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[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4774 Introduced in House (IH)]

<DOC>

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.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Training 
Tomorrow's Doctors Today Act''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Distribution of additional residency positions.
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.

SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.

    (a) DGME.--Section 1886(h) of the Social Security Act (42 U.S.C. 
1395ww(h)) is amended--
            (1) in paragraph (4)(F)(i), by striking ``paragraphs (7) 
        and (8)'' and inserting ``paragraphs (7), (8), and (9)'';
            (2) in paragraph (4)(H)(i), by striking ``paragraphs (7) 
        and (8)'' and inserting ``paragraphs (7), (8), and (9)'';
            (3) in paragraph (7)(E), by inserting ``paragraph (9),'' 
        after ``paragraph (8),''; and
            (4) by adding at the end the following new paragraph:
            ``(9) Distribution of additional residency positions.--
                    ``(A) Additional residency positions.--
                            ``(i) In general.--For each of fiscal years 
                        2017 through 2021 (and succeeding fiscal years 
                        if the Secretary determines that there are 
                        additional residency positions available to 
                        distribute under clause (iv)(II)), the 
                        Secretary shall, subject to clause (ii) and 
                        subparagraph (D), increase the otherwise 
                        applicable resident limit for each qualifying 
                        hospital that submits a timely application 
                        under this subparagraph by such number as the 
                        Secretary may approve for portions of cost 
                        reporting periods occurring on or after July 1 
                        of the fiscal year of the increase.
                            ``(ii) Number available for distribution.--
                        For each such fiscal year, the Secretary shall 
                        determine the total number of additional 
                        residency positions available for distribution 
                        under clause (i) in accordance with the 
                        following:
                                    ``(I) Allocation to hospitals 
                                already operating over resident 
                                limit.--One-third of such number shall 
                                be available for distribution only to 
                                hospitals described in subparagraph 
                                (B).
                                    ``(II) Aggregate limitation.--
                                Except as provided in clause (iv)(I), 
                                the aggregate number of increases in 
                                the otherwise applicable resident limit 
                                under this subparagraph shall be equal 
                                to 3,000 in each such year.
                            ``(iii) Process for distributing 
                        positions.--
                                    ``(I) Rounds of applications.--The 
                                Secretary shall initiate 5 separate 
                                rounds of applications for an increase 
                                under clause (i), 1 round with respect 
                                to each of fiscal years 2017 through 
                                2021.
                                    ``(II) Number available.--In each 
                                of such rounds, the aggregate number of 
                                positions available for distribution in 
                                the fiscal year under clause (ii) shall 
                                be distributed, plus any additional 
                                positions available under clause (iv).
                                    ``(III) Timing.--The Secretary 
                                shall notify hospitals of the number of 
                                positions distributed to the hospital 
                                under this paragraph as a result of an 
                                increase in the otherwise applicable 
                                resident limit by January 1 of the 
                                fiscal year of the increase. Such 
                                increase shall be effective for 
                                portions of cost reporting periods 
                                beginning on or after July 1 of that 
                                fiscal year.
                            ``(iv) Positions not distributed during the 
                        fiscal year.--
                                    ``(I) In general.--If the number of 
                                resident full-time equivalent positions 
                                distributed under this paragraph in a 
                                fiscal year is less than the aggregate 
                                number of positions available for 
                                distribution in the fiscal year (as 
                                described in clause (ii), including 
                                after application of this subclause), 
                                the difference between such number 
                                distributed and such number available 
                                for distribution shall be added to the 
                                aggregate number of positions available 
                                for distribution in the following 
                                fiscal year.
                                    ``(II) Exception if positions not 
                                distributed by end of fiscal year 
                                2021.--If the aggregate number of 
                                positions distributed under this 
                                paragraph during the 5-year period of 
                                fiscal years 2017 through 2021 is less 
                                than 15,000, the Secretary shall, in 
                                accordance with the provisions of 
                                clause (ii) and subparagraph (D) and 
                                the considerations and priority 
                                described in subparagraph (C), conduct 
                                an application and distribution process 
                                in each subsequent fiscal year until 
                                such time as the aggregate amount of 
                                positions distributed under this 
                                paragraph is equal to 15,000.
                    ``(B) Allocation of distribution for positions to 
                hospitals already operating over resident limit.--
                            ``(i) In general.--Subject to clauses (ii) 
                        and (iii), in the case of a hospital in which 
                        the reference resident level of the hospital 
                        (as specified in subparagraph (G)(iii)) is 
                        greater than the otherwise applicable resident 
                        limit, the increase in the otherwise applicable 
                        resident limit under subparagraph (A) for a 
                        fiscal year described in such subparagraph 
                        shall be an amount equal to the product of the 
                        total number of additional residency positions 
                        available for distribution under subparagraph 
                        (A)(ii)(I) for such fiscal year and the 
                        quotient of--
                                    ``(I) the number of resident 
                                positions by which the reference 
                                resident level of the hospital exceeds 
                                the otherwise applicable resident limit 
                                for the hospital; and
                                    ``(II) the number of resident 
                                positions by which the reference 
                                resident level of all such hospitals 
                                with respect to which an application is 
                                approved under this paragraph exceeds 
