I 

113TH CONGRESS 

1ST SESSION H. R. 1201 

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. SCHOCK (for himself and Ms. SCHWARTZ) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for the distribution of additional residency positions, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

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

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Distribution of additional residency positions. 


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

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

Sec. 5. Treatment of hospitals with rotating residents. 

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

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

Sec. 8. Medicare indirect medical education performance adjustment. 

Sec. 9. Increasing graduate medical education transparency. 

Sec. 10. GAO studies and reports. 

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

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

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

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

7 (8), and (9)’’; 

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

10 (8), and (9)’’; 

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

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

14 paragraph: 

15 ‘‘(9) DISTRIBUTION OF ADDITIONAL RESIDENCY

16 POSITIONS.— 

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

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

20 years 2014 through 2018 (and succeeding 


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1 fiscal years if the Secretary determines 

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

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

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

6 the otherwise applicable resident limit for 

7 each qualifying hospital that submits a 

8 timely application under this subparagraph 

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

11 occurring on or after July 1 of the fiscal 

12 year of the increase. 

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

15 the Secretary shall determine the total 

16 number of additional residency positions 

17 available for distribution under clause (i) 

18 in accordance with the following: 

19 ‘‘(I) ALLOCATION TO HOSPITALS

20 ALREADY OPERATING OVER RESIDENT

21 LIMIT.—One-third of such number 

22 shall be available for distribution only 

23 to hospitals described in subparagraph 

24 (B). 


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1 ‘‘(II) AGGREGATE LIMITATION.— 

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

3 the aggregate number of increases in 

4 the otherwise applicable resident limit 

5 under this subparagraph shall be 

6 equal to 3,000 in each such year. 

7 ‘‘(iii) PROCESS FOR DISTRIBUTING

8 POSITIONS.— 

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

11 separate rounds of applications for an 

12 increase under clause (i), 1 round 

13 with respect to each of fiscal years 

14 2014 through 2018. 

15 ‘‘(II) NUMBER AVAILABLE.—In 

16 each of such rounds, the aggregate 

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

19 clause (ii) shall be distributed, plus 

20 any additional positions available 

21 under clause (iv). 

22 ‘‘(III) TIMING.—The Secretary 

23 shall notify hospitals of the number of 

24 positions distributed to the hospital 

25 under this paragraph as a result of an 


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1 increase in the otherwise applicable 

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

4 shall be effective for portions of cost 

5 reporting periods beginning on or 

6 after July 1 of that fiscal year. 

7 ‘‘(iv) POSITIONS NOT DISTRIBUTED

8 DURING THE FISCAL YEAR.— 

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

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

15 (as described in clause (ii), including 

16 after application of this subclause), 

17 the difference between such number 

18 distributed and such number available 

19 for distribution shall be added to the 

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

22 fiscal year. 

23 ‘‘(II) EXCEPTION IF POSITIONS

24 NOT DISTRIBUTED BY END OF FISCAL

25 YEAR 2018.—If the aggregate number 


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1 of positions distributed under this 

2 paragraph during the 5-year period of 

3 fiscal years 2014 through 2018 is less 

4 than 15,000, the Secretary shall, in 

5 accordance with the provisions of 

6 clause (ii) and subparagraph (D) and 

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

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

11 until such time as the aggregate 

12 amount of positions distributed under 

13 this paragraph is equal to 15,000. 

14 ‘‘(B) ALLOCATION OF DISTRIBUTION FOR

15 POSITIONS TO HOSPITALS ALREADY OPERATING

16 OVER RESIDENT LIMIT.— 

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

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

19 which the reference resident level of the 

20 hospital (as specified in subparagraph 

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

23 otherwise applicable resident limit under 

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


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1 amount equal to the product of the total 

2 number of additional residency positions 

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

5 the quotient of— 

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

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

10 hospital; and 

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

13 level of all such hospitals with respect 

14 to which an application is approved 

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

17 such hospitals. 

