HR 2350 IHCommentsClose CommentsPermalink

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.CommentsClose CommentsPermalink

May 12, 2009CommentsClose CommentsPermalink

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. GIFFORDS, 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 Wisconsin, Mr. MORAN of Virginia, Mr. PATRICK J. MURPHY of Pennsylvania, 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. WATERS, Ms. WATSON, Mr. WEINER, Mr. WILSON of Ohio, Mr. YARMUTH, Mr. MEEKS of New York, Ms. LINDA T. SANCHEZ 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 Committees 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 concernedCommentsClose CommentsPermalink

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.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

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’.CommentsClose CommentsPermalink





(b) Table of Contents- The table of contents is as follows:CommentsClose CommentsPermalink





Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink





Sec. 2. Findings.CommentsClose CommentsPermalink





Sec. 3. Definitions.CommentsClose CommentsPermalink

TITLE I--MEDICAL EDUCATION

Sec. 101. Recruitment incentives.CommentsClose CommentsPermalink





Sec. 102. Debt forgiveness, scholarships, and service obligations.CommentsClose CommentsPermalink





Sec. 103. Deferment of loans during residency and internships.CommentsClose CommentsPermalink





Sec. 104. Educating medical students about primary care careers.CommentsClose CommentsPermalink





Sec. 105. Training in a family medicine, general internal medicine, general geriatrics, general pediatrics, physician assistance, general dentistry, and pediatric dentistry.CommentsClose CommentsPermalink





Sec. 106. Increased funding for National Health Service Corps Scholarship and Loan Repayment Programs.CommentsClose CommentsPermalink

TITLE II--MEDICAID RELATED PROVISIONS

Sec. 201. Transformation grants to support patient centered medical homes under Medicaid and CHIP.CommentsClose CommentsPermalink

TITLE III--MEDICARE PROVISIONS

Subtitle A--Primary Care

Sec. 301. Reforming payment systems under Medicare to support primary care.CommentsClose CommentsPermalink





Sec. 302. Coverage of patient centered medical home services.CommentsClose CommentsPermalink





Sec. 303. Medicare primary care payment equity and access provision.CommentsClose CommentsPermalink





Sec. 304. Additional incentive payment program for primary care services furnished in health professional shortage areas.CommentsClose CommentsPermalink





Sec. 305. Permanent extension of floor on Medicare work geographic adjustment under the Medicare physician fee schedule.CommentsClose CommentsPermalink





Sec. 306. Permanent extension of Medicare incentive payment program for physician scarcity areas.CommentsClose CommentsPermalink





Sec. 307. HHS study and report on the process for determining relative value under the Medicare physician fee schedule.CommentsClose CommentsPermalink

Subtitle B--Preventive Services

Sec. 311. Eliminating time restriction for initial preventive physical examination.CommentsClose CommentsPermalink





Sec. 312. Elimination of cost-sharing for preventive benefits under the Medicare program.CommentsClose CommentsPermalink





Sec. 313. HHS study and report on facilitating the receipt of Medicare preventive services by Medicare beneficiaries.CommentsClose CommentsPermalink

Subtitle C--Other Provisions

Sec. 321. HHS study and report on improving the ability of physicians and primary care providers to assist Medicare beneficiaries in obtaining needed prescriptions under Medicare part D.CommentsClose CommentsPermalink





Sec. 322. HHS study and report on improved patient care through increased caregiver and physician interaction.CommentsClose CommentsPermalink





Sec. 323. Improved patient care through expanded support for limited English proficiency (LEP) services.CommentsClose CommentsPermalink





Sec. 324. HHS study and report on use of real-time Medicare claims adjudication.CommentsClose CommentsPermalink





Sec. 325. Ongoing assessment by MedPAC of the impact of medicare payments on primary care access and equity.CommentsClose CommentsPermalink





Sec. 326. Distribution of additional residency positions.CommentsClose CommentsPermalink





Sec. 327. Counting resident time in outpatient settings.CommentsClose CommentsPermalink





Sec. 328. Rules for counting resident time for didactic and scholarly activities and other activities.CommentsClose CommentsPermalink





Sec. 329. Preservation of resident cap positions from closed and acquired hospitals.CommentsClose CommentsPermalink





Sec. 330. Quality improvement organization assistance for physician practices seeking to be patient centered medical home practices.CommentsClose CommentsPermalink

TITLE IV--STUDIES

Sec. 401. Study concerning the designation of primary care as a shortage profession.CommentsClose CommentsPermalink





Sec. 402. Study concerning the education debt of medical school graduates.CommentsClose CommentsPermalink





Sec. 403. Study on minority representation in primary care.CommentsClose CommentsPermalink

SEC. 2. FINDINGS.

