I

103D CONGRESS

1ST SESSION H. R. 2804

To establish a national policy respecting medical residency training programs

and the health care workforce, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

JULY 29, 1993

Mr. WAXMAN (for himself and Mr. CARDIN) introduced the following bill;

which was referred to the Committee on Energy and Commerce

A BILL

To establish a national policy respecting medical residency

training programs and the health care workforce, 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.

4 This Act may be cited as the ‘‘Primary Care

5 Workforce Act of 1993’’.

6 SEC. 2. DEFINITIONS.

7 In this Act, the following definitions shall apply:

8 (1) The term ‘‘approved medical residency

9 training program’’ has the meaning given such term

10 in section 1886(h)(5)(A) of the Social Security Act.
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1 (2) The term ‘‘entry position’’ means, with re2 spect to a medical residency training program, a po3 sition as a resident in the initial year of study in the

4 program.

5 (3) The term ‘‘primary care resident’’ means

6 (in accordance with criteria established by the Sec7 retary) a resident being trained in a distinct pro8 gram of primary health care (as defined in section

9 723(d)(5) of the Public Health Service Act).

10 (4) The term ‘‘resident’’ has the meaning given

11 such term in section 1886(h)(5)(H) of the Social Se12 curity Act.

13 (5) The term ‘‘Secretary’’ means the Secretary

14 of Health and Human Services.

15 (6) The term ‘‘State’’ has the meaning given

16 such term under section 799(9) of the Public Health

17 Service Act.

18 (7) The term ‘‘United States medical graduate’’

19 means a resident who is a graduate of—

20 (A) a school of medicine accredited by the

21 Liaison Committee on Medical Education of the

22 American Medical Association and the Associa23 tion of American Medical Colleges (or approved

24 by such Committee as meeting the standards

25 necessary for such accreditation); or
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1 (B) a school of osteopathy accredited by

2 the American Osteopathic Association, or ap3 proved by such Association as meeting the

4 standards necessary for such accreditation.

5 SEC. 3. ESTABLISHMENT AND ENFORCEMENT OF NA6 TIONAL POLICY FOR APPROVED MEDICAL

7 RESIDENCY TRAINING PROGRAMS.

8 (a) IN GENERAL.—The Secretary of Health and

9 Human Services shall establish a national policy respect10 ing the number of positions in each State in each approved

11 medical residency training program of the different medi12 cal specialties conducted in the State.

13 (b) SPECIFIC DISTRIBUTION RULES.—

14 (1) LIMIT ON TOTAL NUMBER OF POSITIONS.—

15 The national policy established under subsection (a)

16 shall provide that, with respect to residents who

17 begin an initial residency period on or after June 1,

18 1998, the total number of entry positions in ap19 proved medical residency training programs in the

20 United States in which residents may enroll without

21 having previously completed another medical resi22 dency training program may not for any fiscal year

23 exceed 110 percent of the number of United States

24 medical graduates.
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1 (2) DISTRIBUTION OF PRIMARY CARE AND

2 NONPRIMARY CARE POSITIONS.—

3 (A) GENERAL RULE.—The national policy

4 established under subsection (a) shall provide

5 that, after a three-year transition period begin6 ning on June 1, 1995, the number of entry po7 sitions in all approved medical residency train8 ing programs in a State for residents who begin

9 an initial residency period on or after June 1,

10 1998, who are not primary care residents may

11 not exceed 50 percent of the total number of

12 entry positions in all such programs in a State

13 for all residents who are United States medical

14 graduates.

15 (B) WAIVER FOR CERTAIN STATES.—The

16 Secretary may waive the application of the gen17 eral rule described in subparagraph (A) to a

18 State if the Secretary finds that the application

19 of the rule to the State is not practicable.

20 (c) TIMETABLE.—

21 (1) PUBLICATION OF INTERIM FINAL REGULA22 TION.—The Secretary shall publish an interim final

23 regulation carrying out the national policy referred

24 to in subsection (a) not later than sixty days after

25 the National Health Professional Workforce Advi-
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1 sory Board submits its recommendations to the Sec2 retary regarding such national policy pursuant to

3 section 3(b).