                                the otherwise applicable resident limit 
                                for such hospitals.
                            ``(ii) Requirements.--A hospital described 
                        in clause (i)--
                                    ``(I) is not eligible for an 
                                increase in the otherwise applicable 
                                resident limit under this subparagraph 
                                unless the amount by which the 
                                reference resident level of the 
                                hospital exceeds the otherwise 
                                applicable resident limit is not less 
                                than 10 and the hospital trains at 
                                least 30 percent of the full-time 
                                equivalent residents of the hospital in 
                                primary care and general surgery (as of 
                                the date of enactment of this 
                                paragraph); and
                                    ``(II) shall continue to train at 
                                least 30 percent of the full-time 
                                equivalent residents of the hospital in 
                                primary care and general surgery for 
                                the 5-year period beginning on such 
                                date.
                        In the case where the Secretary determines that 
                        a hospital described in clause (i) no longer 
                        meets the requirement of subclause (II), the 
                        Secretary may reduce the otherwise applicable 
                        resident limit of the hospital by the amount by 
                        which such limit was increased under this 
                        subparagraph.
                            ``(iii) Clarification regarding eligibility 
                        for other additional residency positions.--
                        Nothing in this subparagraph shall be construed 
                        as preventing a hospital described in clause 
                        (i) from applying for and receiving additional 
                        residency positions under this paragraph that 
                        are not reserved for distribution under this 
                        subparagraph.
                    ``(C) Distribution of other positions.--For 
                purposes of determining an increase in the otherwise 
                applicable resident limit under subparagraph (A) (other 
                than such an increase described in subparagraph (B)), 
                the following shall apply:
                            ``(i) Considerations in distribution.--In 
                        determining for which hospitals such an 
                        increase is provided under subparagraph (A), 
                        the Secretary shall take into account the 
                        demonstrated likelihood of the hospital filling 
                        the positions made available under this 
                        paragraph within the first 5 cost reporting 
                        periods beginning after the date the increase 
                        would be effective, as determined by the 
                        Secretary.
                            ``(ii) Priority for certain hospitals.--
                        Subject to clause (iii), in determining for 
                        which hospitals such an increase is provided, 
                        the Secretary shall distribute the increase in 
                        the following priority order:
                                    ``(I) First, to hospitals with 
                                approved medical residency programs 
                                affiliated with medical schools that 
                                have at least 40 percent of graduates 
                                matched in primary care residency 
                                program in the 5 years prior.
                                    ``(II) Second, to hospitals in 
                                States with (aa) new medical schools 
                                that received Candidate School status 
                                from the Liaison Committee on Medical 
                                Education or that received Pre-
                                Accreditation status from the American 
                                Osteopathic Association Commission on 
                                Osteopathic College Accreditation on or 
                                after January 1, 2000, and that have 
                                achieved or continue to progress toward 
                                Full Accreditation status (as such term 
                                is defined by the Liaison Committee on 
                                Medical Education) or toward 
                                Accreditation status (as such term is 
                                defined by the American Osteopathic 
                                Association Commission on Osteopathic 
                                College Accreditation), or (bb) 
                                additional locations and branch 
                                campuses established on or after 
                                January 1, 2000, by medical schools 
                                with Full Accreditation status (as such 
                                term is defined by the Liaison 
                                Committee on Medical Education) or 
                                Accreditation status (as such term is 
                                defined by the American Osteopathic 
                                Association Commission on Osteopathic 
                                College Accreditation).
                                    ``(III) Third, to hospitals with 
                                which the Secretary cooperates under 
                                section 7302(d) of title 38, United 
                                States Code.
                                    ``(IV) Fourth, to all other 
                                hospitals.
                            ``(iii) Distribution to hospitals in higher 
                        priority group prior to distribution in lower 
                        priority groups.--The Secretary may only 
                        distribute such an increase to a lower priority 
                        group under clause (ii) if all qualifying 
                        hospitals in the higher priority group or 
                        groups have received the maximum number of 
                        increases under such subparagraph that the 
                        hospital is eligible for under this paragraph 
                        for the fiscal year.
                            ``(iv) Requirements for use of additional 
                        positions.--
                                    ``(I) In general.--Subject to 
                                subclause (II), a hospital that 
                                receives such an increase shall ensure, 
                                during the 5-year period beginning on 
                                the effective date of such increase, 
                                that--
                                            ``(aa) not less than 50 
                                        percent of the positions 
                                        attributable to such increase 
                                        that are used in a given year 
                                        during such 5-year period are 
                                        used to train full-time 
                                        equivalent residents in a 
                                        shortage specialty residency 
                                        program (as defined in 
                                        subparagraph (G)(v)), as 
                                        determined by the Secretary at 
                                        the end of such 5-year period;
                                            ``(bb) the total number of 
                                        full-time equivalent residents, 
                                        excluding any additional 
                                        positions attributable to such 