Congress makes the following findings:CommentsClose CommentsPermalink





(1) Approximately 21 percent of physicians who were board certified in general internal medicine during the early 1990s have left internal medicine, compared to a 5 percent departure rate for those who were certified in subspecialties of internal medicine.CommentsClose CommentsPermalink





(2) The number of United States medical graduates going into family medicine has fallen by more than 50 percent from 1997 to 2005.CommentsClose CommentsPermalink





(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.CommentsClose CommentsPermalink





(4) In 2006, only 24 percent of third-year internal medicine resident intended to pursue careers in general internal medicine, down from 54 percent in 1998.CommentsClose CommentsPermalink





(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 duplicative testing.CommentsClose CommentsPermalink





(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.CommentsClose CommentsPermalink





(7) Patients with primary care physicians or primary care providers have lower health care expenditures and primary care is correlated with better health status, lower overall mortality, and longer life expectancy.CommentsClose CommentsPermalink





(8) Higher proportions of primary care physicians are associated with significantly reduced utilization.CommentsClose CommentsPermalink





(9) The United States has a higher ratio of specialists to primary care physicians than other industrialized nations and the population of the United States is growing faster than the expected rate of growth in the supply of primary care physicians.CommentsClose CommentsPermalink





(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.CommentsClose CommentsPermalink





(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 inadequate access to primary care.CommentsClose CommentsPermalink





(12) The National Health Service Corps program has a proven record of supplying physicians to underserved areas, and has played an important role in expanding access for underserved populations in rural and inner city communities.CommentsClose CommentsPermalink





(13) Individuals in many geographic areas, especially rural areas, lack adequate access to high quality preventive, primary health care, contributing to significant health disparities that impair America’s public health and economic productivity.CommentsClose CommentsPermalink





(14) About 20 percent of the population of the United States resides in primary medical care Health Professional Shortage Areas.CommentsClose CommentsPermalink

SEC. 3. DEFINITIONS.

(a) General Definitions- In this Act:CommentsClose CommentsPermalink





(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 following services:CommentsClose CommentsPermalink





(A) The development of an initial plan of care, and subsequent appropriate revisions to such plan of care.CommentsClose CommentsPermalink





(B) The management of, and referral for, medical and other health services, including interdisciplinary care conferences and management with other providers.CommentsClose CommentsPermalink





(C) The monitoring and management of medications.CommentsClose CommentsPermalink





(D) Patient education and counseling services.CommentsClose CommentsPermalink





(E) Family caregiver education and counseling services.CommentsClose CommentsPermalink





(F) Self-management services, including health education and risk appraisal to identify behavioral risk factors through self-assessment.CommentsClose CommentsPermalink





(G) Providing access by telephone with physicians and other appropriate health care professionals, including 24-hour availability of such professionals for emergencies.CommentsClose CommentsPermalink





(H) Management with the principal nonprofessional caregiver in the home.CommentsClose CommentsPermalink





(I) Managing and facilitating transitions among health care professionals and across settings of care, including the following:CommentsClose CommentsPermalink





(i) Pursuing the treatment option elected by the individual.CommentsClose CommentsPermalink





(ii) Including any advance directive executed by the individual in the medical file of the individual.CommentsClose CommentsPermalink





(J) Information about, and referral to, hospice care, including patient and family caregiver education and counseling about hospice care, and facilitating transition to hospice care when elected.CommentsClose CommentsPermalink





(K) Information about, referral to, and management with, community services.CommentsClose CommentsPermalink





