that a hospital described in clause (i) no 

14 longer meets the requirement of subclause 

15 (II), the Secretary may reduce the other16 wise applicable resident limit of the hos17 pital by the amount by which such limit 

18 was increased under this subparagraph. 

19 ‘‘(iii) CLARIFICATION REGARDING ELI20 GIBILITY FOR OTHER ADDITIONAL RESI21 DENCY POSITIONS.—Nothing in this sub22 paragraph shall be construed as preventing 

23 a hospital described in clause (i) from ap24 plying for and receiving additional resi25 dency positions under this paragraph that 


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1 are not reserved for distribution under this 

2 subparagraph. 

3 ‘‘(C) DISTRIBUTION OF OTHER POSI4 TIONS.—For purposes of determining an in5 crease in the otherwise applicable resident limit 

6 under subparagraph (A) (other than such an in7 crease described in subparagraph (B)), the fol8 lowing shall apply: 

9 ‘‘(i) CONSIDERATIONS IN DISTRIBU10 TION.—In determining for which hospitals 

11 such an increase is provided under sub12 paragraph (A), the Secretary shall take 

13 into account the demonstrated likelihood of 

14 the hospital filling the positions made 

15 available under this paragraph within the 

16 first 5 cost reporting periods beginning 

17 after the date the increase would be effec18 tive, as determined by the Secretary. 

19 ‘‘(ii) PRIORITY FOR CERTAIN HOS20 PITALS.—Subject to clause (iii), in deter21 mining for which hospitals such an in22 crease is provided, the Secretary shall dis23 tribute the increase in the following pri24 ority order: 


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1 ‘‘(I) First, to hospitals with ap2 proved medical residency programs af3 filiated with medical schools that have 

4 at least 40 percent of graduates 

5 matched in primary care residency 

6 program in the 5 years prior. 

7 ‘‘(II) Second, to hospitals in 

8 States with (aa) new medical schools 

9 that received Candidate School status 

10 from the Liaison Committee on Med11 ical Education or that received Pre12 Accreditation status from the Amer13 ican Osteopathic Association Commis14 sion on Osteopathic College Accredita15 tion on or after January 1, 2000, and 

16 that have achieved or continue to 

17 progress toward Full Accreditation 

18 status (as such term is defined by the 

19 Liaison Committee on Medical Edu20 cation) or toward Accreditation status 

21 (as such term is defined by the Amer22 ican Osteopathic Association Commis23 sion on Osteopathic College Accredita24 tion), or (bb) additional locations and 

25 branch campuses established on or 


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1 after January 1, 2000, by medical 

2 schools with Full Accreditation status 

3 (as such term is defined by the Liai4 son Committee on Medical Education) 

5 or Accreditation status (as such term 

6 is defined by the American Osteo7 pathic Association Commission on Os8 teopathic College Accreditation). 

9 ‘‘(III) Third, to hospitals with 

10 which the Secretary cooperates under 

11 section 7302(d) of title 38, United 

12 States Code. 

13 ‘‘(IV) Fourth, to all other hos14 pitals. 

15 ‘‘(iii) DISTRIBUTION TO HOSPITALS IN

16 HIGHER PRIORITY GROUP PRIOR TO DIS17 TRIBUTION IN LOWER PRIORITY GROUPS.— 

18 The Secretary may only distribute such an 

19 increase to a lower priority group under 

20 clause (ii) if all qualifying hospitals in the 

21 higher priority group or groups have re22 ceived the maximum number of increases 

23 under such subparagraph that the hospital 

24 is eligible for under this paragraph for the 

25 fiscal year. 


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1 ‘‘(iv) REQUIREMENTS FOR USE OF AD2 DITIONAL POSITIONS.— 

3 ‘‘(I) IN GENERAL.—Subject to 

4 subclause (II), a hospital that receives 

5 such an increase shall ensure, during 

6 the 5-year period beginning on the ef7 fective date of such increase, that— 

8 ‘‘(aa) not less than 50 per9 cent of the positions attributable 

10 to such increase that are used in 

11 a given year during such 5-year 

12 period are used to train full-time 

13 equivalent residents in a shortage 

14 specialty residency program (as 

15 defined in subparagraph (G)(v)), 

16 as determined by the Secretary 

17 at the end of such 5-year period; 

18 ‘‘(bb) the total number of 

19 full-time equivalent residents, ex20 cluding any additional positions 

21 attributable to such increase, is 

22 not less than the average number 

23 of full-time equivalent residents 

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1 fore the effective date of such in2 crease; and 

3 ‘‘(cc) the ratio of full-time 

4 equivalent residents in a shortage 

5 specialty residency program (as 

6 so defined) is not less than the 

7 average ratio of full-time equiva8 lent residents in such a program 

9 during the 3 most recent cost re10 porting periods ending on or be11 fore the effective date of such in12 crease. 

