‘‘(L) TREATMENT OF TIME SPENT IN AP-
PROVED MEDICAL RESIDENCY TRAINING PRO-
GRAM
WITH
RESPECT
TO
CERTAIN
HOS-
PITALS.—For purposes of cost reporting peri-
ods beginning on or after July 1, 2014, in de-
termining the number of full-time equivalent 
residents of the hospital for purposes of this 
paragraph, all the time spent by an intern or 
resident in an approved medical residency train-
ing program, regardless of setting, shall be 
counted toward the determination of full-time 
equivalency, and subparagraphs (J) and (K) 
shall not apply, if the hospital— 
‘‘(i) is recognized as a subsection (d) 
hospital; 
‘‘(ii) is recognized as a subsection (d) 
Puerto Rico hospital; 
‘‘(iii) is reimbursed under a reim-
bursement system authorized under section 
1814(b)(3); or 
‘‘(iv) is a provider-based hospital out-
patient department.’’. 
(b) IME.—The second clause (x) of section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) is amended— 
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(1) in subclause (II), by striking ‘‘In deter-
mining’’ and inserting ‘‘Subject to subclause (x)(IV), 
in determining’’; 
(2) in subclause (III), by striking ‘‘In deter-
mining’’ and inserting ‘‘Subject to subclause (x)(IV), 
in determining’’; and 
(3) by adding at the end the following new sub-
clause: 
‘‘(IV) The provisions of subpara-
graph (L) of subsection (h)(4) shall 
apply under this subparagraph in the 
same manner as they apply under 
such subsection.’’. 
SEC. 5. TREATMENT OF HOSPITALS WITH ROTATING RESI-
DENTS. 
Section 1886(h)(2)(F) of the Social Security Act (42 
U.S.C. 1395ww(h)(2)(F)) is amended by adding at the 
end the following sentence: ‘‘In applying this subpara-
graph for cost reporting periods beginning on or after July 
1, 2013, the Secretary shall not treat a cost reporting pe-
riod for which a hospital trains residents participating in 
a program of another hospital as a period for which the 
hospital has an approved medical residency training pro-
gram.’’. 
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SEC. 6. AGGREGATION RULES RELATING TO APPLYING 
LIMITATION ON NUMBER OF RESIDENTS. 
(a) REQUIRED RULES TO PERMIT MEMBERS
OF 
SAME AFFILIATED GROUP TO ELECT TO APPLY LIMITA-
TION ON AGGREGATE LEVEL.—Section 1886(h)(4)(H)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(h)(4)(H)(ii)) is amended by striking ‘‘may’’ and 
inserting ‘‘shall’’. 
(b) ELECTION FOR NEW FACILITIES.—Such section 
is further amended by adding at the end the following new 
sentence: ‘‘Such rules shall provide that all facilities estab-
lished on or after January 1, 2000, whose resident limits 
are adjusted according to this subparagraph on or after 
January 1, 1997, may elect to apply the limitation under 
subparagraph (F) on an aggregate basis after a period 
specified by the Secretary but that shall not exceed 5 years 
from the date of such adjustment.’’. 
SEC. 7. PERIOD OF BOARD ELIGIBILITY FOR RESIDENTS 
WHO CHANGE PROGRAMS. 
Section 1886(h)(5)(G) of the Social Security Act (42 
U.S.C. 1395ww(h)(5)(G)) is amended— 
(1) in clause (i), by striking ‘‘(iv), and (v)’’ and 
inserting ‘‘(iv), (v), and (vi)’’; and 
(2) by adding at the end the following new 
clause: 
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‘‘(vi) In the case of a resident who 
changes residency specialties, the period of 
board eligibility and the initial residency 
period shall be equal to the minimum num-
ber of years of formal training required to 
satisfy the requirements for the initial 
board eligibility of the program into which 
the resident transfers.’’. 
SEC. 8. MEDICARE INDIRECT MEDICAL EDUCATION PER-
FORMANCE ADJUSTMENT. 
Section 1886 of the Social Security Act (42 U.S.C. 
1395ww) is amended— 
(1) in subsection (d)(5)(B), in the matter pre-
ceding clause (i), by inserting ‘‘subject to subsection 
(t) and’’ before ‘‘except as follows’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(t) INDIRECT MEDICAL EDUCATION PERFORMANCE 
ADJUSTMENTS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding 
provisions of this subsection, the Secretary shall es-
tablish 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) 
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for discharges occurring during a fiscal year is ad-
justed based on the reporting of measures and the 
performance of the hospital on measures of patient 
care 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 patient care 
priorities specified by the Secretary under this sub-
section shall include the extent of training provided 
in— 
‘‘(A) the delivery of services categorized as 
evaluation and management codes by the Cen-
ters for Medicare & Medicaid Services; 
‘‘(B) a variety of settings and systems; 
‘‘(C) the coordination of patient care 
across settings; 
‘‘(D) the relevant cost and value of various 
diagnostic and treatment options; 
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‘‘(E) 
interprofessional 
and 
multidisci-
plinary care teams; 
‘‘(F) methods for identifying system errors 
and implementing system solutions; and 
‘‘(G) the use of health information tech-
nology. 
