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[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 2728 Introduced in Senate (IS)]

113th CONGRESS
  2d Session
                                S. 2728

 To amend title XVIII of the Social Security Act to provide community-
 based medical education payments to primary care teaching centers, to 
     provide for a Medicare indirect medical education performance 
    adjustment, and to increase Medicare graduate medical education 
                 transparency, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                             July 31, 2014

  Mrs. Murray introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
 To amend title XVIII of the Social Security Act to provide community-
 based medical education payments to primary care teaching centers, to 
     provide for a Medicare indirect medical education performance 
    adjustment, and to increase Medicare graduate medical education 
                 transparency, and for other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Community-Based Medical Education 
Act of 2014''.

SEC. 2. TEACHING HEALTH CENTER EXTENSION.

    (a) THC Program.--Section 340H of the Public Health Service Act (42 
U.S.C. 256h) is amended--
            (1) in subsection (g)--
                    (A) by striking ``not to exceed $230,000,000, for 
                the period of fiscal years 2011 through 2015.'' and 
                inserting ``not to exceed--''; and
                    (B) by adding at the end the following:
            ``(1) $230,000,000, for the period of fiscal years 2011 
        through 2015; and
            ``(2) $420,000,000, for the period of fiscal years 2016 
        through 2019.''; and
            (2) by adding at the end the following:
    ``(k) Evaluation of Program; Participation in Primary Care Teaching 
Program.--The Secretary shall--
            ``(1) not later than December 31, 2017, conduct a 
        comprehensive evaluation of the program under this section; and
            ``(2) establish a process by which qualified teaching 
        health centers that have received payments under this section 
        prior to the date on which the primary care teaching centers 
        program is established under section 1899B of the Social 
        Security Act may become eligible to participate in such primary 
        care teaching program.''.
    (b) Teaching Health Centers Development Grants.--Section 749A of 
the Public Health Service Act (42 U.S.C. 293l-1) is amended--
            (1) in subsection (a), by inserting ``, based on 
        demonstrated financial need,'' after ``centers'';
            (2) in subsection (b), by striking ``$500,000'' and 
        inserting ``$250,000''; and
            (3) in subsection (g), by striking ``fiscal year 2010, 
        $50,000,000 for fiscal year 2011, $50,000,000 for fiscal year 
        2012'' and inserting ``each of fiscal years 2016, 2017, and 
        2018''.

SEC. 3. COMMUNITY-BASED MEDICAL EDUCATION PAYMENTS.

    Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is 
amended by adding at the end the following new section:

              ``community-based medical education payments

    ``Sec. 1899B.  (a) In General.--The Secretary shall establish a 
program under which the Secretary makes payments to primary care 
teaching centers (as defined in subsection (c)) under this section.
    ``(b) Implementation.--The Secretary shall establish the program 
under this section not later than January 1, 2019.
    ``(c) Definitions.--
            ``(1) Definition of primary care teaching center.--In this 
        section, the term `primary care teaching center' means an 
        entity described in paragraph (2) that--
                    ``(A) is accredited by the Accreditation Council on 
                Graduate Medical Education, the American Osteopathic 
                Association, or the Commission on Dental Accreditation; 
                and
                    ``(B) operates a community-based primary care 
                residency program (as defined in paragraph (5)) in a 
                rural or underserved area.
            ``(2) Entity described.--The following entities are 
        described in this paragraph:
                    ``(A) An entity that received payments under 
                section 340H of the Public Health Service Act for a 
                community based, ambulatory patient care center which 
                operates a primary care residency program or a related 
                consortia recognized by the Health Resources and 
                Services Administration.
                    ``(B) A community-based, independent corporate 
                entity collaborating with one or more hospitals in 
                operating one or more primary care residency programs.
                    ``(C) A medical education entity established by one 
                or more hospitals to develop and operate one or more 
                primary care residency programs. The hospital or 
                hospitals may be the sole corporate members of the 
                entity, but the governing board of the entity shall 
                include representatives of the community.
                    ``(D) A medical education entity that is 
                independent of any hospital but collaborates with a 
                hospital in operating one or more medical residency 
                training programs. The medical education entity may 
                include a university or a school of medicine.
                    ``(E) A subsidiary of a hospital or independent 
                corporation operating one or more primary care 
                residency programs for the hospital with community 
                participation in the governance of the organization.
                    ``(F) A rural training track program (as defined in 
                paragraph (6)).
            ``(3) Inclusion of certain entities.--The term `primary 
        care teaching center' includes the following:
                    ``(A) A Federally qualified health center (as 
                defined in section 1905(l)(2)(B)).
                    ``(B) A community mental health center (as defined 
                in section 1861(ff)(3)(B)).
                    ``(C) A rural health clinic, as defined in section 
                1861(aa).
                    ``(D) A health center operated by the Indian Health 
                Service, an Indian tribe or tribal organization, or an 
                urban Indian organization (as defined in section 4 of 
                the Indian Health Care Improvement Act).
                    ``(E) An entity receiving funds under title X of 
                the Public Health Service Act.
                    ``(F) A critical access hospital.
                    ``(G) An entity that collaborates to form a 
                consortium that operates an accredited primary care 
                residency program, so long as the consortium is 
                accredited in the primary care specialty and is listed 
                as the institutional sponsor by the relevant 
                accrediting body. Within the consortium, a community-
                based ambulatory care center shall play an integral 
                role in the academic, financial, and administrative 
                operations of the primary care residency program.
            ``(4) Definition of primary care.--In this section, the 
        term `primary care' means family medicine, internal medicine, 
        pediatrics, internal medicine-pediatrics, obstetrics and 
        gynecology, psychiatry, general dentistry, pediatric dentistry, 
        or geriatrics.
            ``(5) Definition of primary care residency program.--In 
        this section, the term `primary care residency program' means 
        an approved medical residency training program (as defined in 
        section 1886(h)(5)(A)) in primary care.
            ``(6) Definition of rural training track program.--In this 
        section, the term `rural training track program' means an 
        alternative training track integrated with a larger more urban 