13 ‘‘(II) REDISTRIBUTION OF POSI14 TIONS IF HOSPITAL NO LONGER

15 MEETS CERTAIN REQUIREMENTS.— 

16 With respect to each fiscal year de17 scribed in subparagraph (A), the Sec18 retary shall determine whether or not 

19 a hospital described in subclause (I) 

20 meets the requirements of such sub21 clause. In the case that the Secretary 

22 determines that such a hospital does 

23 not meet such requirements, the Sec24 retary shall— 


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1 ‘‘(aa) reduce the otherwise 

2 applicable resident limit of the 

3 hospital by the amount by which 

4 such limit was increased under 

5 this paragraph; and 

6 ‘‘(bb) provide for the dis7 tribution of positions attributable 

8 to such reduction in accordance 

9 with the requirements of this 

10 paragraph. 

11 ‘‘(D) LIMITATION.—A hospital may not re12 ceive more than 75 full-time equivalent addi13 tional residency positions under this paragraph 

14 for any fiscal year. 

15 ‘‘(E) APPLICATION OF PER RESIDENT

16 AMOUNTS FOR PRIMARY CARE AND NONPRI17 MARY CARE.—With respect to additional resi18 dency positions in a hospital attributable to the 

19 increase provided under this paragraph, the ap20 proved FTE per resident amounts are deemed 

21 to be equal to the hospital per resident amounts 

22 for primary care and nonprimary care com23 puted under paragraph (2)(D) for that hospital. 

24 ‘‘(F) PERMITTING FACILITIES TO APPLY

25 AGGREGATION RULES.—The Secretary shall 


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1 permit hospitals receiving additional residency 

2 positions attributable to the increase provided 

3 under this paragraph to, beginning in the fifth 

4 year after the effective date of such increase, 

5 apply such positions to the limitation amount 

6 under paragraph (4)(F) that may be aggre7 gated pursuant to paragraph (4)(H) among 

8 members of the same affiliated group. 

9 ‘‘(G) DEFINITIONS.—In this paragraph: 

10 ‘‘(i) OTHERWISE APPLICABLE RESI11 DENT LIMIT.—The term ‘otherwise appli12 cable resident limit’ means, with respect to 

13 a hospital, the limit otherwise applicable 

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

15 paragraph (4) on the resident level for the 

16 hospital determined without regard to this 

17 paragraph but taking into account para18 graphs (7)(A), (7)(B), (8)(A), and (8)(B). 

19 ‘‘(ii) PRIMARY CARE.—The term ‘pri20 mary care’ means family medicine, general 

21 internal medicine, general pediatrics, geri22 atrics, preventive medicine, obstetrics and 

23 gynecology, general surgery, and psychi24 atry. 


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1 ‘‘(iii) REFERENCE RESIDENT

2 LEVEL.—Except as otherwise provided in 

3 subclause (II), the term ‘reference resident 

4 level’ means, with respect to a hospital, the 

5 resident level for the most recent cost re6 porting period of the hospital ending on or 

7 before the date of enactment of this para8 graph, for which a cost report has been 

9 settled (or, if not, submitted (subject to 

10 audit)), as determined by the Secretary. 

11 ‘‘(iv) RESIDENT LEVEL.—The term 

12 ‘resident level’ has the meaning given such 

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

14 ‘‘(v) SHORTAGE SPECIALTY RESI15 DENCY PROGRAM.—The term ‘shortage 

16 specialty residency program’ means the fol17 lowing: 

18 ‘‘(I) PRIOR TO REPORT ON

19 SHORTAGE SPECIALTIES.—Prior to 

20 the date on which the report is sub21 mitted under section 10(a) of the 

22 Training Tomorrow’s Doctors Today 

23 Act, any approved residency training 

24 program in a specialty identified in 

25 the report entitled ‘The Physician 


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1 Workforce: Projections and Research 

2 into Current Issues Affecting Supply 

3 and Demand’, issued in December 

4 2008 by the Health Resources and 

5 Services Administration, as a specialty 

6 whose baseline physician requirements 

7 projections exceed the projected sup8 ply of total active physicians for the 

9 period of 2005 through 2020. 

10 ‘‘(II) AFTER REPORT ON SHORT11 AGE SPECIALITIES.—On or after the 

12 date on which the report is submitted 

13 under such section 5, any approved 

14 residency training program in a physi15 cian specialty identified in such report 

16 as a specialty for which there is a 

17 shortage.’’. 

