II 

111TH CONGRESS 

1ST SESSION S. 1174 

To amend the Public Health Service Act and the Social Security Act to 

increase the number of primary care physicians and primary care providers and to improve patient access to primary care services, and for 

other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 3, 2009 

Ms. CANTWELL (for herself, Ms. COLLINS, and Mr. WHITEHOUSE) introduced 

the following bill; which was read twice and referred to the Committee 

on Finance 

A BILL 

To amend the Public Health Service Act and the Social 

Security Act to increase the number of primary care 

physicians and primary care providers and to improve 

patient access to primary care services, 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 ‘‘Preserving Patient Access to Primary Care Act of 2009’’. 

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

7 as follows: 


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Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. Definitions. 

TITLE I—MEDICAL EDUCATION 

Sec. 101. Recruitment incentives. 

Sec. 102. Debt forgiveness, scholarships, and service obligations. 

Sec. 103. Deferment of loans during residency and internships. 

Sec. 104. Educating medical students about primary care careers. 

Sec. 105. Training in a family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistant education, general 

dentistry, and pediatric dentistry. 

Sec. 106. Increased funding for National Health Service Corps Scholarship and 

Loan Repayment Programs. 

TITLE II—MEDICAID RELATED PROVISIONS 

Sec. 201. Transformation grants to support patient centered medical homes 

under Medicaid and CHIP. 

TITLE III—MEDICARE PROVISIONS 

Subtitle A—Primary Care 

Sec. 301. Reforming payment systems under Medicare to support primary care. 

Sec. 302. Coverage of patient centered medical home services. 

Sec. 303. Medicare primary care payment equity and access provision. 

Sec. 304. Additional incentive payment program for primary care services furnished in health professional shortage areas. 

Sec. 305. Permanent extension of floor on Medicare work geographic adjustment under the Medicare physician fee schedule. 

Sec. 306. Permanent extension of Medicare incentive payment program for physician scarcity areas. 

Sec. 307. HHS study and report on the process for determining relative value 

under the Medicare physician fee schedule. 

Subtitle B—Preventive Services 

Sec. 311. Eliminating time restriction for initial preventive physical examination. 

Sec. 312. Elimination of cost-sharing for preventive benefits under the Medicare program. 

Sec. 313. HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries. 

Subtitle C—Other Provisions 

Sec. 321. HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D. 

Sec. 322. HHS study and report on improved patient care through increased 

caregiver and physician interaction. 

Sec. 323. Improved patient care through expanded support for limited English 

proficiency (LEP) services. 

Sec. 324. HHS study and report on use of real-time Medicare claims adjudication. 


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Sec. 325. Ongoing assessment by MedPAC of the impact of medicare payments 

on primary care access and equity. 

Sec. 326. Distribution of additional residency positions. 

Sec. 327. Counting resident time in outpatient settings. 

Sec. 328. Rules for counting resident time for didactic and scholarly activities 

and other activities. 

Sec. 329. Preservation of resident cap positions from closed and acquired hospitals. 

Sec. 330. Quality improvement organization assistance for physician practices 

seeking to be patient centered medical home practices. 

TITLE IV—STUDIES 

Sec. 401. Study concerning the designation of primary care as a shortage profession. 

Sec. 402. Study concerning the education debt of medical school graduates. 

Sec. 403. Study on minority representation in primary care. 

1 SEC. 2. FINDINGS. 

2 Congress makes the following findings: 

3 (1) Approximately 21 percent of physicians who 

4 were board certified in general internal medicine 

5 during the early 1990s have left internal medicine, 

6 compared to a 5 percent departure rate for those 

7 who were certified in subspecialties of internal medi8 cine. 

9 (2) The number of United States medical grad10 uates going into family medicine has fallen by more 

11 than 50 percent from 1997 to 2005. 

12 (3) In 2007, only 88 percent of the available 

13 medicine residency positions were filled and only 42 

14 percent of those were filled by United States medical 

15 school graduates. 

16 (4) In 2006, only 24 percent of third-year inter17 nal medicine resident intended to pursue careers in 


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1 general internal medicine, down from 54 percent in 

2 1998. 

3 (5) Primary care physicians serve as the point 

4 of first contact for most patients and are able to co5 ordinate the care of the whole person, reducing un6 necessary care and duplicative testing. 

7 (6) Primary care physicians and primary care 

8 providers practicing preventive care, including 

9 screening for illness and treating diseases, can help 

10 prevent complications that result in more costly 

11 care. 

12 (7) Patients with primary care physicians or 

13 primary care providers have lower health care ex14 penditures and primary care is correlated with better 

15 health status, lower overall mortality, and longer life 

16 expectancy. 

17 (8) Higher proportions of primary care physi18 cians are associated with significantly reduced utili19 zation. 

20 (9) The United States has a higher ratio of spe21 cialists to primary care physicians than other indus22 trialized nations and the population of the United 

23 States is growing faster than the expected rate of 

24 growth in the supply of primary care physicians. 


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1 (10) The number of Americans age 65 and 

2 older, those eligible for Medicare and who use far 

3 more ambulatory care visits per person as those 

4 under age 65, is expected to double from 2000 to 

5 2030. 

6 (11) A decrease in Federal spending to carry 

7 out programs authorized by title VII of the Public 

8 Health Service Act threatens the viability of one of 

9 the programs used to solve the problem of inad10 equate access to primary care. 

11 (12) The National Health Service Corps pro12 gram has a proven record of supplying physicians to 

13 underserved areas, and has played an important role 

14 in expanding access for underserved populations in 

15 rural and inner city communities. 

16 (13) Individuals in many geographic areas, es17 pecially rural areas, lack adequate access to high 

18 quality preventive, primary health care, contributing 

19 to significant health disparities that impair Amer20 ica’s public health and economic productivity. 

21 (14) About 20 percent of the population of the 

22 United States resides in primary medical care 

23 Health Professional Shortage Areas. 

24 SEC. 3. DEFINITIONS. 

25 (a) GENERAL DEFINITIONS.—In this Act: 


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1 (1) CHRONIC CARE COORDINATION.—The term 

2 ‘‘chronic care coordination’’ means the coordination 

3 of services that is based on the Chronic Care Model 

4 that provides on-going health care to patients with 

5 chronic diseases that may include any of the fol6 lowing services: 

7 (A) The development of an initial plan of 

8 care, and subsequent appropriate revisions to 

9 such plan of care. 

10 (B) The management of, and referral for, 

11 medical and other health services, including 

12 interdisciplinary care conferences and manage13 ment with other providers. 

14 (C) The monitoring and management of 

15 medications. 

16 (D) Patient education and counseling serv17 ices. 

18 (E) Family caregiver education and coun19 seling services. 

20 (F) Self-management services, including 

21 health education and risk appraisal to identify 

22 behavioral risk factors through self-assessment. 

23 (G) Providing access by telephone with 

24 physicians and other appropriate health care 


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1 professionals, including 24-hour availability of 

2 such professionals for emergencies. 

3 (H) Management with the principal non4 professional caregiver in the home. 

5 (I) Managing and facilitating transitions 

6 among health care professionals and across set7 tings of care, including the following: 

8 (i) Pursuing the treatment option 

9 elected by the individual. 

10 (ii) Including any advance directive 

11 executed by the individual in the medical 

12 file of the individual. 

13 (J) Information about, and referral to, 

14 hospice care, including patient and family care15 giver education and counseling about hospice 

16 care, and facilitating transition to hospice care 

17 when elected. 

18 (K) Information about, referral to, and 

19 management with, community services. 

20 (2) CRITICAL SHORTAGE HEALTH FACILITY.— 

21 The term ‘‘critical shortage health facility’’ means a 

22 public or private nonprofit health facility that does 

23 not serve a health professional shortage area (as 

24 designated under section 332 of the Public Health 

25 Service Act), but that has a critical shortage of phyVerDate Nov 24 2008 01:24 Jun 04, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1174.IS S1174

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1 sicians (as determined by the Secretary) in a pri2 mary care field. 

3 (3) PHYSICIAN.—The term physician has the 

4 meaning given such term in section 1861(r)(1) of 

5 the Social Security Act. 

6 (4) PRIMARY CARE.—The term ‘‘primary care’’ 

7 means the provision of integrated, high-quality, ac8 cessible health care services by health care providers 

9 who are accountable for addressing a full range of 

10 personal health and health care needs, developing a 

11 sustained partnership with patients, practicing in 

12 the context of family and community, and working 

13 to minimize disparities across population subgroups. 

14 (5) PRIMARY CARE FIELD.—The term ‘‘primary 

15 care field’’ means any of the following fields: 

16 (A) The field of family medicine. 

17 (B) The field of general internal medicine. 

18 (C) The field of geriatric medicine. 

19 (D) The field of pediatric medicine 

20 (6) PRIMARY CARE PHYSICIAN.—The term ‘‘pri21 mary care physician’’ means a physician who is 

22 trained in a primary care field who provides first 

23 contact, continuous, and comprehensive care to pa24 tients. 


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1 (7) PRIMARY CARE PROVIDER.—The term ‘‘pri2 mary care provider’’ means— 

3 (A) a nurse practitioner; or 

4 (B) a physician assistant practicing as a 

5 member of a physician-directed team; 

6 who provides first contact, continuous, and com7 prehensive care to patients. 

8 (8) PRINCIPAL CARE.—The term ‘‘principal 

9 care’’ means integrated, accessible health care that 

10 is provided by a physician who is a medical sub11 specialist that addresses the majority of the personal 

12 health care needs of patients with chronic conditions 

13 requiring the subspecialist’s expertise, and for whom 

14 the subspecialist assumes care management, devel15 oping a sustained physician-patient partnership and 

16 practicing within the context of family and commu17 nity. 

18 (9) SECRETARY.—The term ‘‘Secretary’’ means 

19 the Secretary of Health and Human Services. 

20 (b) PRIMARY MEDICAL CARE SHORTAGE AREA.— 

21 (1) IN GENERAL.—In this Act, the term ‘‘pri22 mary medical care shortage area’’ or ‘‘PMCSA’’ 

23 means a geographic area with a shortage of physi24 cians (as designated by the Secretary) in a primary 


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1 care field, as designated in accordance with para2 graph (2). 

3 (2) DESIGNATION.—To be designated by the 

4 Secretary as a PMCSA, the Secretary must find 

5 that the geographic area involved has an established 

6 shortage of primary care physicians for the popu7 lation served. The Secretary shall make such a des8 ignation with respect to an urban or rural geo9 graphic area if the following criteria are met: 

10 (A) The area is a rational area for the de11 livery of primary care services. 

12 (B) One of the following conditions pre13 vails within the area: 

14 (i) The area has a population to full15 time-equivalent primary care physician 

16 ratio of at least 3,500 to 1. 

17 (ii) The area has a population to full18 time-equivalent primary care physician 

19 ratio of less than 3,500 to 1 and has un20 usually high needs for primary care serv21 ices or insufficient capacity of existing pri22 mary care providers. 

23 (C) Primary care providers in contiguous 

24 geographic areas are overutilized. 

25 (c) MEDICALLY UNDERSERVED AREA.— 


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1 (1) IN GENERAL.—In this Act, the term ‘‘medi2 cally underserved area’’ or ‘‘MUA’’ means a rational 

3 service area with a demonstrable shortage of pri4 mary health care resources relative to the needs of 

5 the entire population within the service area as de6 termined in accordance with paragraph (2) through 

7 the use of the Index of Medical Underservice (re8 ferred to in this subsection as the ‘‘IMU’’) with re9 spect to data on a service area. 

10 (2) DETERMINATIONS.—Under criteria to be 

11 established by the Secretary with respect to the 

12 IMU, if a service area is determined by the Sec13 retary to have a score of 62.0 or less, such area shall 

14 be eligible to be designated as a MUA. 

15 (3) IMU VARIABLES.—In establishing criteria 

16 under paragraph (2), the Secretary shall ensure that 

17 the following variables are utilized: 

18 (A) The ratio of primary medical care phy19 sicians per 1,000 individuals in the population 

20 of the area involved. 

21 (B) The infant mortality rate in the area 

22 involved. 

23 (C) The percentage of the population in24 volved with incomes below the poverty level. 


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1 (D) The percentage of the population in2 volved age 65 or over. 

3 The value of each of such variables for the service 

4 area involved shall be converted by the Secretary to 

5 a weighted value, according to established criteria, 

6 and added together to obtain the area’s IMU score. 