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

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

21 in the otherwise applicable resident 

22 limit under this subparagraph unless 

23 the amount by which the reference 

24 resident level of the hospital exceeds 

25 the otherwise applicable resident limit 


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1 is not less than 10 and the hospital 

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

6 this paragraph); and 

7 ‘‘(II) shall continue to train at 

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

11 5-year period beginning on such date. 

12 In the case where the Secretary determines 

13 that a hospital described in clause (i) no 

14 longer meets the requirement of subclause 

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

18 was increased under this subparagraph. 

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

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


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1 are not reserved for distribution under this 

2 subparagraph. 

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

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

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

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

13 into account the demonstrated likelihood of 

14 the hospital filling the positions made 

15 available under this paragraph within the 

16 first 5 cost reporting periods beginning 

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

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


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1 ‘‘(I) First, to hospitals with ap2 proved medical residency training pro3 grams affiliated with medical schools 

4 that have at least 40 percent of grad5 uates matched in primary care resi6 dency program in the 5 years prior. 

7 ‘‘(II) Second, to hospitals in 

8 States with (aa) new medical schools 

9 that received Candidate School status 

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

16 that have achieved or continue to 

17 progress toward Full Accreditation 

18 status (as such term is defined by the 

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

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

25 branch campuses established on or 


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1 after January 1, 2000, by medical 

2 schools with Full Accreditation status 

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

5 or Accreditation status (as such term 

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

9 ‘‘(III) Third, to hospitals that 

10 are eligible for incentive payments 

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

12 of the date the hospital submits an 

13 application for such increase under 

14 subparagraph (A). 

15 ‘‘(IV) Fourth, to all other hos16 pitals. 

17 ‘‘(iii) DISTRIBUTION TO HOSPITALS IN

18 HIGHER PRIORITY GROUP PRIOR TO DIS19 TRIBUTION IN LOWER PRIORITY GROUPS.— 

20 The Secretary may only distribute such an 

21 increase to a lower priority group under 

22 clause (ii) if all qualifying hospitals in the 

23 higher priority group or groups have re24 ceived the maximum number of increases 

25 under such subparagraph that the hospital 


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1 is eligible for under this paragraph for the 

2 fiscal year. 

3 ‘‘(iv) REQUIREMENTS FOR USE OF AD4 DITIONAL POSITIONS.— 

5 ‘‘(I) IN GENERAL.—Subject to 

6 subclause (II), a hospital that receives 

7 such an increase shall ensure, during 

8 the 5-year period beginning on the ef9 fective date of such increase, that— 

10 ‘‘(aa) not less than 50 per11 cent of the positions attributable 

12 to such increase that are used in 

13 a given year during such 5-year 

14 period are used to train full-time 

15 equivalent residents in a shortage 

16 specialty residency program (as 

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

18 as determined by the Secretary 

19 at the end of such 5-year period; 

20 ‘‘(bb) the total number of 

21 full-time equivalent residents, ex22 cluding any additional positions 

23 attributable to such increase, is 

24 not less than the average number 

25 of full-time equivalent residents 


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1 during the 3 most recent cost re2 porting periods ending on or be3 fore the effective date of such in4 crease; and 

5 ‘‘(cc) the ratio of full-time 

6 equivalent residents in a shortage 

7 specialty residency program (as 

8 so defined) is not less than the 

9 average ratio of full-time equiva10 lent residents in such a program 

11 during the 3 most recent cost re12 porting periods ending on or be13 fore the effective date of such in14 crease. 

15 ‘‘(II) REDISTRIBUTION OF POSI16 TIONS IF HOSPITAL NO LONGER

17 MEETS CERTAIN REQUIREMENTS.— 

18 With respect to each fiscal year de19 scribed in subparagraph (A), the Sec20 retary shall determine whether or not 

21 a hospital described in subclause (I) 

22 meets the requirements of such sub23 clause. In the case that the Secretary 

24 determines that such a hospital does 


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1 not meet such requirements, the Sec2 retary shall— 

3 ‘‘(aa) reduce the otherwise 

4 applicable resident limit of the 

5 hospital by the amount by which 

6 such limit was increased under 

7 this paragraph; and 

8 ‘‘(bb) provide for the dis9 tribution of positions attributable 

10 to such reduction in accordance 

11 with the requirements of this 

12 paragraph. 

