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.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Primary Care
Workforce Act of 1993’’.
SEC. 2. DEFINITIONS.
In this Act, the following definitions shall apply:
(1) The term ‘‘approved medical residency
training program’’ has the meaning given such term
in section 1886(h)(5)(A) of the Social Security Act.
(2) The term ‘‘entry position’’ means, with re-
spect to a medical residency training program, a po-
sition as a resident in the initial year of study in the
program.
(3) The term ‘‘primary care resident’’ means
(in accordance with criteria established by the Sec-
retary) a resident being trained in a distinct pro-
gram of primary health care (as defined in section
723(d)(5) of the Public Health Service Act).
(4) The term ‘‘resident’’ has the meaning given
such term in section 1886(h)(5)(H) of the Social Se-
curity Act.
(5) The term ‘‘Secretary’’ means the Secretary
of Health and Human Services.
(6) The term ‘‘State’’ has the meaning given
such term under section 799(9) of the Public Health
Service Act.
(7) The term ‘‘United States medical graduate’’
means a resident who is a graduate of—
(A) a school of medicine accredited by the
Liaison Committee on Medical Education of the
American Medical Association and the Associa-
tion of American Medical Colleges (or approved
by such Committee as meeting the standards
necessary for such accreditation); or
(B) a school of osteopathy accredited by
the American Osteopathic Association, or ap-
proved by such Association as meeting the
standards necessary for such accreditation.
SEC. 3. ESTABLISHMENT AND ENFORCEMENT OF NA-
TIONAL POLICY FOR APPROVED MEDICAL
RESIDENCY TRAINING PROGRAMS.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall establish a national policy respect-
ing the number of positions in each State in each approved
medical residency training program of the different medi-
cal specialties conducted in the State.
(b) SPECIFIC DISTRIBUTION RULES.—
(1) LIMIT ON TOTAL NUMBER OF POSITIONS.—
The national policy established under subsection (a)
shall provide that, with respect to residents who
begin an initial residency period on or after June 1,
1998, the total number of entry positions in ap-
proved medical residency training programs in the
United States in which residents may enroll without
having previously completed another medical resi-
dency training program may not for any fiscal year
exceed 110 percent of the number of United States
medical graduates.
(2) DISTRIBUTION
OF
PRIMARY
CARE
AND
NONPRIMARY CARE POSITIONS.—
(A) GENERAL RULE.—The national policy
established under subsection (a) shall provide
that, after a three-year transition period begin-
ning on June 1, 1995, the number of entry po-
sitions in all approved medical residency train-
ing programs in a State for residents who begin
an initial residency period on or after June 1,
1998, who are not primary care residents may
not exceed 50 percent of the total number of
entry positions in all such programs in a State
for all residents who are United States medical
graduates.
(B) WAIVER FOR CERTAIN STATES.—The
Secretary may waive the application of the gen-
eral rule described in subparagraph (A) to a
State if the Secretary finds that the application
of the rule to the State is not practicable.
(c) TIMETABLE.—
(1) PUBLICATION OF INTERIM FINAL REGULA-
TION.—The Secretary shall publish an interim final
regulation carrying out the national policy referred
to in subsection (a) not later than sixty days after
the National Health Professional Workforce Advi-
sory Board submits its recommendations to the Sec-
retary regarding such national policy pursuant to
section 3(b).
(2) USE
OF
BOARD’S
RECOMMENDATIONS
AS
DEFAULT POLICY.—If the Secretary does not meet
the requirements of paragraph (1), the recommenda-
tions of the National Health Professional Workforce
Advisory Board submitted to the Secretary pursuant
to section 3(b) shall, for purposes of this Act and
the amendments made by this Act, be deemed to be
the national policy established by the Secretary
under subsection (a) respecting the number of posi-
tions in each State in the approved medical resi-
dency training programs of the different medical
specialities conducted in the State.
(d) ASSURING CONFORMITY
OF MEDICARE PAY-
MENTS FOR MEDICAL EDUCATION WITH NATIONAL POL-
ICY.—
(1) PAYMENT
FOR
DIRECT
MEDICAL
EDU-
CATION.—Section 1886(h)(5)(A) of the Social Secu-
rity Act (42 U.S.C. 1395ww(h)(5)(A)) is amended—
(A) by striking ‘‘means’’ and inserting
‘‘means, with respect to a hospital,’’; and
(B) by striking the period at the end and
inserting the following: ‘‘, but only if (with re-
spect to residents who begin an initial residency
period on or after June 1, 1995) entry positions
in each such program of the hospital are in ac-
cordance with the national policy established by
the Secretary under section 3(a) of the Primary
Care Workforce Act of 1993 respecting the
number of positions in such program.’’.