7 (d) PATIENT CENTERED MEDICAL HOME.— 

8 (1) IN GENERAL.—In this Act, the term ‘‘pa9 tient centered medical home’’ means a physician-di10 rected practice (or a nurse practitioner-directed 

11 practice in those States in which such functions are 

12 included in the scope of practice of licensed nurse 

13 practitioners) that has been certified by an organiza14 tion under paragraph (3) as meeting the following 

15 standards: 

16 (A) The practice provides patients who 

17 elect to obtain care through a patient centered 

18 medical home (referred to as ‘‘participating pa19 tients’’) with direct and ongoing access to a pri20 mary or principal care physician or a primary 

21 care provider who accepts responsibility for pro22 viding first contact, continuous, and comprehen23 sive care to the whole person, in collaboration 

24 with teams of other health professionals, includVerDate Nov 24 2008 01:24 Jun 04, 2009 Jkt 079200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S1174.IS S1174

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1 ing nurses and specialist physicians, as needed 

2 and appropriate. 

3 (B) The practice applies standards for ac4 cess to care and communication with partici5 pating beneficiaries. 

6 (C) The practice has readily accessible, 

7 clinically useful information on participating pa8 tients that enables the practice to treat such 

9 patients comprehensively and systematically. 

10 (D) The practice maintains continuous re11 lationships with participating patients by imple12 menting evidence-based guidelines and applying 

13 such guidelines to the identified needs of indi14 vidual beneficiaries over time and with the in15 tensity needed by such beneficiaries. 

16 (2) RECOGNITION OF NCQA APPROVAL.—Such 

17 term also includes a physician-directed (or nurse18 practitioner-directed) practice that has been recog19 nized as a medical home through the Physician 

20 Practice Connections—patient centered Medical 

21 Home (‘‘PPC–PCMH’’) voluntary recognition proc22 ess of the National Committee for Quality Assur23 ance. 

24 (3) STANDARD SETTING AND QUALIFICATION

25 PROCESS FOR MEDICAL HOMES.—The Secretary 


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1 shall establish a process for the selection of a quali2 fied standard setting and certification organiza3 tion— 

4 (A) to establish standards, consistent with 

5 this subsection, to enable medical practices to 

6 qualify as patient centered medical homes; and 

7 (B) to provide for the review and certifi8 cation of medical practices as meeting such 

9 standards. 

10 (4) TREATMENT OF CERTAIN PRACTICES.— 

11 Nothing in this section shall be construed as pre12 venting a nurse practitioner from leading a patient13 centered medical home so long as— 

14 (A) all of the requirements of this section 

15 are met; and 

16 (B) the nurse practitioner is acting con17 sistently with State law. 

18 (e) APPLICATION UNDER MEDICARE, MEDICAID, 

19 PHSA, ETC.—Unless otherwise provided, the provisions of 

20 the previous subsections shall apply for purposes of provi21 sions of the Social Security Act, the Public Health Service 

22 Act, and any other Act amended by this Act. 


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1 TITLE I—MEDICAL EDUCATION 

2 SEC. 101. RECRUITMENT INCENTIVES. 

3 Title VII of the Higher Education Act of 1965 (20 

4 U.S.C. 1133 et seq.) is amended by adding at the end 

5 the following: 

6 ‘‘PART F—MEDICAL EDUCATION RECRUITMENT 

7 INCENTIVES 

8 ‘‘SEC. 786. MEDICAL EDUCATION RECRUITMENT INCEN9 TIVES. 

10 ‘‘(a) IN GENERAL.—The Secretary is authorized to 

11 award grants or contracts to institutions of higher edu12 cation that are graduate medical schools, to enable the 

13 graduate medical schools to improve primary care edu14 cation and training for medical students. 

15 ‘‘(b) APPLICATION.—A graduate medical school that 

16 desires to receive a grant under this section shall submit 

17 to the Secretary an application at such time, in such man18 ner, and containing such information as the Secretary may 

19 require. 

20 ‘‘(c) USES OF FUNDS.—A graduate medical school 

21 that receives a grant under this section shall use such 

22 grant funds to carry out 1 or more of the following: 

23 ‘‘(1) The creation of primary care mentorship 

24 programs. 


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1 ‘‘(2) Curriculum development for population2 based primary care models of care, such as the pa3 tient centered medical home. 

4 ‘‘(3) Increased opportunities for ambulatory, 

5 community-based training. 

6 ‘‘(4) Development of generalist curriculum to 

7 enhance care for rural and underserved populations 

8 in primary care or general surgery. 

9 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

10 is authorized to be appropriated to carry out this section 

11 $50,000,000 for each of the fiscal years 2010 through 

12 2012.’’. 

13 SEC. 102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERV14 ICE OBLIGATIONS. 

15 (a) PURPOSE.—It is the purpose of this section to 

16 encourage individuals to enter and continue in primary 

17 care physician careers. 

18 (b) AMENDMENT TO THE PUBLIC HEALTH SERVICE

19 ACT.—Part D of title III of the Public Health Service Act 

20 (42 U.S.C. 254b et seq.) is amended by adding at the end 

21 the following: 

22 ‘‘Subpart XI—Primary Care Medical Education 

23 ‘‘SEC. 340I. SCHOLARSHIPS. 

24 ‘‘(a) IN GENERAL.—The Secretary, acting through 

25 the Administrator of the Health Resources and Services 


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1 Administration, shall award grants to critical shortage 

2 health facilities to enable such facilities to provide scholar3 ships to individuals who agree to serve as physicians at 

4 such facilities after completing a residency in a primary 

5 care field (as defined in section 3(a)(5) of the Preserving 

6 Patient Access to Primary Care Act of 2009). 

7 ‘‘(b) SCHOLARSHIPS.—A health facility shall use 

8 amounts received under a grant under this section to enter 

9 into contracts with eligible individuals under which— 

10 ‘‘(1) the facility agrees to provide the individual 

11 with a scholarship for each school year (not to ex12 ceed 4 school years) in which the individual is en13 rolled as a full-time student in a school of medicine 

14 or a school of osteopathic medicine; and 

15 ‘‘(2) the individual agrees— 

16 ‘‘(A) to maintain an acceptable level of 

17 academic standing; 

18 ‘‘(B) to complete a residency in a primary 

19 care field; and 

20 ‘‘(C) after completing the residency, to 

21 serve as a primary care physician at such facil22 ity in such field for a time period equal to the 

23 greater of— 


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1 ‘‘(i) one year for each school year for 

2 which the individual was provided a schol3 arship under this section; or 

4 ‘‘(ii) two years. 

5 ‘‘(c) AMOUNT.— 

6 ‘‘(1) IN GENERAL.—The amount paid by a 

7 health facility to an individual under a scholarship 

8 under this section shall not exceed $35,000 for any 

9 school year. 

10 ‘‘(2) CONSIDERATIONS.—In determining the 

11 amount of a scholarship to be provided to an indi12 vidual under this section, a health facility may take 

13 into consideration the individual’s financial need, ge14 ographic differences, and educational costs. 

15 ‘‘(3) EXCLUSION FROM GROSS INCOME.—For 

16 purposes of the Internal Revenue Code of 1986, 

17 gross income shall not include any amount received 

18 as a scholarship under this section. 

19 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

20 provisions of subpart III of part D shall, except as incon21 sistent with this section, apply to the program established 

22 in subsection (a) in the same manner and to the same 

23 extent as such provisions apply to the National Health 

24 Service Corps Scholarship Program established in such 

25 subpart. 


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1 ‘‘(e) DEFINITIONS.—In this section: 

2 ‘‘(1) CRITICAL SHORTAGE HEALTH FACILITY.— 

3 The term ‘critical shortage health facility’ means a 

4 public or private nonprofit health facility that does 

5 not serve a health professional shortage area (as 

6 designated under section 332), but has a critical 

7 shortage of physicians (as determined by the Sec8 retary) in a primary care field. 

9 ‘‘(2) ELIGIBLE INDIVIDUAL.—The term ‘eligible 

10 individual’ means an individual who is enrolled, or 

11 accepted for enrollment, as a full-time student in an 

12 accredited school of medicine or school of osteo13 pathic medicine. 

14 ‘‘SEC. 340J. LOAN REPAYMENT PROGRAM. 

15 ‘‘(a) PURPOSE.—It is the purpose of this section to 

16 alleviate critical shortages of primary care physicians and 

17 primary care providers. 

18 ‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 

19 through the Administrator of the Health Resources and 

20 Services Administration, shall establish a program of en21 tering into contracts with eligible individuals under 

22 which— 

23 ‘‘(1) the individual agrees to serve— 

24 ‘‘(A) as a primary care physician or pri25 mary care provider in a primary care field; and 


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1 ‘‘(B) in an area that is not a health profes2 sional shortage area (as designated under sec3 tion 332), but has a critical shortage of primary 

4 care physicians and primary care providers (as 

5 determined by the Secretary) in such field; and 

6 ‘‘(2) the Secretary agrees to pay, for each year 

7 of such service, not more than $35,000 of the prin8 cipal and interest of the undergraduate or graduate 

9 educational loans of the individual. 

10 ‘‘(c) SERVICE REQUIREMENT.—A contract entered 

11 into under this section shall allow the individual receiving 

12 the loan repayment to satisfy the service requirement de13 scribed in subsection (a)(1) through employment in a solo 

14 or group practice, a clinic, a public or private nonprofit 

15 hospital, or any other appropriate health care entity. 

16 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

17 provisions of subpart III of part D shall, except as incon18 sistent with this section, apply to the program established 

19 in subsection (a) in the same manner and to the same 

20 extent as such provisions apply to the National Health 

21 Service Corps Scholarship Program established in such 

22 subpart. 

23 ‘‘(e) DEFINITION.—In this section, the term ‘eligible 

24 individual’ means— 


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1 ‘‘(1) an individual with a degree in medicine or 

2 osteopathic medicine; or 

3 ‘‘(2) a primary care provider (as defined in sec4 tion 3(a)(7) of the Preserving Patient Access to Pri5 mary Care Act of 2009). 

6 ‘‘SEC. 340K. LOAN REPAYMENTS FOR PHYSICIANS IN THE 

7 FIELDS OF OBSTETRICS AND GYNECOLOGY 

8 AND CERTIFIED NURSE MIDWIVES. 

9 ‘‘(a) PURPOSE.—It is the purpose of this section to 

10 alleviate critical shortages of physicians in the fields of 

11 obstetrics and gynecology and certified nurse midwives. 

12 ‘‘(b) LOAN REPAYMENTS.—The Secretary, acting 

13 through the Administrator of the Health Resources and 

14 Services Administration, shall establish a program of en15 tering into contracts with eligible individuals under 

16 which— 

17 ‘‘(1) the individual agrees to serve— 

18 ‘‘(A) as a physician in the field of obstet19 rics and gynecology or as a certified nurse mid20 wife; and 

21 ‘‘(B) in an area that is not a health profes22 sional shortage area (as designated under sec23 tion 332), but has a critical shortage of physi24 cians in the fields of obstetrics and gynecology 


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1 or certified nurse midwives (as determined by 

2 the Secretary), respectively; and 

3 ‘‘(2) the Secretary agrees to pay, for each year 

4 of such service, not more than $35,000 of the prin5 cipal and interest of the undergraduate or graduate 

6 educational loans of the individual. 

7 ‘‘(c) SERVICE REQUIREMENT.—A contract entered 

8 into under this section shall allow the individual receiving 

9 the loan repayment to satisfy the service requirement de10 scribed in subsection (a)(1) through employment in a solo 

11 or group practice, a clinic, a public or private nonprofit 

12 hospital, or any other appropriate health care entity. 

13 ‘‘(d) APPLICATION OF CERTAIN PROVISIONS.—The 

14 provisions of subpart III of part D shall, except as incon15 sistent with this section, apply to the program established 

16 in subsection (a) in the same manner and to the same 

17 extent as such provisions apply to the National Health 

18 Service Corps Scholarship Program established in such 

19 subpart. 

20 ‘‘(e) DEFINITION.—In this section, the term ‘eligible 

21 individual’ means— 

22 ‘‘(1) a physician in the field of obstetrics and 

23 gynecology; or 

24 ‘‘(2) a certified nurse midwife. 


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1 ‘‘SEC. 340L. REPORTS. 