        or community hospital program and separately accredited as 
        such, with a rural location, a rural mission, or a major rural 
        service area, in which the residents spend approximately two of 
        three years in a place of practice separate and more rural or 
        rurally focused than the larger program.
    ``(d) Limitations on Number of Resident Training Positions.--
            ``(1) Limitation on total number under program.--Subject to 
        paragraph (3), the Secretary shall make payments under this 
        section for not more than 1,500 new full-time equivalent 
        resident training positions to be distributed to primary care 
        teaching centers at a rate of not more than 300 per year until 
        expended.
            ``(2) Limitation on total number for each primary care 
        teaching center.--Subject to paragraph (3), no single primary 
        care teaching center shall receive a total of more than 50 of 
        the positions distributed under the program, which must be in 
        primary care specialties.
            ``(3) Exception for existing residents of teaching health 
        centers.--The limitation under each of paragraphs (1) and (2) 
        shall not apply with respect to a resident training position of 
        a teaching health center that received payments under section 
        340H of the Public Health Service Act if the resident training 
        position was in a medical residency training program operated 
        by the teaching health center prior to the participation of the 
        teaching health center as a primary care teaching center under 
        this section. The Secretary shall make payments for a resident 
        in a training position described in the preceding center under 
        this section in accordance with subsection (f).
    ``(e) Preference for Teaching Health Centers.--The Secretary shall 
give preference to teaching health centers that received payments under 
section 340H of the Public Health Service Act that are seeking to 
participate as a primary care teaching center under this section.
    ``(f) Payment of Annual Per Resident Payment Amount.--
            ``(1) Methodology.--Subject to paragraph (2) and subsection 
        (i), for each year of the program, the Secretary shall develop 
        a methodology to determine the per resident payment amount for 
        each full-time equivalent resident of a primary care teaching 
        center under this section.
            ``(2) Minimum payment amount.--Subject to subsection (i), 
        the per resident payment amount for each full-time equivalent 
        resident of a primary care teaching center under this section 
        for a year shall be not less than--
                    ``(A) for 2014, $150,000; and
                    ``(B) for each subsequent year, the amount 
                determined under this paragraph for the preceding year 
                increased by the percentage increase in the consumer 
                price index for all urban consumers (United States city 
                average) for the 12-month period ending with June of 
                the preceding year.
            ``(3) Direct payment.--Any payment under this section with 
        respect to a full-time equivalent resident of a primary care 
        teaching center shall be made directly to the primary care 
        teaching center.
    ``(g) No Effect on Other Payments or Limitation on Number of 
Residents Under Section 1886.--Nothing in this section shall effect 
payments under section 1886(d)(5)(B) or section 1886(h) or the 
application of the limitation on the number of residents under section 
1886(h)(4)(F).
    ``(h) Requirements for Entities Receiving Medicare Graduate Medical 
Education Payments.--In the case where a primary care residency 
program, including a rural training track program, funded by a hospital 
through payments under subsections (d)(5)(B) and (h) of section 1886 
becomes a primary care teaching center under this section, the hospital 
shall ensure, during the 10-year period beginning on the date of the 
transition, that the total number of full-time equivalent residents of 
the hospital in primary care does not decrease. The transition 
described in the preceding sentence shall begin on the date when the 
primary care teaching center receives its first payment under this 
section.
    ``(i) Performance Adjustments.--
            ``(1) In general.--Subject to the succeeding provisions of 
        this subsection, the Secretary shall establish and implement 
        procedures under which the amount of payments that a primary 
        care teaching center would otherwise receive under this section 
        for a year is adjusted based on the reporting of measures and 
        the performance of the primary care teaching center on measures 
        of population health priorities specified by the Secretary.
            ``(2) Adjustments to begin in 2021.--The adjustments shall 
        apply to payments--