                                        increase, is not less than the 
                                        average number of full-time 
                                        equivalent residents during the 
                                        3 most recent cost reporting 
                                        periods ending on or before the 
                                        effective date of such 
                                        increase; and
                                            ``(cc) the ratio of full-
                                        time equivalent residents in a 
                                        shortage specialty residency 
                                        program (as so defined) is not 
                                        less than the average ratio of 
                                        full-time equivalent residents 
                                        in such a program during the 3 
                                        most recent cost reporting 
                                        periods ending on or before the 
                                        effective date of such 
                                        increase.
                                    ``(II) Redistribution of positions 
                                if hospital no longer meets certain 
                                requirements.--With respect to each 
                                fiscal year described in subparagraph 
                                (A), the Secretary shall determine 
                                whether or not a hospital described in 
                                subclause (I) meets the requirements of 
                                such subclause. In the case that the 
                                Secretary determines that such a 
                                hospital does not meet such 
                                requirements, the Secretary shall--
                                            ``(aa) reduce the otherwise 
                                        applicable resident limit of 
                                        the hospital by the amount by 
                                        which such limit was increased 
                                        under this paragraph; and
                                            ``(bb) provide for the 
                                        distribution of positions 
                                        attributable to such reduction 
                                        in accordance with the 
                                        requirements of this paragraph.
                    ``(D) Limitation.--A hospital may not receive more 
                than 75 full-time equivalent additional residency 
                positions under this paragraph for any fiscal year.
                    ``(E) Application of per resident amounts for 
                primary care and nonprimary care.--With respect to 
                additional residency positions in a hospital 
                attributable to the increase provided under this 
                paragraph, the approved FTE per resident amounts are 
                deemed to be equal to the hospital per resident amounts 
                for primary care and nonprimary care computed under 
                paragraph (2)(D) for that hospital.
                    ``(F) Permitting facilities to apply aggregation 
                rules.--The Secretary shall permit hospitals receiving 
                additional residency positions attributable to the 
                increase provided under this paragraph to, beginning in 
                the fifth year after the effective date of such 
                increase, apply such positions to the limitation amount 
                under paragraph (4)(F) that may be aggregated pursuant 
                to paragraph (4)(H) among members of the same 
                affiliated group.
                    ``(G) Definitions.--In this paragraph:
                            ``(i) Otherwise applicable resident 
                        limit.--The term `otherwise applicable resident 
                        limit' means, with respect to a hospital, the 
                        limit otherwise applicable under subparagraphs 
                        (F)(i) and (H) of paragraph (4) on the resident 
                        level for the hospital determined without 
                        regard to this paragraph but taking into 
                        account paragraphs (7)(A), (7)(B), (8)(A), and 
                        (8)(B).
                            ``(ii) Primary care.--The term `primary 
                        care' means family medicine, general internal 
                        medicine, general pediatrics, geriatrics, 
                        preventive medicine, obstetrics and gynecology, 
                        general surgery, and psychiatry.
                            ``(iii) Reference resident level.--Except 
                        as otherwise provided in subclause (II), the 
                        term `reference resident level' means, with 
                        respect to a hospital, the resident level for 
                        the most recent cost reporting period of the 
                        hospital ending on or before the date of 
                        enactment of this paragraph, for which a cost 
                        report has been settled (or, if not, submitted 
                        (subject to audit)), as determined by the 
                        Secretary.
                            ``(iv) Resident level.--The term `resident 
                        level' has the meaning given such term in 
                        paragraph (7)(C)(i).
                            ``(v) Shortage specialty residency 
                        program.--The term `shortage specialty 
                        residency program' means the following:
                                    ``(I) Prior to report on shortage 
                                specialties.--Prior to the date on 
                                which the report is submitted under 
                                section 10(a) of the Training 
                                Tomorrow's Doctors Today Act, any 
                                approved residency training program in 
                                a specialty identified in the report 
                                entitled `The Physician Workforce: 
                                Projections and Research into Current 
                                Issues Affecting Supply and Demand', 
                                issued in December 2008 by the Health 
                                Resources and Services Administration, 
                                as a specialty whose baseline physician 
                                requirements projections exceed the 
                                projected supply of total active 
                                physicians for the period of 2005 
                                through 2020.
                                    ``(II) After report on shortage 
                                specialities.--On or after the date on 
                                which the report is submitted under 
                                such section 5, any approved residency 
                                training program in a physician 
                                specialty identified in such report as 
                                a specialty for which there is a 
                                shortage.''.
    (b) IME.--Section 1886(d)(5)(B) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(B)) is amended--
            (1) in clause (v), in the second sentence, by striking 
        ``subsections (h)(7) and (h)(8)'' and inserting ``subsections 
        (h)(7), (h)(8), and (h)(9)'';
            (2) by redesignating clause (x), as added by section 
        5505(b) of the Patient Protection and Affordable Care Act 
        (Public Law 111-148), as clause (xi) and moving such clause 4 
        ems to the left; and
            (3) by adding after clause (xi), as redesignated by 
        subparagraph (A), the following new clause:
            ``(xii) For discharges occurring on or after July 1, 2016, 
        insofar as an additional payment amount under this subparagraph 
        is attributable to resident positions distributed to a hospital 
        under subsection (h)(9), the indirect teaching adjustment 
        factor shall be computed in the same manner as provided under 
        clause (ii) with respect to such resident positions.''.