2 ‘‘Not later than 18 months after the date of enact3 ment of this section, and annually thereafter, the Sec4 retary shall submit to Congress a report that describes 

5 the programs carried out under this subpart, including 

6 statements concerning— 

7 ‘‘(1) the number of enrollees, scholarships, loan 

8 repayments, and grant recipients; 

9 ‘‘(2) the number of graduates; 

10 ‘‘(3) the amount of scholarship payments and 

11 loan repayments made; 

12 ‘‘(4) which educational institution the recipients 

13 attended; 

14 ‘‘(5) the number and placement location of the 

15 scholarship and loan repayment recipients at health 

16 care facilities with a critical shortage of primary 

17 care physicians; 

18 ‘‘(6) the default rate and actions required; 

19 ‘‘(7) the amount of outstanding default funds of 

20 both the scholarship and loan repayment programs; 

21 ‘‘(8) to the extent that it can be determined, 

22 the reason for the default; 

23 ‘‘(9) the demographics of the individuals par24 ticipating in the scholarship and loan repayment 

25 programs; 


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1 ‘‘(10) the justification for the allocation of 

2 funds between the scholarship and loan repayment 

3 programs; and 

4 ‘‘(11) an evaluation of the overall costs and 

5 benefits of the programs. 

6 ‘‘SEC. 340M. AUTHORIZATION OF APPROPRIATIONS. 

7 ‘‘To carry out sections 340I, 340J, and 340K there 

8 are authorized to be appropriated $55,000,000 for fiscal 

9 year 2010, $90,000,000 for fiscal year 2011, and 

10 $125,000,000 for fiscal year 2012, to be used solely for 

11 scholarships and loan repayment awards for primary care 

12 physicians and primary care providers.’’. 

13 SEC. 103. DEFERMENT OF LOANS DURING RESIDENCY AND 

14 INTERNSHIPS. 

15 (a) LOAN REQUIREMENTS.—Section 427(a)(2)(C)(i) 

16 of the Higher Education Act of 1965 (20 U.S.C. 

17 1077(a)(2)(C)(i)) is amended by inserting ‘‘unless the 

18 medical internship or residency program is in a primary 

19 care field (as defined in section 3(a)(5) of the Preserving 

20 Patient Access to Primary Care Act of 2009)’’ after ‘‘resi21 dency program’’. 

22 (b) FFEL LOANS.—Section 428(b)(1)(M)(i) of the 

23 Higher Education Act of 1965 (20 U.S.C. 

24 1078(b)(1)(M)(i)) is amended by inserting ‘‘unless the 

25 medical internship or residency program is in a primary 


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1 care field (as defined in section 3(a)(5) of the Preserving 

2 Patient Access to Primary Care Act of 2009)’’ after ‘‘resi3 dency program’’. 

4 (c) FEDERAL DIRECT LOANS.—Section 455(f)(2)(A) 

5 of the Higher Education Act of 1965 (20 U.S.C. 

6 1087e(f)(2)(A)) is amended by inserting ‘‘unless the med7 ical internship or residency program is in a primary care 

8 field (as defined in section 3(a)(5) of the Preserving Pa9 tient Access to Primary Care Act of 2009)’’ after ‘‘resi10 dency program’’. 

11 (d) FEDERAL PERKINS LOANS.—Section 

12 464(c)(2)(A)(i) of the Higher Education Act of 1965 (20 

13 U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting ‘‘un14 less the medical internship or residency program is in a 

15 primary care field (as defined in section 3(a)(5) of the 

16 Preserving Patient Access to Primary Care Act of 2009)’’ 

17 after ‘‘residency program’’. 

18 SEC. 104. EDUCATING MEDICAL STUDENTS ABOUT PRI19 MARY CARE CAREERS. 

20 Part C of title VII of the Public Health Service Act 

21 (42 U.S.C. 293k) is amended by adding at the end the 

22 following: 


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1 ‘‘SEC. 749. EDUCATING MEDICAL STUDENTS ABOUT PRI2 MARY CARE CAREERS. 

3 ‘‘(a) IN GENERAL.—The Secretary shall award 

4 grants to eligible State and local government entities for 

5 the development of informational materials that promote 

6 careers in primary care by highlighting the advantages 

7 and rewards of primary care, and that encourage medical 

8 students, particularly students from disadvantaged back9 grounds, to become primary care physicians. 

10 ‘‘(b) ANNOUNCEMENT.—The grants described in sub11 section (a) shall be announced through a publication in 

12 the Federal Register and through appropriate media out13 lets in a manner intended to reach medical education insti14 tutions, associations, physician groups, and others who 

15 communicate with medical students. 

16 ‘‘(c) ELIGIBILITY.—To be eligible to receive a grant 

17 under this section an entity shall— 

18 ‘‘(1) be a State or local entity; and 

19 ‘‘(2) submit to the Secretary an application at 

20 such time, in such manner, and containing such in21 formation as the Secretary may require. 

22 ‘‘(d) USE OF FUNDS.— 

23 ‘‘(1) IN GENERAL.—An entity shall use 

24 amounts received under a grant under this section to 

25 support State and local campaigns through appro26 priate media outlets to promote careers in primary 


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1 care and to encourage individuals from disadvan2 taged backgrounds to enter and pursue careers in 

3 primary care. 

4 ‘‘(2) SPECIFIC USES.—In carrying out activities 

5 under paragraph (1), an entity shall use grants 

6 funds to develop informational materials in a man7 ner intended to reach as wide and diverse an audi8 ence of medical students as possible, in order to— 

9 ‘‘(A) advertise and promote careers in pri10 mary care; 

11 ‘‘(B) promote primary care medical edu12 cation programs; 

13 ‘‘(C) inform the public of financial assist14 ance regarding such education programs; 

15 ‘‘(D) highlight individuals in the commu16 nity who are practicing primary care physicians; 

17 or 

18 ‘‘(E) provide any other information to re19 cruit individuals for careers in primary care. 

20 ‘‘(e) LIMITATION.—An entity shall not use amounts 

21 received under a grant under this section to advertise par22 ticular employment opportunities. 

23 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There 

24 is authorized to be appropriated to carry out this section, 


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1 such sums as may be necessary for each of fiscal years 

2 2010 through 2013.’’. 

3 SEC. 105. TRAINING IN A FAMILY MEDICINE, GENERAL IN4 TERNAL MEDICINE, GENERAL GERIATRICS, 

5 GENERAL PEDIATRICS, PHYSICIAN ASSIST6 ANT EDUCATION, GENERAL DENTISTRY, AND 

7 PEDIATRIC DENTISTRY. 

8 Section 747(e) of the Public Health Service Act (42 

9 U.S.C. 293k) is amended by striking paragraph (1) and 

10 inserting the following: 

11 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

12 For the purpose of carrying out this section, there 

13 is authorized to be appropriated $198,000,000 for 

14 each of fiscal years 2010 through 2012.’’. 

15 SEC. 106. INCREASED FUNDING FOR NATIONAL HEALTH 

16 SERVICE CORPS SCHOLARSHIP AND LOAN 

17 REPAYMENT PROGRAMS. 

18 (a) IN GENERAL.—There is authorized to be appro19 priated $332,000,000 for the period of fiscal years 2010 

20 through 2012 for the purpose of carrying out subpart III 

21 of part D of title III of the Public Health Service Act 

22 (42 U.S.C. 254l et seq.). Such authorization of appropria23 tions is in addition to the authorization of appropriations 

24 in section 338H of such Act (42 U.S.C. 254q) and any 

25 other authorization of appropriations for such purpose. 


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1 (b) ALLOCATION.—Of the amounts appropriated 

2 under subsection (a) for the period of fiscal years 2010 

3 through 2012, the Secretary shall obligate $96,000,000 

4 for the purpose of providing contracts for scholarships and 

5 loan repayments to individuals who— 

6 (1) are primary care physicians or primary care 

7 providers; and 

8 (2) have not previously received a scholarship or 

9 loan repayment under subpart III of part D of title 

10 III of the Public Health Service Act (42 U.S.C. 254l 

11 et seq.). 

12 TITLE II—MEDICAID RELATED 

13 PROVISIONS 

14 SEC. 201. TRANSFORMATION GRANTS TO SUPPORT PA15 TIENT CENTERED MEDICAL HOMES UNDER 

16 MEDICAID AND CHIP. 

17 (a) IN GENERAL.—Section 1903(z) of the Social Se18 curity Act (42 U.S.C. 1396b(z)) is amended— 

19 (1) in paragraph (2), by adding at the end the 

20 following new subparagraph: 

21 ‘‘(G) Methods for improving the effective22 ness and efficiency of medical assistance pro23 vided under this title and child health assist24 ance provided under title XXI by encouraging 

25 the adoption of medical practices that satisfy 


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1 the standards established by the Secretary 

2 under paragraph (2) of section 3(d) of the Pre3 serving Patient Access to Primary Care Act of 

4 2009 for medical practices to qualify as patient 

5 centered medical homes (as defined in para6 graph (1) of such section).’’; and 

7 (2) in paragraph (4)— 

8 (A) in subparagraph (A)— 

9 (i) in clause (i), by striking ‘‘and’’ at 

10 the end; 

11 (ii) in clause (ii), by striking the pe12 riod at the end and inserting ‘‘; and’’; and 

13 (iii) by inserting after clause (ii), the 

14 following new clause: 

15 ‘‘(iii) $25,000,000 for each of fiscal 

16 years 2010, 2011, and 2012.’’; and 

17 (B) in subparagraph (B), by striking the 

18 second and third sentences and inserting the 

19 following: ‘‘Such method shall provide that 100 

20 percent of such funds for each of fiscal years 

21 2010, 2011, and 2012 shall be allocated among 

22 States that design programs to adopt the inno23 vative methods described in paragraph (2)(G), 

24 with preference given to States that design pro25 grams involving multipayers (including under 


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1 title XVIII and private health plans) test 

2 projects for implementation of the elements nec3 essary to be recognized as a patient centered 

4 medical home practice under the National Com5 mittee for Quality Assurance Physicians Prac6 tice Connection-PCMH module (or any other 

7 equivalent process, as determined by the Sec8 retary).’’. 

9 (b) EFFECTIVE DATE.—The amendments made by 

10 this section take effect on October 1, 2010. 

11 TITLE III—MEDICARE 

12 PROVISIONS 

13 Subtitle A—Primary Care 

14 SEC. 301. REFORMING PAYMENT SYSTEMS UNDER MEDI15 CARE TO SUPPORT PRIMARY CARE. 

16 (a) INCREASING BUDGET NEUTRALITY LIMITS

17 UNDER THE PHYSICIAN FEE SCHEDULE TO ACCOUNT

18 FOR ANTICIPATED SAVINGS RESULTING FROM PAYMENTS

19 FOR CERTAIN SERVICES AND THE COORDINATION OF

20 BENEFICIARY CARE.—Section 1848(c)(2)(B) of the Social 

21 Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended— 

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

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

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

25 clause: 


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1 ‘‘(vii) INCREASE IN LIMITATION TO

2 ACCOUNT FOR CERTAIN ANTICIPATED SAV3 INGS.— 

4 ‘‘(I) IN GENERAL.—Effective for 

5 fee schedules established beginning 

6 with 2010, the Secretary shall in7 crease the limitation on annual ad8 justments under clause (ii)(II) by an 

9 amount equal to the anticipated sav10 ings under parts A, B, and D (includ11 ing any savings with respect to items 

12 and services for which payment is not 

13 made under this section) which are a 

14 result of payments for designated pri15 mary care services and comprehensive 

16 care coordination services under sec17 tion 1834(m) and the coverage of pa18 tient centered medical home services 

19 under section 1861(s)(2)(FF) (as de20 termined by the Secretary). 

21 ‘‘(II) MECHANISM TO DETER22 MINE APPLICATION OF INCREASE.— 

23 The Secretary shall establish a mecha24 nism for determining which relative 

25 value units established under this 


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1 paragraph for physicians’ services 

2 shall be subject to an adjustment 

3 under clause (ii)(I) as a result of the 

4 increase under subclause (I). 

5 ‘‘(III) ADDITIONAL FUNDING AS

6 DETERMINED NECESSARY BY THE

7 SECRETARY.—In addition to any 

8 funding that may be made available 

9 as a result of an increase in the limi10 tation on annual adjustments under 

11 subclause (I), there shall also be avail12 able to the Secretary, for purposes of 

13 making payments under this title for 

14 new services and capabilities to im15 prove care provided to individuals 

16 under this title and to generate effi17 ciencies under this title, such addi18 tional funds as the Secretary deter19 mines are necessary.’’. 

20 (b) SEPARATE MEDICARE PAYMENT FOR DES21 IGNATED PRIMARY CARE SERVICES AND COMPREHENSIVE

22 CARE COORDINATION SERVICES.— 

23 (1) IN GENERAL.—Section 1834 of the Social 

24 Security Act (42 U.S.C. 1395m) is amended by add25 ing at the end the following new subsection: 


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1 ‘‘(n) PAYMENT FOR DESIGNATED PRIMARY CARE

2 SERVICES AND COMPREHENSIVE CARE COORDINATION

3 SERVICES.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall pay for 

5 designated primary care services and comprehensive 

6 care coordination services furnished to an individual 

7 enrolled under this part. 

