I 

113TH CONGRESS 

1ST SESSION H. R. 487 

To provide for a Medicare primary care graduate medical education pilot 

project in order to improve access to the primary care workforce. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 4, 2013 

Mrs. MCMORRIS RODGERS (for herself and Mr. THOMPSON of California) 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 provide for a Medicare primary care graduate medical 

education pilot project in order to improve access to 

the primary care workforce. 

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 ‘‘Primary Care Work5 force Access Improvement Act of 2013’’. 

mstockstill on DSK4VPTVN1PROD with BILLS

2 

•HR 487 IH

1 SEC. 2. MEDICARE PRIMARY CARE GRADUATE MEDICAL 

2 EDUCATION PILOT PROJECT. 

3 (a) ESTABLISHMENT.—The Secretary of Health and 

4 Human Services (in this section referred to as the ‘‘Sec5 retary’’) shall conduct a pilot project under the Medicare 

6 program under title XVIII of the Social Security Act, in 

7 accordance with the provisions of this section, to test mod8 els for providing payment under such title for direct grad9 uate medical education and indirect medical education to 

10 medical education entities, which entities are not otherwise 

11 eligible to receive such payments under the Medicare pro12 gram, for the costs of training primary care residents. 

13 (b) DURATION.—The Secretary shall conduct the 

14 pilot project under this section over a 5-year period, which 

15 shall begin not later than 180 days after the date of the 

16 enactment of this Act. 

17 (c) MODELS.— 

18 (1) REQUIRED MODELS.—Under the pilot 

19 project, the Secretary shall test two of each of the 

20 following models: 

21 (A) A model in which the medical edu22 cation entity receiving funds under the pilot 

23 project is a community-based independent cor24 porate entity collaborating with two or more 

25 hospitals to operate one or more primary care 

26 graduate medical residency training programs. 

mstockstill on DSK4VPTVN1PROD with BILLS

3 

•HR 487 IH

1 (B) A model in which— 

2 (i) the medical education entity receiv3 ing funds under the pilot project is estab4 lished by two or more hospitals to operate 

5 one or more primary care graduate medical 

6 residency training programs; and 

7 (ii) such hospitals may be the sole 

8 corporate members of the entity but the 

9 governing board of the entity shall include 

10 at least one community representative. 

11 (C) A model in which the medical edu12 cation entity receiving funds under the pilot 

13 project is a hospital subsidiary or independent 

14 corporation that operates one or more primary 

15 care graduate medical residency training pro16 grams for a hospital with community participa17 tion in the governance of the subsidiary or cor18 poration. 

19 (D) A model in which— 

20 (i) the medical education entity receiv21 ing funds under the pilot project is inde22 pendent of any hospital but collaborates 

23 with a hospital in operating one or more 

24 primary care graduate medical residency 

25 training programs; and 

mstockstill on DSK4VPTVN1PROD with BILLS

4 

•HR 487 IH

1 (ii) the medical education entity may 

2 include a university or school of medicine. 

3 (2) ADDITIONAL MODELS.—Under the pilot 

4 project, the Secretary may test models of medical 

5 education entities in addition to those described in 

6 paragraph (1). 

7 (d) PRIORITIZATION.—Under the pilot project, the 

8 Secretary of Health and Human Services may give priority 

9 to testing models that demonstrate the capability of im10 proving the quality, quantity, and distribution of primary 

11 care physicians, including the ability to enhance primary 

12 care delivery in rural and underserved areas. 

13 (e) PAYMENTS.— 

14 (1) PAYMENTS TO MEDICAL EDUCATION ENTI15 TIES.—Under the pilot project, the Secretary shall 

16 establish a process under which payments are made 

17 to each medical education entity participating under 

18 such project for direct graduate medical education 

19 and indirect medical education costs with respect to 

20 primary care residents enrolled under a primary care 

21 graduate medical residency training program oper22 ated pursuant to a model of such entity under sub23 section (c) instead of any payment or adjustment 

24 that would otherwise be made to a participant hos25 pital (as defined in subsection (m)) of such entity 

mstockstill on DSK4VPTVN1PROD with BILLS

5 

•HR 487 IH

1 for indirect and direct graduate medical education 

2 costs under subsections (d)(5)(B) and (h) of section 

3 1886 of the Social Security Act (42 U.S.C. 1395ww) 

4 during the period of participation of such entity in 

5 such project. 

6 (2) CALCULATION OF PAYMENTS.—Payments to 

7 a medical education entity under the pilot project, 

8 with respect to a primary care graduate medical 

9 education residency program, for a cost reporting 

10 period during which the entity is participating in 

11 such pilot shall be, based on the most recently avail12 able data with respect to a previous cost reporting 

13 period, equal to the sum of the following: 

14 (A) DIRECT GME.—The amount that, out 

15 of all of the payment amounts (determined on 

16 a per resident basis) received by hospitals under 

17 section 1886(h) of the Social Security Act (42 

18 U.S.C. 1395ww(h)) for such previous cost re19 porting period, is equal to the 95th percentile of 

20 such payment amounts. 