(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 physicians (as determined by the Secretary) in a primary care field.CommentsClose CommentsPermalink





(3) PHYSICIAN- The term physician has the meaning given such term in section 1861(r)(1) of the Social Security Act.CommentsClose CommentsPermalink





(4) PRIMARY CARE- The term ‘primary care’ means the provision of integrated, high-quality, accessible 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 the context of family and community, and working to minimize disparities across population subgroups.CommentsClose CommentsPermalink





(5) PRIMARY CARE FIELD- The term ‘primary care field’ means any of the following fields:CommentsClose CommentsPermalink





(A) The field of family medicine.CommentsClose CommentsPermalink





(B) The field of general internal medicine.CommentsClose CommentsPermalink





(C) The field of geriatric medicine.CommentsClose CommentsPermalink





(D) The field of pediatric medicineCommentsClose CommentsPermalink





(6) PRIMARY CARE PHYSICIAN- The term ‘primary care physician’ means a physician who is trained in a primary care field who provides first contact, continuous, and comprehensive care to patients.CommentsClose CommentsPermalink





(7) PRIMARY CARE PROVIDER- The term ‘primary care provider’ means--CommentsClose CommentsPermalink





(A) a nurse practitioner; orCommentsClose CommentsPermalink





(B) a physician assistant practicing as a member of a physician-directed or nurse-practitioner-directed team;CommentsClose CommentsPermalink





who provides first contact, continuous, and comprehensive care to patients.CommentsClose CommentsPermalink





(8) PRINCIPAL CARE- The term ‘principal care’ means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management, developing a sustained physician-patient partnership and practicing within the context of family and community.CommentsClose CommentsPermalink





(9) SECRETARY- The term ‘Secretary’ means the Secretary of Health and Human Services.CommentsClose CommentsPermalink





(b) Primary Medical Care Shortage Area-CommentsClose CommentsPermalink





(1) IN GENERAL- In this Act, the term ‘primary medical care shortage area’ or ‘PMCSA’ means a geographic area with a shortage of physicians (as designated by the Secretary) in a primary care field, as designated in accordance with paragraph (2).CommentsClose CommentsPermalink





(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 population served. The Secretary shall make such a designation with respect to an urban or rural geographic area if the following criteria are met:CommentsClose CommentsPermalink





(A) The area is a rational area for the delivery of primary care services.CommentsClose CommentsPermalink





(B) One of the following conditions prevails within the area:CommentsClose CommentsPermalink





(i) The area has a population to full-time-equivalent primary care physician ratio of at least 3,500 to 1.CommentsClose CommentsPermalink





(ii) The area has a population to full-time-equivalent primary care physician ratio of less than 3,500 to 1 and has unusually high needs for primary care services or insufficient capacity of existing primary care providers.CommentsClose CommentsPermalink





(C) Primary care providers in contiguous geographic areas are overutilized.CommentsClose CommentsPermalink





(c) Medically Underserved Area-CommentsClose CommentsPermalink





(1) IN GENERAL- In this Act, the term ‘medically underserved area’ or ‘MUA’ means a rational service area with a demonstrable shortage of primary health care resources relative to the needs of the entire population within the service area as determined in accordance with paragraph (2) through the use of the Index of Medical Underservice (referred to in this subsection as the ‘IMU’) with respect to data on a service area.CommentsClose CommentsPermalink





(2) DETERMINATIONS- Under criteria to be established by the Secretary with respect to the IMU, if a service area is determined by the Secretary to have a score of 62.0 or less, such area shall be eligible to be designated as a MUA.CommentsClose CommentsPermalink





(3) IMU VARIABLES- In establishing criteria under paragraph (2), the Secretary shall ensure that the following variables are utilized:CommentsClose CommentsPermalink





(A) The ratio of primary medical care physicians per 1,000 individuals in the population of the area involved.CommentsClose CommentsPermalink





(B) The infant mortality rate in the area involved.CommentsClose CommentsPermalink





(C) The percentage of the population involved with incomes below the poverty level.CommentsClose CommentsPermalink





(D) The percentage of the population involved age 65 or over.CommentsClose CommentsPermalink





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.CommentsClose CommentsPermalink





