I 

116TH CONGRESS 

1ST SESSION H. R. 1763 

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 14, 2019 

Ms. SEWELL of Alabama (for herself, Mr. KATKO, Ms. TORRES SMALL of New 

Mexico, and Mr. RODNEY DAVIS of Illinois) 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. 

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

5 Shortage Reduction Act of 2019’’. 


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

3 (a) IN GENERAL.—Section 1886(h) of the Social Se4 curity 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 2021 through 2025 (and succeeding 

21 fiscal years if the Secretary determines 

22 that there are additional residency posi23 tions available to distribute under clause 

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

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

26 the otherwise applicable resident limit for 


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1 each qualifying hospital that submits a 

2 timely application under this subparagraph 

3 by such number as the Secretary may ap4 prove for portions of cost reporting periods 

5 occurring on or after July 1 of the fiscal 

6 year of the increase. 

7 ‘‘(ii) NUMBER AVAILABLE FOR DIS8 TRIBUTION.—For each such fiscal year, 

9 the Secretary shall determine the total 

10 number of additional residency positions 

11 available for distribution under clause (i) 

12 in accordance with the following: 

13 ‘‘(I) ALLOCATION TO HOSPITALS

14 ALREADY OPERATING OVER RESIDENT

15 LIMIT.—One-third of such number 

16 shall be available for distribution only 

17 to hospitals described in subparagraph 

18 (B). 

19 ‘‘(II) AGGREGATE LIMITATION.— 

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

21 the aggregate number of increases in 

22 the otherwise applicable resident limit 

23 under this subparagraph shall be 

24 equal to 3,000 in each such year. 


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1 ‘‘(iii) PROCESS FOR DISTRIBUTING

2 POSITIONS.— 

3 ‘‘(I) ROUNDS OF APPLICA4 TIONS.—The Secretary shall initiate 5 

5 separate rounds of applications for an 

6 increase under clause (i), 1 round 

7 with respect to each of fiscal years 

8 2021 through 2025. 

9 ‘‘(II) NUMBER AVAILABLE.—In 

10 each of such rounds, the aggregate 

11 number of positions available for dis12 tribution in the fiscal year under 

13 clause (ii) shall be distributed, plus 

14 any additional positions available 

15 under clause (iv). 

16 ‘‘(III) TIMING.—The Secretary 

17 shall notify hospitals of the number of 

18 positions distributed to the hospital 

19 under this paragraph as a result of an 

20 increase in the otherwise applicable 

21 resident limit by January 1 of the fis22 cal year of the increase. Such increase 

23 shall be effective for portions of cost 

24 reporting periods beginning on or 

25 after July 1 of that fiscal year. 


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1 ‘‘(iv) POSITIONS NOT DISTRIBUTED

2 DURING THE FISCAL YEAR.— 

3 ‘‘(I) IN GENERAL.—If the num4 ber of resident full-time equivalent po5 sitions distributed under this para6 graph in a fiscal year is less than the 

7 aggregate number of positions avail8 able for distribution in the fiscal year 

9 (as described in clause (ii), including 

10 after application of this subclause), 

11 the difference between such number 

12 distributed and such number available 

13 for distribution shall be added to the 

14 aggregate number of positions avail15 able for distribution in the following 

16 fiscal year. 

17 ‘‘(II) EXCEPTION IF POSITIONS

18 NOT DISTRIBUTED BY END OF FISCAL

19 YEAR 2025.—If the aggregate number 

20 of positions distributed under this 

21 paragraph during the 5-year period of 

22 fiscal years 2021 through 2025 is less 

23 than 15,000, the Secretary shall, in 

24 accordance with the provisions of 

25 clause (ii) and subparagraph (D) and 


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1 the considerations and priority de2 scribed in subparagraph (C), conduct 

3 an application and distribution proc4 ess in each subsequent fiscal year 

5 until such time as the aggregate 

6 amount of positions distributed under 

7 this paragraph is equal to 15,000. 

