I 
111TH CONGRESS 
1ST SESSION H. R. 2350 
To amend the Public Health Service Act and the Social Security Act to 
increase the number of primary care physicians and primary care pro-
viders and to improve patient access to primary care services, and for 
other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 12, 2009 
Ms. SCHWARTZ (for herself, Mr. ABERCROMBIE, Ms. BERKLEY, Mr. BERMAN, 
Mr. BISHOP of New York, Mr. BLUMENAUER, Mr. BOSWELL, Mr. BRADY 
of Pennsylvania, Mrs. CAPPS, Mr. CARNAHAN, Ms. CASTOR of Florida, 
Mrs. CHRISTENSEN, Ms. CLARKE, Mr. CLEAVER, Mr. COHEN, Mr. 
CONNOLLY of Virginia, Mr. COURTNEY, Mr. CROWLEY, Mr. CUELLAR, 
Mr. DAVIS of Illinois, Ms. DELAURO, Mr. DOGGETT, Mr. DRIEHAUS, Mr. 
EDWARDS of Texas, Mr. ELLISON, Mr. FARR, Mr. FATTAH, Ms. GIF-
FORDS, Mr. GUTIERREZ, Mrs. HALVORSON, Mr. HARE, Mr. HASTINGS of 
Florida, Mr. HIGGINS, Mr. HINCHEY, Ms. HIRONO, Mr. HOLT, Mr. 
ISRAEL, Ms. JACKSON-LEE of Texas, Ms. KAPTUR, Mr. KENNEDY, Ms. 
KILROY, Mr. KIND, Mr. KUCINICH, Ms. LEE of California, Mr. LEVIN, 
Mr. LEWIS of Georgia, Mr. LOEBSACK, Mr. MAFFEI, Ms. MATSUI, Ms. 
MCCOLLUM, Mr. MCDERMOTT, Mr. MCGOVERN, Ms. MOORE of Wis-
consin, Mr. MORAN of Virginia, Mr. PATRICK J. MURPHY of Pennsyl-
vania, Mr. MURTHA, Mrs. NAPOLITANO, Mr. NEAL of Massachusetts, Mr. 
OLVER, Mr. PERLMUTTER, Mr. PETERS, Ms. PINGREE of Maine, Mr. 
SALAZAR, Mr. SCHRADER, Mr. SCOTT of Virginia, Mr. SCOTT of Georgia, 
Ms. SHEA-PORTER, Mr. SIRES, Mr. SNYDER, Mr. VAN HOLLEN, Ms. WA-
TERS, Ms. WATSON, Mr. WEINER, Mr. WILSON of Ohio, Mr. YARMUTH, 
Mr. MEEKS of New York, Ms. LINDA T. SA´NCHEZ of California, Mr. 
HONDA, Mr. ETHERIDGE, Ms. SUTTON, Mr. HOLDEN, Mr. KANJORSKI, 
Mr. LANGEVIN, Mr. LARSON of Connecticut, Mr. DOYLE, Mr. WEXLER, 
and Ms. DEGETTE) introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Commit-
tees on Ways and Means and Education and Labor, 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 con-
cerned 
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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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Preserving Patient Access to Primary Care Act of 2009’’. 
(b) TABLE OF CONTENTS.—The table of contents is 
as follows: 
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 geri-
atrics, general pediatrics, physician assistance, general den-
tistry, 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. 
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Sec. 304. Additional incentive payment program for primary care services fur-
nished in health professional shortage areas. 
Sec. 305. Permanent extension of floor on Medicare work geographic adjust-
ment under the Medicare physician fee schedule. 
Sec. 306. Permanent extension of Medicare incentive payment program for phy-
sician 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 examina-
tion. 
Sec. 312. Elimination of cost-sharing for preventive benefits under the Medi-
care program. 
Sec. 313. HHS study and report on facilitating the receipt of Medicare preven-
tive services by Medicare beneficiaries. 
Subtitle C—Other Provisions 
Sec. 321. HHS study and report on improving the ability of physicians and pri-
mary care providers to assist Medicare beneficiaries in obtain-
ing 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 adjudica-
tion. 
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 hos-
pitals. 
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 pro-
fession. 
Sec. 402. Study concerning the education debt of medical school graduates. 