SEC. 3. ADDITIONAL RULES RELATING TO APPLICATION OF 3-YEAR ROLLING 
              AVERAGE FOR REDISTRIBUTED RESIDENCY POSITIONS.

    (a) Elimination of 3-Year Rolling Average Relating to 
Redistributions After a Hospital Closes and Under PPACA 
Redistributions.--
            (1) DGME.--
                    (A) Redistribution of residency slots after a 
                hospital closes.--
                            (i) In general.--Section 1886(h)(4)(H)(vi) 
                        of the Social Security Act (42 U.S.C. 
                        1395ww(h)(4)(H)(vi)) is amended by adding at 
                        the end the following new subclause:
                                    ``(VI) Three-year rolling average 
                                inapplicable.--In applying subparagraph 
                                (G), in the case of additional 
                                residency positions in a hospital 
                                attributable to the increase in the 
                                otherwise applicable resident limit 
                                provided under this paragraph pursuant 
                                to this clause, the reference to `the 
                                average of the actual full-time 
                                equivalent resident counts for the cost 
                                reporting period and the preceding two 
                                cost reporting periods' shall be deemed 
                                to be a reference to `the actual full-
                                time equivalent residents count for the 
                                cost reporting period'.''.
                            (ii) Effective date.--The amendment made by 
                        clause (i) shall apply with respect to 
                        hospitals with an approved medical residency 
                        program that closes on or after March 23, 2008.
                    (B) Distribution of additional residency slots 
                under ppaca.--
                            (i) In general.--Section 1886(h)(8) of the 
                        Social Security Act (42 U.S.C. 1395ww(h)(8)) is 
                        amended by adding at the end the following new 
                        subparagraph:
                    ``(J) Three-year rolling average inapplicable.--In 
                applying paragraph (4)(G), in the case of additional 
                residency positions in a hospital attributable to the 
                increase in the otherwise applicable resident limit 
                provided under this paragraph, the reference to `the 
                average of the actual full-time equivalent resident 
                counts for the cost reporting period and the preceding 
                two cost reporting periods' shall be deemed to be a 
                reference to `the actual full-time equivalent residents 
                count for the cost reporting period'.''.
                            (ii) Effective date.--The amendment made by 
                        clause (i) shall apply with respect to cost 
                        reporting periods occurring on or after July 1, 
                        2011.
            (2) 3-year rolling average and intern and resident bed 
        ratio cap inapplicable under ime.--
                    (A) In general.--Section 1886(d)(5)(B) of the 
                Social Security Act (42 U.S.C. 1395ww(d)(5)(B)), as 
                amended by section 2(b), is further amended--
                            (i) in subclause (I) of clause (xi), as 
                        redesignated by section 2(b)(2), by striking 
                        ``The provisions'' and inserting ``Subject to 
                        clauses (xiii) and (xiv)''; and
                            (ii) by adding at the end the following new 
                        clauses:
                            ``(xiii) In the case of additional 
                        residency positions in a hospital attributable 
                        to the increase in the otherwise applicable 
                        resident limit provided under subsection 
                        (h)(4)(H)(vi) or (h)(8), the provisions of 
                        clause (vi)(II) shall be applied by deeming the 
                        reference to `the average of the actual full-
                        time equivalent resident count for the cost 
                        reporting period and the preceding two cost 
                        reporting periods' to be a reference to `the 
                        actual full-time equivalent resident count for 
                        the cost reporting period'.
                            ``(xiv) In the case of additional residency 
                        positions in a hospital attributable to the 
                        increase in the otherwise applicable resident 
                        limit provided under subsection (h)(4)(H)(vi) 
                        or (h)(8), the ratio of the hospital's full-
                        time equivalent interns and residents to beds 
                        shall be equal to the ratio for the hospital's 
                        current cost reporting period.''.
                    (B) Effective date.--The amendments made by 
                subparagraph (A) shall apply--
                            (i) to the extent such amendments relate to 
                        section 1886(h)(4)(H)(vi) of the Social 
                        Security Act, as if included in the enactment 
                        of section 5506 of the Patient Protection and 
                        Affordable Care Act; and
                            (ii) to the extent such amendments relate 
                        to section 1886(h)(8) of the Social Security 
                        Act, as if included in the enactment of section 
                        5503 of the Patient Protection and Affordable 
                        Care Act.
    (b) Elimination of 3-Year Rolling Average and Intern and Resident 
Bed Ratio Cap Beginning in 2015.--
            (1) DGME.--Section 1886(h)(4)(G) of the Social Security Act 
        (42 U.S.C. 1395ww(h)(4)(G)) is amended--
                    (A) in clause (i), by inserting ``and before 
                December 31, 2014,'' after ``October 1, 1997,''; and
                    (B) by adding at the end the following new clause:
                            ``(iv) Current year count used to determine 
                        full-time equivalent resident count.--For cost 
                        reporting periods beginning on or after 
                        December 31, 2014, subject to the limit 
                        described in subparagraph (F), the total number 
                        of full-time equivalent residents for 
                        determining a hospital's graduate medical 
                        education payment shall equal the actual full-
                        time equivalent residents count for the 
                        hospital's cost reporting period.''.
            (2) IME.--Section 1886(d)(5)(B) of the Social Security Act 
        (42 U.S.C. 1395ww(d)(5)(B)), as amended by subsection (b), is 
        further amended by adding at the end the following new clauses:
                            ``(xv) For cost reporting periods beginning 
                        on or after December 31, 2014, subject to the 
                        limits described in clauses (iv) and (v), the 
                        total number of full-time equivalent residents 
                        for payment purposes shall equal the actual 
                        full-time equivalent resident count for the 
                        hospital's cost reporting period.
                            ``(xvi) For cost reporting periods 
                        beginning on or after December 31, 2014, the 
                        ratio of the hospital's full-time equivalent 
                        interns and residents to beds shall be equal to 
                        the ratio for the hospital's cost reporting 
                        period.''.