8 ‘‘(B) ALLOCATION OF DISTRIBUTION FOR

9 POSITIONS TO HOSPITALS ALREADY OPERATING

10 OVER RESIDENT LIMIT.— 

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

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

13 which the reference resident level of the 

14 hospital (as specified in subparagraph 

15 (G)(iii)) is greater than the otherwise ap16 plicable resident limit, the increase in the 

17 otherwise applicable resident limit under 

18 subparagraph (A) for a fiscal year de19 scribed in such subparagraph shall be an 

20 amount equal to the product of the total 

21 number of additional residency positions 

22 available for distribution under subpara23 graph (A)(ii)(I) for such fiscal year and 

24 the quotient of— 


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1 ‘‘(I) the number of resident posi2 tions by which the reference resident 

3 level of the hospital exceeds the other4 wise applicable resident limit for the 

5 hospital; and 

6 ‘‘(II) the number of resident po7 sitions by which the reference resident 

8 level of all such hospitals with respect 

9 to which an application is approved 

10 under this paragraph exceeds the oth11 erwise applicable resident limit for 

12 such hospitals. 

13 ‘‘(ii) REQUIREMENTS.—A hospital de14 scribed in clause (i)— 

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

16 in the otherwise applicable resident 

17 limit under this subparagraph unless 

18 the amount by which the reference 

19 resident level of the hospital exceeds 

20 the otherwise applicable resident limit 

21 is not less than 10 and the hospital 

22 trains at least 25 percent of the full23 time equivalent residents of the hos24 pital in primary care and general surVerDate Sep 11 2014 02:31 Mar 29, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H1763.IH H1763

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1 gery (as of the date of enactment of 

2 this paragraph); and 

3 ‘‘(II) shall continue to train at 

4 least 25 percent of the full-time equiv5 alent residents of the hospital in pri6 mary care and general surgery for the 

7 5-year period beginning on such date. 

8 In the case where the Secretary determines 

9 that a hospital described in clause (i) no 

10 longer meets the requirement of subclause 

11 (II), the Secretary may reduce the other12 wise applicable resident limit of the hos13 pital by the amount by which such limit 

14 was increased under this subparagraph. 

15 ‘‘(iii) CLARIFICATION REGARDING ELI16 GIBILITY FOR OTHER ADDITIONAL RESI17 DENCY POSITIONS.—Nothing in this sub18 paragraph shall be construed as preventing 

19 a hospital described in clause (i) from ap20 plying for and receiving additional resi21 dency positions under this paragraph that 

22 are not reserved for distribution under this 

23 subparagraph. 

24 ‘‘(C) DISTRIBUTION OF OTHER POSI25 TIONS.—For purposes of determining an inVerDate Sep 11 2014 02:31 Mar 29, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H1763.IH H1763

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1 crease in the otherwise applicable resident limit 

2 under subparagraph (A) (other than such an in3 crease described in subparagraph (B)), the fol4 lowing shall apply: 

5 ‘‘(i) CONSIDERATIONS IN DISTRIBU6 TION.—In determining for which hospitals 

7 such an increase is provided under sub8 paragraph (A), the Secretary shall take 

9 into account the demonstrated likelihood of 

10 the hospital filling the positions made 

11 available under this paragraph within the 

12 first 5 cost reporting periods beginning 

13 after the date the increase would be effec14 tive, as determined by the Secretary. 

15 ‘‘(ii) PRIORITY FOR CERTAIN HOS16 PITALS.—Subject to clause (iii), in deter17 mining for which hospitals such an in18 crease is provided, the Secretary shall dis19 tribute the increase in the following pri20 ority order: 

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

22 with— 

23 ‘‘(aa) new medical schools 

24 that received ‘Candidate School’ 

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1 mittee on Medical Education or 

2 that received ‘Pre-Accreditation’ 

3 status from the American Osteo4 pathic Association Commission 

5 on Osteopathic College Accredita6 tion on or after January 1, 2000, 

7 and that have achieved or con8 tinue to progress toward ‘Full 

9 Accreditation’ status (as such 

10 term is defined by the Liaison 

11 Committee on Medical Edu12 cation) or toward ‘Accreditation’ 

13 status (as such term is defined 

14 by the American Osteopathic As15 sociation Commission on Osteo16 pathic College Accreditation); or 