13 ‘‘(D) LIMITATION.—A hospital may not re14 ceive more than 75 full-time equivalent addi15 tional residency positions under this paragraph 

16 for any fiscal year. 

17 ‘‘(E) APPLICATION OF PER RESIDENT

18 AMOUNTS FOR PRIMARY CARE AND NONPRI19 MARY CARE.—With respect to additional resi20 dency positions in a hospital attributable to the 

21 increase provided under this paragraph, the ap22 proved FTE per resident amounts are deemed 

23 to be equal to the hospital per resident amounts 

24 for primary care and nonprimary care com25 puted under paragraph (2)(D) for that hospital. 


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1 ‘‘(F) PERMITTING FACILITIES TO APPLY

2 AGGREGATION RULES.—The Secretary shall 

3 permit hospitals receiving additional residency 

4 positions attributable to the increase provided 

5 under this paragraph to, beginning in the fifth 

6 year after the effective date of such increase, 

7 apply such positions to the limitation amount 

8 under paragraph (4)(F) that may be aggre9 gated pursuant to paragraph (4)(H) among 

10 members of the same affiliated group. 

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

12 ‘‘(i) OTHERWISE APPLICABLE RESI13 DENT LIMIT.—The term ‘otherwise appli14 cable resident limit’ means, with respect to 

15 a hospital, the limit otherwise applicable 

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

17 paragraph (4) on the resident level for the 

18 hospital determined without regard to this 

19 paragraph but taking into account para20 graphs (7)(A), (7)(B), (8)(A), and (8)(B). 

21 ‘‘(ii) PRIMARY CARE.—The term ‘pri22 mary care’ means family medicine, general 

23 internal medicine, general pediatrics, geri24 atrics, preventive medicine, obstetrics and 


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1 gynecology, general surgery, and psychi2 atry. 

3 ‘‘(iii) REFERENCE RESIDENT

4 LEVEL.—Except as otherwise provided in 

5 subclause (II), the term ‘reference resident 

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

7 resident level for the most recent cost re8 porting period of the hospital ending on or 

9 before the date of enactment of this para10 graph, for which a cost report has been 

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

12 audit)), as determined by the Secretary. 

13 ‘‘(iv) RESIDENT LEVEL.—The term 

14 ‘resident level’ has the meaning given such 

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

16 ‘‘(v) SHORTAGE SPECIALTY RESI17 DENCY PROGRAM.—The term ‘shortage 

18 specialty residency program’ means the fol19 lowing: 

20 ‘‘(I) PRIOR TO REPORT ON

21 SHORTAGE SPECIALTIES.—Prior to 

22 the date on which the report is sub23 mitted under section 10(a) of the 

24 Training Tomorrow’s Doctors Today 

25 Act, any approved residency training 


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1 program in a specialty identified in 

2 the report entitled ‘The Physician 

3 Workforce: Projections and Research 

4 into Current Issues Affecting Supply 

5 and Demand’, issued in December 

6 2008 by the Health Resources and 

7 Services Administration, as a specialty 

8 whose baseline physician requirements 

9 projections exceed the projected sup10 ply of total active physicians for the 

11 period of 2005 through 2020. 

12 ‘‘(II) AFTER REPORT ON SHORT13 AGE SPECIALITIES.—On or after the 

14 date on which the report is submitted 

15 under such section 5, any approved 

16 residency training program in a physi17 cian specialty identified in such report 

18 as a specialty for which there is a 

19 shortage.’’. 