18 (b) IME.—Section 1886(d)(5)(B) of the Social Secu19 rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 

20 (1) in clause (v), in the second sentence, by 

21 striking ‘‘subsections (h)(7) and (h)(8)’’ and insert22 ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 

23 (2) by redesignating clause (x), as added by 

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1 fordable Care Act (Public Law 111–148), as clause 

2 (xi) and moving such clause 4 ems to the left; and 

3 (3) by adding after clause (xi), as redesignated 

4 by subparagraph (A), the following new clause: 

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

6 1, 2016, insofar as an additional payment amount 

7 under this subparagraph is attributable to resident 

8 positions distributed to a hospital under subsection 

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

10 be computed in the same manner as provided under 

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

12 SEC. 3. ADDITIONAL RULES RELATING TO APPLICATION OF 

13 3-YEAR ROLLING AVERAGE FOR REDISTRIB14 UTED RESIDENCY POSITIONS. 

15 (a) ELIMINATION OF 3-YEAR ROLLING AVERAGE RE16 LATING TO REDISTRIBUTIONS AFTER A HOSPITAL

17 CLOSES AND UNDER PPACA REDISTRIBUTIONS.— 

18 (1) DGME.— 

19 (A) REDISTRIBUTION OF RESIDENCY

20 SLOTS AFTER A HOSPITAL CLOSES.— 

21 (i) IN GENERAL.—Section 

22 1886(h)(4)(H)(vi) of the Social Security 

23 Act (42 U.S.C. 1395ww(h)(4)(H)(vi)) is 

24 amended by adding at the end the fol25 lowing new subclause: 


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1 ‘‘(VI) THREE-YEAR ROLLING AV2 ERAGE INAPPLICABLE.—In applying 

3 subparagraph (G), in the case of addi4 tional residency positions in a hospital 

5 attributable to the increase in the oth6 erwise applicable resident limit pro7 vided under this paragraph pursuant 

8 to this clause, the reference to ‘the av9 erage of the actual full-time equiva10 lent resident counts for the cost re11 porting period and the preceding two 

12 cost reporting periods’ shall be 

13 deemed to be a reference to ‘the ac14 tual full-time equivalent residents 

15 count for the cost reporting period’.’’. 

16 (ii) EFFECTIVE DATE.—The amend17 ment made by clause (i) shall apply with 

18 respect to hospitals with an approved med19 ical residency program that closes on or 

20 after March 23, 2008. 

21 (B) DISTRIBUTION OF ADDITIONAL RESI22 DENCY SLOTS UNDER PPACA.— 

23 (i) IN GENERAL.—Section 1886(h)(8) 

24 of the Social Security Act (42 U.S.C. 


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1 1395ww(h)(8)) is amended by adding at 

2 the end the following new subparagraph: 

3 ‘‘(J) THREE-YEAR ROLLING AVERAGE IN4 APPLICABLE.—In applying paragraph (4)(G), in 

5 the case of additional residency positions in a 

6 hospital attributable to the increase in the oth7 erwise applicable resident limit provided under 

8 this paragraph, the reference to ‘the average of 

9 the actual full-time equivalent resident counts 

10 for the cost reporting period and the preceding 

11 two cost reporting periods’ shall be deemed to 

12 be a reference to ‘the actual full-time equivalent 

13 residents count for the cost reporting period’.’’. 

14 (ii) EFFECTIVE DATE.—The amend15 ment made by clause (i) shall apply with 

16 respect to cost reporting periods occurring 

17 on or after July 1, 2011. 

18 (2) 3-YEAR ROLLING AVERAGE AND INTERN

19 AND RESIDENT BED RATIO CAP INAPPLICABLE

20 UNDER IME.— 

21 (A) IN GENERAL.—Section 1886(d)(5)(B) 

22 of the Social Security Act (42 U.S.C. 

23 1395ww(d)(5)(B)), as amended by section 2(b), 

24 is further amended— 


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1 (i) in subclause (I) of clause (xi), as 

2 redesignated by section 2(b)(2), by striking 

3 ‘‘The provisions’’ and inserting ‘‘Subject to 

4 clauses (xiii) and (xiv)’’; and 

5 (ii) by adding at the end the following 

6 new clauses: 

7 ‘‘(xiii) In the case of additional resi8 dency positions in a hospital attributable 

9 to the increase in the otherwise applicable 

10 resident limit provided under subsection 

11 (h)(4)(H)(vi) or (h)(8), the provisions of 

12 clause (vi)(II) shall be applied by deeming 

13 the reference to ‘the average of the actual 

14 full-time equivalent resident count for the 

15 cost reporting period and the preceding 

16 two cost reporting periods’ to be a ref17 erence to ‘the actual full-time equivalent 

18 resident count for the cost reporting pe19 riod’. 

