```

[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2389 Introduced in House (IH)]

<DOC>

118th CONGRESS
  1st Session
                                H. R. 2389

  To amend title XVIII of the Social Security Act to provide for the 
distribution of additional residency positions, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             March 29, 2023

 Ms. Sewell (for herself and Mr. Fitzpatrick) introduced the following 
  bill; which was referred to the Committee on Ways and Means, and in 
 addition to the Committee on Energy and Commerce, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL

 
  To amend title XVIII of the Social Security Act to provide for the 
distribution of additional residency positions, and for other purposes.

    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 ``Resident Physician Shortage 
Reduction Act of 2023''.

SEC. 2. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.

    (a) In General.--Section 1886(h) of the Social Security Act (42 
U.S.C. 1395ww(h)) is amended--
            (1) in paragraph (4)(F)(i), by striking ``paragraphs (7), 
        (8), (9), and (10)'' and inserting ``paragraphs (7), (8), (9), 
        (10), and (11)'';
            (2) in paragraph (4)(H)(i), by striking ``paragraphs (7), 
        (8), (9), and (10)'' and inserting ``paragraphs (7), (8), (9), 
        (10), and (11)'';
            (3) in paragraph (7)(E), by inserting ``paragraph (10),'' 
        after ``paragraph (8),''; and
            (4) by adding at the end the following new paragraph:
            ``(11) Distribution of additional residency positions.--
                    ``(A) Additional residency positions.--
                            ``(i) In general.--For each of fiscal years 
                        2025 through 2031 (and succeeding fiscal years 
                        if the Secretary determines that there are 
                        additional residency positions available to 
                        distribute under clause (iv)(II)), the 
                        Secretary shall, subject to clause (ii) and 
                        subparagraph (D), increase the otherwise 
                        applicable resident limit for each qualifying 
                        hospital (as defined in subparagraph (H)) that 
                        submits a timely application under this 
                        subparagraph by such number as the Secretary 
                        may approve for portions of cost reporting 
                        periods occurring on or after July 1 of the 
                        fiscal year of the increase.
                            ``(ii) Number available for distribution.--
                        For each such fiscal year, the Secretary shall 
                        determine the total number of additional 
                        residency positions available for distribution 
                        under clause (i) in accordance with the 
                        following:
                                    ``(I) Allocation to hospitals 
                                already operating over resident 
                                limit.--One-third of such number shall 
                                be available for distribution only to 
                                hospitals described in subparagraph 
                                (B).
                                    ``(II) Aggregate limitation.--
                                Except as provided in clause (iv)(I), 
                                the aggregate number of increases in 
                                the otherwise applicable resident limit 
                                under this subparagraph shall be equal 
                                to 2,000 in each such year.
                            ``(iii) Process for distributing 
                        positions.--
                                    ``(I) Rounds of applications.--The 
                                Secretary shall initiate 7 separate 
                                rounds of applications for an increase 
                                under clause (i), 1 round with respect 
                                to each of fiscal years 2025 through 
                                2031.
                                    ``(II) Number available.--In each 
                                of such rounds, the aggregate number of 
                                positions available for distribution in 
                                the fiscal year under clause (ii) shall 
                                be distributed, plus any additional 
                                positions available under clause (iv).
                                    ``(III) Timing.--The Secretary 
                                shall notify hospitals of the number of 
                                positions distributed to the hospital 
                                under this paragraph as a result of an 
                                increase in the otherwise applicable 
                                resident limit by January 1 of the 
                                fiscal year of the increase. Such 
                                increase shall be effective for 
                                portions of cost reporting periods 
                                beginning on or after July 1 of that 
                                fiscal year.