(2) PAYMENT
FOR
INDIRECT
MEDICAL
EDU-
CATION.—Section 1886(d)(5)(B) of such Act (42
U.S.C. 1395ww(d)(5)(B)) is amended by adding at
the end the following new clauses:
‘‘(v) In determining such adjustment, the Sec-
retary may not take into account the services of any
interns and residents in a medical residency training
program for a specialty or subspecialty unless, with
respect to interns and residents who begin an initial
residency period (as defined in subsection (h)(5)(F))
on or after June 1, 1995, entry positions in each
such program of the hospital are in accordance with
the national policy established by the Secretary
under section 3(a) of the Primary Care Workforce
Act of 1993 respecting the number of positions in
such program.
‘‘(vi) With respect to payments during each of
the first 5 fiscal years for which clause (v) is in ef-
fect, the application of such clause may not result in
a reduction of the additional payment amount made
to the hospital under this subparagraph during the
fiscal year to an amount that is less than—
‘‘(I) in the case of a hospital receiving an
additional payment amount under subpara-
graph (F) during the fiscal year that is com-
puted under clause (vii)(I) of such subpara-
graph, 95 percent of the additional payment
amount made to the hospital under this sub-
paragraph during the previous fiscal year; or
‘‘(II) in the case of any other hospital, 90
percent of the additional payment amount made
to the hospital under this subparagraph during
the previous fiscal year.’’.
SEC. 4. NATIONAL HEALTH PROFESSIONAL WORKFORCE
ADVISORY BOARD.
(a) ESTABLISHMENT; COMPOSITION.—There is here-
by established the National Health Professional Workforce
Advisory Board (hereafter in this section referred to as
the ‘‘Board’’), to be composed of the Secretary of Health
and Human Services, the Secretary of Veterans’ Affairs,
and seven other members appointed by the President not
later than three months after the date of the enactment
of this Act, of whom—
(1) at least one shall be a dean of a school of
medicine;
(2) at least one shall be a health care profes-
sional who is not a physician;
(3) at least one shall be the program director
of an approved medical residency training program;
(4) at least one shall be the chief executive offi-
cer of a hospital that operates an approved medical
residency training program;
(5) at least one shall be the vice-president or
vice-chancellor for health affairs of a multi-discipli-
nary academic health center; and
(6) at least one shall represent the general
public.
(b) DUTIES.—
(1) IN GENERAL.—The Board shall—
(A) prepare initial recommendations re-
garding the national policy referred to in sec-
tion 3(a) for the number of positions in ap-
proved medical residency training programs of
the different medical specialties (subject to the
requirements of section 3(b) regarding the total
number of entry positions in such programs and
the distribution of such positions under such
programs among primary care and non-primary
care residents at various sites), and submit
such recommendations to the Secretary not
later than one year after the date of the enact-
ment of this Act;
(B) submit recommendations to the Sec-
retary regarding the supply and role of provid-
ers of primary care services who are not physi-
cians;
(C) with respect to funds available pursu-
ant to title XVIII of the Social Security Act for
direct graduate medical education for the clini-
cal training of physicians and nurses, study the
appropriateness of expending such funds to
make reimbursements under such title for the
clinical training in primary care of additional
practitioners;
(D) submit annual reports to Congress and
the Secretary on the implementation of such
national policy; and
(E) provide the Secretary with such tech-
nical and other assistance regarding such na-
tional policy as the Secretary may request.
(2) CRITERIA
FOR
RECOMMENDATIONS.—In
preparing its recommendations under paragraph (1),
the Board shall take into consideration—
(A) the quality of graduate medical resi-
dency training programs;
(B) the need to maintain the operation of
such programs that have demonstrated success
in recruiting, retaining, and promoting minority
practitioners;
(C) the need to assure that the distribution
of entry positions in such programs is not in-
equitable in relation to the States and hospitals
in urban and rural areas that are qualified to
offer such programs;
(D) the need to assure the provision of pri-
mary care and other health care services to
medically underserved communities; and
(E) such other criteria as the Board (in
consultation with the accrediting bodies referred
to in subsection (c)) considers appropriate.