20 ‘‘(xiv) In the case of additional resi21 dency positions in a hospital attributable 

22 to the increase in the otherwise applicable 

23 resident limit provided under subsection 

24 (h)(4)(H)(vi) or (h)(8), the ratio of the 

25 hospital’s full-time equivalent interns and 


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1 residents to beds shall be equal to the ratio 

2 for the hospital’s current cost reporting pe3 riod.’’. 

4 (B) EFFECTIVE DATE.—The amendments 

5 made by subparagraph (A) shall apply— 

6 (i) to the extent such amendments re7 late to section 1886(h)(4)(H)(vi) of the So8 cial Security Act, as if included in the en9 actment of section 5506 of the Patient 

10 Protection and Affordable Care Act; and 

11 (ii) to the extent such amendments re12 late to section 1886(h)(8) of the Social Se13 curity Act, as if included in the enactment 

14 of section 5503 of the Patient Protection 

15 and Affordable Care Act. 

16 (b) ELIMINATION OF 3-YEAR ROLLING AVERAGE

17 AND INTERN AND RESIDENT BED RATIO CAP BEGINNING

18 IN 2015.— 

19 (1) DGME.—Section 1886(h)(4)(G) of the So20 cial Security Act (42 U.S.C. 1395ww(h)(4)(G)) is 

21 amended— 

22 (A) in clause (i), by inserting ‘‘and before 

23 December 31, 2014,’’ after ‘‘October 1, 1997,’’; 

24 and 


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1 (B) by adding at the end the following new 

2 clause: 

3 ‘‘(iv) CURRENT YEAR COUNT USED TO

4 DETERMINE FULL-TIME EQUIVALENT RESI5 DENT COUNT.—For cost reporting periods 

6 beginning on or after December 31, 2014, 

7 subject to the limit described in subpara8 graph (F), the total number of full-time 

9 equivalent residents for determining a hos10 pital’s graduate medical education payment 

11 shall equal the actual full-time equivalent 

12 residents count for the hospital’s cost re13 porting period.’’. 

14 (2) IME.—Section 1886(d)(5)(B) of the Social 

15 Security Act (42 U.S.C. 1395ww(d)(5)(B)), as 

16 amended by subsection (b), is further amended by 

17 adding at the end the following new clauses: 

18 ‘‘(xv) For cost reporting periods be19 ginning on or after December 31, 2014, 

20 subject to the limits described in clauses 

21 (iv) and (v), the total number of full-time 

22 equivalent residents for payment purposes 

23 shall equal the actual full-time equivalent 

24 resident count for the hospital’s cost re25 porting period. 


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1 ‘‘(xvi) For cost reporting periods be2 ginning on or after December 31, 2014, 

3 the ratio of the hospital’s full-time equiva4 lent interns and residents to beds shall be 

5 equal to the ratio for the hospital’s cost re6 porting period.’’. 

7 SEC. 4. RULES FOR DETERMINING FULL-TIME EQUIVALENT 

8 RESIDENTS. 

9 (a) DGME.—Section 1886(h)(4) of the Social Secu10 rity Act (42 U.S.C. 1395ww(h)(4)) is amended— 

11 (1) in subparagraph (E), by striking ‘‘Subject 

12 to subparagraphs (J) and (K), such rules’’ and in13 serting ‘‘Subject to subparagraphs (J), (K), and (L), 

14 such rules’’; 

15 (2) in subparagraph (J), by striking ‘‘Such 

16 rules’’ and inserting ‘‘Subject to subparagraph (L), 

17 such rules’’; 

18 (3) in subparagraph (K), by striking ‘‘In deter19 mining’’ and inserting ‘‘Subject to subparagraph 

20 (L), in determining’’; and 

21 (4) by adding at the end the following new sub22 paragraph: 

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1 PITALS.—For purposes of cost reporting peri2 ods beginning on or after July 1, 2017, in de3 termining the number of full-time equivalent 

4 residents of the hospital for purposes of this 

5 paragraph, all the time spent by an intern or 

6 resident in an approved medical residency train7 ing program, regardless of setting, shall be 

8 counted toward the determination of full-time 

9 equivalency, and subparagraphs (J) and (K) 

10 shall not apply, if the hospital— 

11 ‘‘(i) is recognized as a subsection (d) 

12 hospital; 

13 ‘‘(ii) is recognized as a subsection (d) 

14 Puerto Rico hospital; 

15 ‘‘(iii) is reimbursed under a reim16 bursement system authorized under section 

17 1814(b)(3); or 

18 ‘‘(iv) is a provider-based hospital out19 patient department.’’. 