                            ``(iv) Positions not distributed during the 
                        fiscal year.--
                                    ``(I) In general.--If the number of 
                                resident full-time equivalent positions 
                                distributed under this paragraph in a 
                                fiscal year is less than the aggregate 
                                number of positions available for 
                                distribution in the fiscal year (as 
                                described in clause (ii), including 
                                after application of this subclause), 
                                the difference between such number 
                                distributed and such number available 
                                for distribution shall be added to the 
                                aggregate number of positions available 
                                for distribution in the following 
                                fiscal year.
                                    ``(II) Exception if positions not 
                                distributed by end of fiscal year 
                                2031.--If the aggregate number of 
                                positions distributed under this 
                                paragraph during the 7-year period of 
                                fiscal years 2025 through 2031 is less 
                                than 14,000, the Secretary shall, in 
                                accordance with the provisions of 
                                clause (ii) and subparagraph (E) and 
                                the considerations and priority 
                                described in subparagraph (C), conduct 
                                an application and distribution process 
                                in each subsequent fiscal year until 
                                such time as the aggregate amount of 
                                positions distributed under this 
                                paragraph is equal to 14,000.
                    ``(B) Allocation of distribution for positions to 
                hospitals already operating over resident limit.--
                            ``(i) In general.--Subject to clauses (ii) 
                        and (iii), in the case of a hospital in which 
                        the reference resident level of the hospital 
                        (as specified in subparagraph (H)(ii)) is 
                        greater than the otherwise applicable resident 
                        limit, the increase in the otherwise applicable 
                        resident limit under subparagraph (A) for a 
                        fiscal year described in such subparagraph 
                        shall be an amount equal to the product of the 
                        total number of additional residency positions 
                        available for distribution under subparagraph 
                        (A)(ii)(I) for such fiscal year and the 
                        quotient of--
                                    ``(I) the number of resident 
                                positions by which the reference 
                                resident level of the hospital exceeds 
                                the otherwise applicable resident limit 
                                for the hospital; and
                                    ``(II) the number of resident 
                                positions by which the reference 
                                resident level of all such hospitals 
                                with respect to which an application is 
                                approved under this paragraph exceeds 
                                the otherwise applicable resident limit 
                                for such hospitals.
                            ``(ii) Requirements.--A hospital described 
                        in clause (i)--
                                    ``(I) is not eligible for an 
                                increase in the otherwise applicable 
                                resident limit under this subparagraph 
                                unless the amount by which the 
                                reference resident level of the 
                                hospital exceeds the otherwise 
                                applicable resident limit is not less 
                                than 10 and the hospital trains at 
                                least 25 percent of the full-time 
                                equivalent residents of the hospital in 
                                primary care and general surgery (as of 
                                the date of enactment of this 
                                paragraph); and
                                    ``(II) shall continue to train at 
                                least 25 percent of the full-time 
                                equivalent residents of the hospital in 
                                primary care and general surgery for 
                                the 5-year period beginning on such 
                                date.
                        In the case where the Secretary determines that 
                        a hospital described in clause (i) no longer 
                        meets the requirement of subclause (II), the 
                        Secretary may reduce the otherwise applicable 
                        resident limit of the hospital by the amount by 
                        which such limit was increased under this 
                        subparagraph.
                            ``(iii) Clarification regarding eligibility 
                        for other additional residency positions.--
                        Nothing in this subparagraph shall be construed 
                        as preventing a hospital described in clause 
                        (i) from applying for and receiving additional 
                        residency positions under this paragraph that 
                        are not reserved for distribution under this 
                        subparagraph.
                    ``(C) Distribution of other positions.--For 
                purposes of determining an increase in the otherwise 
                applicable resident limit under subparagraph (A) (other 
                than such an increase described in subparagraph (B)), 
                the following shall apply:
                            ``(i) Considerations in distribution.--In 
                        determining for which hospitals such an 
                        increase is provided under subparagraph (A), 
                        the Secretary shall take into account the 
                        demonstrated likelihood of the hospital filling 
                        the positions made available under this 
                        paragraph within the first 5 cost reporting 
                        periods beginning after the date the increase 
                        would be effective, as determined by the 
                        Secretary.