8 ‘‘(2) PAYMENT AMOUNT.—The Secretary shall 

9 determine the amount of payment for designated 

10 primary care services and comprehensive care co11 ordination services under this subsection. 

12 ‘‘(3) DOCUMENTATION REQUIREMENTS.—The 

13 Secretary shall propose appropriate documentation 

14 requirements to justify payments for designated pri15 mary care services and comprehensive care coordina16 tion services under this subsection. 

17 ‘‘(4) DEFINITIONS.— 

18 ‘‘(A) COMPREHENSIVE CARE COORDINA19 TION SERVICES.—The term ‘comprehensive care 

20 coordination services’ means care coordination 

21 services with procedure codes established by the 

22 Secretary (as appropriate) which are furnished 

23 to an individual enrolled under this part by a 

24 primary care provider or principal care physi25 cian. 


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1 ‘‘(B) DESIGNATED PRIMARY CARE SERV2 ICES.—The term ‘designated primary care serv3 ice’ means a service which the Secretary deter4 mines has a procedure code which involves a 

5 clinical interaction with an individual enrolled 

6 under this part that is inherent to care coordi7 nation, including interactions outside of a face8 to-face encounter. Such term includes the fol9 lowing: 

10 ‘‘(i) Care plan oversight. 

11 ‘‘(ii) Evaluation and management pro12 vided by phone. 

13 ‘‘(iii) Evaluation and management 

14 provided using internet resources. 

15 ‘‘(iv) Collection and review of physio16 logic data, such as from a remote moni17 toring device. 

18 ‘‘(v) Education and training for pa19 tient self management. 

20 ‘‘(vi) Anticoagulation management 

21 services. 

22 ‘‘(vii) Any other service determined 

23 appropriate by the Secretary.’’. 


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1 (2) EFFECTIVE DATE.—The amendment made 

2 by this section shall apply to items and services fur3 nished on or after January 1, 2010. 

4 SEC. 302. COVERAGE OF PATIENT CENTERED MEDICAL 

5 HOME SERVICES. 

6 (a) IN GENERAL.—Section 1861(s)(2) of the Social 

7 Security Act (42 U.S.C. 1395x(s)(2)) is amended— 

8 (1) in subparagraph (DD), by striking ‘‘and’’ at 

9 the end; 

10 (2) in subparagraph (EE), by inserting ‘‘and’’ 

11 at the end; and 

12 (3) by adding at the end the following new sub13 paragraph: 

14 ‘‘(FF) patient centered medical home services 

15 (as defined in subsection (hhh)(1));’’. 

16 (b) DEFINITION OF PATIENT CENTERED MEDICAL

17 HOME SERVICES.—Section 1861 of the Social Security 

18 Act (42 U.S.C. 1395x) is amended by adding at the end 

19 the following new subsection: 

20 ‘‘Patient Centered Medical Home Services 

21 ‘‘(hhh)(1) The term ‘patient centered medical home 

22 services’ means care coordination services furnished by a 

23 qualified patient centered medical home. 

24 ‘‘(2) The term ‘qualified patient centered medical 

25 home’ means a patient centered medical home (as defined 


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1 in section 3(d) of the Preserving Patient Access to Pri2 mary Care Act of 2009).’’. 

3 (c) MONTHLY FEE FOR PATIENT CENTERED MED4 ICAL HOME SERVICES.—Section 1848 of the Social Secu5 rity Act (42 U.S.C. 1395w–4) is amended by adding at 

6 the end the following new subsection: 

7 ‘‘(p) MONTHLY FEE FOR PATIENT CENTERED MED8 ICAL HOME SERVICES.— 

9 ‘‘(1) MONTHLY FEE.— 

10 ‘‘(A) IN GENERAL.—Not later than Janu11 ary 1, 2012, the Secretary shall establish a pay12 ment methodology for patient centered medical 

13 home services (as defined in paragraph (1) of 

14 section 1861(hhh)). Under such payment meth15 odology, the Secretary shall pay qualified pa16 tient centered medical homes (as defined in 

17 paragraph (2) of such section) a monthly fee 

18 for each individual who elects to receive patient 

19 centered medical home services at that medical 

20 home. Such fee shall be paid on a prospective 

21 basis. 

22 ‘‘(B) CONSIDERATIONS.—The Secretary 

23 shall take into account the results of the Medi24 care medical home demonstration project under 

25 section 204 of the Medicare Improvement and 


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1 Extension Act of 2006 (42 U.S.C. 1395b–1 

2 note; division B of Public Law 109–432) in es3 tablishing the payment methodology under sub4 paragraph (A). 

5 ‘‘(2) AMOUNT OF PAYMENT.— 

6 ‘‘(A) CONSIDERATIONS.—In determining 

7 the amount of such fee, subject to paragraph 

8 (3), the Secretary shall consider the following: 

9 ‘‘(i) The clinical work and practice ex10 penses involved in providing care coordina11 tion services consistent with the patient 

12 centered medical home model (such as pro13 viding increased access, care coordination, 

14 disease population management, and edu15 cation) for which payment is not made 

16 under this section as of the date of enact17 ment of this subsection. 

18 ‘‘(ii) Ensuring that the amount of 

19 payment is sufficient to support the acqui20 sition, use, and maintenance of clinical in21 formation systems which— 

22 ‘‘(I) are needed by a qualified pa23 tient centered medical home; and 


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1 ‘‘(II) have been shown to facili2 tate improved outcomes through care 

3 coordination. 

4 ‘‘(iii) The establishment of a tiered 

5 monthly care management fee that pro6 vides for a range of payment depending on 

7 how advanced the capabilities of a qualified 

8 patient centered medical home are in hav9 ing the information systems needed to sup10 port care coordination. 

11 ‘‘(B) RISK-ADJUSTMENT.—The Secretary 

12 shall use appropriate risk-adjustment in deter13 mining the amount of the monthly fee under 

14 this paragraph. 

15 ‘‘(3) FUNDING.— 

16 ‘‘(A) IN GENERAL.—The Secretary shall 

17 determine the aggregate estimated savings for a 

18 calendar year as a result of the implementation 

19 of this subsection on reducing preventable hos20 pital admissions, duplicate testing, medication 

21 errors and drug interactions, and other savings 

22 under this part and part A (including any sav23 ings with respect to items and services for 

24 which payment is not made under this section). 


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1 ‘‘(B) FUNDING.—Subject to subparagraph 

2 (C), the aggregate amount available for pay3 ment of the monthly fee under this subsection 

4 during a calendar year shall be equal to the ag5 gregate estimated savings (as determined under 

6 subparagraph (A)) for the calendar year (as de7 termined by the Secretary). 

8 ‘‘(C) ADDITIONAL FUNDING.—In the case 

9 where the amount of the aggregate actual sav10 ings during the preceding 3 years exceeds the 

11 amount of the aggregate estimated savings (as 

12 determined under subparagraph (A)) during 

13 such period, the aggregate amount available for 

14 payment of the monthly fee under this sub15 section during the calendar year (as determined 

16 under subparagraph (B)) shall be increased by 

17 the amount of such excess. 

18 ‘‘(D) ADDITIONAL FUNDING AS DETER19 MINED NECESSARY BY THE SECRETARY.—In 

20 addition to any funding made available under 

21 subparagraphs (B) and (C), there shall also be 

22 available to the Secretary, for purposes of effec23 tively implementing this subsection, such addi24 tional funds as the Secretary determines are 

25 necessary. 


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1 ‘‘(4) PERFORMANCE-BASED BONUS PAY2 MENTS.—The Secretary shall establish a process for 

3 paying a performance-based bonus to qualified pa4 tient centered medical homes which meet or achieve 

5 substantial improvements in performance (as speci6 fied under clinical, patient satisfaction, and effi7 ciency benchmarks established by the Secretary). 

8 Such bonus shall be in an amount determined appro9 priate by the Secretary. 

10 ‘‘(5) NO EFFECT ON PAYMENTS FOR EVALUA11 TION AND MANAGEMENT SERVICES.—The monthly 

12 fee under this subsection shall have no effect on the 

13 amount of payment for evaluation and management 

14 services under this title.’’. 

15 (d) COINSURANCE.—Section 1833(a)(1) of the Social 

16 Security Act (42 U.S.C. 1395l(a)(1)) is amended— 

17 (1) by striking ‘‘and’’ before ‘‘(W)’’; and 

18 (2) by inserting before the semicolon at the end 

19 the following: ‘‘, and (X) with respect to patient cen20 tered medical home services (as defined in section 

21 1861(hhh)(1)), the amount paid shall be (i) in the 

22 case of such services which are physicians’ services, 

23 the amount determined under subparagraph (N), 

24 and (ii) in the case of all other such services, 80 per25 cent of the lesser of the actual charge for the service 


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1 or the amount determined under a fee schedule es2 tablished by the Secretary for purposes of this sub3 paragraph’’. 

4 (e) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to services furnished on or after 

6 January 1, 2012. 

7 SEC. 303. MEDICARE PRIMARY CARE PAYMENT EQUITY AND 

8 ACCESS PROVISION. 

9 (a) IN GENERAL.—Section 1848 of the Social Secu10 rity Act (42 U.S.C. 1395w–4), as amended by section 

11 302(c), is amended by adding at the end the following new 

12 subsection: 

13 ‘‘(q) PRIMARY CARE PAYMENT EQUITY AND AC14 CESS.— 

15 ‘‘(1) IN GENERAL.—Not later than January 1, 

16 2010, the Secretary shall develop a methodology, in 

17 consultation with primary care physician organiza18 tions and primary care provider organizations, the 

19 Medicare Payment Advisory Commission, and other 

20 experts, to increase payments under this section for 

21 designated evaluation and management services pro22 vided by primary care physicians, primary care pro23 viders, and principal care providers through 1 or 

24 more of the following: 


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1 ‘‘(A) A service-specific modifier to the rel2 ative value units established for such services. 

3 ‘‘(B) Service-specific bonus payments. 

4 ‘‘(C) Any other methodology determined 

5 appropriate by the Secretary. 

6 ‘‘(2) INCLUSION OF PROPOSED CRITERIA.—The 

7 methodology developed under paragraph (1) shall in8 clude proposed criteria for providers to qualify for 

9 such increased payments, including consideration 

10 of— 

11 ‘‘(A) the type of service being rendered; 

12 ‘‘(B) the specialty of the provider providing 

13 the service; and 

14 ‘‘(C) demonstration by the provider of vol15 untary participation in programs to improve 

16 quality, such as participation in the Physician 

17 Quality Reporting Initiative (as determined by 

18 the Secretary) or practice-level qualification as 

19 a patient centered medical home. 

20 ‘‘(3) FUNDING.— 

21 ‘‘(A) DETERMINATION.—The Secretary 

22 shall determine the aggregate estimated savings 

23 for a calendar year as a result of such increased 

24 payments on reducing preventable hospital ad25 missions, duplicate testing, medication errors 


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1 and drug interactions, Intensive Care Unit ad2 missions, per capita health care expenditures, 

3 and other savings under this part and part A 

4 (including any savings with respect to items 

5 and services for which payment is not made 

6 under this section). 

7 ‘‘(B) FUNDING.—The aggregate amount 

8 available for such increased payments during a 

9 calendar year shall be equal to the aggregate 

10 estimated savings (as determined under sub11 paragraph (A)) for the calendar year (as deter12 mined by the Secretary). 

13 ‘‘(C) ADDITIONAL FUNDING AS DETER14 MINED NECESSARY BY THE SECRETARY.—In 

15 addition to any funding made available under 

16 subparagraph (B), there shall also be available 

17 to the Secretary, for purposes of effectively im18 plementing this subsection, such additional 

19 funds as the Secretary determines are nec20 essary.’’. 