‘‘(4) MEASURE DEVELOPMENT PROCESS.— 
‘‘(A) IN GENERAL.—The measures of pa-
tient 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 Accredita-
tion Council for Graduate Medical 
Education or American Osteopathic 
Association); and 
‘‘(II) be measures that the Sec-
retary identifies as having used a con-
sensus-based process for developing 
such measures; and 
‘‘(ii) may include measures that have 
been submitted by teaching hospitals and 
medical schools. 
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‘‘(B) PROPOSED
SET
OF
INITIAL
MEAS-
URES.—Not later than July 1, 2015, the Sec-
retary 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 Sec-
retary may, through notice and comment rule-
making, periodically update the measures speci-
fied under this subsection pursuant to the re-
quirements under subparagraph (A). 
‘‘(5) PERFORMANCE
STANDARDS.—The Sec-
retary shall establish performance standards with re-
spect 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. 
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‘‘(7) REPORTING
OF
MEASURES.—The proce-
dures 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 ac-
cordance 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 hos-
pital would otherwise receive under subsection 
(d)(5)(B) for discharges in such fiscal year 
shall be reduced by 0.5 percent. 
‘‘(B) PERFORMANCE
FOR
FISCAL
YEAR 
2019 AND SUBSEQUENT FISCAL YEARS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), based on the performance of each hos-
pital with respect to compliance with the 
measures for a performance period for a 
fiscal year (beginning with fiscal year 
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2019), the Secretary shall determine the 
amount of any adjustment under this sub-
paragraph 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 sub-
section 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 mak-
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ing payments to a hospital under this section in a 
subsequent fiscal year. 
‘‘(10) EVALUATION
OF
SUBMISSION
OF
PER-
FORMANCE MEASURES.—Not later than January 1, 
2018, the Secretary shall submit to Congress a re-
port on the implementation of this subsection, in-
cluding— 
‘‘(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 bar-
riers described in subparagraph (A) or (B). 
‘‘(11) DEFINITION OF HOSPITAL.—In this sub-
section, the term ‘hospital’ means a hospital that re-
ceives payments under subsection (d)(5)(B).’’. 
SEC. 9. INCREASING 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 receive under the Medicare pro-
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gram. The report shall include the following information 
with respect to each hospital that receives such payments: 
(1) The direct graduate medical education pay-
ments 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 de-
scribed in paragraph (1). 
(5) The number of full-time-equivalent residents 
counted for purposes of making the payments de-
scribed in paragraph (3). 
(6) The number of full-time-equivalent resi-
dents, if any, that are not counted for purposes of 
making payments described in paragraph (1). 
(7) The number of full-time-equivalent resi-
dents, if any, that are not counted for purposes of 
making payments described in paragraph (3). 
(8) The factors contributing to the higher costs 
of patient care provided by the hospital, including— 
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(A) the costs of trauma, burn, other stand-
by services; 
(B) translation services for disabled or 
non-English speaking patients; 
(C) the cost of uncompensated care; 
(D) financial losses with respect to Med-
icaid patients; and 
(E) uncompensated costs of clinical re-
search. 
SEC. 10. GAO STUDIES AND REPORTS. 
(a) ON PHYSICIAN WORKFORCE.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study on the physician 
workforce. Such study shall include the identification 
of physician specialties for which there is a shortage, 
as defined by the Comptroller General. 
(2) REPORT.—Not later than January 1, 2015, 
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 Gen-
eral determines appropriate. 
(b) ON STRATEGIES FOR INCREASING DIVERSITY.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study on strategies for 
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increasing the diversity of the health professional 
workforce. Such study shall include an analysis of 
strategies for increasing the number of health pro-
fessionals from rural, lower income, and under-rep-
resented minority communities, including which 
strategies are most effective for achieving such goal. 
(2) REPORT.—Not later than 2 years after the 
date of enactment of this Act, the Comptroller Gen-
eral shall submit to Congress a report on the study 
conducted under subsection (a), together with rec-
ommendations for such legislation and administra-
tive action as the Comptroller General determines 
appropriate. 
(c) ON PROTECTING OLDER ADULTS.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study that addresses 
the competency of the physician workforce to care 
for older adults upon the completion of such 
workforce’s residency training. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report on such 
study, including such recommendations for legisla-
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