21 (B) INDIRECT GME.—The amount that, 

22 out of all of the additional payment amounts 

23 (determined on a per resident basis) received by 

24 hospitals under section 1886(d)(5)(B) of the 

25 Social Security Act (42 U.S.C. 

mstockstill on DSK4VPTVN1PROD with BILLS

6 

•HR 487 IH

1 1395ww(d)(5)(B)) for such previous cost re2 porting period, is equal to the 95th percentile of 

3 such payment amounts. 

4 (3) ADDITIONAL PAYMENTS FOR PROGRAMS

5 SERVING UNDERSERVED AREAS.—Payments in addi6 tion to the payments described in paragraph (2) may 

7 be made under the pilot project for primary care 

8 graduate medical residency training programs 

9 that— 

10 (A) operate in sites and areas that are un11 derserved by primary care physicians; or 

12 (B) change their training sites to include 

13 those areas. 

14 (4) PAYMENTS FROM MEDICARE TRUST

15 FUNDS.—In providing for such payments under this 

16 subsection to medical education entities, the Sec17 retary shall provide for an allocation of such pay18 ments between part A and part B (and the Federal 

19 Hospital Insurance Trust Fund under section 1817 

20 of the Social Security Act (42 U.S.C. 1395i) and the 

21 Federal Supplementary Medical Insurance Trust 

22 Fund under section 1841 of such Act (42 U.S.C. 

23 1395t)) in the same manner as the Secretary pro24 vides for an allocation of payments under submstockstill on DSK4VPTVN1PROD with BILLS

7 

•HR 487 IH

1 sections (d)(5)(B) and (h), respectively, of section 

2 1886 of such Act (42 U.S.C. 1395ww). 

3 (f) USES OF PAYMENTS.— 

4 (1) IN GENERAL.—A medical education entity 

5 receiving payments under the pilot project shall use 

6 such payments for the training of primary care resi7 dents, including training activities in appropriate in8 patient and outpatient settings in primary care 

9 graduate medical residency training programs ac10 credited by the Accreditation Council for Graduate 

11 Medical Education or the American Osteopathic As12 sociation and for all relevant topics including patient 

13 care, care management, working in teams, super14 vision, and quality improvement. 

15 (2) LIMITATIONS.—Payments shall only be 

16 made for training primary care residents up to the 

17 initial board certification of such residents, except 

18 that with respect to training in geriatric medicine, 

19 payments may also be made for a fellowship after 

20 initial board certification. 

21 (g) EXPANSION DURING PILOT PROJECT.—A med22 ical education entity receiving funds under the pilot 

23 project, with respect to a primary care graduate medical 

24 residency training program, shall be allowed to increase 

25 by up to 50 percent the number of full-time equivalent 

mstockstill on DSK4VPTVN1PROD with BILLS

8 

•HR 487 IH

1 primary care residents enrolled in the such program (de2 termined in accordance with the process under subsection 

3 (e)(1)) during the duration of the participation of such 

4 entity in such project. 

5 (h) TREATMENT AFTER PROJECT.— 

6 (1) IN GENERAL.—Subject to paragraphs (2) 

7 and (3), after the last day of the pilot project, which 

8 may be extended at the discretion of the Secretary, 

9 any participant hospital of a medical education enti10 ty under the pilot project, shall receive payments 

11 under subsection (d)(5)(B) and (h) of section 1886 

12 of the Social Security Act (42 U.S.C. 1395ww) in 

13 the same manner and to the same extent such hos14 pital would receive such payments without applica15 tion of this Act and such payments shall be cal16 culated based on the number of full-time equivalent 

17 residents enrolled in such program without regard to 

18 any increase made pursuant to subsection (g). 

19 (2) EXCEPTION TO ENSURE RESIDENTS EN20 ROLLED DURING PILOT ARE ABLE TO COMPLETE

21 TRAINING.—Subject to paragraph (3), a medical 

22 education entity receiving funds under the pilot 

23 project, with respect to a primary care graduate 

24 medical residency training program, shall continue 

25 to receive funding under this section (even after the 

mstockstill on DSK4VPTVN1PROD with BILLS

9 

•HR 487 IH

1 last day of the project), with respect to each primary 

2 care resident who is enrolled under such program 

3 while the entity is participating in such project, to 

4 the extent and in such amounts necessary to allow 

5 for the full duration of training, subject to sub6 section (f)(2), of such primary care resident. Any 

7 such payments made pursuant to this subparagraph 

8 shall be deemed to be a payment made under the 

9 pilot project. 