                    ``(A) with respect to the adjustments for reporting 
                under paragraph (7)(A), made for 2021; and
                    ``(B) with respect to the adjustments for 
                performance under paragraph (7)(B), made for 2022 and 
                subsequent years.
            ``(3) Measures.--The measures of population health 
        priorities specified by the Secretary under this subsection 
        shall be the measures specified by the Secretary under section 
        1886(t).
            ``(4) Performance standards.--The Secretary shall establish 
        performance standards with respect to measures specified by the 
        Secretary under this subsection for a performance period for a 
        year (as established under paragraph (5)).
            ``(5) Performance period.--The Secretary shall establish 
        the performance period for a year. Such performance period 
        shall begin and end prior to the beginning of such year.
            ``(6) Reporting of measures.--The procedures established 
        and implemented under paragraph (1) shall include a process 
        under which primary care teaching centers shall submit data on 
        the measures specified by the Secretary under this subsection 
        to the Secretary in a form and manner, and at a time, specified 
        by the Secretary for purposes of this subsection.
            ``(7) Adjustments.--
                    ``(A) Reporting for 2021.--For 2021, in the case of 
                a primary care teaching center that does not submit, to 
                the Secretary in accordance with this subsection, data 
                required to be submitted under paragraph (6) for a 
                period (determined appropriate by the Secretary) for 
                such year, the total amount that the primary care 
                teaching center would otherwise receive under this 
                section for such year shall be reduced by 1 percent.
                    ``(B) Performance for 2022 and subsequent years.--
                            ``(i) In general.--Subject to clause (ii), 
                        based on the performance of each primary care 
                        teaching center with respect to compliance with 
                        the measures for a performance period for a 
                        year (beginning with 2022), the Secretary shall 
                        determine the amount of any adjustment under 
                        this subparagraph to payments to the primary 
                        care teaching center under this section for 
                        such year. Such adjustment may not exceed an 
                        amount equal to 1 percent of the total amount 
                        that the primary care teaching center would 
                        otherwise receive under this section for such 
                        year.
                            ``(ii) Budget neutral.--In making 
                        adjustments under this subparagraph, the 
                        Secretary shall ensure that the total amount of 
                        payments made to all primary care teaching 
                        centers under this section for a year is equal 
                        to the total amount of payments that would have 
                        been made to such centers under this section 
                        for such year if this subsection had not been 
                        enacted.
            ``(8) No effect in subsequent years.--Any adjustment under 
        subparagraph (A) or (B) of paragraph (7) shall apply only with 
        respect to the year involved, and the Secretary shall not take 
        into account any such adjustment in making payments to a 
        primary care teaching center under this section in a subsequent 
        year.
    ``(j) Evaluation and Report.--Not later than January 1, 2021, and 
every five years thereafter, the Secretary shall submit to Congress a 
report on the implementation of the program under this section, 
including--
            ``(1) the measure development procedures under subsection 
        (i), including any barriers to measure development;
            ``(2) the compliance with reporting on the performance 
        measures under that subsection, including any barriers to such 
        compliance; and
            ``(3) recommendations to address any barriers described in 
        subparagraph (A) or (B).
    ``(k) Funding.--For purposes of carrying out this section, the 
Secretary shall provide for the transfer, from the Federal Hospital 
Insurance Trust Fund under section 1817 and the Federal Supplementary 
Medical Insurance Trust Fund under section 1841 (in such proportion as 
the Secretary determines appropriate), of such sums as are necessary to 
the Centers for Medicare & Medicaid Services Program Management Account 
for fiscal year 2019 and each succeeding fiscal year. Amounts 
transferred under the preceding sentence shall remain available until 
expended.''.