20 (b) IME.—Section 1886(d)(5)(B) of the Social Secu21 rity Act (42 U.S.C. 1395ww(d)(5)(B)) is amended— 

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

23 striking ‘‘subsections (h)(7) and (h)(8)’’ and insert24 ing ‘‘subsections (h)(7), (h)(8), and (h)(9)’’; 


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

2 section 5505(b) of the Patient Protection and Af3 fordable Care Act (Public Law 111–148), as clause 

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

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

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

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

8 1, 2014, insofar as an additional payment amount 

9 under this subparagraph is attributable to resident 

10 positions distributed to a hospital under subsection 

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

12 be computed in the same manner as provided under 

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

14 SEC. 3. ADDITIONAL RULES RELATING TO APPLICATION OF 

15 3-YEAR ROLLING AVERAGE FOR REDISTRIB16 UTED RESIDENCY POSITIONS. 

17 (a) ELIMINATION OF 3-YEAR ROLLING AVERAGE RE18 LATING TO REDISTRIBUTIONS AFTER A HOSPITAL

19 CLOSES AND UNDER PPACA REDISTRIBUTIONS.— 

20 (1) DGME.— 

21 (A) REDISTRIBUTION OF RESIDENCY

22 SLOTS AFTER A HOSPITAL CLOSES.— 

23 (i) IN GENERAL.—Section 

24 1886(h)(4)(H)(vi) of the Social Security 

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


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1 amended by adding at the end the fol2 lowing new subclause: 

3 ‘‘(VI) THREE-YEAR ROLLING AV4 ERAGE INAPPLICABLE.—In applying 

5 subparagraph (G), in the case of addi6 tional residency positions in a hospital 

7 attributable to the increase in the oth8 erwise applicable resident limit pro9 vided under this paragraph pursuant 

10 to this clause, the reference to ‘the av11 erage of the actual full-time equiva12 lent resident counts for the cost re13 porting period and the preceding two 

14 cost reporting periods’ shall be 

15 deemed to be a reference to ‘the ac16 tual full-time equivalent residents 

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

18 (ii) EFFECTIVE DATE.—The amend19 ment made by clause (i) shall apply with 

20 respect to hospitals with an approved med21 ical residency program that closes on or 

22 after March 23, 2008. 

23 (B) DISTRIBUTION OF ADDITIONAL RESI24 DENCY SLOTS UNDER PPACA.— 


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1 (i) IN GENERAL.—Section 1886(h)(8) 

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

3 1395ww(h)(8)) is amended by adding at 

4 the end the following new subparagraph: 

5 ‘‘(J) THREE-YEAR ROLLING AVERAGE IN6 APPLICABLE.—In applying paragraph (4)(G), in 

7 the case of additional residency positions in a 

8 hospital attributable to the increase in the oth9 erwise applicable resident limit provided under 

10 this paragraph, the reference to ‘the average of 

11 the actual full-time equivalent resident counts 

12 for the cost reporting period and the preceding 

13 two cost reporting periods’ shall be deemed to 

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

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

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

18 respect to cost reporting periods occurring 

19 on or after July 1, 2011. 

20 (2) 3-YEAR ROLLING AVERAGE AND INTERN

21 AND RESIDENT BED RATIO CAP INAPPLICABLE

22 UNDER IME.— 

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

24 of the Social Security Act (42 U.S.C. 1395 


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1 ww(d)(5)(B)), as amended by section 2(b), is 

2 further amended— 

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

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

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

6 clauses (xiii) and (xiv)’’; and 

7 (ii) by adding at the end the following 

8 new clauses: 

9 ‘‘(xiii) In the case of additional resi10 dency positions in a hospital attributable 

11 to the increase in the otherwise applicable 

12 resident limit provided under subsection 

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

14 clause (vi)(II) shall be applied be deeming 

15 the reference to ‘the average of the actual 

16 full-time equivalent resident count for the 

17 cost reporting period and the preceding 

18 two cost reporting periods’ to be a ref19 erence to ‘the actual full-time equivalent 

20 resident count for the cost reporting pe21 riod’. 