Sec. 403. Study on minority representation in primary care. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) Approximately 21 percent of physicians who 
were board certified in general internal medicine 
during the early 1990s have left internal medicine, 
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compared to a 5 percent departure rate for those 
who were certified in subspecialties of internal medi-
cine. 
(2) The number of United States medical grad-
uates going into family medicine has fallen by more 
than 50 percent from 1997 to 2005. 
(3) In 2007, only 88 percent of the available 
medicine residency positions were filled and only 42 
percent of those were filled by United States medical 
school graduates. 
(4) In 2006, only 24 percent of third-year inter-
nal medicine resident intended to pursue careers in 
general internal medicine, down from 54 percent in 
1998. 
(5) Primary care physicians and primary care 
providers serve as the point of first contact for most 
patients and are able to coordinate the care of the 
whole person, reducing unnecessary care and dupli-
cative testing. 
(6) Primary care physicians and primary care 
providers 
practicing 
preventive 
care, 
including 
screening for illness and treating diseases, can help 
prevent complications that result in more costly 
care. 
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(7) Patients with primary care physicians or 
primary care providers have lower health care ex-
penditures and primary care is correlated with better 
health status, lower overall mortality, and longer life 
expectancy. 
(8) Higher proportions of primary care physi-
cians are associated with significantly reduced utili-
zation. 
(9) The United States has a higher ratio of spe-
cialists to primary care physicians than other indus-
trialized nations and the population of the United 
States is growing faster than the expected rate of 
growth in the supply of primary care physicians. 
(10) The number of Americans age 65 and 
older, those eligible for Medicare and who use far 
more ambulatory care visits per person as those 
under age 65, is expected to double from 2000 to 
2030. 
(11) A decrease in Federal spending to carry 
out programs authorized by title VII of the Public 
Health Service Act threatens the viability of one of 
the programs used to solve the problem of inad-
equate access to primary care. 
(12) The National Health Service Corps pro-
gram has a proven record of supplying physicians to 
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underserved areas, and has played an important role 
in expanding access for underserved populations in 
rural and inner city communities. 
(13) Individuals in many geographic areas, es-
pecially rural areas, lack adequate access to high 
quality preventive, primary health care, contributing 
to significant health disparities that impair Amer-
ica’s public health and economic productivity. 
(14) About 20 percent of the population of the 
United States resides in primary medical care 
Health Professional Shortage Areas. 
SEC. 3. DEFINITIONS. 
(a) GENERAL DEFINITIONS.—In this Act: 
(1) CHRONIC CARE COORDINATION.—The term 
‘‘chronic care coordination’’ means the coordination 
of services that is based on the Chronic Care Model 
that provides on-going health care to patients with 
chronic diseases that may include any of the fol-
lowing services: 
(A) The development of an initial plan of 
care, and subsequent appropriate revisions to 
such plan of care. 
(B) The management of, and referral for, 
medical and other health services, including 
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interdisciplinary care conferences and manage-
ment with other providers. 
(C) The monitoring and management of 
medications. 
(D) Patient education and counseling serv-
ices. 
(E) Family caregiver education and coun-
seling services. 
(F) Self-management services, including 
health education and risk appraisal to identify 
behavioral risk factors through self-assessment. 
(G) Providing access by telephone with 
physicians and other appropriate health care 
professionals, including 24-hour availability of 
such professionals for emergencies. 
(H) Management with the principal non-
professional caregiver in the home. 
(I) Managing and facilitating transitions 
among health care professionals and across set-
tings of care, including the following: 
(i) Pursuing the treatment option 
elected by the individual. 
(ii) Including any advance directive 
executed by the individual in the medical 
file of the individual. 
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(J) Information about, and referral to, 
hospice care, including patient and family care-
giver education and counseling about hospice 
care, and facilitating transition to hospice care 
when elected. 
(K) Information about, referral to, and 
management with, community services. 
(2) CRITICAL SHORTAGE HEALTH FACILITY.— 
The term ‘‘critical shortage health facility’’ means a 
public or private nonprofit health facility that does 
not serve a health professional shortage area (as 
designated under section 332 of the Public Health 
Service Act), but that has a critical shortage of phy-
sicians (as determined by the Secretary) in a pri-
mary care field. 
(3) PHYSICIAN.—The term physician has the 
meaning given such term in section 1861(r)(1) of 
the Social Security Act. 