10 (3) LIMITATION.—In no case may the total du11 ration of the pilot project exceed seven years and in 

12 no case may payments be made under this section 

13 to a medical education entity for a period exceeding 

14 seven years. 

15 (i) BUDGET NEUTRALITY.—For each year that the 

16 pilot project under this section is being conducted (and 

17 for any subsequent year to the extent subsection (h)(2) 

18 applies), the Secretary shall reduce payments under sub19 sections (d)(5)(B) and (h) of section 1886 of the Social 

20 Security Act (42 U.S.C. 1395ww) by such amount as the 

21 Secretary determines to be necessary to ensure that car22 rying out the pilot project under this section during such 

23 year does not result in expenditures under title XVIII of 

24 the Social Security Act for such year that exceed the 

mstockstill on DSK4VPTVN1PROD with BILLS

10 

•HR 487 IH

1 amount of such expenditures that would have been made 

2 for such year without application of this section. 

3 (j) WAIVER AUTHORITY.—The Secretary may waive 

4 such requirements of titles XI and XVIII of the Social 

5 Security Act as may be necessary to carry out the purpose 

6 of the pilot project under this section. 

7 (k) REPORT TO CONGRESS.—The Secretary is au8 thorized to enter into an agreement with the Institute of 

9 Medicine to conduct a study on the results of the pilot 

10 project. Such agreement shall provide for the Institute of 

11 Medicine to submit, not later than 1 year after the comple12 tion of the pilot project under this section (or, if sooner, 

13 January 1, 2021), to Congress a report on the results of 

14 such study, including— 

15 (1) a detailed analysis of the effects of the pilot, 

16 including the quality, quantity, and distribution of 

17 primary care physicians during and after the pilot 

18 project compared to the quality, quantity, and dis19 tribution of such physicians before the pilot project; 

20 and the governance, administration and financial 

21 strength of the medical educational entities that par22 ticipated in the pilot project; 

23 (2) recommendations on the extent to which the 

24 pilot project should be expanded to all primary care 

25 residents; and 

mstockstill on DSK4VPTVN1PROD with BILLS

11 

•HR 487 IH

1 (3) recommendations for such legislation and 

2 administrative actions as needed. 

3 (l) EXPANSION.—If the Secretary determines that 

4 any of the models tested under the pilot project under this 

5 section enhance the quality, quantity, and distribution of 

6 primary care physicians for Medicare beneficiaries, the 

7 Secretary may initiate comparable primary care training 

8 projects. 

9 (m) DEFINITIONS.—For purposes of this section: 

10 (1) DIRECT GRADUATE MEDICAL EDUCATION

11 COSTS; INDIRECT GRADUATE MEDICAL EDUCATION

12 COSTS.—The terms ‘‘direct graduate medical edu13 cation costs’’ and ‘‘indirect graduate medical edu14 cation’’ have the meanings given such terms for pur15 poses of subsections (h) and (d)(5)(B), respectively, 

16 of section 1886 of the Social Security Act (42 

17 U.S.C. 1395ww). 

18 (2) MEDICAL EDUCATION ENTITY.—The term 

19 ‘‘medical education entity’’ means a corporate, non20 profit, or academic entity that has as its principal 

21 mission the education and training of primary care 

22 residents. 

23 (3) MEDICARE BENEFICIARY.—The term 

24 ‘‘Medicare beneficiary’’ means an individual entitled 

mstockstill on DSK4VPTVN1PROD with BILLS

12 

•HR 487 IH

1 to benefits under part A of title XVIII of the Social 

2 Security Act or enrolled under part B of such title. 

3 (4) PARTICIPANT HOSPITAL.—The term ‘‘par4 ticipant hospital’’ means, with respect to a medical 

5 education entity, any hospital that establishes, is col6 laborating with, a component of, or otherwise associ7 ated with, such entity to operate a primary care 

8 graduate medical residency training program under 

9 a model described in subsection (c). 

10 (5) PRIMARY CARE GRADUATE MEDICAL RESI11 DENCY TRAINING PROGRAM.—The term ‘‘primary 

12 care graduate medical residency training program’’ 

13 means an approved medical residency training pro14 gram (as defined in section 1886(h)(5)(A) of the So15 cial Security Act (42 U.S.C. 1395ww(h)(5)(A))) for 

16 training primary care residents. 

17 (6) PRIMARY CARE RESIDENT.—The term ‘‘pri18 mary care resident’’ means a resident enrolled in an 

19 approved medical residency training program in fam20 ily medicine, general internal medicine, general pedi21 atrics, or geriatric medicine. 

Æ 

mstockstill on DSK4VPTVN1PROD with BILLS