4 (2) USE OF BOARD’S RECOMMENDATIONS AS

5 DEFAULT POLICY.—If the Secretary does not meet

6 the requirements of paragraph (1), the recommenda7 tions of the National Health Professional Workforce

8 Advisory Board submitted to the Secretary pursuant

9 to section 3(b) shall, for purposes of this Act and

10 the amendments made by this Act, be deemed to be

11 the national policy established by the Secretary

12 under subsection (a) respecting the number of posi13 tions in each State in the approved medical resi14 dency training programs of the different medical

15 specialities conducted in the State.

16 (d) ASSURING CONFORMITY OF MEDICARE PAY17 MENTS FOR MEDICAL EDUCATION WITH NATIONAL POL18 ICY.—

19 (1) PAYMENT FOR DIRECT MEDICAL EDU20 CATION.—Section 1886(h)(5)(A) of the Social Secu21 rity Act (42 U.S.C. 1395ww(h)(5)(A)) is amended—

22 (A) by striking ‘‘means’’ and inserting

23 ‘‘means, with respect to a hospital,’’; and

24 (B) by striking the period at the end and

25 inserting the following: ‘‘, but only if (with re-
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1 spect to residents who begin an initial residency

2 period on or after June 1, 1995) entry positions

3 in each such program of the hospital are in ac4 cordance with the national policy established by

5 the Secretary under section 3(a) of the Primary

6 Care Workforce Act of 1993 respecting the

7 number of positions in such program.’’.

8 (2) PAYMENT FOR INDIRECT MEDICAL EDU9 CATION.—Section 1886(d)(5)(B) of such Act (42

10 U.S.C. 1395ww(d)(5)(B)) is amended by adding at

11 the end the following new clauses:

12 ‘‘(v) In determining such adjustment, the Sec13 retary may not take into account the services of any

14 interns and residents in a medical residency training

15 program for a specialty or subspecialty unless, with

16 respect to interns and residents who begin an initial

17 residency period (as defined in subsection (h)(5)(F))

18 on or after June 1, 1995, entry positions in each

19 such program of the hospital are in accordance with

20 the national policy established by the Secretary

21 under section 3(a) of the Primary Care Workforce

22 Act of 1993 respecting the number of positions in

23 such program.

24 ‘‘(vi) With respect to payments during each of

25 the first 5 fiscal years for which clause (v) is in ef-
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1 fect, the application of such clause may not result in

2 a reduction of the additional payment amount made

3 to the hospital under this subparagraph during the

4 fiscal year to an amount that is less than—

5 ‘‘(I) in the case of a hospital receiving an

6 additional payment amount under subpara7 graph (F) during the fiscal year that is com8 puted under clause (vii)(I) of such subpara9 graph, 95 percent of the additional payment

10 amount made to the hospital under this sub11 paragraph during the previous fiscal year; or

12 ‘‘(II) in the case of any other hospital, 90

13 percent of the additional payment amount made

14 to the hospital under this subparagraph during

15 the previous fiscal year.’’.

16 SEC. 4. NATIONAL HEALTH PROFESSIONAL WORKFORCE

17 ADVISORY BOARD.

18 (a) ESTABLISHMENT; COMPOSITION.—There is here19 by established the National Health Professional Workforce

20 Advisory Board (hereafter in this section referred to as

21 the ‘‘Board’’), to be composed of the Secretary of Health

22 and Human Services, the Secretary of Veterans’ Affairs,

23 and seven other members appointed by the President not

24 later than three months after the date of the enactment

25 of this Act, of whom—
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1 (1) at least one shall be a dean of a school of

2 medicine;

3 (2) at least one shall be a health care profes4 sional who is not a physician;

5 (3) at least one shall be the program director

6 of an approved medical residency training program;

7 (4) at least one shall be the chief executive offi8 cer of a hospital that operates an approved medical

9 residency training program;

10 (5) at least one shall be the vice-president or

11 vice-chancellor for health affairs of a multi-discipli12 nary academic health center; and

13 (6) at least one shall represent the general

14 public.

