I 
113TH CONGRESS 
1ST SESSION 
H. R. 487 
To provide for a Medicare primary care graduate medical education pilot 
project in order to improve access to the primary care workforce. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 4, 2013 
Mrs. MCMORRIS RODGERS (for herself and Mr. THOMPSON of California) in-
troduced 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 provide for a Medicare primary care graduate medical 
education pilot project in order to improve access to 
the primary care workforce. 
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 Work-
force Access Improvement Act of 2013’’. 
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SEC. 2. MEDICARE PRIMARY CARE GRADUATE MEDICAL 
EDUCATION PILOT PROJECT. 
(a) ESTABLISHMENT.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall conduct a pilot project under the Medicare 
program under title XVIII of the Social Security Act, in 
accordance with the provisions of this section, to test mod-
els for providing payment under such title for direct grad-
uate medical education and indirect medical education to 
medical education entities, which entities are not otherwise 
eligible to receive such payments under the Medicare pro-
gram, for the costs of training primary care residents. 
(b) DURATION.—The Secretary shall conduct the 
pilot project under this section over a 5-year period, which 
shall begin not later than 180 days after the date of the 
enactment of this Act. 
(c) MODELS.— 
(1) REQUIRED
MODELS.—Under the pilot 
project, the Secretary shall test two of each of the 
following models: 
(A) A model in which the medical edu-
cation entity receiving funds under the pilot 
project is a community-based independent cor-
porate entity collaborating with two or more 
hospitals to operate one or more primary care 
graduate medical residency training programs. 
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(B) A model in which— 
(i) the medical education entity receiv-
ing funds under the pilot project is estab-
lished by two or more hospitals to operate 
one or more primary care graduate medical 
residency training programs; and 
(ii) such hospitals may be the sole 
corporate members of the entity but the 
governing board of the entity shall include 
at least one community representative. 
(C) A model in which the medical edu-
cation entity receiving funds under the pilot 
project is a hospital subsidiary or independent 
corporation that operates one or more primary 
care graduate medical residency training pro-
grams for a hospital with community participa-
tion in the governance of the subsidiary or cor-
poration. 
(D) A model in which— 
(i) the medical education entity receiv-
ing funds under the pilot project is inde-
pendent of any hospital but collaborates 
with a hospital in operating one or more 
primary care graduate medical residency 
training programs; and 
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(ii) the medical education entity may 
include a university or school of medicine. 
(2) ADDITIONAL
MODELS.—Under the pilot 
project, the Secretary may test models of medical 
education entities in addition to those described in 
paragraph (1). 
(d) PRIORITIZATION.—Under the pilot project, the 
Secretary of Health and Human Services may give priority 
to testing models that demonstrate the capability of im-
proving the quality, quantity, and distribution of primary 
care physicians, including the ability to enhance primary 
care delivery in rural and underserved areas. 
(e) PAYMENTS.— 
(1) PAYMENTS TO MEDICAL EDUCATION ENTI-
TIES.—Under the pilot project, the Secretary shall 
establish a process under which payments are made 
to each medical education entity participating under 
such project for direct graduate medical education 
and indirect medical education costs with respect to 
primary care residents enrolled under a primary care 
graduate medical residency training program oper-
ated pursuant to a model of such entity under sub-
section (c) instead of any payment or adjustment 
that would otherwise be made to a participant hos-
pital (as defined in subsection (m)) of such entity 
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for indirect and direct graduate medical education 
costs under subsections (d)(5)(B) and (h) of section 
1886 of the Social Security Act (42 U.S.C. 1395ww) 
during the period of participation of such entity in 
such project. 
(2) CALCULATION OF PAYMENTS.—Payments to 
a medical education entity under the pilot project, 
with respect to a primary care graduate medical 
education residency program, for a cost reporting 
period during which the entity is participating in 
such pilot shall be, based on the most recently avail-
able data with respect to a previous cost reporting 
period, equal to the sum of the following: 
(A) DIRECT GME.—The amount that, out 
of all of the payment amounts (determined on 
a per resident basis) received by hospitals under 
section 1886(h) of the Social Security Act (42 
U.S.C. 1395ww(h)) for such previous cost re-
porting period, is equal to the 95th percentile of 
such payment amounts. 