21 (b) EFFECTIVE DATE.—The amendment made by 

22 this section shall apply to services furnished on or after 

23 January 1, 2010. 


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1 SEC. 304. ADDITIONAL INCENTIVE PAYMENT PROGRAM 

2 FOR PRIMARY CARE SERVICES FURNISHED 

3 IN HEALTH PROFESSIONAL SHORTAGE 

4 AREAS. 

5 (a) IN GENERAL.—Section 1833 of the Social Secu6 rity Act (42 U.S.C. 1395l) is amended by adding at the 

7 end the following new subsection: 

8 ‘‘(x) ADDITIONAL INCENTIVE PAYMENTS FOR PRI9 MARY CARE SERVICES FURNISHED IN HEALTH PROFES10 SIONAL SHORTAGE AREAS.— 

11 ‘‘(1) IN GENERAL.—In the case of primary care 

12 services furnished on or after January 1, 2010, by 

13 a primary care physician or primary care provider in 

14 an area that is designated (under section 

15 332(a)(1)(A) of the Public Health Service Act) as a 

16 health professional shortage area as identified by the 

17 Secretary prior to the beginning of the year involved, 

18 in addition to the amount of payment that would 

19 otherwise be made for such services under this part, 

20 there also shall be paid (on a monthly or quarterly 

21 basis) an amount equal to 10 percent of the pay22 ment amount for the service under this part. 

23 ‘‘(2) DEFINITIONS.—In this subsection: 

24 ‘‘(A) PRIMARY CARE PHYSICIAN; PRIMARY

25 CARE PROVIDER.—The terms ‘primary care 

26 physician’ and ‘primary care provider’ have the 


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1 meaning given such terms in paragraphs (6) 

2 and (7), respectively, of section 3(a) of the Pre3 serving Patient Access to Primary Care Act of 

4 2009. 

5 ‘‘(B) PRIMARY CARE SERVICES.—The term 

6 ‘primary care services’ means procedure codes 

7 for services in the category of the Healthcare 

8 Common Procedure Coding System, as estab9 lished by the Secretary under section 

10 1848(c)(5) (as of December 31, 2008, and as 

11 subsequently modified by the Secretary) con12 sisting of evaluation and management services, 

13 but limited to such procedure codes in the cat14 egory of office or other outpatient services, and 

15 consisting of subcategories of such procedure 

16 codes for services for both new and established 

17 patients. 

18 ‘‘(3) JUDICIAL REVIEW.—There shall be no ad19 ministrative or judicial review under section 1869, 

20 1878, or otherwise, respecting the identification of 

21 primary care physicians, primary care providers, or 

22 primary care services under this subsection.’’. 

23 (b) CONFORMING AMENDMENT.—Section 

24 1834(g)(2)(B) of the Social Security Act (42 U.S.C. 

25 1395m(g)(2)(B)) is amended by adding at the end the folVerDate Nov 24 2008 01:24 Jun 04, 2009 Jkt 079200 PO 00000 Frm 00046 Fmt 6652 Sfmt 6201 E:\BILLS\S1174.IS S1174

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1 lowing sentence: ‘‘Section 1833(x) shall not be taken into 

2 account in determining the amounts that would otherwise 

3 be paid pursuant to the preceding sentence.’’. 

4 SEC. 305. PERMANENT EXTENSION OF FLOOR ON MEDI5 CARE WORK GEOGRAPHIC ADJUSTMENT 

6 UNDER THE MEDICARE PHYSICIAN FEE 

7 SCHEDULE. 

8 Section 1848(e)(1)(E) of the Social Security Act (42 

9 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘and 

10 before January 1, 2010,’’. 

11 SEC. 306. PERMANENT EXTENSION OF MEDICARE INCEN12 TIVE PAYMENT PROGRAM FOR PHYSICIAN 

13 SCARCITY AREAS. 

14 Section 1833(u) of the Social Security Act (42 U.S.C. 

15 1395l(u)) is amended— 

16 (1) in paragraph (1)— 

17 (A) by inserting ‘‘or on or after July 1, 

18 2009’’ after ‘‘before July 1, 2008’’; and 

19 (B) by inserting ‘‘(or, in the case of serv20 ices furnished on or after July 1, 2009, 10 per21 cent)’’ after ‘‘5 percent’’; and 

22 (2) in paragraph (4)(D), by striking ‘‘before 

23 July 1, 2008’’ and inserting ‘‘before January 1, 

24 2010’’. 


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1 SEC. 307. HHS STUDY AND REPORT ON THE PROCESS FOR 

2 DETERMINING RELATIVE VALUE UNDER THE 

3 MEDICARE PHYSICIAN FEE SCHEDULE. 

4 (a) STUDY.—The Secretary shall conduct a study on 

5 the process used by the Secretary for determining relative 

6 value under the Medicare physician fee schedule under 

7 section 1848(c) of the Social Security Act (42 U.S.C. 

8 1395w–4(c)). Such study shall include an analysis of the 

9 following: 

10 (1)(A) Whether the existing process includes 

11 equitable representation of primary care physicians 

12 (as defined in section 3(a)(6)); and 

13 (B) any changes that may be necessary to en14 sure such equitable representation. 

15 (2)(A) Whether the existing process provides 

16 the Secretary with expert and impartial input from 

17 physicians in medical specialties that provide pri18 mary care to patients with multiple chronic diseases, 

19 the fastest growing part of the Medicare population; 

20 and 

21 (B) any changes that may be necessary to en22 sure such input. 

23 (3)(A) Whether the existing process includes 

24 equitable representation of physician medical special25 ties in proportion to their relative contributions to26 ward caring for Medicare beneficiaries, as deterVerDate Nov 24 2008 01:24 Jun 04, 2009 Jkt 079200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\S1174.IS S1174

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1 mined by the percentage of Medicare billings per 

2 specialty, percentage of Medicare encounters by spe3 cialty, or such other measures of relative contribu4 tions to patient care as determined by the Secretary; 

5 and 

6 (B) any changes that may be necessary to re7 flect such equitable representation. 

8 (4)(A) Whether the existing process, including 

9 the application of budget neutrality rules, unfairly 

10 disadvantages primary care physicians, primary care 

11 providers, or other physicians who principally pro12 vide evaluation and management services; and 

13 (B) any changes that may be necessary to 

14 eliminate such disadvantages. 

15 (b) REPORT.—Not later than 12 months after the 

16 date of enactment of this Act, the Secretary shall submit 

17 to Congress a report containing the results of the study 

18 conducted under subsection (a), together with rec19 ommendations for such legislation and administrative ac20 tion as the Secretary determines appropriate. 

21 Subtitle B—Preventive Services 

22 SEC. 311. ELIMINATING TIME RESTRICTION FOR INITIAL 

23 PREVENTIVE PHYSICAL EXAMINATION. 

24 (a) IN GENERAL.—Section 1862(a)(1)(K) of the So25 cial Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended 


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1 by striking ‘‘more than’’ and all that follows before the 

2 comma at the end and inserting ‘‘more than one time dur3 ing the lifetime of the individual’’. 

4 (b) EFFECTIVE DATE.—The amendments made by 

5 this section shall apply to services furnished on or after 

6 January 1, 2010. 

7 SEC. 312. ELIMINATION OF COST-SHARING FOR PREVEN8 TIVE BENEFITS UNDER THE MEDICARE PRO9 GRAM. 

10 (a) DEFINITION OF PREVENTIVE SERVICES.—Sec11 tion 1861(ddd) of the Social Security Act (42 U.S.C. 

12 1395w(dd)) is amended— 

13 (1) in the heading, by inserting ‘‘; Preventive 

14 Services’’ after ‘‘Services’’; 

15 (2) in paragraph (1), by striking ‘‘not otherwise 

16 described in this title’’ and inserting ‘‘not described 

17 in subparagraphs (A) through (N) of paragraph 

18 (3)’’; and 

19 (3) by adding at the end the following new 

20 paragraph: 

21 ‘‘(3) The term ‘preventive services’ means the fol22 lowing: 

23 ‘‘(A) Prostate cancer screening tests (as defined 

24 in subsection (oo)). 


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1 ‘‘(B) Colorectal cancer screening tests (as de2 fined in subsection (pp)). 

3 ‘‘(C) Diabetes outpatient self-management 

4 training services (as defined in subsection (qq)). 

5 ‘‘(D) Screening for glaucoma for certain indi6 viduals (as described in subsection (s)(2)(U)). 

7 ‘‘(E) Medical nutrition therapy services for cer8 tain individuals (as described in subsection 

9 (s)(2)(V)). 

10 ‘‘(F) An initial preventive physical examination 

11 (as defined in subsection (ww)). 

12 ‘‘(G) Cardiovascular screening blood tests (as 

13 defined in subsection (xx)(1)). 

14 ‘‘(H) Diabetes screening tests (as defined in 

15 subsection (yy)). 

16 ‘‘(I) Ultrasound screening for abdominal aortic 

17 aneurysm for certain individuals (as described in 

18 subsection (s)(2)(AA)). 

19 ‘‘(J) Pneumococcal and influenza vaccine and 

20 their administration (as described in subsection 

21 (s)(10)(A)). 

22 ‘‘(K) Hepatitis B vaccine and its administration 

23 for certain individuals (as described in subsection 

24 (s)(10)(B)). 


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1 ‘‘(L) Screening mammography (as defined in 

2 subsection (jj)). 

3 ‘‘(M) Screening pap smear and screening pelvic 

4 exam (as described in subsection (s)(14)). 

5 ‘‘(N) Bone mass measurement (as defined in 

6 subsection (rr)). 

7 ‘‘(O) Additional preventive services (as deter8 mined under paragraph (1)).’’. 

9 (b) COINSURANCE.— 

10 (1) GENERAL APPLICATION.— 

11 (A) IN GENERAL.—Section 1833(a)(1) of 

12 the Social Security Act (42 U.S.C. 

13 1395l(a)(1)), as amended by section 302, is 

14 amended— 

15 (i) in subparagraph (T), by striking 

16 ‘‘80 percent’’ and inserting ‘‘100 percent’’; 

17 (ii) in subparagraph (W), by striking 

18 ‘‘80 percent’’ and inserting ‘‘100 percent’’; 

19 (iii) by striking ‘‘and’’ before ‘‘(X)’’; 

20 and 

21 (iv) by inserting before the semicolon 

22 at the end the following: ‘‘, and (Y) with 

23 respect to preventive services described in 

24 subparagraphs (A) through (O) of section 

25 1861(ddd)(3), the amount paid shall be 


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1 100 percent of the lesser of the actual 

2 charge for the services or the amount de3 termined under the fee schedule that ap4 plies to such services under this part’’. 

5 (2) ELIMINATION OF COINSURANCE FOR

6 SCREENING SIGMOIDOSCOPIES AND

7 COLONOSCOPIES.—Section 1834(d) of the Social Se8 curity Act (42 U.S.C. 1395m(d)) is amended— 

9 (A) in paragraph (2)— 

10 (i) in subparagraph (A), by inserting 

11 ‘‘, except that payment for such tests 

12 under such section shall be 100 percent of 

13 the payment determined under such sec14 tion for such tests’’ before the period at 

15 the end; and 

16 (ii) in subparagraph (C)— 

17 (I) by striking clause (ii); and 

18 (II) in clause (i)— 

19 (aa) by striking ‘‘(i) IN GEN20 ERAL.—Notwithstanding’’ and 

21 inserting ‘‘Notwithstanding’’; 

22 (bb) by redesignating sub23 clauses (I) and (II) as clauses (i) 

24 and (ii), respectively, and moving 


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1 such clauses 2 ems to the left; 

2 and 

3 (cc) in the flush matter fol4 lowing clause (ii), as so redesig5 nated, by inserting ‘‘100 percent 

6 of’’ after ‘‘based on’’; and 

7 (B) in paragraph (3)— 

8 (i) in subparagraph (A), by inserting 

9 ‘‘, except that payment for such tests 

10 under such section shall be 100 percent of 

11 the payment determined under such sec12 tion for such tests’’ before the period at 

13 the end; and 

14 (ii) in subparagraph (C)— 

15 (I) by striking clause (ii); and 

16 (II) in clause (i)— 

17 (aa) by striking ‘‘(i) IN GEN18 ERAL.—Notwithstanding’’ and 

19 inserting ‘‘Notwithstanding’’; and 

20 (bb) by inserting ‘‘100 per21 cent of’’ after ‘‘based on’’. 

22 (3) ELIMINATION OF COINSURANCE IN OUT23 PATIENT HOSPITAL SETTINGS.— 

24 (A) EXCLUSION FROM OPD FEE SCHED25 ULE.—Section 1833(t)(1)(B)(iv) of the Social 


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1 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 

2 amended by striking ‘‘and diagnostic mammog3 raphy’’ and inserting ‘‘, diagnostic mammog4 raphy, and preventive services (as defined in 

5 section 1861(ddd)(3))’’. 