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

    (a) DGME.--Section 1886(h)(4) of the Social Security Act (42 U.S.C. 
1395ww(h)(4)) is amended--
            (1) in subparagraph (E), by striking ``Subject to 
        subparagraphs (J) and (K), such rules'' and inserting ``Subject 
        to subparagraphs (J), (K), and (L), such rules'';
            (2) in subparagraph (J), by striking ``Such rules'' and 
        inserting ``Subject to subparagraph (L), such rules'';
            (3) in subparagraph (K), by striking ``In determining'' and 
        inserting ``Subject to subparagraph (L), in determining''; and
            (4) by adding at the end the following new subparagraph:
                    ``(L) Treatment of time spent in approved medical 
                residency training program with respect to certain 
                hospitals.--For purposes of cost reporting periods 
                beginning on or after July 1, 2017, in determining the 
                number of full-time equivalent residents of the 
                hospital for purposes of this paragraph, all the time 
                spent by an intern or resident in an approved medical 
                residency training program, regardless of setting, 
                shall be counted toward the determination of full-time 
                equivalency, and subparagraphs (J) and (K) shall not 
                apply, if the hospital--
                            ``(i) is recognized as a subsection (d) 
                        hospital;
                            ``(ii) is recognized as a subsection (d) 
                        Puerto Rico hospital;
                            ``(iii) is reimbursed under a reimbursement 
                        system authorized under section 1814(b)(3); or
                            ``(iv) is a provider-based hospital 
                        outpatient department.''.
    (b) IME.--The second clause (x) of section 1886(d)(5)(B) of the 
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended--
            (1) in subclause (II), by striking ``In determining'' and 
        inserting ``Subject to subclause (x)(IV), in determining'';
            (2) in subclause (III), by striking ``In determining'' and 
        inserting ``Subject to subclause (x)(IV), in determining''; and
            (3) by adding at the end the following new subclause:
                                    ``(IV) The provisions of 
                                subparagraph (L) of subsection (h)(4) 
                                shall apply under this subparagraph in 
                                the same manner as they apply under 
                                such subsection.''.

SEC. 5. MEDICARE GME TREATMENT OF HOSPITALS ESTABLISHING NEW MEDICAL 
              RESIDENCY TRAINING PROGRAMS AFTER HOSTING MEDICAL 
              RESIDENT ROTATORS FOR SHORT DURATIONS.