(B) INDIRECT
GME.—The amount that, 
out of all of the additional payment amounts 
(determined on a per resident basis) received by 
hospitals under section 1886(d)(5)(B) of the 
Social 
Security 
Act 
(42 
U.S.C. 
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1395ww(d)(5)(B)) for such previous cost re-
porting period, is equal to the 95th percentile of 
such payment amounts. 
(3) ADDITIONAL
PAYMENTS
FOR
PROGRAMS 
SERVING UNDERSERVED AREAS.—Payments in addi-
tion to the payments described in paragraph (2) may 
be made under the pilot project for primary care 
graduate 
medical 
residency 
training 
programs 
that— 
(A) operate in sites and areas that are un-
derserved by primary care physicians; or 
(B) change their training sites to include 
those areas. 
(4) 
PAYMENTS
FROM
MEDICARE
TRUST 
FUNDS.—In providing for such payments under this 
subsection to medical education entities, the Sec-
retary shall provide for an allocation of such pay-
ments between part A and part B (and the Federal 
Hospital Insurance Trust Fund under section 1817 
of the Social Security Act (42 U.S.C. 1395i) and the 
Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 
1395t)) in the same manner as the Secretary pro-
vides for an allocation of payments under sub-
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sections (d)(5)(B) and (h), respectively, of section 
1886 of such Act (42 U.S.C. 1395ww). 
(f) USES OF PAYMENTS.— 
(1) IN GENERAL.—A medical education entity 
receiving payments under the pilot project shall use 
such payments for the training of primary care resi-
dents, including training activities in appropriate in-
patient and outpatient settings in primary care 
graduate medical residency training programs ac-
credited by the Accreditation Council for Graduate 
Medical Education or the American Osteopathic As-
sociation and for all relevant topics including patient 
care, care management, working in teams, super-
vision, and quality improvement. 
(2) LIMITATIONS.—Payments shall only be 
made for training primary care residents up to the 
initial board certification of such residents, except 
that with respect to training in geriatric medicine, 
payments may also be made for a fellowship after 
initial board certification. 
(g) EXPANSION DURING PILOT PROJECT.—A med-
ical education entity receiving funds under the pilot 
project, with respect to a primary care graduate medical 
residency training program, shall be allowed to increase 
by up to 50 percent the number of full-time equivalent 
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primary care residents enrolled in the such program (de-
termined in accordance with the process under subsection 
(e)(1)) during the duration of the participation of such 
entity in such project. 
(h) TREATMENT AFTER PROJECT.— 
(1) IN GENERAL.—Subject to paragraphs (2) 
and (3), after the last day of the pilot project, which 
may be extended at the discretion of the Secretary, 
any participant hospital of a medical education enti-
ty under the pilot project, shall receive payments 
under subsection (d)(5)(B) and (h) of section 1886 
of the Social Security Act (42 U.S.C. 1395ww) in 
the same manner and to the same extent such hos-
pital would receive such payments without applica-
tion of this Act and such payments shall be cal-
culated based on the number of full-time equivalent 
residents enrolled in such program without regard to 
any increase made pursuant to subsection (g). 
(2) EXCEPTION
TO
ENSURE
RESIDENTS
EN-
ROLLED
DURING
PILOT
ARE
ABLE
TO
COMPLETE 
TRAINING.—Subject to paragraph (3), a medical 
education entity receiving funds under the pilot 
project, with respect to a primary care graduate 
medical residency training program, shall continue 
to receive funding under this section (even after the 
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last day of the project), with respect to each primary 
care resident who is enrolled under such program 
while the entity is participating in such project, to 
the extent and in such amounts necessary to allow 
for the full duration of training, subject to sub-
section (f)(2), of such primary care resident. Any 
such payments made pursuant to this subparagraph 
shall be deemed to be a payment made under the 
pilot project. 
