I 

113TH CONGRESS 

1ST SESSION H. R. 1180 

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, 2013 

Mr. CROWLEY (for himself and Mr. GRIMM) 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 2013’’. 

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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 2015 through 2019 (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 2015 through 2019. 

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 2019.—If the aggregate number 

20 of positions distributed under this 

21 paragraph during the 5-year period of 

22 fiscal years 2015 through 2019 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 surmstockstill on DSK4VPTVN1PROD with BILLS

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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 inmstockstill on DSK4VPTVN1PROD with BILLS

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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 (aa) new medical schools that re23 ceived ‘Candidate School’ status from 

24 the Liaison Committee on Medical 

25 Education or that received ‘Pre-Acmstockstill on DSK4VPTVN1PROD with BILLS

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1 creditation’ status from the American 

2 Osteopathic Association Commission 

3 on Osteopathic College Accreditation 

4 on or after January 1, 2000, and that 

5 have achieved or continue to progress 

6 toward ‘Full Accreditation’ status (as 

7 such term is defined by the Liaison 

8 Committee on Medical Education) or 

9 toward ‘Accreditation’ status (as such 

10 term is defined by the American Os11 teopathic Association Commission on 

12 Osteopathic College Accreditation), or 

13 (bb) additional locations and branch 

14 campuses established on or after Jan15 uary 1, 2000, by medical schools with 

16 ‘Full Accreditation’ status (as such 

17 term is defined by the Liaison Com18 mittee on Medical Education) or ‘Ac19 creditation’ status (as such term is 

20 defined by the American Osteopathic 

21 Association Commission on Osteo22 pathic College Accreditation). 

23 ‘‘(II) Second, to hospitals that 

24 emphasize training in community 

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1 tings or in hospital outpatient depart2 ments. 

3 ‘‘(III) Third, to hospitals that 

4 are eligible for incentive payments 

5 under section 1886(n) or 1903(t) as 

6 of the date the hospital submits an 

7 application for such increase under 

8 subparagraph (A). 

9 ‘‘(IV) Fourth, to all other hos10 pitals. 

11 ‘‘(iii) DISTRIBUTION TO HOSPITALS IN

12 HIGHER PRIORITY GROUP PRIOR TO DIS13 TRIBUTION IN LOWER PRIORITY GROUPS.— 

14 The Secretary may only distribute such an 

15 increase to a lower priority group under 

16 clause (ii) if all qualifying hospitals in the 

17 higher priority group or groups have re18 ceived the maximum number of increases 

19 under such subparagraph that the hospital 

20 is eligible for under this paragraph for the 

21 fiscal year. 

22 ‘‘(iv) REQUIREMENTS FOR USE OF AD23 DITIONAL POSITIONS.— 

24 ‘‘(I) IN GENERAL.—Subject to 

25 subclause (II), a hospital that receives 

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1 such an increase shall ensure, during 

2 the 5-year period beginning on the ef3 fective date of such increase, that— 

4 ‘‘(aa) not less than 50 per5 cent of the positions attributable 

6 to such increase that are used in 

7 a given year during such 5-year 

8 period are used to train full-time 

9 equivalent residents in a shortage 

10 specialty residency program (as 

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

12 as determined by the Secretary 

13 at the end of such 5-year period; 

14 ‘‘(bb) the total number of 

15 full-time equivalent residents, ex16 cluding any additional positions 

17 attributable to such increase, is 

18 not less than the average number 

19 of full-time equivalent residents 

20 during the 3 most recent cost re21 porting periods ending on or be22 fore the effective date of such in23 crease; and 

24 ‘‘(cc) the ratio of full-time 

25 equivalent residents in a shortage 

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1 specialty residency program (as 

2 so defined) is not less than the 

3 average ratio of full-time equiva4 lent residents in such a program 

5 during the 3 most recent cost re6 porting periods ending on or be7 fore the effective date of such in8 crease. 

9 ‘‘(II) REDISTRIBUTION OF POSI10 TIONS IF HOSPITAL NO LONGER

11 MEETS CERTAIN REQUIREMENTS.— 

12 With respect to each fiscal year de13 scribed in subparagraph (A), the Sec14 retary shall determine whether or not 

15 a hospital described in subclause (I) 

16 meets the requirements of such sub17 clause. In the case that the Secretary 

18 determines that such a hospital does 

19 not meet such requirements, the Sec20 retary shall— 

21 ‘‘(aa) reduce the otherwise 

22 applicable resident limit of the 

23 hospital by the amount by which 

24 such limit was increased under 

25 this paragraph; and 

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1 ‘‘(bb) provide for the dis2 tribution of positions attributable 

3 to such reduction in accordance 

4 with the requirements of this 

5 paragraph. 

6 ‘‘(D) LIMITATION.—A hospital may not re7 ceive more than 75 full-time equivalent addi8 tional residency positions under this paragraph 

9 for any fiscal year. 