22 ‘‘(xiv) In the case of additional resi23 dency positions in a hospital attributable 

24 to the increase in the otherwise applicable 

25 resident limit provided under subsection 


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

2 hospital’s full-time equivalent interns and 

3 residents to beds shall be equal to the ratio 

4 for the hospital’s current cost reporting pe5 riod.’’. 

6 (B) EFFECTIVE DATE.—The amendments 

7 made by subparagraph (A) shall apply— 

8 (i) to the extent such amendments re9 late to section 1886(h)(4)(H)(vi) of the So10 cial Security Act, as if included in the en11 actment of section 5506 of the Patient 

12 Protection and Affordable Care Act; and 

13 (ii) to the extent such amendments re14 late to section 1886(h)(8) of the Social Se15 curity Act, as if included in the enactment 

16 of section 5503 of the Patient Protection 

17 and Affordable Care Act. 

18 (b) ELIMINATION OF 3-YEAR ROLLING AVERAGE

19 AND INTERN AND RESIDENT BED RATIO CAP BEGINNING

20 IN 2013.— 

21 (1) DGME.—Section 1886(h)(4)(G) of the So22 cial Security Act (42 U.S.C. 1395ww(h)(4)(G)) is 

23 amended— 


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

2 December 31, 2012,’’ after ‘‘October 1, 1997,’’; 

3 and 

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

5 clause: 

6 ‘‘(iv) CURRENT YEAR COUNT USED TO

7 DETERMINE FULL-TIME EQUIVALENT RESI8 DENT COUNT.—For cost reporting periods 

9 beginning on or after December 31, 2012, 

10 subject to the limit described in subpara11 graph (F), the total number of full-time 

12 equivalent residents for determining a hos13 pital’s graduate medical education payment 

14 shall equal the actual full-time equivalent 

15 residents count for the hospital’s cost re16 porting period.’’. 

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

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

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

20 adding at the end the following new clauses: 

21 ‘‘(xv) For cost reporting periods be22 ginning on or after December 31, 2012, 

23 subject to the limits described in clauses 

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

25 equivalent residents for payment purposes 


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1 shall equal the actual full-time equivalent 

2 resident count for the hospital’s cost re3 porting period. 

4 ‘‘(xvi) For cost reporting periods be5 ginning on or after December 31, 2012, 

6 the ratio of the hospital’s full-time equiva7 lent interns and residents to beds shall be 

8 equal to the ratio for the hospital’s cost re9 porting period.’’. 

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

11 RESIDENTS. 

12 (a) DGME.—Section 1886(h)(4) of the Social Secu13 rity Act (42 U.S.C. 1395ww(h)(4)) is amended— 

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

15 to subparagraphs (J) and (K), such rules’’ and in16 serting ‘‘Subject to subparagraphs (J), (K), and (L), 

17 such rules’’; 

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

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

20 such rules’’ 

21 (3) in subparagraph (K), by striking ‘‘In deter22 mining’’ and inserting ‘‘Subject to subparagraph 

23 (L), in determining’’; and 

24 (4) by adding at the end the following new sub25 paragraph: 


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1 ‘‘(L) TREATMENT OF TIME SPENT IN AP2 PROVED MEDICAL RESIDENCY TRAINING PRO3 GRAM WITH RESPECT TO CERTAIN HOS4 PITALS.—For purposes of cost reporting peri5 ods beginning on or after July 1, 2014, in de6 termining the number of full-time equivalent 

7 residents of the hospital for purposes of this 

8 paragraph, all the time spent by an intern or 

9 resident in an approved medical residency train10 ing program, regardless of setting, shall be 

11 counted toward the determination of full-time 

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

13 shall not apply, if the hospital— 

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

15 hospital; 

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

17 Puerto Rico hospital; 

18 ‘‘(iii) is reimbursed under a reim19 bursement system authorized under section 

20 1814(b)(3); or 

21 ‘‘(iv) is a provider-based hospital out22 patient department.’’. 