(3) LIMITATION.—In no case may the total du-
ration of the pilot project exceed seven years and in 
no case may payments be made under this section 
to a medical education entity for a period exceeding 
seven years. 
(i) BUDGET NEUTRALITY.—For each year that the 
pilot project under this section is being conducted (and 
for any subsequent year to the extent subsection (h)(2) 
applies), the Secretary shall reduce payments under sub-
sections (d)(5)(B) and (h) of section 1886 of the Social 
Security Act (42 U.S.C. 1395ww) by such amount as the 
Secretary determines to be necessary to ensure that car-
rying out the pilot project under this section during such 
year does not result in expenditures under title XVIII of 
the Social Security Act for such year that exceed the 
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amount of such expenditures that would have been made 
for such year without application of this section. 
(j) WAIVER AUTHORITY.—The Secretary may waive 
such requirements of titles XI and XVIII of the Social 
Security Act as may be necessary to carry out the purpose 
of the pilot project under this section. 
(k) REPORT TO CONGRESS.—The Secretary is au-
thorized to enter into an agreement with the Institute of 
Medicine to conduct a study on the results of the pilot 
project. Such agreement shall provide for the Institute of 
Medicine to submit, not later than 1 year after the comple-
tion of the pilot project under this section (or, if sooner, 
January 1, 2021), to Congress a report on the results of 
such study, including— 
(1) a detailed analysis of the effects of the pilot, 
including the quality, quantity, and distribution of 
primary care physicians during and after the pilot 
project compared to the quality, quantity, and dis-
tribution of such physicians before the pilot project; 
and the governance, administration and financial 
strength of the medical educational entities that par-
ticipated in the pilot project; 
(2) recommendations on the extent to which the 
pilot project should be expanded to all primary care 
residents; and 
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(3) recommendations for such legislation and 
administrative actions as needed. 
(l) EXPANSION.—If the Secretary determines that 
any of the models tested under the pilot project under this 
section enhance the quality, quantity, and distribution of 
primary care physicians for Medicare beneficiaries, the 
Secretary may initiate comparable primary care training 
projects. 
(m) DEFINITIONS.—For purposes of this section: 
(1) DIRECT
GRADUATE
MEDICAL
EDUCATION 
COSTS; INDIRECT GRADUATE MEDICAL EDUCATION 
COSTS.—The terms ‘‘direct graduate medical edu-
cation costs’’ and ‘‘indirect graduate medical edu-
cation’’ have the meanings given such terms for pur-
poses of subsections (h) and (d)(5)(B), respectively, 
of section 1886 of the Social Security Act (42 
U.S.C. 1395ww). 
(2) MEDICAL EDUCATION ENTITY.—The term 
‘‘medical education entity’’ means a corporate, non-
profit, or academic entity that has as its principal 
mission the education and training of primary care 
residents. 
(3) 
MEDICARE
BENEFICIARY.—The 
term 
‘‘Medicare beneficiary’’ means an individual entitled 
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to benefits under part A of title XVIII of the Social 
Security Act or enrolled under part B of such title. 
(4) PARTICIPANT HOSPITAL.—The term ‘‘par-
ticipant hospital’’ means, with respect to a medical 
education entity, any hospital that establishes, is col-
laborating with, a component of, or otherwise associ-
ated with, such entity to operate a primary care 
graduate medical residency training program under 
a model described in subsection (c). 
(5) PRIMARY CARE GRADUATE MEDICAL RESI-
DENCY
TRAINING
PROGRAM.—The term ‘‘primary 
care graduate medical residency training program’’ 
means an approved medical residency training pro-
gram (as defined in section 1886(h)(5)(A) of the So-
cial Security Act (42 U.S.C. 1395ww(h)(5)(A))) for 
training primary care residents. 
(6) PRIMARY CARE RESIDENT.—The term ‘‘pri-
mary care resident’’ means a resident enrolled in an 
approved medical residency training program in fam-
ily medicine, general internal medicine, general pedi-
atrics, or geriatric medicine. 
Æ 
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