I 113th CONGRESS 1st Session H. R. 487 IN THE HOUSE OF REPRESENTATIVES February 4, 2013 Mrs. McMorris Rodgers (for herself and Mr. Thompson of California ) introduced 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.

1. Short title This Act may be cited as the Primary Care Workforce Access Improvement Act of 2013 . 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 Secretary ) 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 models for providing payment under such title for direct graduate medical education and indirect medical education to medical education entities, which entities are not otherwise eligible to receive such payments under the Medicare program, 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 education entity receiving funds under the pilot project is a community-based independent corporate entity collaborating with two or more hospitals to operate one or more primary care graduate medical residency training programs. (B) A model in which— (i) the medical education entity receiving funds under the pilot project is established 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 education 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 programs for a hospital with community participation in the governance of the subsidiary or corporation. (D) A model in which— (i) the medical education entity receiving funds under the pilot project is independent of any hospital but collaborates with a hospital in operating one or more primary care graduate medical residency training programs; and (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 improving 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 entities 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 operated pursuant to a model of such entity under subsection (c) instead of any payment or adjustment that would otherwise be made to a participant hospital (as defined in subsection (m)) of such entity 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 available 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 reporting 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. 1395ww(d)(5)(B) ) for such previous cost reporting period, is equal to the 95th percentile of such payment amounts. (3) Additional payments for programs serving underserved areas Payments in addition 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 underserved 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 Secretary shall provide for an allocation of such payments 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 provides for an allocation of payments under subsections (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 residents, including training activities in appropriate inpatient and outpatient settings in primary care graduate medical residency training programs accredited by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association and for all relevant topics including patient care, care management, working in teams, supervision, 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 medical 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 primary care residents enrolled in the such program (determined 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 entity 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 hospital would receive such payments without application of this Act and such payments shall be calculated 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 enrolled 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 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 subsection (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 duration 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 subsections (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 carrying 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 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 authorized 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 completion 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 distribution of such physicians before the pilot project; and the governance, administration and financial strength of the medical educational entities that participated in the pilot project; (2) recommendations on the extent to which the pilot project should be expanded to all primary care residents; and (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 education costs and indirect graduate medical education have the meanings given such terms for purposes 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, nonprofit, 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 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 participant hospital means, with respect to a medical education entity, any hospital that establishes, is collaborating with, a component of, or otherwise associated 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 residency training program The term primary care graduate medical residency training program means an approved medical residency training program (as defined in section 1886(h)(5)(A) of the Social Security Act ( 42 U.S.C. 1395ww(h)(5)(A) )) for training primary care residents. (6) Primary care resident The term primary care resident means a resident enrolled in an approved medical residency training program in family medicine, general internal medicine, general pediatrics, or geriatric medicine.