                            ``(ii) Minimum distribution for certain 
                        categories of hospitals.--With respect to the 
                        aggregate number of such positions available 
                        for distribution under this paragraph, the 
                        Secretary shall distribute not less than 10 
                        percent of such aggregate number to each of the 
                        following categories of hospitals:
                                    ``(I) Hospitals that are located in 
                                a rural area (as defined in subsection 
                                (d)(2)(D)) or are treated as being 
                                located in a rural area pursuant to 
                                subsection (d)(8)(E) or are located in 
                                Alaska, Hawaii, or a territory of the 
                                United States.
                                    ``(II) Hospitals in which the 
                                reference resident level of the 
                                hospital (as specified in subparagraph 
                                (H)(ii)) is greater than the otherwise 
                                applicable resident limit.
                                    ``(III) Hospitals in States with--
                                            ``(aa) new medical schools 
                                        that received `Candidate 
                                        School' status from the Liaison 
                                        Committee on Medical Education 
                                        or that received `Pre-
                                        Accreditation' status from the 
                                        American Osteopathic 
                                        Association Commission on 
                                        Osteopathic College 
                                        Accreditation on or after 
                                        January 1, 2000, and that have 
                                        achieved or continue to 
                                        progress toward `Full 
                                        Accreditation' status (as such 
                                        term is defined by the Liaison 
                                        Committee on Medical Education) 
                                        or toward `Accreditation' 
                                        status (as such term is defined 
                                        by the American Osteopathic 
                                        Association Commission on 
                                        Osteopathic College 
                                        Accreditation); or
                                            ``(bb) additional locations 
                                        and branch campuses established 
                                        on or after January 1, 2000, by 
                                        medical schools with `Full 
                                        Accreditation' status (as such 
                                        term is defined by the Liaison 
                                        Committee on Medical Education) 
                                        or `Accreditation' status (as 
                                        such term is defined by the 
                                        American Osteopathic 
                                        Association Commission on 
                                        Osteopathic College 
                                        Accreditation).
                                    ``(IV) Hospitals that serve areas 
                                designated as health professional 
                                shortage areas under section 
                                332(a)(1)(A) of the Public Health 
                                Service Act, as determined by the 
                                Secretary.
                            ``(iii) Prioritization in distribution to 
                        hpsa hospitals.--In distributing positions to a 
                        hospital described in clause (ii)(IV), the 
                        Secretary shall give priority to hospitals that 
                        are affiliated with--
                                    ``(I) a historically Black medical 
                                school (as defined in subparagraph 
                                (H)); or
                                    ``(II) any other school listed in 
                                section 326(e)(1) of the Higher 
                                Education Act of 1965 that establishes 
                                a medical college.
                    ``(D) Prohibition on distribution to hospitals 
                without an increase agreement.--No increase in the 
                otherwise applicable resident limit of a hospital may 
                be made under subparagraph (C) unless such hospital 
                agrees to increase the total number of full-time 
                equivalent residency positions under the approved 
                medical residency training program of such hospital by 
                the number of such positions made available by such 
                increase under the subparagraph.
                    ``(E) Limitation.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), a hospital may not receive more 
                        than 75 full-time equivalent additional 
                        residency positions in the aggregate under this 
                        paragraph, paragraph (9), and paragraph (10) 
                        over the period of fiscal years 2025 through 
                        2031.
                            ``(ii) Increase in number of additional 
                        positions a hospital may receive.--The 
                        Secretary shall increase the aggregate number 
                        of full-time equivalent additional residency 
                        positions a hospital may receive under this 
                        paragraph over such period if the Secretary 
                        estimates that the number of positions 
                        available for distribution under subparagraph 
                        (A) exceeds the number of applications approved 
                        under such subparagraph over such period.