6 (B) CONFORMING AMENDMENTS.—Section 

7 1833(a)(2) of the Social Security Act (42 

8 U.S.C. 1395l(a)(2)) is amended— 

9 (i) in subparagraph (F), by striking 

10 ‘‘and’’ after the semicolon at the end; 

11 (ii) in subparagraph (G)(ii), by adding 

12 ‘‘and’’ at the end; and 

13 (iii) by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(H) with respect to preventive services (as 

16 defined in section 1861(ddd)(3)) furnished by 

17 an outpatient department of a hospital, the 

18 amount determined under paragraph (1)(W) or 

19 (1)(X), as applicable;’’. 

20 (c) WAIVER OF APPLICATION OF DEDUCTIBLE.—The 

21 first sentence of section 1833(b) of the Social Security Act 

22 (42 U.S.C. 1395l(b)) is amended— 

23 (1) in clause (1), by striking ‘‘items and serv24 ices described in section 1861(s)(10)(A)’’ and insertVerDate Nov 24 2008 01:24 Jun 04, 2009 Jkt 079200 PO 00000 Frm 00055 Fmt 6652 Sfmt 6201 E:\BILLS\S1174.IS S1174

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1 ing ‘‘preventive services (as defined in section 

2 1861(ddd)(3))’’; 

3 (2) by inserting ‘‘and’’ before ‘‘(4)’’; and 

4 (3) by striking ‘‘, (5)’’ and all that follows up 

5 to the period at the end. 

6 SEC. 313. HHS STUDY AND REPORT ON FACILITATING THE 

7 RECEIPT OF MEDICARE PREVENTIVE SERV8 ICES BY MEDICARE BENEFICIARIES. 

9 (a) STUDY.—The Secretary, in consultation with pro10 vider organizations and other appropriate stakeholders, 

11 shall conduct a study on— 

12 (1) ways to assist primary care physicians and 

13 primary care providers (as defined in section 3(a)) 

14 in— 

15 (A) furnishing appropriate preventive serv16 ices (as defined in section 1861(ddd)(3) of the 

17 Social Security Act, as added by section 312) to 

18 individuals enrolled under part B of title XVIII 

19 of such Act; and 

20 (B) referring such individuals for other 

21 items and services furnished by other physicians 

22 and health care providers; and 

23 (2) the advisability and feasability of making 

24 additional payments under the Medicare program to 

25 physicians and primary care providers for— 


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1 (A) the work involved in ensuring that 

2 such individuals receive appropriate preventive 

3 services furnished by other physicians and 

4 health care providers; and 

5 (B) incorporating the resulting clinical in6 formation into the treatment plan for the indi7 vidual. 

8 (b) REPORT.—Not later than 12 months after the 

9 date of enactment of this Act, the Secretary shall submit 

10 to Congress a report containing the results of the study 

11 conducted under subsection (a), together with rec12 ommendations for such legislation and administrative ac13 tion as the Secretary determines appropriate. 

14 Subtitle C—Other Provisions 

15 SEC. 321. HHS STUDY AND REPORT ON IMPROVING THE 

16 ABILITY OF PHYSICIANS AND PRIMARY CARE 

17 PROVIDERS TO ASSIST MEDICARE BENE18 FICIARIES IN OBTAINING NEEDED PRESCRIP19 TIONS UNDER MEDICARE PART D. 

20 (a) STUDY.—The Secretary, in consultation with phy21 sician organizations and other appropriate stakeholders, 

22 shall conduct a study on the development and implementa23 tion of mechanisms to facilitate increased efficiency relat24 ing to the role of physicians and primary care providers 

25 in Medicare beneficiaries obtaining needed prescription 


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1 drugs under the Medicare prescription drug program 

2 under part D of title XVIII of the Social Security Act. 

3 Such study shall include an analysis of ways to— 

4 (1) improve the accessibility of formulary infor5 mation; 

6 (2) streamline the prior authorization, excep7 tion, and appeals processes, through, at a minimum, 

8 standardizing formats and allowing electronic ex9 change of information; and 

10 (3) recognize the work of the physician and pri11 mary care provider involved in the prescribing proc12 ess, especially work that may extend beyond the 

13 amount considered to be bundled into payment for 

14 evaluation and management services. 

15 (b) REPORT.—Not later than 12 months after the 

16 date of enactment of this Act, the Secretary shall submit 

17 to Congress a report containing the results of the study 

18 conducted under subsection (a), together with rec19 ommendations for such legislation and administrative ac20 tion as the Secretary determines appropriate. 

21 SEC. 322. HHS STUDY AND REPORT ON IMPROVED PATIENT 

22 CARE THROUGH INCREASED CAREGIVER AND 

23 PHYSICIAN INTERACTION. 

24 (a) STUDY.—The Secretary, in consultation with ap25 propriate stakeholders, shall conduct a study on the develVerDate Nov 24 2008 01:24 Jun 04, 2009 Jkt 079200 PO 00000 Frm 00058 Fmt 6652 Sfmt 6201 E:\BILLS\S1174.IS S1174

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1 opment and implementation of mechanisms to promote 

2 and increase interaction between physicians or primary 

3 care providers and the families of Medicare beneficiaries, 

4 as well as other caregivers who support such beneficiaries, 

5 for the purpose of improving patient care under the Medi6 care program. Such study shall include an analysis of— 

7 (1) ways to recognize the work of physicians 

8 and primary care providers involved in discussing 

9 clinical issues with caregivers that relate to the care 

10 of the beneficiary; and 

11 (2) regulations under the Medicare program 

12 that are barriers to interactions between caregivers 

13 and physicians or primary care providers and how 

14 such regulations should be revised to eliminate such 

15 barriers. 

16 (b) REPORT.—Not later than 12 months after the 

17 date of enactment of this Act, the Secretary shall submit 

18 to Congress a report containing the results of the study 

19 conducted under subsection (a), together with rec20 ommendations for such legislation and administrative ac21 tion as the Secretary determines appropriate. 


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1 SEC. 323. IMPROVED PATIENT CARE THROUGH EXPANDED 

2 SUPPORT FOR LIMITED ENGLISH PRO3 FICIENCY (LEP) SERVICES. 

4 (a) ADDITIONAL PAYMENTS FOR PRIMARY CARE

5 PHYSICIANS AND PRIMARY CARE PROVIDERS.—Section 

6 1833 of the Social Security Act (42 U.S.C. 1395l), as 

7 amended by section 304, is amended by adding at the end 

8 the following new subsection: 

9 ‘‘(y) ADDITIONAL PAYMENTS FOR PROVIDING SERV10 ICES TO INDIVIDUALS WITH LIMITED ENGLISH PRO11 FICIENCY.— 

12 ‘‘(1) IN GENERAL.—In the case of primary care 

13 providers’ services furnished on or after January 1, 

14 2010, to an individual with limited English pro15 ficiency by a provider, in addition to the amount of 

16 payment that would otherwise be made for such 

17 services under this part, there shall also be paid an 

18 appropriate amount (as determined by the Sec19 retary) in order to recognize the additional time in20 volved in furnishing the service to such individual. 

21 ‘‘(2) JUDICIAL REVIEW.—There shall be no ad22 ministrative or judicial review under section 1869, 

23 1878, or otherwise, respecting the determination of 

24 the amount of additional payment under this sub25 section.’’. 


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1 (b) NATIONAL CLEARINGHOUSE.—Not later than 

2 180 days after the date of enactment of this Act, the Sec3 retary shall establish a national clearinghouse to make 

4 available to the primary care physicians, primary care pro5 viders, patients, and States translated documents regard6 ing patient care and education under the Medicare pro7 gram, the Medicaid program, and the State Children’s 

8 Health Insurance Program under titles XVIII, XIX, and 

9 XXI, respectively, of the Social Security Act. 

10 (c) GRANTS TO SUPPORT LANGUAGE TRANSLATION

11 SERVICES IN UNDERSERVED COMMUNITIES.— 

12 (1) AUTHORITY TO AWARD GRANTS.—The Sec13 retary shall award grants to support language trans14 lation services for primary care physicians and pri15 mary care providers in medically underserved areas 

16 (as defined in section 3(c)). 

17 (2) AUTHORIZATION OF APPROPRIATIONS.— 

18 There are authorized to be appropriated to the Sec19 retary to award grants under this subsection, such 

20 sums as are necessary for fiscal years beginning with 

21 fiscal year 2010. 

22 SEC. 324. HHS STUDY AND REPORT ON USE OF REAL-TIME 

23 MEDICARE CLAIMS ADJUDICATION. 

24 (a) STUDY.—The Secretary shall conduct a study to 

25 assess the ability of the Medicare program under title 


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1 XVIII of the Social Security Act to engage in real-time 

2 claims adjudication for items and services furnished to 

3 Medicare beneficiaries. 

4 (b) CONSULTATION.—In conducting the study under 

5 subsection (a), the Secretary consult with stakeholders in 

6 the private sector, including stakeholders who are using 

7 or are testing real-time claims adjudication systems. 

8 (c) REPORT.—Not later than January 1, 2011, the 

9 Secretary shall submit to Congress a report containing the 

10 results of the study conducted under subsection (a), to11 gether with recommendations for such legislation and ad12 ministrative action as the Secretary determines appro13 priate. 

14 SEC. 325. ONGOING ASSESSMENT BY MEDPAC OF THE IM15 PACT OF MEDICARE PAYMENTS ON PRIMARY 

16 CARE ACCESS AND EQUITY. 

17 The Medicare Payment Advisory Commission, begin18 ning in 2010 and in each of its subsequent annual reports 

19 to Congress on Medicare physician payment policies, shall 

20 provide an assessment of the impact of changes in Medi21 care payment policies in improving access to and equity 

22 of payments to primary care physicians and primary care 

23 providers. Such assessment shall include an assessment of 

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1 mary care as well as any other payment changes that may 

2 be required by Congress to improve access to and equity 

3 of payments to primary care physicians and primary care 

4 providers. 

5 SEC. 326. DISTRIBUTION OF ADDITIONAL RESIDENCY POSI6 TIONS. 

7 (a) IN GENERAL.—Section 1886(h) of the Social Se8 curity Act (42 U.S.C. 1395ww(h)) is amended— 

9 (1) in paragraph (4)(F)(i), by striking ‘‘para10 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

11 (2) in paragraph (4)(H)(i), by striking ‘‘para12 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

13 and 

14 (3) by adding at the end the following new 

15 paragraph: 

16 ‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY

17 POSITIONS.— 

18 ‘‘(A) ADDITIONAL RESIDENCY POSI19 TIONS.— 

20 ‘‘(i) REDUCTION IN LIMIT BASED ON

21 UNUSED POSITIONS.— 

22 ‘‘(I) IN GENERAL.—The Sec23 retary shall reduce the otherwise ap24 plicable resident limit for a hospital 

25 that the Secretary determines had 


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1 residency positions that were unused 

2 for all 5 of the most recent cost re3 porting periods ending prior to the 

4 date of enactment of this paragraph 

5 by an amount that is equal to the 

6 number of such unused residency po7 sitions. 

8 ‘‘(II) EXCEPTION FOR RURAL

9 HOSPITALS AND CERTAIN OTHER HOS10 PITALS.—This subparagraph shall not 

11 apply to a hospital— 

12 ‘‘(aa) located in a rural area 

13 (as defined in subsection 

14 (d)(2)(D)(ii)); 

15 ‘‘(bb) that has participated 

16 in a voluntary reduction plan 

17 under paragraph (6); or 

18 ‘‘(cc) that has participated 

19 in a demonstration project ap20 proved as of October 31, 2003, 

21 under the authority of section 

22 402 of Public Law 90–248. 

23 ‘‘(ii) NUMBER AVAILABLE FOR DIS24 TRIBUTION.—The number of additional 

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1 tion under subparagraph (B) shall be an 

2 amount that the Secretary determines 

3 would result in a 15 percent increase in 

4 the aggregate number of full-time equiva5 lent residents in approved medical training 

6 programs (as determined based on the 

7 most recent cost reports available at the 

8 time of distribution). One-third of such 

9 number shall only be available for distribu10 tion to hospitals described in subclause (I) 

11 of subparagraph (B)(ii) under such sub12 paragraph. 

13 ‘‘(B) DISTRIBUTION.— 

14 ‘‘(i) IN GENERAL.—The Secretary 

15 shall increase the otherwise applicable resi16 dent limit for each qualifying hospital that 

17 submits an application under this subpara18 graph by such number as the Secretary 

19 may approve for portions of cost reporting 

20 periods occurring on or after the date of 

21 enactment of this paragraph. The aggre22 gate number of increases in the otherwise 

23 applicable resident limit under this sub24 paragraph shall be equal to the number of 


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1 additional residency positions available for 

2 distribution under subparagraph (A)(ii). 