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

24 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

25 1395ww(d)(5)(B)) is amended— 


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

3 in determining’’; 

4 (2) in subclause (III), by striking ‘‘In deter5 mining’’ and inserting ‘‘Subject to subclause (x)(IV), 

6 in determining’’; and 

7 (3) by adding at the end the following new sub8 clause: 

9 ‘‘(IV) The provisions of subpara10 graph (L) of subsection (h)(4) shall 

11 apply under this subparagraph in the 

12 same manner as they apply under 

13 such subsection.’’. 

14 SEC. 5. TREATMENT OF HOSPITALS WITH ROTATING RESI15 DENTS. 

16 Section 1886(h)(2)(F) of the Social Security Act (42 

17 U.S.C. 1395ww(h)(2)(F)) is amended by adding at the 

18 end the following sentence: ‘‘In applying this subpara19 graph for cost reporting periods beginning on or after July 

20 1, 2013, the Secretary shall not treat a cost reporting pe21 riod for which a hospital trains residents participating in 

22 a program of another hospital as a period for which the 

23 hospital has an approved medical residency training pro24 gram.’’. 


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1 SEC. 6. AGGREGATION RULES RELATING TO APPLYING 

2 LIMITATION ON NUMBER OF RESIDENTS. 

3 (a) REQUIRED RULES TO PERMIT MEMBERS OF

4 SAME AFFILIATED GROUP TO ELECT TO APPLY LIMITA5 TION ON AGGREGATE LEVEL.—Section 1886(h)(4)(H)(ii) 

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

7 1395ww(h)(4)(H)(ii)) is amended by striking ‘‘may’’ and 

8 inserting ‘‘shall’’. 

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

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

11 sentence: ‘‘Such rules shall provide that all facilities estab12 lished on or after January 1, 2000, whose resident limits 

13 are adjusted according to this subparagraph on or after 

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

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

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

17 from the date of such adjustment.’’. 

18 SEC. 7. PERIOD OF BOARD ELIGIBILITY FOR RESIDENTS 

19 WHO CHANGE PROGRAMS. 

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

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

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

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

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

25 clause: 


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

2 changes residency specialties, the period of 

3 board eligibility and the initial residency 

4 period shall be equal to the minimum num5 ber of years of formal training required to 

6 satisfy the requirements for the initial 

7 board eligibility of the program into which 

8 the resident transfers.’’. 

9 SEC. 8. MEDICARE INDIRECT MEDICAL EDUCATION PER10 FORMANCE ADJUSTMENT. 

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

12 1395ww) is amended— 

13 (1) in subsection (d)(5)(B), in the matter pre14 ceding clause (i), by inserting ‘‘subject to subsection 

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

16 (2) by adding at the end the following new sub17 section: 

18 ‘‘(t) INDIRECT MEDICAL EDUCATION PERFORMANCE

19 ADJUSTMENTS.— 

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

21 provisions of this subsection, the Secretary shall es22 tablish and implement procedures under which the 

23 amount of payments that a hospital (as defined in 

24 paragraph (11)) would otherwise receive for indirect 

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


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1 for discharges occurring during a fiscal year is ad2 justed based on the reporting of measures and the 

3 performance of the hospital on measures of patient 

4 care priorities specified by the Secretary. 

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

6 2018.—The adjustments shall apply to payments for 

7 discharges occurring— 

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

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

10 year 2018; and 

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

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

13 after October 1, 2018. 

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

15 priorities specified by the Secretary under this sub16 section shall include the extent of training provided 

17 in— 

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

19 evaluation and management codes by the Cen20 ters for Medicare & Medicaid Services; 

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

22 ‘‘(C) the coordination of patient care 

23 across settings; 

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

25 diagnostic and treatment options; 


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1 ‘‘(E) interprofessional and multidisci2 plinary care teams; 

3 ‘‘(F) methods for identifying system errors 

4 and implementing system solutions; and 

5 ‘‘(G) the use of health information tech6 nology. 