    (a) Redetermination of Approved FTE Resident Amount.--Section 
1886(h)(2)(F) of the Social Security Act (42 U.S.C. 1395ww(h)(2)(F)) is 
amended--
            (1) by inserting ``(i)'' before ``In the case of''; and
            (2) by adding at the end the following:
                            ``(ii) In applying this subparagraph to a 
                        hospital that has not entered into a GME 
                        affiliation agreement (as defined by the 
                        Secretary for purposes of paragraph 
                        (4)(H)(ii)), the Secretary shall not provide 
                        for the establishment of an FTE resident amount 
                        until such time as the Secretary determines 
                        that the hospital has a medical residency 
                        training program that trains more than 1.0 
                        full-time-equivalent resident in a cost 
                        reporting period.
                            ``(iii) In the case of a hospital with an 
                        approved FTE resident amount--
                                    ``(I) based on the training of less 
                                than 1.0 full-time-equivalent resident 
                                before October 1, 1997, or
                                    ``(II) based on the training of no 
                                more than 3.0 full-time-equivalent 
                                residents in a new medical residency 
                                training program in any cost reporting 
                                period beginning on or after October 1, 
                                1997, and before the date of the 
                                enactment of this clause,
                        the Secretary shall provide the hospital an 
                        opportunity to have a new FTE resident amount 
                        established when the hospital begins training 
                        at least 1.0 full-time equivalent resident (in 
                        the case of a hospital described in subclause 
                        (I)) or more than 3.0 full-time-equivalent 
                        residents (in the case of a hospital described 
                        in subclause (II)) for cost reporting periods 
                        beginning on or after the date of the enactment 
                        of this clause and in accordance with the 
                        methodology under the rules in effect as of 
                        October 1, 2015.''.
    (b) Redetermination of FTE Resident Limitation.--Section 
1886(h)(4)(H)(i) of the Social Security Act (42 U.S.C. 
1395ww(h)(4)(H)(i)) is amended--
            (1) by inserting ``(I)'' before ``The Secretary''; and
            (2) by adding at the end the following:
                                    ``(II) Under this clause the 
                                Secretary shall not determine an 
                                adjustment in the limitation applicable 
                                to a hospital under subparagraph (F) 
                                until the hospital trains more than 1.0 
                                full-time equivalent resident in a new 
                                medical residency training program in a 
                                cost reporting period.
                                    ``(III) In the case of a hospital 
                                that has a limitation under 
                                subparagraph (F) of less than 1.0 full-
                                time-equivalent resident as of the date 
                                of the enactment of this subclause 
                                based on training before October 1, 
                                1997, under this clause the Secretary 
                                shall provide the hospital an 
                                opportunity to have a new adjustment in 
                                such limitation determined when such 
                                hospital begins training at least 1.0 
                                full-time equivalent resident in 
                                accordance with the methodology 
                                applicable to hospitals under the rules 
                                in effect as of October 1, 2015, and 
                                applied for cost reporting periods 
                                beginning on or after the date of the 
                                enactment of this subclause.
                                    ``(IV) In the case of a hospital 
                                for which an adjustment in the 
                                limitation applicable to a hospital 
                                under subparagraph (F) is based on the 
                                training of no more than 3.0 full-time-
                                equivalent residents in a new medical 
                                residency training program in a cost 
                                reporting period beginning on or after 
                                October 1, 1997, and before the date of 
                                the enactment of this subclause, the 
                                Secretary shall provide the hospital an 
                                opportunity to have a new adjustment in 
                                such limitation determined when the 
                                hospital begins training more than 3.0 
                                full-time-equivalent residents in 
                                accordance with the methodology 
                                applicable to hospitals under the rules 
                                in effect as of October 1, 2015, and 
                                applied for cost reporting periods 
                                beginning on or after the date of the 
                                enactment of this subclause.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to payment under section 1886 of the Social Security Act (42 
U.S.C. 1395ww) for cost reporting periods beginning on or after the 
date of the enactment of this Act.

SEC. 6. AGGREGATION RULES RELATING TO APPLYING LIMITATION ON NUMBER OF 
              RESIDENTS.

    (a) Required Rules To Permit Members of Same Affiliated Group To 
Elect To Apply Limitation on Aggregate Level.--Section 
1886(h)(4)(H)(ii) of the Social Security Act (42 U.S.C. 
1395ww(h)(4)(H)(ii)) is amended by striking ``may'' and inserting 
``shall''.
    (b) Election for New Facilities.--Such section is further amended 
by adding at the end the following new sentence: ``Such rules shall 
provide that all facilities established on or after January 1, 2000, 
whose resident limits are adjusted according to this subparagraph on or 
after January 1, 1997, may elect to apply the limitation under 
subparagraph (F) on an aggregate basis after a period specified by the 
Secretary but that shall not exceed 5 years from the date of such 
adjustment.''.

SEC. 7. PERIOD OF BOARD ELIGIBILITY FOR RESIDENTS WHO CHANGE PROGRAMS.