3 ‘‘(ii) DISTRIBUTION TO HOSPITALS

4 ALREADY OPERATING OVER RESIDENT

5 LIMIT.— 

6 ‘‘(I) IN GENERAL.—Subject to 

7 subclause (II), in the case of a hos8 pital in which the reference resident 

9 level of the hospital (as defined in 

10 clause (ii)) is greater than the other11 wise applicable resident limit, the in12 crease in the otherwise applicable resi13 dent limit under this subparagraph 

14 shall be an amount equal to the prod15 uct of the total number of additional 

16 residency positions available for dis17 tribution under subparagraph (A)(ii) 

18 and the quotient of— 

19 ‘‘(aa) the number of resident 

20 positions by which the reference 

21 resident level of the hospital ex22 ceeds the otherwise applicable 

23 resident limit for the hospital; 

24 and 


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1 ‘‘(bb) the number of resident 

2 positions by which the reference 

3 resident level of all such hospitals 

4 with respect to which an applica5 tion is approved under this sub6 paragraph exceeds the otherwise 

7 applicable resident limit for such 

8 hospitals. 

9 ‘‘(II) REQUIREMENTS.—A hos10 pital described in subclause (I)— 

11 ‘‘(aa) is not eligible for an 

12 increase in the otherwise applica13 ble resident limit under this sub14 paragraph unless the amount by 

15 which the reference resident level 

16 of the hospital exceeds the other17 wise applicable resident limit is 

18 not less than 10 and the hospital 

19 trains at least 25 percent of the 

20 full-time equivalent residents of 

21 the hospital in primary care and 

22 general surgery (as of the date of 

23 enactment of this paragraph); 

24 and 


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1 ‘‘(bb) shall continue to train 

2 at least 25 percent of the full3 time equivalent residents of the 

4 hospital in primary care and gen5 eral surgery for the 10-year pe6 riod beginning on such date. 

7 In the case where the Secretary deter8 mines that a hospital no longer meets 

9 the requirement of item (bb), the Sec10 retary may reduce the otherwise appli11 cable resident limit of the hospital by 

12 the amount by which such limit was 

13 increased under this clause. 

14 ‘‘(III) CLARIFICATION REGARD15 ING ELIGIBILITY FOR OTHER ADDI16 TIONAL RESIDENCY POSITIONS.— 

17 Nothing in this clause shall be con18 strued as preventing a hospital de19 scribed in subclause (I) from applying 

20 for additional residency positions 

21 under this paragraph that are not re22 served for distribution under this 

23 clause. 

24 ‘‘(iii) REFERENCE RESIDENT

25 LEVEL.— 


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1 ‘‘(I) IN GENERAL.—Except as 

2 otherwise provided in subclause (II), 

3 the reference resident level specified in 

4 this clause for a hospital is the resi5 dent level for the most recent cost re6 porting period of the hospital ending 

7 on or before the date of enactment of 

8 this paragraph, for which a cost re9 port has been settled (or, if not, sub10 mitted (subject to audit)), as deter11 mined by the Secretary. 

12 ‘‘(II) USE OF MOST RECENT AC13 COUNTING PERIOD TO RECOGNIZE EX14 PANSION OF EXISTING PROGRAM OR

15 ESTABLISHMENT OF NEW PRO16 GRAM.—If a hospital submits a timely 

17 request to increase its resident level 

18 due to an expansion of an existing 

19 residency training program or the es20 tablishment of a new residency train21 ing program that is not reflected on 

22 the most recent cost report that has 

23 been settled (or, if not, submitted 

24 (subject to audit)), after audit and 

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1 retary, the reference resident level for 

2 such hospital is the resident level for 

3 the cost reporting period that includes 

4 the additional residents attributable to 

5 such expansion or establishment, as 

6 determined by the Secretary. 

7 ‘‘(C) CONSIDERATIONS IN REDISTRIBU8 TION.—In determining for which hospitals the 

9 increase in the otherwise applicable resident 

10 limit is provided under subparagraph (B) (other 

11 than an increase under subparagraph (B)(ii)), 

12 the Secretary shall take into account the dem13 onstrated likelihood of the hospital filling the 

14 positions within the first 3 cost reporting peri15 ods beginning on or after July 1, 2010, made 

16 available under this paragraph, as determined 

17 by the Secretary. 

18 ‘‘(D) PRIORITY FOR CERTAIN AREAS.—In 

19 determining for which hospitals the increase in 

20 the otherwise applicable resident limit is pro21 vided under subparagraph (B) (other than an 

22 increase under subparagraph (B)(ii)), the Sec23 retary shall distribute the increase to hospitals 

24 based on the following criteria: 


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1 ‘‘(i) The Secretary shall give pref2 erence to hospitals that submit applica3 tions for new primary care and general 

4 surgery residency positions. In the case of 

5 any increase based on such preference, a 

6 hospital shall ensure that— 

7 ‘‘(I) the position made available 

8 as a result of such increase remains a 

9 primary care or general surgery resi10 dency position for not less than 10 

11 years after the date on which the posi12 tion is filled; and 

13 ‘‘(II) the total number of primary 

14 care and general surgery residency po15 sitions in the hospital (determined 

16 based on the number of such positions 

17 as of the date of such increase, includ18 ing any position added as a result of 

19 such increase) is not decreased during 

20 such 10-year period. 

21 In the case where the Secretary determines 

22 that a hospital no longer meets the re23 quirement of subclause (II), the Secretary 

24 may reduce the otherwise applicable resi25 dent limit of the hospital by the amount by 


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1 which such limit was increased under this 

2 paragraph. 

3 ‘‘(ii) The Secretary shall give pref4 erence to hospitals that emphasizes train5 ing in community health centers and other 

6 community-based clinical settings. 

7 ‘‘(iii) The Secretary shall give pref8 erence to hospitals in States that have 

9 more medical students than residency posi10 tions available (including a greater pref11 erence for those States with smaller resi12 dent-to-medical-student ratios). In deter13 mining the number of medical students in 

14 a State for purposes of the preceding sen15 tence, the Secretary shall include planned 

16 students at medical schools which have 

17 provisional accreditation by the Liaison 

18 Committee on Medical Education or the 

19 American Osteopathic Association. 

20 ‘‘(iv) The Secretary shall give pref21 erence to hospitals in States that have low 

22 resident-to-population ratios (including a 

23 greater preference for those States with 

24 lower resident-to-population ratios). 

25 ‘‘(E) LIMITATION.— 


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1 ‘‘(i) IN GENERAL.—Except as pro2 vided in clause (ii), in no case may a hos3 pital (other than a hospital described in 

4 subparagraph (B)(ii)(I), subject to the lim5 itation under subparagraph (B)(ii)(III)) 

6 apply for more than 50 full-time equivalent 

7 additional residency positions under this 

8 paragraph. 

9 ‘‘(ii) INCREASE IN NUMBER OF ADDI10 TIONAL POSITIONS AVAILABLE FOR DIS11 TRIBUTION.—The Secretary shall increase 

12 the number of full-time equivalent addi13 tional residency positions a hospital may 

14 apply for under this paragraph if the Sec15 retary determines that the number of addi16 tional residency positions available for dis17 tribution under subparagraph (A)(ii) ex18 ceeds the number of such applications ap19 proved. 

20 ‘‘(F) APPLICATION OF PER RESIDENT

21 AMOUNTS FOR PRIMARY CARE AND NONPRI22 MARY CARE.—With respect to additional resi23 dency positions in a hospital attributable to the 

24 increase provided under this paragraph, the ap25 proved FTE resident amounts are deemed to be 


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1 equal to the hospital per resident amounts for 

2 primary care and nonprimary care computed 

3 under paragraph (2)(D) for that hospital. 

4 ‘‘(G) DISTRIBUTION.—The Secretary shall 

5 distribute the increase to hospitals under this 

6 paragraph not later than 2 years after the date 

7 of enactment of this paragraph.’’. 

8 (b) IME.— 

9 (1) IN GENERAL.—Section 1886(d)(5)(B)(v) of 

10 the Social Security Act (42 U.S.C. 

11 1395ww(d)(5)(B)(v)), in the second sentence, is 

12 amended— 

13 (A) by striking ‘‘subsection (h)(7)’’ and in14 serting ‘‘subsections (h)(7) and (h)(8)’’; and 

15 (B) by striking ‘‘it applies’’ and inserting 

16 ‘‘they apply’’. 

17 (2) CONFORMING PROVISION.—Section 

18 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

19 1395ww(d)(5)(B)) is amended by adding at the end 

20 the following clause: 

21 ‘‘(x) For discharges occurring on or after the 

22 date of enactment of this clause, insofar as an addi23 tional payment amount under this subparagraph is 

24 attributable to resident positions distributed to a 

25 hospital under subsection (h)(8)(B), the indirect 


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1 teaching adjustment factor shall be computed in the 

2 same manner as provided under clause (ii) with re3 spect to such resident positions.’’. 

4 SEC. 327. COUNTING RESIDENT TIME IN OUTPATIENT SET5 TINGS. 

6 (a) D–GME.—Section 1886(h)(4)(E) of the Social 

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

8 (1) by striking ‘‘under an approved medical 

9 residency training program’’; and 

10 (2) by striking ‘‘if the hospital incurs all, or 

11 substantially all, of the costs for the training pro12 gram in that setting’’ and inserting ‘‘if the hospital 

13 continues to incur the costs of the stipends and 

14 fringe benefits of the resident during the time the 

15 resident spends in that setting’’. 

16 (b) IME.—Section 1886(d)(5)(B)(iv) of the Social 

17 Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend18 ed— 

19 (1) by striking ‘‘under an approved medical 

20 residency training program’’; and 

21 (2) by striking ‘‘if the hospital incurs all, or 

22 substantially all, of the costs for the training pro23 gram in that setting’’ and inserting ‘‘if the hospital 

24 continues to incur the costs of the stipends and 


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1 fringe benefits of the intern or resident during the 

2 time the intern or resident spends in that setting’’. 

3 (c) EFFECTIVE DATES; APPLICATION.— 

4 (1) IN GENERAL.—Effective for cost reporting 

5 periods beginning on or after July 1, 2009, the Sec6 retary of Health and Human Services shall imple7 ment the amendments made by this section in a 

8 manner so as to apply to cost reporting periods be9 ginning on or after July 1, 2009. 

10 (2) APPLICATION.—The amendments made by 

11 this section shall not be applied in a manner that re12 quires reopening of any settled hospital cost reports 

13 as to which there is not a jurisdictionally proper ap14 peal pending as of the date of the enactment of this 

15 Act on the issue of payment for indirect costs of 

16 medical education under section 1886(d)(5)(B) of 

17 the Social Security Act (42 U.S.C. 

18 1395ww(d)(5)(B)) or for direct graduate medical 

19 education costs under section 1886(h) of such Act 

20 (42 U.S.C. 1395ww(h)). 


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1 SEC. 328. RULES FOR COUNTING RESIDENT TIME FOR DI2 DACTIC AND SCHOLARLY ACTIVITIES AND 

3 OTHER ACTIVITIES. 

4 (a) GME.—Section 1886(h) of the Social Security 

5 Act (42 U.S.C. 1395ww(h)), as amended by section 

6 327(a), is amended— 

7 (1) in paragraph (4)(E)— 

8 (A) by designating the first sentence as a 

9 clause (i) with the heading ‘‘IN GENERAL’’ and 

10 appropriate indentation and by striking ‘‘Such 

11 rules’’ and inserting ‘‘Subject to clause (ii), 

12 such rules’’; and 

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

14 clause: 

15 ‘‘(ii) TREATMENT OF CERTAIN NON16 HOSPITAL AND DIDACTIC ACTIVITIES.— 

17 Such rules shall provide that all time spent 

18 by an intern or resident in an approved 

19 medical residency training program in a 

20 nonhospital setting that is primarily en21 gaged in furnishing patient care (as de22 fined in paragraph (5)(K)) in non-patient 

23 care activities, such as didactic conferences 

24 and seminars, but not including research 

25 not associated with the treatment or diag26 nosis of a particular patient, as such time 


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1 and activities are defined by the Secretary, 

2 shall be counted toward the determination 

3 of full-time equivalency.’’; 

4 (2) in paragraph (4), by adding at the end the 

5 following new subparagraph: 

6 ‘‘(I) In determining the hospital’s number 

7 of full-time equivalent residents for purposes of 

8 this subsection, all the time that is spent by an 

9 intern or resident in an approved medical resi10 dency training program on vacation, sick leave, 

11 or other approved leave, as such time is defined 

12 by the Secretary, and that does not prolong the 

13 total time the resident is participating in the 

14 approved program beyond the normal duration 

15 of the program shall be counted toward the de16 termination of full-time equivalency.’’; and 

17 (3) in paragraph (5), by adding at the end the 

18 following new subparagraph: 

19 ‘‘(M) NONHOSPITAL SETTING THAT IS PRI20 MARILY ENGAGED IN FURNISHING PATIENT

21 CARE.—The term ‘nonhospital setting that is 

22 primarily engaged in furnishing patient care’ 

23 means a nonhospital setting in which the pri24 mary activity is the care and treatment of pa25 tients, as defined by the Secretary.’’. 