7 ‘‘(4) MEASURE DEVELOPMENT PROCESS.— 

8 ‘‘(A) IN GENERAL.—The measures of pa9 tient care specified by the Secretary under this 

10 subsection— 

11 ‘‘(i) shall— 

12 ‘‘(I) be measures that have been 

13 adopted or endorsed by an accrediting 

14 organization (such as the Accredita15 tion Council for Graduate Medical 

16 Education or American Osteopathic 

17 Association); and 

18 ‘‘(II) be measures that the Sec19 retary identifies as having used a con20 sensus-based process for developing 

21 such measures; and 

22 ‘‘(ii) may include measures that have 

23 been submitted by teaching hospitals and 

24 medical schools. 


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1 ‘‘(B) PROPOSED SET OF INITIAL MEAS2 URES.—Not later than July 1, 2015, the Sec3 retary shall publish in the Federal Register a 

4 proposed initial set of measures for use under 

5 this subsection. The Secretary shall provide for 

6 a period of public comment on such measures. 

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

8 Not later than January 1, 2016, the Secretary 

9 shall publish in the Federal Register the set of 

10 initial measures to be specified by the Secretary 

11 for use under this subsection. 

12 ‘‘(D) UPDATE OF MEASURES.—The Sec13 retary may, through notice and comment rule14 making, periodically update the measures speci15 fied under this subsection pursuant to the re16 quirements under subparagraph (A). 

17 ‘‘(5) PERFORMANCE STANDARDS.—The Sec18 retary shall establish performance standards with re19 spect to measures specified by the Secretary under 

20 this subsection for a performance period for a fiscal 

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

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

23 shall establish the performance period for a fiscal 

24 year. Such performance period shall begin and end 

25 prior to the beginning of such fiscal year. 


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1 ‘‘(7) REPORTING OF MEASURES.—The proce2 dures established and implemented under paragraph 

3 (1) shall include a process under which hospitals 

4 shall submit data on the measures specified by the 

5 Secretary under this subsection to the Secretary in 

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

7 Secretary for purposes of this subsection. 

8 ‘‘(8) ADJUSTMENTS.— 

9 ‘‘(A) REPORTING FOR FISCAL YEAR 2018.— 

10 For fiscal year 2018, in the case of a hospital 

11 that does not submit, to the Secretary in ac12 cordance with this subsection, data required to 

13 be submitted under paragraph (7) for a period 

14 (determined appropriate by the Secretary) for 

15 such fiscal year, the total amount that the hos16 pital would otherwise receive under subsection 

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

18 shall be reduced by 0.5 percent. 

19 ‘‘(B) PERFORMANCE FOR FISCAL YEAR

20 2019 AND SUBSEQUENT FISCAL YEARS.— 

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

22 (ii), based on the performance of each hos23 pital with respect to compliance with the 

24 measures for a performance period for a 

25 fiscal year (beginning with fiscal year 


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1 2019), the Secretary shall determine the 

2 amount of any adjustment under this sub3 paragraph to payments to the hospital 

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

5 in such fiscal year. Such adjustment may 

6 not exceed an amount equal to 2 percent 

7 of the total amount that the hospital would 

8 otherwise receive under such subsection for 

9 discharges in such fiscal year. 

10 ‘‘(ii) BUDGET NEUTRAL.—In making 

11 adjustments under this subparagraph, the 

12 Secretary shall ensure that the total 

13 amount of payments made to all hospitals 

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

15 in a fiscal year is equal to the total amount 

16 of payments that would have been made to 

17 such hospitals under such subsection for 

18 discharges in such fiscal year if this sub19 section had not been enacted. 