(4) PRIMARY CARE.—The term ‘‘primary care’’ 
means the provision of integrated, high-quality, ac-
cessible health care services by health care providers 
who are accountable for addressing a full range of 
personal health and health care needs, developing a 
sustained partnership with patients, practicing in 
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the context of family and community, and working 
to minimize disparities across population subgroups. 
(5) PRIMARY CARE FIELD.—The term ‘‘primary 
care field’’ means any of the following fields: 
(A) The field of family medicine. 
(B) The field of general internal medicine. 
(C) The field of geriatric medicine. 
(D) The field of pediatric medicine 
(6) PRIMARY CARE PHYSICIAN.—The term ‘‘pri-
mary care physician’’ means a physician who is 
trained in a primary care field who provides first 
contact, continuous, and comprehensive care to pa-
tients. 
(7) PRIMARY CARE PROVIDER.—The term ‘‘pri-
mary care provider’’ means— 
(A) a nurse practitioner; or 
(B) a physician assistant practicing as a 
member of a physician-directed or nurse-practi-
tioner-directed team; 
who provides first contact, continuous, and com-
prehensive care to patients. 
(8) PRINCIPAL
CARE.—The term ‘‘principal 
care’’ means integrated, accessible health care that 
is provided by a physician who is a medical sub-
specialist that addresses the majority of the personal 
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health care needs of patients with chronic conditions 
requiring the subspecialist’s expertise, and for whom 
the subspecialist assumes care management, devel-
oping a sustained physician-patient partnership and 
practicing within the context of family and commu-
nity. 
(9) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(b) PRIMARY MEDICAL CARE SHORTAGE AREA.— 
(1) IN GENERAL.—In this Act, the term ‘‘pri-
mary medical care shortage area’’ or ‘‘PMCSA’’ 
means a geographic area with a shortage of physi-
cians (as designated by the Secretary) in a primary 
care field, as designated in accordance with para-
graph (2). 
(2) DESIGNATION.—To be designated by the 
Secretary as a PMCSA, the Secretary must find 
that the geographic area involved has an established 
shortage of primary care physicians for the popu-
lation served. The Secretary shall make such a des-
ignation with respect to an urban or rural geo-
graphic area if the following criteria are met: 
(A) The area is a rational area for the de-
livery of primary care services. 
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(B) One of the following conditions pre-
vails within the area: 
(i) The area has a population to full- 
time-equivalent primary care physician 
ratio of at least 3,500 to 1. 
(ii) The area has a population to full- 
time-equivalent primary care physician 
ratio of less than 3,500 to 1 and has un-
usually high needs for primary care serv-
ices or insufficient capacity of existing pri-
mary care providers. 
(C) Primary care providers in contiguous 
geographic areas are overutilized. 
(c) MEDICALLY UNDERSERVED AREA.— 
(1) IN GENERAL.—In this Act, the term ‘‘medi-
cally underserved area’’ or ‘‘MUA’’ means a rational 
service area with a demonstrable shortage of pri-
mary health care resources relative to the needs of 
the entire population within the service area as de-
termined in accordance with paragraph (2) through 
the use of the Index of Medical Underservice (re-
ferred to in this subsection as the ‘‘IMU’’) with re-
spect to data on a service area. 
(2) DETERMINATIONS.—Under criteria to be 
established by the Secretary with respect to the 
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IMU, if a service area is determined by the Sec-
retary to have a score of 62.0 or less, such area shall 
be eligible to be designated as a MUA. 
(3) IMU VARIABLES.—In establishing criteria 
under paragraph (2), the Secretary shall ensure that 
the following variables are utilized: 
(A) The ratio of primary medical care phy-
sicians per 1,000 individuals in the population 
of the area involved. 
(B) The infant mortality rate in the area 
involved. 
(C) The percentage of the population in-
volved with incomes below the poverty level. 
(D) The percentage of the population in-
volved age 65 or over. 
The value of each of such variables for the service 
area involved shall be converted by the Secretary to 
a weighted value, according to established criteria, 
and added together to obtain the area’s IMU score. 