17 ‘‘(bb) additional locations 

18 and branch campuses established 

19 on or after January 1, 2000, by 

20 medical schools with ‘Full Ac21 creditation’ status (as such term 

22 is defined by the Liaison Com23 mittee on Medical Education) or 

24 ‘Accreditation’ status (as such 

25 term is defined by the American 


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1 Osteopathic Association Commis2 sion on Osteopathic College Ac3 creditation). 

4 ‘‘(II) Second, to hospitals with 

5 which the Secretary cooperates under 

6 section 7302(d) of title 38, United 

7 States Code. 

8 ‘‘(III) Third, to hospitals that 

9 emphasize training in community10 based settings or in hospital out11 patient departments. 

12 ‘‘(IV) Fourth, to hospitals that 

13 are not located in a rural area and op14 erate an approved medical residency 

15 training program (or rural track) in a 

16 rural area or an approved medical 

17 residency training program with an 

18 integrated rural track. 

19 ‘‘(V) Fifth, to all other hospitals. 

20 ‘‘(iii) DISTRIBUTION TO HOSPITALS IN

21 HIGHER PRIORITY GROUP PRIOR TO DIS22 TRIBUTION IN LOWER PRIORITY GROUPS.— 

23 The Secretary may only distribute such an 

24 increase to a lower priority group under 

25 clause (ii) if all qualifying hospitals in the 


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1 higher priority group or groups have re2 ceived the maximum number of increases 

3 under such subparagraph that the hospital 

4 is eligible for under this paragraph for the 

5 fiscal year. 

6 ‘‘(iv) REQUIREMENTS FOR USE OF AD7 DITIONAL POSITIONS.— 

8 ‘‘(I) IN GENERAL.—Subject to 

9 subclause (II), a hospital that receives 

10 such an increase shall ensure, during 

11 the 5-year period beginning on the ef12 fective date of such increase, that— 

13 ‘‘(aa) not less than 50 per14 cent of the positions attributable 

15 to such increase that are used in 

16 a given year during such 5-year 

17 period are used to train full-time 

18 equivalent residents in a shortage 

19 specialty residency program (as 

20 defined in subparagraph (G)(iv)), 

21 as determined by the Secretary 

22 at the end of such 5-year period; 

23 ‘‘(bb) the total number of 

24 full-time equivalent residents, ex25 cluding any additional positions 


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1 attributable to such increase, is 

2 not less than the average number 

3 of full-time equivalent residents 

4 during the 3 most recent cost re5 porting periods ending on or be6 fore the effective date of such in7 crease; and 

8 ‘‘(cc) the ratio of full-time 

9 equivalent residents in a shortage 

10 specialty residency program (as 

11 so defined) is not less than the 

12 average ratio of full-time equiva13 lent residents in such a program 

14 during the 3 most recent cost re15 porting periods ending on or be16 fore the effective date of such in17 crease. 

18 ‘‘(II) REDISTRIBUTION OF POSI19 TIONS IF HOSPITAL NO LONGER

20 MEETS CERTAIN REQUIREMENTS.— 

21 With respect to each fiscal year de22 scribed in subparagraph (A), the Sec23 retary shall determine whether or not 

24 a hospital described in subclause (I) 

25 meets the requirements of such subVerDate Sep 11 2014 02:31 Mar 29, 2019 Jkt 089200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H1763.IH H1763

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1 clause. In the case that the Secretary 

2 determines that such a hospital does 

3 not meet such requirements, the Sec4 retary shall— 

5 ‘‘(aa) reduce the otherwise 

6 applicable resident limit of the 

7 hospital by the amount by which 

8 such limit was increased under 

9 this paragraph; and 

10 ‘‘(bb) provide for the dis11 tribution of positions attributable 

12 to such reduction in accordance 

13 with the requirements of this 

14 paragraph. 