20 (b) IME.—The second clause (x) of section 

21 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

22 1395ww(d)(5)(B)) is amended— 

23 (1) in subclause (II), by striking ‘‘In deter24 mining’’ and inserting ‘‘Subject to subclause (x)(IV), 

25 in determining’’; 


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1 (2) in subclause (III), by striking ‘‘In deter2 mining’’ and inserting ‘‘Subject to subclause (x)(IV), 

3 in determining’’; and 

4 (3) by adding at the end the following new sub5 clause: 

6 ‘‘(IV) The provisions of subpara7 graph (L) of subsection (h)(4) shall 

8 apply under this subparagraph in the 

9 same manner as they apply under 

10 such subsection.’’. 

11 SEC. 5. MEDICARE GME TREATMENT OF HOSPITALS ESTAB12 LISHING NEW MEDICAL RESIDENCY TRAIN13 ING PROGRAMS AFTER HOSTING MEDICAL 

14 RESIDENT ROTATORS FOR SHORT DURA15 TIONS. 

16 (a) REDETERMINATION OF APPROVED FTE RESI17 DENT AMOUNT.—Section 1886(h)(2)(F) of the Social Se18 curity Act (42 U.S.C. 1395ww(h)(2)(F)) is amended— 

19 (1) by inserting ‘‘(i)’’ before ‘‘In the case of’’; 

20 and 

21 (2) by adding at the end the following: 

22 ‘‘(ii) In applying this subparagraph to 

23 a hospital that has not entered into a 

24 GME affiliation agreement (as defined by 

25 the Secretary for purposes of paragraph 


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1 (4)(H)(ii)), the Secretary shall not provide 

2 for the establishment of an FTE resident 

3 amount until such time as the Secretary 

4 determines that the hospital has a medical 

5 residency training program that trains 

6 more than 1.0 full-time-equivalent resident 

7 in a cost reporting period. 

8 ‘‘(iii) In the case of a hospital with an 

9 approved FTE resident amount— 

10 ‘‘(I) based on the training of less 

11 than 1.0 full-time-equivalent resident 

12 before October 1, 1997, or 

13 ‘‘(II) based on the training of no 

14 more than 3.0 full-time-equivalent 

15 residents in a new medical residency 

16 training program in any cost report17 ing period beginning on or after Octo18 ber 1, 1997, and before the date of 

19 the enactment of this clause, 

20 the Secretary shall provide the hospital an 

21 opportunity to have a new FTE resident 

22 amount established when the hospital be23 gins training at least 1.0 full-time equiva24 lent resident (in the case of a hospital de25 scribed in subclause (I)) or more than 3.0 


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1 full-time-equivalent residents (in the case 

2 of a hospital described in subclause (II)) 

3 for cost reporting periods beginning on or 

4 after the date of the enactment of this 

5 clause and in accordance with the method6 ology under the rules in effect as of Octo7 ber 1, 2015.’’. 

8 (b) REDETERMINATION OF FTE RESIDENT LIMITA9 TION.—Section 1886(h)(4)(H)(i) of the Social Security 

10 Act (42 U.S.C. 1395ww(h)(4)(H)(i)) is amended— 

11 (1) by inserting ‘‘(I)’’ before ‘‘The Secretary’’; 

12 and 

13 (2) by adding at the end the following: 

14 ‘‘(II) Under this clause the Sec15 retary shall not determine an adjust16 ment in the limitation applicable to a 

17 hospital under subparagraph (F) until 

18 the hospital trains more than 1.0 full19 time equivalent resident in a new 

20 medical residency training program in 

21 a cost reporting period. 

22 ‘‘(III) In the case of a hospital 

23 that has a limitation under subpara24 graph (F) of less than 1.0 full-time25 equivalent resident as of the date of 


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1 the enactment of this subclause based 

2 on training before October 1, 1997, 

3 under this clause the Secretary shall 

4 provide the hospital an opportunity to 

5 have a new adjustment in such limita6 tion determined when such hospital 

7 begins training at least 1.0 full-time 

8 equivalent resident in accordance with 

9 the methodology applicable to hos10 pitals under the rules in effect as of 

11 October 1, 2015, and applied for cost 

12 reporting periods beginning on or 

13 after the date of the enactment of this 

14 subclause. 