15 (b) DUTIES.—

16 (1) IN GENERAL.—The Board shall—

17 (A) prepare initial recommendations re18 garding the national policy referred to in sec19 tion 3(a) for the number of positions in ap20 proved medical residency training programs of

21 the different medical specialties (subject to the

22 requirements of section 3(b) regarding the total

23 number of entry positions in such programs and

24 the distribution of such positions under such

25 programs among primary care and non-primary
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1 care residents at various sites), and submit

2 such recommendations to the Secretary not

3 later than one year after the date of the enact4 ment of this Act;

5 (B) submit recommendations to the Sec6 retary regarding the supply and role of provid7 ers of primary care services who are not physi8 cians;

9 (C) with respect to funds available pursu10 ant to title XVIII of the Social Security Act for

11 direct graduate medical education for the clini12 cal training of physicians and nurses, study the

13 appropriateness of expending such funds to

14 make reimbursements under such title for the

15 clinical training in primary care of additional

16 practitioners;

17 (D) submit annual reports to Congress and

18 the Secretary on the implementation of such

19 national policy; and

20 (E) provide the Secretary with such tech21 nical and other assistance regarding such na22 tional policy as the Secretary may request.

23 (2) CRITERIA FOR RECOMMENDATIONS.—In

24 preparing its recommendations under paragraph (1),

25 the Board shall take into consideration—
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1 (A) the quality of graduate medical resi2 dency training programs;

3 (B) the need to maintain the operation of

4 such programs that have demonstrated success

5 in recruiting, retaining, and promoting minority

6 practitioners;

7 (C) the need to assure that the distribution

8 of entry positions in such programs is not in9 equitable in relation to the States and hospitals

10 in urban and rural areas that are qualified to

11 offer such programs;

12 (D) the need to assure the provision of pri13 mary care and other health care services to

14 medically underserved communities; and

15 (E) such other criteria as the Board (in

16 consultation with the accrediting bodies referred

17 to in subsection (c)) considers appropriate.

18 (c) ROLE OF ACCREDITING BODIES AND CERTIFYING

19 BOARDS.—In preparing its recommendations regarding

20 the national policy referred to in section 3(a), the Board

21 shall—

22 (1) request each accrediting body for approved

23 medical residency training programs for a specialty

24 or subspecialty, and each certification board for such

25 specialty or subspecialty, to prepare and submit a
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1 plan that provides for the achievement of such na2 tional policy with respect to approved medical resi3 dency training programs for such specialty or sub4 specialty;

5 (2) analyze the extent to which the Board may

6 adopt such plans as the basis for its recommenda7 tions; and

8 (3) maintain close consultation with such bodies

9 and boards throughout the process of preparing its

10 recommendations.

11 (d) CHAIRPERSON; ADDITIONAL DUTIES.—The

12 President shall designate a Chairperson from among the

13 members, who (subject to the approval of the Board)

14 may—

15 (1) employ and fix the compensation of an Ex16 ecutive Director and such other personnel (not to ex17 ceed twenty-five) as may be necessary to carry out

18 the Board’s duties;

19 (2) seek such assistance and support as may be

20 required in the performance of the Board’s duties

21 from appropriate Federal departments and agencies;

22 (3) enter into contracts or make other arrange23 ments, as may be necessary for the conduct of the

24 work of the Board (without regard to section 3709

25 of the Revised Statutes (41 U.S.C. 5));
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1 (4) make advance, progress, and other pay2 ments which relate to the work of the Commission;

3 (5) provide transportation and subsistence for

4 persons serving without compensation; and

5 (6) prescribe such rules and regulations as the

6 Board deems necessary with respect to its internal

7 organization and operation.