    Section 1886(h)(5)(G) of the Social Security Act (42 U.S.C. 
1395ww(h)(5)(G)) is amended--
            (1) in clause (i), by striking ``(iv), and (v)'' and 
        inserting ``(iv), (v), and (vi)''; and
            (2) by adding at the end the following new clause:
                            ``(vi) In the case of a resident who 
                        changes residency specialties, the period of 
                        board eligibility and the initial residency 
                        period shall be equal to the minimum number of 
                        years of formal training required to satisfy 
                        the requirements for the initial board 
                        eligibility of the program into which the 
                        resident transfers.''.

SEC. 8. MEDICARE INDIRECT MEDICAL EDUCATION PERFORMANCE ADJUSTMENT.

    Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is 
amended--
            (1) in subsection (d)(5)(B), in the matter preceding clause 
        (i), by inserting ``subject to subsection (t) and'' before 
        ``except as follows''; and
            (2) by adding at the end the following new subsection:
    ``(t) Indirect Medical Education Performance Adjustments.--
            ``(1) In general.--Subject to the succeeding provisions of 
        this subsection, the Secretary shall establish and implement 
        procedures under which the amount of payments that a hospital 
        (as defined in paragraph (11)) would otherwise receive for 
        indirect medical education costs under subsection (d)(5)(B) for 
        discharges occurring during a fiscal year is adjusted based on 
        the reporting of measures and the performance of the hospital 
        on measures of patient care priorities specified by the 
        Secretary.
            ``(2) Adjustments to begin in fiscal year 2020.--The 
        adjustments shall apply to payments for discharges occurring--
                    ``(A) with respect to the adjustments for reporting 
                under paragraph (8)(A), during fiscal year 2020; and
                    ``(B) with respect to the adjustments for 
                performance under paragraph (8)(B), on or after October 
                1, 2020.
            ``(3) Measures.--The measures of patient care priorities 
        specified by the Secretary under this subsection shall include 
        the extent of training provided in--
                    ``(A) the delivery of services categorized as 
                evaluation and management codes by the Centers for 
                Medicare & Medicaid Services;
                    ``(B) a variety of settings and systems;
                    ``(C) the coordination of patient care across 
                settings;
                    ``(D) the relevant cost and value of various 
                diagnostic and treatment options;
                    ``(E) interprofessional and multidisciplinary care 
                teams;
                    ``(F) methods for identifying system errors and 
                implementing system solutions; and
                    ``(G) the use of health information technology.
            ``(4) Measure development process.--
                    ``(A) In general.--The measures of patient care 
                specified by the Secretary under this subsection--
                            ``(i) shall--
                                    ``(I) be measures that have been 
                                adopted or endorsed by an accrediting 
                                organization (such as the Accreditation 
                                Council for Graduate Medical Education 
                                or American Osteopathic Association); 
                                and
                                    ``(II) be measures that the 
                                Secretary identifies as having used a 
                                consensus-based process for developing 
                                such measures; and
                            ``(ii) may include measures that have been 
                        submitted by teaching hospitals and medical 
                        schools.
                    ``(B) Proposed set of initial measures.--Not later 
                than July 1, 2018, the Secretary shall publish in the 
                Federal Register a proposed initial set of measures for 
                use under this subsection. The Secretary shall provide 
                for a period of public comment on such measures.
                    ``(C) Final set of initial measures.--Not later 
                than January 1, 2019, the Secretary shall publish in 
                the Federal Register the set of initial measures to be 
                specified by the Secretary for use under this 
                subsection.
                    ``(D) Update of measures.--The Secretary may, 
                through notice and comment rulemaking, periodically 
                update the measures specified under this subsection 
                pursuant to the requirements under subparagraph (A).
            ``(5) Performance standards.--The Secretary shall establish 
        performance standards with respect to measures specified by the 
        Secretary under this subsection for a performance period for a 
        fiscal year (as established under paragraph (6)).
            ``(6) Performance period.--The Secretary shall establish 
        the performance period for a fiscal year. Such performance 
        period shall begin and end prior to the beginning of such 
        fiscal year.
            ``(7) Reporting of measures.--The procedures established 
        and implemented under paragraph (1) shall include a process 
        under which hospitals shall submit data on the measures 
        specified by the Secretary under this subsection to the 
        Secretary in a form and manner, and at a time, specified by the 
        Secretary for purposes of this subsection.
            ``(8) Adjustments.--
                    ``(A) Reporting for fiscal year 2021.--For fiscal 
                year 2021, in the case of a hospital that does not 
                submit, to the Secretary in accordance with this 
                subsection, data required to be submitted under 
                paragraph (7) for a period (determined appropriate by 
                the Secretary) for such fiscal year, the total amount 
                that the hospital would otherwise receive under 
                subsection (d)(5)(B) for discharges in such fiscal year 
                shall be reduced by 0.5 percent.
                    ``(B) Performance for fiscal year 2022 and 
                subsequent fiscal years.--
                            ``(i) In general.--Subject to clause (ii), 
                        based on the performance of each hospital with 
                        respect to compliance with the measures for a 
                        performance period for a fiscal year (beginning 
                        with fiscal year 2022), the Secretary shall 
                        determine the amount of any adjustment under 
                        this subparagraph to payments to the hospital 
                        under subsection (d)(5)(B) for discharges in 
                        such fiscal year. Such adjustment may not 
                        exceed an amount equal to 2 percent of the 
                        total amount that the hospital would otherwise 
                        receive under such subsection for discharges in 
                        such fiscal year.
                            ``(ii) Budget neutral.--In making 
                        adjustments under this subparagraph, the 
                        Secretary shall ensure that the total amount of 
                        payments made to all hospitals under subsection 
                        (d)(5)(B) for discharges in a fiscal year is 
                        equal to the total amount of payments that 
                        would have been made to such hospitals under 
                        such subsection for discharges in such fiscal 
                        year if this subsection had not been enacted.
            ``(9) No effect in subsequent fiscal years.--Any adjustment 
        under subparagraph (A) or (B) of paragraph (8) shall apply only 
        with respect to the fiscal year involved, and the Secretary 
        shall not take into account any such adjustment in making 
        payments to a hospital under this section in a subsequent 
        fiscal year.
            ``(10) Evaluation of submission of performance measures.--
        Not later than January 1, 2021, the Secretary shall submit to 
        Congress a report on the implementation of this subsection, 
        including--
                    ``(A) the measure development procedures, including 
                any barriers to measure development;
                    ``(B) the compliance with reporting on the 
                performance measures, including any barriers to such 
                compliance; and
                    ``(C) recommendations to address any barriers 
                described in subparagraph (A) or (B).
            ``(11) Definition of hospital.--In this subsection, the 
        term `hospital' means a hospital that receives payments under 
        subsection (d)(5)(B).''.