15 ‘‘(IV) In the case of a hospital 

16 for which an adjustment in the limita17 tion applicable to a hospital under 

18 subparagraph (F) is based on the 

19 training of no more than 3.0 full-time20 equivalent residents in a new medical 

21 residency training program in a cost 

22 reporting period beginning on or after 

23 October 1, 1997, and before the date 

24 of the enactment of this subclause, 

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1 pital an opportunity to have a new ad2 justment in such limitation deter3 mined when the hospital begins train4 ing more than 3.0 full-time-equivalent 

5 residents in accordance with the meth6 odology applicable to hospitals under 

7 the rules in effect as of October 1, 

8 2015, and applied for cost reporting 

9 periods beginning on or after the date 

10 of the enactment of this subclause.’’. 

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

12 this section shall apply to payment under section 1886 of 

13 the Social Security Act (42 U.S.C. 1395ww) for cost re14 porting periods beginning on or after the date of the en15 actment of this Act. 

16 SEC. 6. AGGREGATION RULES RELATING TO APPLYING 

17 LIMITATION ON NUMBER OF RESIDENTS. 

18 (a) REQUIRED RULES TO PERMIT MEMBERS OF

19 SAME AFFILIATED GROUP TO ELECT TO APPLY LIMITA20 TION ON AGGREGATE LEVEL.—Section 1886(h)(4)(H)(ii) 

21 of the Social Security Act (42 U.S.C. 

22 1395ww(h)(4)(H)(ii)) is amended by striking ‘‘may’’ and 

23 inserting ‘‘shall’’. 

24 (b) ELECTION FOR NEW FACILITIES.—Such section 

25 is further amended by adding at the end the following new 


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1 sentence: ‘‘Such rules shall provide that all facilities estab2 lished on or after January 1, 2000, whose resident limits 

3 are adjusted according to this subparagraph on or after 

4 January 1, 1997, may elect to apply the limitation under 

5 subparagraph (F) on an aggregate basis after a period 

6 specified by the Secretary but that shall not exceed 5 years 

7 from the date of such adjustment.’’. 

8 SEC. 7. PERIOD OF BOARD ELIGIBILITY FOR RESIDENTS 

9 WHO CHANGE PROGRAMS. 

10 Section 1886(h)(5)(G) of the Social Security Act (42 

11 U.S.C. 1395ww(h)(5)(G)) is amended— 

12 (1) in clause (i), by striking ‘‘(iv), and (v)’’ and 

13 inserting ‘‘(iv), (v), and (vi)’’; and 

14 (2) by adding at the end the following new 

15 clause: 

16 ‘‘(vi) In the case of a resident who 

17 changes residency specialties, the period of 

18 board eligibility and the initial residency 

19 period shall be equal to the minimum num20 ber of years of formal training required to 

21 satisfy the requirements for the initial 

22 board eligibility of the program into which 

23 the resident transfers.’’. 


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1 SEC. 8. MEDICARE INDIRECT MEDICAL EDUCATION PER2 FORMANCE ADJUSTMENT. 

3 Section 1886 of the Social Security Act (42 U.S.C. 

4 1395ww) is amended— 

5 (1) in subsection (d)(5)(B), in the matter pre6 ceding clause (i), by inserting ‘‘subject to subsection 

7 (t) and’’ before ‘‘except as follows’’; and 

8 (2) by adding at the end the following new sub9 section: 

10 ‘‘(t) INDIRECT MEDICAL EDUCATION PERFORMANCE

11 ADJUSTMENTS.— 

12 ‘‘(1) IN GENERAL.—Subject to the succeeding 

13 provisions of this subsection, the Secretary shall es14 tablish and implement procedures under which the 

15 amount of payments that a hospital (as defined in 

16 paragraph (11)) would otherwise receive for indirect 

17 medical education costs under subsection (d)(5)(B) 

18 for discharges occurring during a fiscal year is ad19 justed based on the reporting of measures and the 

20 performance of the hospital on measures of patient 

21 care priorities specified by the Secretary. 

22 ‘‘(2) ADJUSTMENTS TO BEGIN IN FISCAL YEAR

23 2020.—The adjustments shall apply to payments for 

24 discharges occurring— 


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1 ‘‘(A) with respect to the adjustments for 

2 reporting under paragraph (8)(A), during fiscal 

3 year 2020; and 

4 ‘‘(B) with respect to the adjustments for 

5 performance under paragraph (8)(B), on or 

6 after October 1, 2020. 

7 ‘‘(3) MEASURES.—The measures of patient care 

8 priorities specified by the Secretary under this sub9 section shall include the extent of training provided 

10 in— 

11 ‘‘(A) the delivery of services categorized as 

12 evaluation and management codes by the Cen13 ters for Medicare & Medicaid Services; 

14 ‘‘(B) a variety of settings and systems; 

15 ‘‘(C) the coordination of patient care 

16 across settings; 

17 ‘‘(D) the relevant cost and value of various 

18 diagnostic and treatment options; 

19 ‘‘(E) interprofessional and multidisci20 plinary care teams; 

21 ‘‘(F) methods for identifying system errors 

22 and implementing system solutions; and 

23 ‘‘(G) the use of health information tech24 nology. 