SEC. 4. MEDICARE INDIRECT MEDICAL EDUCATION PERFORMANCE ADJUSTMENT.

    Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is 
amended--
            (1) in subsection (d)(5)(B), in the matter preceding clause 
        (i), by inserting ``subject to subsection (t) and'' before 
        ``except as follows''; and
            (2) by adding at the end the following new subsection:
    ``(t) Indirect Medical Education Performance Adjustments.--
            ``(1) In general.--Subject to the succeeding provisions of 
        this subsection, the Secretary shall establish and implement 
        procedures under which the amount of payments that a hospital 
        (as defined in paragraph (11)) would otherwise receive for 
        indirect medical education costs under subsection (d)(5)(B) for 
        discharges occurring during a fiscal year is adjusted based on 
        the reporting of measures and the performance of the hospital 
        on measures of population health priorities specified by the 
        Secretary.
            ``(2) Adjustments to begin in fiscal year 2018.--The 
        adjustments shall apply to payments for discharges occurring--
                    ``(A) with respect to the adjustments for reporting 
                under paragraph (8)(A), during fiscal year 2018; and
                    ``(B) with respect to the adjustments for 
                performance under paragraph (8)(B), on or after October 
                1, 2018.
            ``(3) Measures.--The measures of population health 
        priorities specified by the Secretary under this subsection 
        shall include measures relating to--
                    ``(A) the extent of training provided in--
                            ``(i) shortage specialties;
                            ``(ii) a variety of settings and systems;
                            ``(iii) the coordination of patient care 
                        across settings;
                            ``(iv) interprofessional and 
                        multidisciplinary care teams;
                            ``(v) methods for identifying system errors 
                        and implementing system solutions; and
                            ``(vi) the use of health information 
                        technology; and
                    ``(B) the number of graduates practicing in 
                shortage specialties 5 years after graduation, 
                including in shortage specialties in health 
                professional shortage areas.
            ``(4) Measure development process.--
                    ``(A) In general.--The measures of patient care 
                specified by the Secretary under this subsection--
                            ``(i) shall--
                                    ``(I) be measures that have been 
                                adopted or endorsed by an accrediting 
                                organization (such as the Accreditation 
                                Council for Graduate Medical Education 
                                or American Osteopathic Association); 
                                and
                                    ``(II) be measures that the 
                                Secretary identifies as having used a 
                                consensus-based process for developing 
                                such measures; and
                            ``(ii) may include measures that have been 
                        submitted by teaching hospitals and medical 
                        schools (allopathic and osteopathic).
                    ``(B) Proposed set of initial measures.--Not later 
                than July 1, 2015, the Secretary shall publish in the 
                Federal Register a proposed initial set of measures for 
                use under this subsection. The Secretary shall provide 
                for a period of public comment on such measures.
                    ``(C) Final set of initial measures.--Not later 
                than January 1, 2016, the Secretary shall publish in 
                the Federal Register the set of initial measures to be 
                specified by the Secretary for use under this 
                subsection.
                    ``(D) Update of measures.--The Secretary may, 
                through notice and comment rulemaking, periodically 
                update the measures specified under this subsection 
                pursuant to the requirements under subparagraph (A).
            ``(5) Performance standards.--The Secretary shall establish 
        performance standards with respect to measures specified by the 
        Secretary under this subsection for a performance period for a 
        fiscal year (as established under paragraph (6)).
            ``(6) Performance period.--The Secretary shall establish 
        the performance period for a fiscal year. Such performance 
        period shall begin and end prior to the beginning of such 
        fiscal year.
            ``(7) Reporting of measures.--The procedures established 
        and implemented under paragraph (1) shall include a process 
        under which hospitals shall submit data on the measures 
        specified by the Secretary under this subsection to the 
        Secretary in a form and manner, and at a time, specified by the 
        Secretary for purposes of this subsection.
            ``(8) Adjustments.--
                    ``(A) Reporting for fiscal year 2018.--For fiscal 
                year 2018, in the case of a hospital that does not 
                submit, to the Secretary in accordance with this 
                subsection, data required to be submitted under 
                paragraph (7) for a period (determined appropriate by 
                the Secretary) for such fiscal year, the total amount 
                that the hospital would otherwise receive under 
                subsection (d)(5)(B) for discharges in such fiscal year 
                shall be reduced by 1 percent.
                    ``(B) Performance for fiscal year 2019 and 
                subsequent fiscal years.--
                            ``(i) In general.--Subject to clause (ii), 
                        based on the performance of each hospital with 
                        respect to compliance with the measures for a 
                        performance period for a fiscal year (beginning 
                        with fiscal year 2019), the Secretary shall 
                        determine the amount of any adjustment under 
                        this subparagraph to payments to the hospital 
                        under subsection (d)(5)(B) for discharges in 
                        such fiscal year. Such adjustment may not 
                        exceed an amount equal to 2 percent of the 
                        total amount that the hospital would otherwise 
                        receive under such subsection for discharges in 
                        such fiscal year.
                            ``(ii) Budget neutral.--In making 
                        adjustments under this subparagraph, the 
                        Secretary shall ensure that the total amount of 
                        payments made to all hospitals under subsection 
                        (d)(5)(B) for discharges in a fiscal year is 
                        equal to the total amount of payments that 
                        would have been made to such hospitals under 
                        such subsection for discharges in such fiscal 
                        year if this subsection had not been enacted.
            ``(9) No effect in subsequent fiscal years.--Any adjustment 
        under subparagraph (A) or (B) of paragraph (8) shall apply only 
        with respect to the fiscal year involved, and the Secretary 
        shall not take into account any such adjustment in making 
        payments to a hospital under this section in a subsequent 
        fiscal year.
            ``(10) Evaluation of submission of performance measures.--
        Not later than January 1, 2018, and every five years 
        thereafter, the Secretary shall submit to Congress a report on 
        the implementation of this subsection, including--
                    ``(A) the measure development procedures, including 
                any barriers to measure development;
                    ``(B) the compliance with reporting on the 
                performance measures, including any barriers to such 
                compliance; and
                    ``(C) recommendations to address any barriers 
                described in subparagraph (A) or (B).
            ``(11) Definitions.--In this subsection:
                    ``(A) Hospital.--The term `hospital' means a 
                hospital that receives payments under subsection 
                (d)(5)(B).
                    ``(B) Shortage specialty.--The term `shortage 
                specialty' means the following specialties and 
                subspecialties:
                            ``(i) Family medicine.
                            ``(ii) Geriatric medicine.
                            ``(iii) General internal medicine.
                            ``(iv) General surgery.
                            ``(v) High priority pediatric 
                        subspecialties.
                            ``(vi) Psychiatry.
                            ``(vii) Other specialties and 
                        subspecialties determined appropriate by the 
                        Secretary.''.