15 ‘‘(D) LIMITATION.—A hospital may not re16 ceive more than 75 full-time equivalent addi17 tional residency positions under this paragraph 

18 for any fiscal year. 

19 ‘‘(E) APPLICATION OF PER RESIDENT

20 AMOUNTS FOR PRIMARY CARE AND NONPRI21 MARY CARE.—With respect to additional resi22 dency positions in a hospital attributable to the 

23 increase provided under this paragraph, the ap24 proved FTE per resident amounts are deemed 

25 to be equal to the hospital per resident amounts 


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1 for primary care and nonprimary care com2 puted under paragraph (2)(D) for that hospital. 

3 ‘‘(F) PERMITTING FACILITIES TO APPLY

4 AGGREGATION RULES.—The Secretary shall 

5 permit hospitals receiving additional residency 

6 positions attributable to the increase provided 

7 under this paragraph to, beginning in the fifth 

8 year after the effective date of such increase, 

9 apply such positions to the limitation amount 

10 under paragraph (4)(F) that may be aggre11 gated pursuant to paragraph (4)(H) among 

12 members of the same affiliated group. 

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

14 ‘‘(i) OTHERWISE APPLICABLE RESI15 DENT LIMIT.—The term ‘otherwise appli16 cable resident limit’ means, with respect to 

17 a hospital, the limit otherwise applicable 

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

19 paragraph (4) on the resident level for the 

20 hospital determined without regard to this 

21 paragraph but taking into account para22 graphs (7)(A), (7)(B), (8)(A), and (8)(B). 

23 ‘‘(ii) REFERENCE RESIDENT LEVEL.— 

24 Except as otherwise provided in subclause 

25 (II), the term ‘reference resident level’ 


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1 means, with respect to a hospital, the resi2 dent level for the most recent cost report3 ing period of the hospital ending on or be4 fore the date of enactment of this para5 graph, for which a cost report has been 

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

7 audit)), as determined by the Secretary. 

8 ‘‘(iii) RESIDENT LEVEL.—The term 

9 ‘resident level’ has the meaning given such 

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

11 ‘‘(iv) SHORTAGE SPECIALTY RESI12 DENCY PROGRAM.—The term ‘shortage 

13 specialty residency program’ means any 

14 approved residency training program in a 

15 specialty identified in the report entitled 

16 ‘The Physician Workforce: Projections and 

17 Research into Current Issues Affecting 

18 Supply and Demand’, issued in December 

19 2008 by the Health Resources and Serv20 ices Administration, as a specialty whose 

21 baseline physician requirements projections 

22 exceed the projected supply of total active 

23 physicians for the period of 2005 through 

24 2020.’’. 


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1 (b) IME.—Section 1886(d)(5)(B) of the Social Secu2 rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 

3 (1) in clause (v), in the third sentence, by strik4 ing ‘‘subsections (h)(7) and (h)(8)’’ and inserting 

5 ‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 

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

7 section 5505(b) of the Patient Protection and Af8 fordable Care Act (Public Law 111–148), as clause 

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

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

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

12 ‘‘(xii) For discharges occurring on or 

13 after July 1, 2021, insofar as an additional 

14 payment amount under this subparagraph 

15 is attributable to resident positions distrib16 uted to a hospital under subsection (h)(9), 

17 the indirect teaching adjustment factor 

18 shall be computed in the same manner as 

19 provided under clause (ii) with respect to 

20 such resident positions.’’. 

21 SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREAS22 ING DIVERSITY. 

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

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

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1 ing the diversity of the health professional workforce. Such 

2 study shall include an analysis of strategies for increasing 

3 the number of health professionals from rural, lower in4 come, and underrepresented minority communities, includ5 ing which strategies are most effective for achieving such 

6 goal. 

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

8 of enactment of this Act, the Comptroller General shall 

9 submit to Congress a report on the study conducted under 

10 subsection (a), together with recommendations for such 

11 legislation and administrative action as the Comptroller 

12 General determines appropriate. 

Æ 


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