8 (e) COMPENSATION.—Members of the Board who are

9 full-time officers or employees of the United States may

10 not receive additional pay, allowances, or benefits by rea11 son of their service on the Board, but may receive travel

12 expenses, including per diem in lieu of subsistence, in ac13 cordance with sections 5702 and 5703 of title 5, United

14 States Code.

15 (f) TERMINATION.—The Board shall terminate upon

16 the expiration of the six-year period that begins on the

17 date of the enactment of this Act. Section 14(a) of the

18 Federal Advisory Committee Act (5 U.S.C. App.; relating

19 to the termination of advisory committees) shall not apply

20 to the Board.

21 (g) CONFORMING AMENDMENT REPEALING COUNCIL

22 ON GRADUATE MEDICAL EDUCATION.—Effective on the

23 date of the enactment of this Act, section 301 of the

24 Health Professions Education Extension Amendments of

25 1992 (Public Law 102–408) is repealed.
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1 SEC. 5. REVISIONS TO MEDICARE METHODOLOGY FOR

2 DETERMINING PAYMENTS FOR MEDICAL

3 RESIDENCY.

4 (a) PAYMENTS FOR DIRECT MEDICAL EDUCATION

5 COSTS OF NON-HOSPITAL PROVIDERS.—Title XVIII of

6 the Social Security Act (42 U.S.C. 1395 et seq.) is amend7 ed by inserting after section 1889 the following new

8 section:

9 ‘‘GRADUATE MEDICAL EDUCATION PAYMENTS FOR NON10 HOSPITAL PROVIDERS

11 ‘‘SEC. 1890. (a) IN GENERAL.—Notwithstanding any

12 other provision of this title, in the case of any entity (other

13 than a hospital) eligible to receive payments under this

14 title that operates an approved medical residency training

15 program, in addition to any other payments that may be

16 made to the entity under this title, the Secretary shall pro17 vide for payment to the entity for direct graduate medical

18 education costs in accordance with subsection (b).

19 ‘‘(b) DETERMINATION OF AMOUNT OF PAYMENT.—

20 ‘‘(1) IN GENERAL.—The amount of payment

21 made to an entity under this section for direct medi22 cal education for a fiscal year is equal to the product

23 of—

24 ‘‘(A) the aggregate approved amount (as

25 defined in paragraph (2)) for the year; and
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1 ‘‘(B) the entity’s medicare patient load (as

2 defined in subsection (d)(2)) for the year.

3 ‘‘(2) AGGREGATE APPROVED AMOUNT.—In

4 paragraph (1), the term ‘aggregate approved

5 amount’ means, for a fiscal year, the product of—

6 ‘‘(A) the approved FTE resident amount

7 (determined under paragraph (3)) for the year;

8 and

9 ‘‘(B) the weighted average number of full10 time equivalent residents (as determined by the

11 Secretary in a manner similar to the manner

12 used to determine the number of such residents

13 under section 1886(h)(4)) in the entity’s ap14 proved medical residency training programs in

15 the year.

16 ‘‘(3) DETERMINATION OF APPROVED FTE RESI17 DENT AMOUNT.—

18 ‘‘(A) IN GENERAL.—For each approved

19 medical residency training program, the Sec20 retary shall determine an approved FTE resi21 dent amount for each fiscal year (beginning

22 with fiscal year 1995) equal to the applicable

23 percentage (as defined in subparagraph (C)) of

24 the national average salary for the year (as de25 fined in subparagraph (B)(ii)).
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1 ‘‘(B) DETERMINATION OF NATIONAL AV2 ERAGE SALARY.—

3 ‘‘(i) DETERMINATION OF BASE

4 AMOUNT.—The Secretary shall determine a

5 base salary amount equal to the Sec6 retary’s estimate (using the most recent

7 available audited cost reports) of the na8 tional average salary, including fringe ben9 efits, for a full-time-equivalent resident in

10 an approved medical residency training

11 program during fiscal year 1990, increased

12 (in a compounded manner) by the sum of

13 the estimated percentage changes in the

14 consumer price index during the 12-month

15 periods between the midpoint of fiscal year

16 1990 and the midpoint of fiscal year 1994.