20 ‘‘(9) NO EFFECT IN SUBSEQUENT FISCAL

21 YEARS.—Any adjustment under subparagraph (A) 

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

23 to the fiscal year involved, and the Secretary shall 

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1 ing payments to a hospital under this section in a 

2 subsequent fiscal year. 

3 ‘‘(10) EVALUATION OF SUBMISSION OF PER4 FORMANCE MEASURES.—Not later than January 1, 

5 2018, the Secretary shall submit to Congress a re6 port on the implementation of this subsection, in7 cluding— 

8 ‘‘(A) the measure development procedures, 

9 including any barriers to measure development; 

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

11 performance measures, including any barriers 

12 to such compliance; and 

13 ‘‘(C) recommendations to address any bar14 riers described in subparagraph (A) or (B). 

15 ‘‘(11) DEFINITION OF HOSPITAL.—In this sub16 section, the term ‘hospital’ means a hospital that re17 ceives payments under subsection (d)(5)(B).’’. 

18 SEC. 9. INCREASING GRADUATE MEDICAL EDUCATION 

19 TRANSPARENCY. 

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

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

22 the Secretary of Health and Human Services shall submit 

23 to Congress and the National Health Care Workforce 

24 Commission a report on the graduate medical education 

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1 gram. The report shall include the following information 

2 with respect to each hospital that receives such payments: 

3 (1) The direct graduate medical education pay4 ments made to the hospital under section 1886(h) of 

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

6 (2) The total costs of direct graduate medical 

7 education to the hospital as reported on the annual 

8 Medicare Cost Reports. 

9 (3) The indirect medical education payments 

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

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

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

13 counted for purposes of making the payments de14 scribed in paragraph (1). 

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

16 counted for purposes of making the payments de17 scribed in paragraph (3). 

18 (6) The number of full-time-equivalent resi19 dents, if any, that are not counted for purposes of 

20 making payments described in paragraph (1). 

21 (7) The number of full-time-equivalent resi22 dents, if any, that are not counted for purposes of 

23 making payments described in paragraph (3). 

24 (8) The factors contributing to the higher costs 

25 of patient care provided by the hospital, including— 


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1 (A) the costs of trauma, burn, other stand2 by services; 

3 (B) translation services for disabled or 

4 non-English speaking patients; 

5 (C) the cost of uncompensated care; 

6 (D) financial losses with respect to Med7 icaid patients; and 

8 (E) uncompensated costs of clinical re9 search. 

10 SEC. 10. GAO STUDIES AND REPORTS. 

11 (a) ON PHYSICIAN WORKFORCE.— 

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

13 United States shall conduct a study on the physician 

14 workforce. Such study shall include the identification 

15 of physician specialties for which there is a shortage, 

16 as defined by the Comptroller General. 

17 (2) REPORT.—Not later than January 1, 2015, 

18 the Comptroller General shall submit to Congress a 

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

20 together with recommendations for such legislation 

21 and administrative action as the Comptroller Gen22 eral determines appropriate. 

23 (b) ON STRATEGIES FOR INCREASING DIVERSITY.— 

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

25 United States shall conduct a study on strategies for 


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1 increasing the diversity of the health professional 

2 workforce. Such study shall include an analysis of 

3 strategies for increasing the number of health pro4 fessionals from rural, lower income, and under-rep5 resented minority communities, including which 

6 strategies are most effective for achieving such goal. 

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

8 date of enactment of this Act, the Comptroller Gen9 eral shall submit to Congress a report on the study 

10 conducted under subsection (a), together with rec11 ommendations for such legislation and administra12 tive action as the Comptroller General determines 

13 appropriate. 

14 (c) ON PROTECTING OLDER ADULTS.— 

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

16 United States shall conduct a study that addresses 

17 the competency of the physician workforce to care 

18 for older adults upon the completion of such 

19 workforce’s residency training. 

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

21 date of the enactment of this Act, the Comptroller 

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1 tion and administrative action as the Comptroller 

2 General determines appropriate based on such study. 

Æ 


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