SEC. 5. INCREASING MEDICARE GRADUATE MEDICAL EDUCATION TRANSPARENCY.

    (a) In General.--Not later than 2 years after the date of the 
enactment of this Act, and annually thereafter, the Secretary of Health 
and Human Services shall submit to Congress and the National Health 
Care Workforce Commission a report on the graduate medical education 
payments that hospitals and primary health training programs receive 
under the Medicare program.
    (b) Requirements.--The report under subsection (a) shall include 
the following information with respect to each hospital or primary 
health training program that receives such payments:
            (1) The direct graduate medical education payments made to 
        the hospital under section 1886(h) of the Social Security Act 
        (42 U.S.C. 1395ww(h)).
            (2) The total costs of direct graduate medical education to 
        the hospital as reported on the annual Medicare Cost Reports.
            (3) The indirect medical education payments made to the 
        hospital under section 1886(d)(5)(B) of such Act (42 U.S.C. 
        1395ww(d)(1)(B)).
            (4) The number of full-time-equivalent residents counted 
        for purposes of making the payments described in paragraph (1).
            (5) The number of full-time-equivalent residents counted 
        for purposes of making the payments described in paragraph (3).
            (6) The number of full-time-equivalent residents, if any, 
        that are not counted for purposes of making payments described 
        in paragraph (1).
            (7) The number of full-time-equivalent residents, if any, 
        that are not counted for purposes of making payments described 
        in paragraph (3).
            (8) The payments made to primary care teaching centers 
        under section 1899B of the Social Security Act, as added by 
        section 3.
            (9) The number of full-time-equivalent residents counted 
        for purposes of making the payments described in paragraph (8).
            (10) The percentage of all graduates of a program for which 
        payments described in paragraph (1) or (3) were made to the 
        hospital that are practicing primary care 5 years after 
        graduation.
            (11) The percentage of all graduates of a program for which 
        payments described in paragraph (1) or (3) were made to the 
        hospital that are practicing primary care in health 
        professional shortage areas 5 years after graduation.
            (12) The percentage of all graduates of a primary care 
        teaching center for which payments described in paragraph (8) 
        were made to the primary care teaching center that are 
        practicing primary care 5 years after graduation.
            (13) The percentage of all graduates of a primary care 
        teaching center for which payments described in paragraph (8) 
        were made to the primary care teaching center that are 
        practicing primary care in health professional shortage areas 5 
        years after graduation.
            (14) Other information determined appropriate by the 
        Secretary.

SEC. 6. REAUTHORIZATION OF THE HEALTH CARE WORKFORCE COMMISSION.

    Section 5101(h)(2) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 294q(h)(2)) is amended to read as follows:
            ``(2) Authorization of appropriations.--To carry out this 
        section, there are authorized to be appropriated $14,000,000 
        for the period of fiscal years 2015 through 2019, and such sums 
        as may be necessary for each subsequent fiscal year.''.

SEC. 7. REDUCTION IN MEDICARE INDIRECT GRADUATE MEDICAL EDUCATION (IME) 
              PAYMENTS.

    (a) In General.--Section 1886(d)(5)(B)(ii) of the Social Security 
Act (42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended--
            (1) in subclause (XI), by striking ``and'' at the end;
            (2) in subclause (XII)--
                    (A) by inserting ``and before October 1, 2016,'' 
                after ``2007,''; and
                    (B) by striking the period at the end and inserting 
                ``; and''; and
            (3) by adding at the end the following new subclause:
                    ``(XIII) on or after October 1, 2016, `c' is equal 
                to 1.32.''.
    (b) Conforming Amendment Relating to Determination of Standardized 
Amount.--Section 1886(d)(2)(C)(i) of the Social Security Act (42 U.S.C. 
1395ww(d)(2)(C)(i)) is amended by inserting ``or of section 7(a) of the 
Community-Based Medical Education Act of 2014'' after ``Act of 1997''.
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