17 ‘‘(ii) NATIONAL AVERAGE SALARY DE18 FINED.—In this paragraph, the ‘national

19 average salary’ for a fiscal year is equal

20 to—

21 ‘‘(I) for fiscal year 1995, the

22 base amount determined under clause

23 (i) updated through the midpoint of

24 the year by projecting the estimated

25 percentage change in the consumer
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1 price index during the 12-month pe2 riod ending at that midpoint (with ap3 propriate adjustments to reflect pre4 vious under- or over-estimations under

5 this subparagraph in the projected

6 percentage change in the consumer

7 price index); and

8 ‘‘(II) for a subsequent fiscal year,

9 the amount determined under this

10 clause for the previous fiscal year up11 dated through the midpoint of the

12 year by projecting the estimated per13 centage change in the consumer price

14 index during the 12-month period

15 ending at that midpoint (with appro16 priate adjustments to reflect previous

17 under- or over-estimations under this

18 subparagraph in the projected per19 centage change in the consumer price

20 index).

21 ‘‘(C) APPLICABLE PERCENTAGE.—In sub22 paragraph (A), the ‘applicable percentage’ is—

23 ‘‘(i) in the case of a primary care resi24 dency training program, 200 percent; or
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1 ‘‘(ii) in the case of medical residency

2 training program that is not a primary

3 care residency training program, 150 per4 cent.

5 ‘‘(c) ALLOCATION OF PAYMENTS AMONG TRUST

6 FUNDS.—In providing for payments under this section,

7 the Secretary shall provide for an allocation of such pay8 ments between part A and part B (and the trust funds

9 established under the respective parts) as reasonably re10 flects the proportion of direct graduate medical costs of

11 entities associated with the provision of services under

12 each respective part.

13 ‘‘(d) DEFINITIONS.—In this section:

14 ‘‘(1) The terms ‘approved medical residency

15 training program’, ‘consumer price index’, ‘direct

16 graduate medical education costs’, and ‘resident’

17 have the meaning given such terms under section

18 1886(h)(5).

19 ‘‘(2) The term ‘medicare patient load’ means,

20 with respect to an entity for a year, the fraction of

21 the entity’s services during the year which are at22 tributable to individuals entitled to benefits under

23 this title (based on such measure of services as the

24 Secretary determines to be appropriate for purposes

25 of this section).
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1 ‘‘(3) The term ‘primary care medical residency

2 training program’ means an approved medical resi3 dency training program consisting of a distinct pro4 gram of primary health care (as defined in section

5 723(d)(5) of the Public Health Service Act).’’.

6 (b) PAYMENT FOR HOSPITAL COSTS OF INDIRECT

7 MEDICAL EDUCATION PROVIDED OFF-SITE.—Section

8 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C.

9 1395ww(d)(5)(B)(iv)) is amended by inserting by striking

10 the period at the end and inserting the following: ‘‘, with11 out regard to the setting in which the services are fur12 nished (if the hospital incurs all, or substantially all, of

13 the costs of the services furnished to the hospital by such

14 interns and residents).’’.

15 (c) EFFECTIVE DATE.—The amendments made by

16 this section shall apply to cost reporting periods (or por17 tions thereof) beginning on or after October 1, 1994.

18 SEC. 6. CERTAIN PRIMARY CARE PROGRAMS UNDER PUB19 LIC HEALTH SERVICE ACT.

20 (a) INCREASE IN FUNDING FOR SCHOLARSHIP AND

21 LOAN REPAYMENT PROGRAMS OF NATIONAL HEALTH

22 SERVICE CORPS.—Section 338H(b)(1) of the Public

23 Health Service Act (42 U.S.C. 254q(b)(1)) is amended—

24 (1) by striking ‘‘and’’ after ‘‘1991,’’;
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1 (2) by striking ‘‘through 2000’’ and inserting

2 ‘‘and 1993’’; and

3 (3) by inserting before the period the following:

4 ‘‘,$226,000,000 for fiscal year 1994, $294,000,000

5 for fiscal year 1995, $381,000,000 for fiscal year

6 1996, $496,000,000 for fiscal year 1997,

7 $644,000,000 for fiscal year 1998, $837,000,000 for

8 fiscal year 1999, and $1,089,000,000 for fiscal year

9 2000’’.