25 ‘‘(4) MEASURE DEVELOPMENT PROCESS.— 


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1 ‘‘(A) IN GENERAL.—The measures of pa2 tient care specified by the Secretary under this 

3 subsection— 

4 ‘‘(i) shall— 

5 ‘‘(I) be measures that have been 

6 adopted or endorsed by an accrediting 

7 organization (such as the Accredita8 tion Council for Graduate Medical 

9 Education or American Osteopathic 

10 Association); and 

11 ‘‘(II) be measures that the Sec12 retary identifies as having used a con13 sensus-based process for developing 

14 such measures; and 

15 ‘‘(ii) may include measures that have 

16 been submitted by teaching hospitals and 

17 medical schools. 

18 ‘‘(B) PROPOSED SET OF INITIAL MEAS19 URES.—Not later than July 1, 2018, the Sec20 retary shall publish in the Federal Register a 

21 proposed initial set of measures for use under 

22 this subsection. The Secretary shall provide for 

23 a period of public comment on such measures. 

24 ‘‘(C) FINAL SET OF INITIAL MEASURES.— 

25 Not later than January 1, 2019, the Secretary 


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1 shall publish in the Federal Register the set of 

2 initial measures to be specified by the Secretary 

3 for use under this subsection. 

4 ‘‘(D) UPDATE OF MEASURES.—The Sec5 retary may, through notice and comment rule6 making, periodically update the measures speci7 fied under this subsection pursuant to the re8 quirements under subparagraph (A). 

9 ‘‘(5) PERFORMANCE STANDARDS.—The Sec10 retary shall establish performance standards with re11 spect to measures specified by the Secretary under 

12 this subsection for a performance period for a fiscal 

13 year (as established under paragraph (6)). 

14 ‘‘(6) PERFORMANCE PERIOD.—The Secretary 

15 shall establish the performance period for a fiscal 

16 year. Such performance period shall begin and end 

17 prior to the beginning of such fiscal year. 

18 ‘‘(7) REPORTING OF MEASURES.—The proce19 dures established and implemented under paragraph 

20 (1) shall include a process under which hospitals 

21 shall submit data on the measures specified by the 

22 Secretary under this subsection to the Secretary in 

23 a form and manner, and at a time, specified by the 

24 Secretary for purposes of this subsection. 

25 ‘‘(8) ADJUSTMENTS.— 


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1 ‘‘(A) REPORTING FOR FISCAL YEAR 2021.— 

2 For fiscal year 2021, in the case of a hospital 

3 that does not submit, to the Secretary in ac4 cordance with this subsection, data required to 

5 be submitted under paragraph (7) for a period 

6 (determined appropriate by the Secretary) for 

7 such fiscal year, the total amount that the hos8 pital would otherwise receive under subsection 

9 (d)(5)(B) for discharges in such fiscal year 

10 shall be reduced by 0.5 percent. 

11 ‘‘(B) PERFORMANCE FOR FISCAL YEAR

12 2022 AND SUBSEQUENT FISCAL YEARS.— 

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

14 (ii), based on the performance of each hos15 pital with respect to compliance with the 

16 measures for a performance period for a 

17 fiscal year (beginning with fiscal year 

18 2022), the Secretary shall determine the 

19 amount of any adjustment under this sub20 paragraph to payments to the hospital 

21 under subsection (d)(5)(B) for discharges 

22 in such fiscal year. Such adjustment may 

23 not exceed an amount equal to 2 percent 

24 of the total amount that the hospital would 


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1 otherwise receive under such subsection for 

2 discharges in such fiscal year. 

3 ‘‘(ii) BUDGET NEUTRAL.—In making 

4 adjustments under this subparagraph, the 

5 Secretary shall ensure that the total 

6 amount of payments made to all hospitals 

7 under subsection (d)(5)(B) for discharges 

8 in a fiscal year is equal to the total amount 

9 of payments that would have been made to 

10 such hospitals under such subsection for 

11 discharges in such fiscal year if this sub12 section had not been enacted. 

13 ‘‘(9) NO EFFECT IN SUBSEQUENT FISCAL

14 YEARS.—Any adjustment under subparagraph (A) 

15 or (B) of paragraph (8) shall apply only with respect 

16 to the fiscal year involved, and the Secretary shall 

17 not take into account any such adjustment in mak18 ing payments to a hospital under this section in a 

19 subsequent fiscal year. 