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1 (b) IME DETERMINATIONS.—Section 1886(d)(5)(B) 

2 of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by 

3 section 326(b), is amended by adding at the end the fol4 lowing new clause: 

5 ‘‘(xi)(I) The provisions of subparagraph (I) of 

6 subsection (h)(4) shall apply under this subpara7 graph in the same manner as they apply under such 

8 subsection. 

9 ‘‘(II) In determining the hospital’s number of 

10 full-time equivalent residents for purposes of this 

11 subparagraph, all the time spent by an intern or 

12 resident in an approved medical residency training 

13 program in non-patient care activities, such as di14 dactic conferences and seminars, as such time and 

15 activities are defined by the Secretary, that occurs in 

16 the hospital shall be counted toward the determina17 tion of full-time equivalency if the hospital— 

18 ‘‘(aa) is recognized as a subsection (d) hos19 pital; 

20 ‘‘(bb) is recognized as a subsection (d) 

21 Puerto Rico hospital; 

22 ‘‘(cc) is reimbursed under a reimbursement 

23 system authorized under section 1814(b)(3); or 

24 ‘‘(dd) is a provider-based hospital out25 patient department. 


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1 ‘‘(III) In determining the hospital’s number of 

2 full-time equivalent residents for purposes of this 

3 subparagraph, all the time spent by an intern or 

4 resident in an approved medical residency training 

5 program in research activities that are not associ6 ated with the treatment or diagnosis of a particular 

7 patient, as such time and activities are defined by 

8 the Secretary, shall not be counted toward the deter9 mination of full-time equivalency.’’. 

10 (c) EFFECTIVE DATES; APPLICATION.— 

11 (1) IN GENERAL.—Except as otherwise pro12 vided, the Secretary of Health and Human Services 

13 shall implement the amendments made by this sec14 tion in a manner so as to apply to cost reporting pe15 riods beginning on or after January 1, 1983. 

16 (2) DIRECT GME.—Section 1886(h)(4)(E)(ii) of 

17 the Social Security Act, as added by subsection 

18 (a)(1)(B), shall apply to cost reporting periods be19 ginning on or after July 1, 2009. 

20 (3) IME.—Section 1886(d)(5)(B)(xi)(III) of 

21 the Social Security Act, as added by subsection (b), 

22 shall apply to cost reporting periods beginning on or 

23 after October 1, 2001. Such section, as so added, 

24 shall not give rise to any inference on how the law 

25 in effect prior to such date should be interpreted. 


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1 (4) APPLICATION.—The amendments made by 

2 this section shall not be applied in a manner that re3 quires reopening of any settled hospital cost reports 

4 as to which there is not a jurisdictionally proper ap5 peal pending as of the date of the enactment of this 

6 Act on the issue of payment for indirect costs of 

7 medical education under section 1886(d)(5)(B) of 

8 the Social Security Act or for direct graduate med9 ical education costs under section 1886(h) of such 

10 Act. 

11 SEC. 329. PRESERVATION OF RESIDENT CAP POSITIONS 

12 FROM CLOSED AND ACQUIRED HOSPITALS. 

13 (a) GME.—Section 1886(h)(4)(H) of the Social Se14 curity Act (42 U.S.C. Section 1395ww(h)(4)(H)) is 

15 amended by adding at the end the following new clauses: 

16 ‘‘(vi) REDISTRIBUTION OF RESIDENCY

17 SLOTS AFTER A HOSPITAL CLOSES.— 

18 ‘‘(I) IN GENERAL.—Subject to 

19 the succeeding provisions of this 

20 clause, the Secretary shall, by regula21 tion, establish a process under which, 

22 in the case where a hospital with an 

23 approved medical residency program 

24 closes on or after the date of enact25 ment of the Balanced Budget Act of 


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1 1997, the Secretary shall increase the 

2 otherwise applicable resident limit 

3 under this paragraph for other hos4 pitals in accordance with this clause. 

5 ‘‘(II) PRIORITY FOR HOSPITALS

6 IN CERTAIN AREAS.—Subject to the 

7 succeeding provisions of this clause, in 

8 determining for which hospitals the 

9 increase in the otherwise applicable 

10 resident limit is provided under such 

11 process, the Secretary shall distribute 

12 the increase to hospitals located in the 

13 following priority order (with pref14 erence given within each category to 

15 hospitals that are members of the 

16 same affiliated group (as defined by 

17 the Secretary under clause (ii)) as the 

18 closed hospital): 

19 ‘‘(aa) First, to hospitals lo20 cated in the same core-based sta21 tistical area as, or a core-based 

22 statistical area contiguous to, the 

23 hospital that closed. 


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1 ‘‘(bb) Second, to hospitals 

2 located in the same State as the 

3 hospital that closed. 

4 ‘‘(cc) Third, to hospitals lo5 cated in the same region of the 

6 country as the hospital that 

7 closed. 

8 ‘‘(dd) Fourth, to all other 

9 hospitals. 

10 ‘‘(III) REQUIREMENT HOSPITAL

11 LIKELY TO FILL POSITION WITHIN

12 CERTAIN TIME PERIOD.—The Sec13 retary may only increase the otherwise 

14 applicable resident limit of a hospital 

15 under such process if the Secretary 

16 determines the hospital has dem17 onstrated a likelihood of filling the po18 sitions made available under this 

19 clause within 3 years. 

20 ‘‘(IV) LIMITATION.—The aggre21 gate number of increases in the other22 wise applicable resident limits for hos23 pitals under this clause shall be equal 

24 to the number of resident positions in 

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1 grams that closed on or after the date 

2 described in subclause (I). 

3 ‘‘(vii) SPECIAL RULE FOR ACQUIRED

4 HOSPITALS.— 

5 ‘‘(I) IN GENERAL.—In the case 

6 of a hospital that is acquired (through 

7 any mechanism) by another entity 

8 with the approval of a bankruptcy 

9 court, during a period determined by 

10 the Secretary (but not less than 3 

11 years), the applicable resident limit of 

12 the acquired hospital shall, except as 

13 provided in subclause (II), be the ap14 plicable resident limit of the hospital 

15 that was acquired (as of the date im16 mediately before the acquisition), 

17 without regard to whether the acquir18 ing entity accepts assignment of the 

19 Medicare provider agreement of the 

20 hospital that was acquired, so long as 

21 the acquiring entity continues to oper22 ate the hospital that was acquired and 

23 to furnish services, medical residency 

24 programs, and volume of patients 

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1 dency programs, and volume of pa2 tients of the hospital that was ac3 quired (as determined by the Sec4 retary) during such period. 

5 ‘‘(II) LIMITATION.—Subclause 

6 (I) shall only apply in the case where 

7 an acquiring entity waives the right as 

8 a new provider under the program 

9 under this title to have the otherwise 

10 applicable resident limit of the ac11 quired hospital re-established or in12 creased.’’. 

13 (b) IME.—Section 1886(d)(5)(B)(v) of the Social Se14 curity Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 

15 sentence, as amended by section 326(b), is amended by 

16 striking ‘‘subsections (h)(7) and (h)(8)’’ and inserting 

17 ‘‘subsections (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and 

18 (h)(8)’’. 

19 (c) APPLICATION.—The amendments made by this 

20 section shall not be applied in a manner that requires re21 opening of any settled hospital cost reports as to which 

22 there is not a jurisdictionally proper appeal pending as 

23 of the date of the enactment of this Act on the issue of 

24 payment for indirect costs of medical education under sec25 tion 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 


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1 1395ww(d)(5)(B)) or for direct graduate medical edu2 cation costs under section 1886(h) of such Act (42 U.S.C. 

3 1395ww(h)). 

4 (d) NO AFFECT ON TEMPORARY FTE CAP ADJUST5 MENTS.—The amendments made by this section shall not 

6 affect any temporary adjustment to a hospital’s FTE cap 

7 under section 413.79(h) of title 42, Code of Federal Regu8 lations (as in effect on the date of enactment of this Act). 

9 SEC. 330. QUALITY IMPROVEMENT ORGANIZATION ASSIST10 ANCE FOR PHYSICIAN PRACTICES SEEKING 

11 TO BE PATIENT CENTERED MEDICAL HOME 

12 PRACTICES. 

13 Not later than 90 days after the date of enactment 

14 of this Act, the Secretary of Health and Human Services 

15 shall revise the 9th Statement of Work under the Quality 

16 Improvement Program under part B of title XI of the So17 cial Security Act to include a requirement that, in order 

18 to be an eligible Quality Improvement Organization (in 

19 this section referred to as a ‘‘QIO’’) for the 9th Statement 

20 of Work contract cycle, a QIO shall provide assistance, 

21 including technical assistance, to physicians under the 

22 Medicare program under title XVIII of the Social Security 

23 Act that seek to acquire the elements necessary to be rec24 ognized as a patient centered medical home practice under 

25 the National Committee for Quality Assurance’s Physician 


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1 Practice Connections-PCMH module (or any successor 

2 module issued by such Committee). 

3 TITLE IV—STUDIES 

4 SEC. 401. STUDY CONCERNING THE DESIGNATION OF PRI5 MARY CARE AS A SHORTAGE PROFESSION. 

6 (a) IN GENERAL.—Not later than June 30, 2010, the 

7 Secretary of Labor shall conduct a study and submit to 

8 the Committee on Education and Labor of the House of 

9 Representatives and the Committee on Health, Education, 

10 Labor, and Pensions a report that contains— 

11 (1) a description of the criteria for the designa12 tion of primary care physicians as professions in 

13 shortage as defined by the Secretary under section 

14 212(a)(5)(A) of the Immigration and Nationality 

15 Act; 

16 (2) the findings of the Secretary on whether 

17 primary care physician professions will, on the date 

18 on which the report is submitted, or within the 5- 

19 year period beginning on such date, satisfy the cri20 teria referred to in paragraph (1); and 

21 (3) if the Secretary finds that such professions 

22 will not satisfy such criteria, recommendations for 

23 modifications to such criteria to enable primary care 

24 physicians to be so designated as a profession in 

25 shortage. 


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1 (b) REQUIREMENTS.—In conducting the study under 

2 subsection (a), the Secretary of Labor shall consider work3 force data from the Health Resources and Services Admin4 istration, the Council on Graduate Medical Education, the 

5 Association of American Medical Colleges, and input from 

6 physician membership organizations that represent pri7 mary care physicians. 

8 SEC. 402. STUDY CONCERNING THE EDUCATION DEBT OF 

9 MEDICAL SCHOOL GRADUATES. 

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

11 States shall conduct a study to evaluate the higher edu12 cation-related indebtedness of medical school graduates in 

13 the United States at the time of graduation from medical 

14 school, and the impact of such indebtedness on specialty 

15 choice, including the impact on the field of primary care. 

16 (b) REPORT.— 

17 (1) SUBMISSION AND DISSEMINATION OF RE18 PORT.—Not later than 1 year after the date of en19 actment of this Act, the Comptroller General shall 

20 submit a report on the study required by subsection 

21 (a) to the Committee on Health, Education, Labor, 

22 and Pensions of the Senate and the Committee on 

23 Education and Labor of the House of Representa24 tives, and shall make such report widely available to 

25 the public. 


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1 (2) ADDITIONAL REPORTS.—The Comptroller 

2 General may periodically prepare and release as nec3 essary additional reports on the topic described in 

4 subsection (a). 

5 SEC. 403. STUDY ON MINORITY REPRESENTATION IN PRI6 MARY CARE. 

7 (a) STUDY.—The Secretary of Health and Human 

8 Services, acting through the Administrator of the Health 

9 Resources and Services Administration, shall conduct a 

10 study of minority representation in training, and in prac11 tice, in primary care specialties. 

12 (b) REPORT.—Not later than 1 year after the date 

13 of enactment of this Act, the Secretary of Health and 

14 Human Services, acting through the Administrator of the 

15 Health Resources and Services Administration, shall sub16 mit to the appropriate committees of Congress a report 

17 concerning the study conducted under subsection (a), in18 cluding recommendations for achieving a primary care 

19 workforce that is more representative of the population of 

20 the United States. 

Æ 


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