10 (b) DEMONSTRATION GRANTS TO STATES FOR COM11 MUNITY SCHOLARSHIP PROGRAMS.—Section 338L(l)(1)

12 of the Public Health Service Act (42 U.S.C. 254t(l)(1))

13 is amended—

14 (1) by striking ‘‘and’’ after ‘‘1992,’’; and

15 (2) by inserting before the period the following:

16 ‘‘, and $5,000,000 for each of the fiscal years 1994

17 through 2000’’.

18 (c) NATIONAL RESEARCH SERVICE AWARDS.—Sec19 tion 487(d)(3) of the Public Health Service Act (42 U.S.C.

20 288(d)(3)), as amended by section 1641(2) of Public Law

21 103–43, is amended—

22 (1) by striking ‘‘1 percent’’ the first place such

23 terms appears and inserting ‘‘2 percent’’; and

24 (2) by striking ‘‘Awards which (A) are made’’

25 and all that follows through ‘‘(B) are for research in
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1 primary medical care;’’ and inserting the following

2 ‘‘Awards made for research in primary medical

3 care;’’.

4 (d) HEALTH CARE POLICY AND RESEARCH.—

5 (1) FUNDING.—Section 926 of the Public

6 Health Service Act (42 U.S.C. 299c–5), as amended

7 by section 10 of Public Law 102–410 (106 Stat.

8 2101), is amended by adding at the end the follow9 ing subsection:

10 ‘‘(f) ALLOCATION REGARDING PRIMARY CARE.—Of

11 the amounts made available for a fiscal year for carrying

12 out this title, the Secretary shall obligate not less than

13 15 percent for carrying out section 902 with respect to

14 primary care.’’.

15 (2) RETRAINING PROGRAMS.—Section 902 of

16 the Public Health Service Act (42 U.S.C. 299a), as

17 amended by section 2 of Public Law 102–410 (106

18 Stat. 2094), is amended by adding at the end the

19 following subsection:

20 ‘‘(f) RETRAINING OF SPECIALISTS.—With respect to

21 physicians who are in a specialty, the Administrator shall,

22 in carrying out subsection (a), conduct or support pro23 grams for training such physicians in primary care.’’.

24 (e) COMMISSION ON OBLIGATED SERVICE.—
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1 (1) IN GENERAL.—Not later than one hundred

2 and eighty days after the date of the enactment of

3 this Act, there shall be established in accordance

4 with this subsection an advisory commission to carry

5 out the duties described in paragraph (2).

6 (2) DUTIES.—The duties referred to in para7 graph (1) are making recommendations to the Presi8 dent and the Secretary on Health and Human Serv9 ices on whether and to what extent students attend10 ing health professions schools pursuant to direct or

11 indirect federal financial assistance (for the students

12 or for the schools, or both) should, as a condition of

13 such attendance, be contractually required to com14 plete a period of providing health services to medi15 cally undeserved individuals. Recommendations

16 under the preceding sentence shall include rec17 ommendations with respect to establishing such a re18 quirement for each student who attends a health

19 professions school pursuant to such assistance.

20 (3) MEMBERSHIP.—The advisory commission

21 established under paragraph (1) shall be comprised

22 of five individuals appointed by the President.

23 (4) ADMINISTRATIVE PROVISIONS.—The advi24 sory commission established under paragraph (1)

25 shall be established within the Department of Health
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1 and Human Services. The Secretary shall provide to

2 the commission such staff, quarters, information,

3 and other assistance as may be necessary for the

4 commission to carry out paragraph (2).

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