20 ‘‘(10) EVALUATION OF SUBMISSION OF PER21 FORMANCE MEASURES.—Not later than January 1, 

22 2021, the Secretary shall submit to Congress a re23 port on the implementation of this subsection, in24 cluding— 


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1 ‘‘(A) the measure development procedures, 

2 including any barriers to measure development; 

3 ‘‘(B) the compliance with reporting on the 

4 performance measures, including any barriers 

5 to such compliance; and 

6 ‘‘(C) recommendations to address any bar7 riers described in subparagraph (A) or (B). 

8 ‘‘(11) DEFINITION OF HOSPITAL.—In this sub9 section, the term ‘hospital’ means a hospital that re10 ceives payments under subsection (d)(5)(B).’’. 

11 SEC. 9. INCREASING GRADUATE MEDICAL EDUCATION 

12 TRANSPARENCY. 

13 (a) IN GENERAL.—Not later than 2 years after the 

14 date of the enactment of this Act, and annually thereafter, 

15 the Secretary of Health and Human Services shall submit 

16 to Congress and the National Health Care Workforce 

17 Commission a report on the graduate medical education 

18 payments that hospitals receive under the Medicare pro19 gram. The report shall include the following information 

20 with respect to each hospital that receives such payments: 

21 (1) The direct graduate medical education pay22 ments made to the hospital under section 1886(h) of 

23 the Social Security Act (42 U.S.C. 1395ww(h)). 


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1 (2) The total costs of direct graduate medical 

2 education to the hospital as reported on the annual 

3 Medicare Cost Reports. 

4 (3) The indirect medical education payments 

5 made to the hospital under section 1886(d)(5)(B) of 

6 such Act (42 U.S.C. 1395ww(d)(1)(B)). 

7 (4) The number of full-time-equivalent residents 

8 counted for purposes of making the payments de9 scribed in paragraph (1). 

10 (5) The number of full-time-equivalent residents 

11 counted for purposes of making the payments de12 scribed in paragraph (3). 

13 (6) The number of full-time-equivalent resi14 dents, if any, that are not counted for purposes of 

15 making payments described in paragraph (1). 

16 (7) The number of full-time-equivalent resi17 dents, if any, that are not counted for purposes of 

18 making payments described in paragraph (3). 

19 (8) The factors contributing to the higher costs 

20 of patient care provided by the hospital, including— 

21 (A) the costs of trauma, burn, other stand22 by services; 

23 (B) translation services for disabled or 

24 non-English speaking patients; 

25 (C) the cost of uncompensated care; 


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1 (D) financial losses with respect to Med2 icaid patients; and 

3 (E) uncompensated costs of clinical re4 search. 

5 SEC. 10. GAO STUDIES AND REPORTS. 

6 (a) ON PHYSICIAN WORKFORCE.— 

7 (1) STUDY.—The Comptroller General of the 

8 United States shall conduct a study on the physician 

9 workforce. Such study shall include the identification 

10 of physician specialties for which there is a shortage, 

11 as defined by the Comptroller General. 

12 (2) REPORT.—Not later than January 1, 2018, 

13 the Comptroller General shall submit to Congress a 

14 report on the study conducted under subsection (a), 

15 together with recommendations for such legislation 

16 and administrative action as the Comptroller Gen17 eral determines appropriate. 

18 (b) ON STRATEGIES FOR INCREASING DIVERSITY.— 

19 (1) STUDY.—The Comptroller General of the 

20 United States shall conduct a study on strategies for 

21 increasing the diversity of the health professional 

22 workforce. Such study shall include an analysis of 

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1 resented minority communities, including which 

2 strategies are most effective for achieving such goal. 

3 (2) REPORT.—Not later than 2 years after the 

4 date of enactment of this Act, the Comptroller Gen5 eral shall submit to Congress a report on the study 

6 conducted under subsection (a), together with rec7 ommendations for such legislation and administra8 tive action as the Comptroller General determines 

9 appropriate. 

10 (c) ON PROTECTING OLDER ADULTS.— 

11 (1) STUDY.—The Comptroller General of the 

12 United States shall conduct a study that addresses 

13 the competency of the physician workforce to care 

14 for older adults upon the completion of such 

15 workforce’s residency training. 

16 (2) REPORT.—Not later than 2 years after the 

17 date of the enactment of this Act, the Comptroller 

18 General shall submit to Congress a report on such 

19 study, including such recommendations for legisla20 tion and administrative action as the Comptroller 

21 General determines appropriate based on such study. 

Æ 


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