SEC. 9. INCREASING GRADUATE MEDICAL EDUCATION TRANSPARENCY.

    (a) In General.--Not later than 2 years after the date of the 
enactment of this Act, and annually thereafter, the Secretary of Health 
and Human Services shall submit to Congress and the National Health 
Care Workforce Commission a report on the graduate medical education 
payments that hospitals receive under the Medicare program. The report 
shall include the following information with respect to each hospital 
that receives such payments:
            (1) The direct graduate medical education payments made to 
        the hospital under section 1886(h) of the Social Security Act 
        (42 U.S.C. 1395ww(h)).
            (2) The total costs of direct graduate medical education to 
        the hospital as reported on the annual Medicare Cost Reports.
            (3) The indirect medical education payments made to the 
        hospital under section 1886(d)(5)(B) of such Act (42 U.S.C. 
        1395ww(d)(1)(B)).
            (4) The number of full-time-equivalent residents counted 
        for purposes of making the payments described in paragraph (1).
            (5) The number of full-time-equivalent residents counted 
        for purposes of making the payments described in paragraph (3).
            (6) The number of full-time-equivalent residents, if any, 
        that are not counted for purposes of making payments described 
        in paragraph (1).
            (7) The number of full-time-equivalent residents, if any, 
        that are not counted for purposes of making payments described 
        in paragraph (3).
            (8) The factors contributing to the higher costs of patient 
        care provided by the hospital, including--
                    (A) the costs of trauma, burn, other standby 
                services;
                    (B) translation services for disabled or non-
                English speaking patients;
                    (C) the cost of uncompensated care;
                    (D) financial losses with respect to Medicaid 
                patients; and
                    (E) uncompensated costs of clinical research.

SEC. 10. GAO STUDIES AND REPORTS.

    (a) On Physician Workforce.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on the physician workforce. Such study 
        shall include the identification of physician specialties for 
        which there is a shortage, as defined by the Comptroller 
        General.
            (2) Report.--Not later than January 1, 2018, the 
        Comptroller General shall submit to Congress a report on the 
        study conducted under subsection (a), together with 
        recommendations for such legislation and administrative action 
        as the Comptroller General determines appropriate.
    (b) On Strategies for Increasing Diversity.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on strategies for increasing the 
        diversity of the health professional workforce. Such study 
        shall include an analysis of strategies for increasing the 
        number of health professionals from rural, lower income, and 
        underrepresented minority communities, including which 
        strategies are most effective for achieving such goal.
            (2) Report.--Not later than 2 years after the date of 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report on the study conducted under subsection (a), 
        together with recommendations for such legislation and 
        administrative action as the Comptroller General determines 
        appropriate.
    (c) On Protecting Older Adults.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study that addresses the competency of the 
        physician workforce to care for older adults upon the 
        completion of such workforce's residency training.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report on such study, including such recommendations 
        for legislation and administrative action as the Comptroller 
        General determines appropriate based on such study.
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