                    ``(F) Application of per resident amounts for 
                primary care and nonprimary care.--With respect to 
                additional residency positions in a hospital 
                attributable to the increase provided under this 
                paragraph, the approved FTE per resident amounts are 
                deemed to be equal to the hospital per resident amounts 
                for primary care and nonprimary care computed under 
                paragraph (2)(D) for that hospital.
                    ``(G) Permitting facilities to apply aggregation 
                rules.--The Secretary shall permit hospitals receiving 
                additional residency positions attributable to the 
                increase provided under this paragraph to, beginning in 
                the fifth year after the effective date of such 
                increase, apply such positions to the limitation amount 
                under paragraph (4)(F) that may be aggregated pursuant 
                to paragraph (4)(H) among members of the same 
                affiliated group.
                    ``(H) Definitions.--In this paragraph:
                            ``(i) Otherwise applicable resident 
                        limit.--The term `otherwise applicable resident 
                        limit' means, with respect to a hospital, the 
                        limit otherwise applicable under subparagraphs 
                        (F)(i) and (H) of paragraph (4) on the resident 
                        level for the hospital determined without 
                        regard to this paragraph but taking into 
                        account paragraphs (7)(A), (7)(B), (8)(A), 
                        (8)(B), (9), (10)(A). and (10)(B).
                            ``(ii) Reference resident level.--Except as 
                        otherwise provided in subclause (II), the term 
                        `reference resident level' means, with respect 
                        to a hospital, the resident level for the most 
                        recent cost reporting period of the hospital 
                        ending on or before the date of enactment of 
                        this paragraph, for which a cost report has 
                        been settled (or, if not, submitted (subject to 
                        audit)), as determined by the Secretary.
                            ``(iii) Resident level.--The term `resident 
                        level' has the meaning given such term in 
                        paragraph (7)(C)(i).
                            ``(iv) Qualifying hospital.--The term 
                        `qualifying hospital' means a hospital 
                        described in subparagraph (B)(i) or any of 
                        subclauses (I) through (IV) of subparagraph 
                        (C)(ii).
                            ``(v) Historically black medical school.--
                        The term `historically Black medical school' 
                        means Howard University College of Medicine, 
                        Charles R. Drew University of Medicine and 
                        Science, Meharry Medical College, Morehouse 
                        School of Medicine, Xavier University Graduate 
                        School of Health Sciences and Medical School, 
                        and Maryland College of Osteopathic Medicine at 
                        Morgan State University.''.
    (b) IME.--Section 1886(d)(5)(B) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(B)) is amended--
            (1) in clause (v), in the third sentence, by striking 
        ``subsections (h)(7), (h)(8), (h)(9), and (h)(10)'' and 
        inserting ``subsections (h)(7), (h)(8), (h)(9), (h)(10), and 
        (h)(11)''; and
            (2) by adding after clause (xiii) the following new clause:
                            ``(xiv) For discharges occurring on or 
                        after July 1, 2026, insofar as an additional 
                        payment amount under this subparagraph is 
                        attributable to resident positions distributed 
                        to a hospital under subsection (h)(11), the 
                        indirect teaching adjustment factor shall be 
                        computed in the same manner as provided under 
                        clause (ii) with respect to such resident 
                        positions.''.

SEC. 3. STUDY AND REPORT ON STRATEGIES FOR INCREASING DIVERSITY.

    (a) Study.--The Comptroller General of the United States (in this 
section referred to as the ``Comptroller General'') shall conduct a 
study on strategies for increasing the diversity of the health 
professional workforce. Such study shall include an analysis of 
strategies for increasing the number of health professionals from 
rural, lower income, and underrepresented minority communities, 
including which strategies are most effective for achieving such goal.
    (b) Report.--Not later than 2 years after the date of enactment of 
this Act, the Comptroller General shall submit to Congress a report on 
the study conducted under subsection (a), together with recommendations 
for such legislation and administrative action as the Comptroller 
General determines appropriate.
                                 <all>
```