(c) ROLE OF ACCREDITING BODIES AND CERTIFYING
BOARDS.—In preparing its recommendations regarding
the national policy referred to in section 3(a), the Board
shall—
(1) request each accrediting body for approved
medical residency training programs for a specialty
or subspecialty, and each certification board for such
specialty or subspecialty, to prepare and submit a
plan that provides for the achievement of such na-
tional policy with respect to approved medical resi-
dency training programs for such specialty or sub-
specialty;
(2) analyze the extent to which the Board may
adopt such plans as the basis for its recommenda-
tions; and
(3) maintain close consultation with such bodies
and boards throughout the process of preparing its
recommendations.
(d) 
CHAIRPERSON; 
ADDITIONAL
DUTIES.—The
President shall designate a Chairperson from among the
members, who (subject to the approval of the Board)
may—
(1) employ and fix the compensation of an Ex-
ecutive Director and such other personnel (not to ex-
ceed twenty-five) as may be necessary to carry out
the Board’s duties;
(2) seek such assistance and support as may be
required in the performance of the Board’s duties
from appropriate Federal departments and agencies;
(3) enter into contracts or make other arrange-
ments, as may be necessary for the conduct of the
work of the Board (without regard to section 3709
of the Revised Statutes (41 U.S.C. 5));
(4) make advance, progress, and other pay-
ments which relate to the work of the Commission;
(5) provide transportation and subsistence for
persons serving without compensation; and
(6) prescribe such rules and regulations as the
Board deems necessary with respect to its internal
organization and operation.
(e) COMPENSATION.—Members of the Board who are
full-time officers or employees of the United States may
not receive additional pay, allowances, or benefits by rea-
son of their service on the Board, but may receive travel
expenses, including per diem in lieu of subsistence, in ac-
cordance with sections 5702 and 5703 of title 5, United
States Code.
(f) TERMINATION.—The Board shall terminate upon
the expiration of the six-year period that begins on the
date of the enactment of this Act. Section 14(a) of the
Federal Advisory Committee Act (5 U.S.C. App.; relating
to the termination of advisory committees) shall not apply
to the Board.
(g) CONFORMING AMENDMENT REPEALING COUNCIL
ON GRADUATE MEDICAL EDUCATION.—Effective on the
date of the enactment of this Act, section 301 of the
Health Professions Education Extension Amendments of
1992 (Public Law 102–408) is repealed.
SEC. 5. REVISIONS TO MEDICARE METHODOLOGY FOR
DETERMINING 
PAYMENTS 
FOR 
MEDICAL
RESIDENCY.
(a) PAYMENTS FOR DIRECT MEDICAL EDUCATION
COSTS OF NON-HOSPITAL PROVIDERS.—Title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.) is amend-
ed by inserting after section 1889 the following new
section:
‘‘GRADUATE MEDICAL EDUCATION PAYMENTS FOR NON-
HOSPITAL PROVIDERS
‘‘SEC. 1890. (a) IN GENERAL.—Notwithstanding any
other provision of this title, in the case of any entity (other
than a hospital) eligible to receive payments under this
title that operates an approved medical residency training
program, in addition to any other payments that may be
made to the entity under this title, the Secretary shall pro-
vide for payment to the entity for direct graduate medical
education costs in accordance with subsection (b).
‘‘(b) DETERMINATION OF AMOUNT OF PAYMENT.—
‘‘(1) IN
GENERAL.—The amount of payment
made to an entity under this section for direct medi-
cal education for a fiscal year is equal to the product
of—
‘‘(A) the aggregate approved amount (as
defined in paragraph (2)) for the year; and
‘‘(B) the entity’s medicare patient load (as
defined in subsection (d)(2)) for the year.
‘‘(2) 
AGGREGATE
APPROVED
AMOUNT.—In
paragraph (1), the term ‘aggregate approved
amount’ means, for a fiscal year, the product of—
‘‘(A) the approved FTE resident amount
(determined under paragraph (3)) for the year;
and
‘‘(B) the weighted average number of full-
time equivalent residents (as determined by the
Secretary in a manner similar to the manner
used to determine the number of such residents
under section 1886(h)(4)) in the entity’s ap-
proved medical residency training programs in
the year.
‘‘(3) DETERMINATION OF APPROVED FTE RESI-
DENT AMOUNT.—
‘‘(A) IN
GENERAL.—For each approved
medical residency training program, the Sec-
retary shall determine an approved FTE resi-
dent amount for each fiscal year (beginning
with fiscal year 1995) equal to the applicable
percentage (as defined in subparagraph (C)) of
the national average salary for the year (as de-
fined in subparagraph (B)(ii)).