10 ‘‘(E) APPLICATION OF PER RESIDENT

11 AMOUNTS FOR PRIMARY CARE AND NONPRI12 MARY CARE.—With respect to additional resi13 dency positions in a hospital attributable to the 

14 increase provided under this paragraph, the ap15 proved FTE per resident amounts are deemed 

16 to be equal to the hospital per resident amounts 

17 for primary care and nonprimary care com18 puted under paragraph (2)(D) for that hospital. 

19 ‘‘(F) PERMITTING FACILITIES TO APPLY

20 AGGREGATION RULES.—The Secretary shall 

21 permit hospitals receiving additional residency 

22 positions attributable to the increase provided 

23 under this paragraph to, beginning in the fifth 

24 year after the effective date of such increase, 

25 apply such positions to the limitation amount 

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1 under paragraph (4)(F) that may be aggre2 gated pursuant to paragraph (4)(H) among 

3 members of the same affiliated group. 

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

5 ‘‘(i) OTHERWISE APPLICABLE RESI6 DENT LIMIT.—The term ‘otherwise appli7 cable resident limit’ means, with respect to 

8 a hospital, the limit otherwise applicable 

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

10 paragraph (4) on the resident level for the 

11 hospital determined without regard to this 

12 paragraph but taking into account para13 graphs (7)(A), (7)(B), (8)(A), and (8)(B). 

14 ‘‘(ii) REFERENCE RESIDENT LEVEL.— 

15 Except as otherwise provided in subclause 

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

17 means, with respect to a hospital, the resi18 dent level for the most recent cost report19 ing period of the hospital ending on or be20 fore the date of enactment of this para21 graph, for which a cost report has been 

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

23 audit)), as determined by the Secretary. 

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1 ‘‘(iii) RESIDENT LEVEL.—The term 

2 ‘resident level’ has the meaning given such 

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

4 ‘‘(iv) SHORTAGE SPECIALTY RESI5 DENCY PROGRAM.—The term ‘shortage 

6 specialty residency program’ means the fol7 lowing: 

8 ‘‘(I) PRIOR TO REPORT ON

9 SHORTAGE SPECIALTIES.—Prior to 

10 the date on which the report of the 

11 National Health Care Workforce 

12 Commission is submitted under sec13 tion 3 of the Resident Physician 

14 Shortage Reduction Act of 2013, any 

15 approved residency training program 

16 in a specialty identified in the report 

17 entitled ‘The Physician Workforce: 

18 Projections and Research into Current 

19 Issues Affecting Supply and Demand’, 

20 issued in December 2008 by the 

21 Health Resources and Services Ad22 ministration, as a specialty whose 

23 baseline physician requirements pro24 jections exceed the projected supply of 

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1 total active physicians for the period 

2 of 2005 through 2020. 

3 ‘‘(II) AFTER REPORT ON SHORT4 AGE SPECIALTIES.—On or after the 

5 date on which the report of the Na6 tional Health Care Workforce Com7 mission is submitted under such sec8 tion, any approved residency training 

9 program in a physician specialty iden10 tified in such report as a specialty for 

11 which there is a shortage.’’. 

12 (b) IME.—Section 1886(d)(5)(B) of the Social Secu13 rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 

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

15 striking ‘‘subsections (h)(7) and (h)(8)’’ and insert16 ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 

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

18 section 5505(b) of the Patient Protection and Af19 fordable Care Act (Public Law 111–148), as clause 

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

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

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

23 ‘‘(xii) For discharges occurring on or 

24 after July 1, 2015, insofar as an additional 

25 payment amount under this subparagraph 

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1 is attributable to resident positions distrib2 uted to a hospital under subsection (h)(9), 

3 the indirect teaching adjustment factor 

4 shall be computed in the same manner as 

5 provided under clause (ii) with respect to 

6 such resident positions.’’. 

7 SEC. 3. STUDY AND REPORT BY NATIONAL HEALTH CARE 

8 WORKFORCE COMMISSION. 

9 (a) STUDY.—The National Health Care Workforce 

10 Commission established under section 5101 of the Patient 

11 Protection and Affordable Care Act (Public Law 111– 

12 148) shall conduct a study of the physician workforce. 

13 Such study shall include the identification of physician 

14 specialties for which there is a shortage, as defined by the 

15 Commission. 

16 (b) REPORT.—Not later than January 1, 2016, the 

17 National Health Care Workforce Commission shall submit 

18 to Congress a report on the study conducted under sub19 section (a), together with recommendations for such legis20 lation and administrative action as the Commission deter21 mines appropriate. 

22 SEC. 4. STUDY AND REPORT ON STRATEGIES FOR INCREAS23 ING DIVERSITY. 

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

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

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1 General’’) shall conduct a study on strategies for increas2 ing the diversity of the health professional workforce. Such 

3 study shall include an analysis of strategies for increasing 

4 the number of health professionals from rural, lower in5 come, and underrepresented minority communities, includ6 ing which strategies are most effective for achieving such 

7 goal. 

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

9 of enactment of this Act, the Comptroller General shall 

10 submit to Congress a report on the study conducted under 

11 subsection (a), together with recommendations for such 

12 legislation and administrative action as the Comptroller 

13 General determines appropriate. 

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