(d) PATIENT CENTERED MEDICAL HOME.— 
(1) IN GENERAL.—In this Act, the term ‘‘pa-
tient centered medical home’’ means a physician-di-
rected practice (or a nurse-practitioner-directed 
practice in those States in which such functions are 
included in the scope of practice of licensed nurse 
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practitioners) that has been certified by an organiza-
tion under paragraph (3) as meeting the following 
standards: 
(A) The practice provides patients who 
elect to obtain care through a patient centered 
medical home (referred to as ‘‘participating pa-
tients’’) with direct and ongoing access to a pri-
mary or principal care physician or nurse prac-
titioner who accepts responsibility for providing 
first contact, continuous, and comprehensive 
care to the whole person, in collaboration with 
teams of other health professionals, including 
nurses and specialist physicians, as needed and 
appropriate. 
(B) The practice applies standards for ac-
cess to care and communication with partici-
pating beneficiaries. 
(C) The practice has readily accessible, 
clinically useful information on participating pa-
tients that enables the practice to treat such 
patients comprehensively and systematically. 
(D) The practice maintains continuous re-
lationships with participating patients by imple-
menting evidence-based guidelines and applying 
such guidelines to the identified needs of indi-
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vidual beneficiaries over time and with the in-
tensity needed by such beneficiaries. 
(2) RECOGNITION OF NCQA APPROVAL.—Such 
term also includes a physician-directed (or nurse- 
practitioner-directed) practice that has been recog-
nized as a medical home through the Physician 
Practice 
Connections—patient 
centered 
Medical 
Home (‘‘PPC–PCMH’’) voluntary recognition proc-
ess of the National Committee for Quality Assur-
ance. 
(3) STANDARD
SETTING
AND
QUALIFICATION 
PROCESS
FOR
MEDICAL
HOMES.—The Secretary 
shall establish a process for the selection of a quali-
fied standard setting and certification organiza-
tion— 
(A) to establish standards, consistent with 
this subsection, to enable medical practices to 
qualify as patient centered medical homes; and 
(B) to provide for the review and certifi-
cation of medical practices as meeting such 
standards. 
(4) TREATMENT
OF
CERTAIN
PRACTICES.— 
Nothing in this section shall be construed as pre-
venting a nurse practitioner from leading a patient 
centered medical home so long as— 
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(A) all of the requirements of this section 
are met; and 
(B) the nurse practitioner is acting con-
sistently with State law. 
(e) APPLICATION UNDER MEDICARE, MEDICAID, 
PHSA, ETC.—Unless otherwise provided, the provisions of 
the previous subsections shall apply for purposes of provi-
sions of the Social Security Act, the Public Health Service 
Act, and any other Act amended by this Act. 
TITLE I—MEDICAL EDUCATION 
SEC. 101. RECRUITMENT INCENTIVES. 
Title VII of the Higher Education Act of 1965 (20 
U.S.C. 1133 et seq.) is amended by adding at the end 
the following: 
‘‘PART F—MEDICAL EDUCATION RECRUITMENT 
INCENTIVES 
‘‘SEC. 786. MEDICAL EDUCATION RECRUITMENT INCEN-
TIVES. 
‘‘(a) IN GENERAL.—The Secretary is authorized to 
award grants or contracts to institutions of higher edu-
cation that are graduate medical schools, to enable the 
graduate medical schools to improve primary care edu-
cation and training for medical students. 
‘‘(b) APPLICATION.—A graduate medical school that 
desires to receive a grant under this section shall submit 
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to the Secretary an application at such time, in such man-
ner, and containing such information as the Secretary may 
require. 
‘‘(c) USES OF FUNDS.—A graduate medical school 
that receives a grant under this section shall use such 
grant funds to carry out 1 or more of the following: 
‘‘(1) The creation of primary care mentorship 
programs. 
‘‘(2) Curriculum development for population- 
based primary care models of care, such as the pa-
tient centered medical home. 
‘‘(3) Increased opportunities for ambulatory, 
community-based training. 
‘‘(4) Development of generalist curriculum to 
enhance care for rural and underserved populations 
in primary care or general surgery. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 
is authorized to be appropriated to carry out this section 
$50,000,000 for each of the fiscal years 2010 through 
2012.’’. 
SEC. 102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERV-
ICE OBLIGATIONS. 
(a) PURPOSE.—It is the purpose of this section to 
encourage individuals to enter and continue in primary 
care physician careers. 
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(b) AMENDMENT TO THE PUBLIC HEALTH SERVICE 
ACT.—Part D of title III of the Public Health Service Act 
(42 U.S.C. 254b et seq.) is amended by adding at the end 
the following: 
‘‘Subpart XI—Primary Care Medical Education 
‘‘SEC. 340I. SCHOLARSHIPS. 
‘‘(a) IN GENERAL.—The Secretary, acting through 
the Administrator of the Health Resources and Services 
Administration, shall award grants to critical shortage 
health facilities to enable such facilities to provide scholar-
ships to individuals who agree to serve as physicians at 
such facilities after completing a residency in a primary 
care field (as defined in section 3(a)(5) of the Preserving 
Patient Access to Primary Care Act of 2009). 
‘‘(b) SCHOLARSHIPS.—A health facility shall use 
amounts received under a grant under this section to enter 
into contracts with eligible individuals under which— 
‘‘(1) the facility agrees to provide the individual 
with a scholarship for each school year (not to ex-
ceed 4 school years) in which the individual is en-
rolled as a full-time student in a school of medicine 
or a school of osteopathic medicine; and 
‘‘(2) the individual agrees— 
‘‘(A) to maintain an acceptable level of 
academic standing; 
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‘‘(B) to complete a residency in a primary 
care field; and 
‘‘(C) after completing the residency, to 
serve as a primary care physician at such facil-
ity in such field for a time period equal to the 
greater of— 
‘‘(i) one year for each school year for 
which the individual was provided a schol-
arship under this section; or 
‘‘(ii) two years. 
‘‘(c) AMOUNT.— 
‘‘(1) IN
GENERAL.—The amount paid by a 
health facility to an individual under a scholarship 
under this section shall not exceed $35,000 for any 
school year. 
‘‘(2) CONSIDERATIONS.—In determining the 
amount of a scholarship to be provided to an indi-
vidual under this section, a health facility may take 
into consideration the individual’s financial need, ge-
ographic differences, and educational costs. 
‘‘(3) EXCLUSION
FROM
GROSS
INCOME.—For 
purposes of the Internal Revenue Code of 1986, 
gross income shall not include any amount received 
as a scholarship under this section. 
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‘‘(G) Methods for improving the effective-
ness and efficiency of medical assistance pro-
vided under this title and child health assist-
ance provided under title XXI by encouraging 
the adoption of medical practices that satisfy 
the standards established by the Secretary 
under paragraph (2) of section 3(d) of the Pre-
serving Patient Access to Primary Care Act of 
2009 for medical practices to qualify as patient 
centered medical homes (as defined in para-
graph (1) of such section).’’; and 
(2) in paragraph (4)— 
(A) in subparagraph (A)— 
(i) in clause (i), by striking ‘‘and’’ at 
the end; 
(ii) in clause (ii), by striking the pe-
riod at the end and inserting ‘‘; and’’; and 
(iii) by inserting after clause (ii), the 
following new clause: 
‘‘(iii) $25,000,000 for each of fiscal 
years 2010, 2011, and 2012.’’; and 
(B) in subparagraph (B), by striking the 
second and third sentences and inserting the 
following: ‘‘Such method shall provide that 100 
percent of such funds for each of fiscal years 
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‘‘Patient Centered Medical Home Services 
‘‘(hhh)(1) The term ‘patient centered medical home 
services’ means care coordination services furnished by a 
qualified patient centered medical home. 
‘‘(2) The term ‘qualified patient centered medical 
home’ means a patient centered medical home (as defined 
in section 3(d) of the Preserving Patient Access to Pri-
mary Care Act of 2009).’’. 
(c) MONTHLY FEE FOR PATIENT CENTERED MED-
ICAL HOME SERVICES.—Section 1848 of the Social Secu-
rity Act (42 U.S.C. 1395w–4) is amended by adding at 
the end the following new subsection: 
‘‘(p) MONTHLY FEE FOR PATIENT CENTERED MED-
ICAL HOME SERVICES.— 
‘‘(1) MONTHLY FEE.— 
‘‘(A) IN GENERAL.—Not later than Janu-
ary 1, 2012, the Secretary shall establish a pay-
ment methodology for patient centered medical 
home services (as defined in paragraph (1) of 
section 1861(hhh)). Under such payment meth-
odology, the Secretary shall pay qualified pa-
tient centered medical homes (as defined in 
paragraph (2) of such section) a monthly fee 
for each individual who elects to receive patient 
centered medical home services at that medical 
VerDate Nov 24 2008 
06:45 May 14, 2009
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