(d) Patient Centered Medical Home-CommentsClose CommentsPermalink





(1) IN GENERAL- In this Act, the term ‘patient centered medical home’ means a physician-directed practice (or a nurse-practitioner-directed practice in those States in which such functions are included in the scope of practice of licensed nurse practitioners) that has been certified by an organization under paragraph (3) as meeting the following standards:CommentsClose CommentsPermalink





(A) The practice provides patients who elect to obtain care through a patient centered medical home (referred to as ‘participating patients’) with direct and ongoing access to a primary or principal care physician or nurse practitioner 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.CommentsClose CommentsPermalink





(B) The practice applies standards for access to care and communication with participating beneficiaries.CommentsClose CommentsPermalink





(C) The practice has readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically.CommentsClose CommentsPermalink





(D) The practice maintains continuous relationships with participating patients by implementing evidence-based guidelines and applying such guidelines to the identified needs of individual beneficiaries over time and with the intensity needed by such beneficiaries.CommentsClose CommentsPermalink





(2) RECOGNITION OF NCQA APPROVAL- Such term also includes a physician-directed (or nurse-practitioner-directed) practice that has been recognized as a medical home through the Physician Practice Connections--patient centered Medical Home (‘PPC-PCMH’) voluntary recognition process of the National Committee for Quality Assurance.CommentsClose CommentsPermalink





(3) STANDARD SETTING AND QUALIFICATION PROCESS FOR MEDICAL HOMES- The Secretary shall establish a process for the selection of a qualified standard setting and certification organization--CommentsClose CommentsPermalink





(A) to establish standards, consistent with this subsection, to enable medical practices to qualify as patient centered medical homes; andCommentsClose CommentsPermalink





(B) to provide for the review and certification of medical practices as meeting such standards.CommentsClose CommentsPermalink





(4) TREATMENT OF CERTAIN PRACTICES- Nothing in this section shall be construed as preventing a nurse practitioner from leading a patient centered medical home so long as--CommentsClose CommentsPermalink





(A) all of the requirements of this section are met; andCommentsClose CommentsPermalink





(B) the nurse practitioner is acting consistently with State law.CommentsClose CommentsPermalink





(e) Application Under Medicare, Medicaid, PHSA, etc- Unless otherwise provided, the provisions of the previous subsections shall apply for purposes of provisions of the Social Security Act, the Public Health Service Act, and any other Act amended by this Act.CommentsClose CommentsPermalink

TITLE I--MEDICAL EDUCATIONCommentsClose CommentsPermalink

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:CommentsClose CommentsPermalink

‘PART F--MEDICAL EDUCATION RECRUITMENT INCENTIVES

‘SEC. 786. MEDICAL EDUCATION RECRUITMENT INCENTIVES.

‘(a) In General- The Secretary is authorized to award grants or contracts to institutions of higher education that are graduate medical schools, to enable the graduate medical schools to improve primary care education and training for medical students.CommentsClose CommentsPermalink





‘(b) Application- A graduate medical school that desires to receive a grant under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.CommentsClose CommentsPermalink





‘(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:CommentsClose CommentsPermalink





‘(1) The creation of primary care mentorship programs.CommentsClose CommentsPermalink





‘(2) Curriculum development for population-based primary care models of care, such as the patient centered medical home.CommentsClose CommentsPermalink





‘(3) Increased opportunities for ambulatory, community-based training.CommentsClose CommentsPermalink





‘(4) Development of generalist curriculum to enhance care for rural and underserved populations in primary care or general surgery.CommentsClose CommentsPermalink





‘(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.’.CommentsClose CommentsPermalink

SEC. 102. DEBT FORGIVENESS, SCHOLARSHIPS, AND SERVICE OBLIGATIONS.

(a) Purpose- It is the purpose of this section to encourage individuals to enter and continue in primary care physician careers.CommentsClose CommentsPermalink





(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:CommentsClose CommentsPermalink

‘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 scholarships 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).CommentsClose CommentsPermalink





‘(b) Scholarships- A health facility shall use amounts received under a grant under this section to enter into contracts with eligible individuals under which--CommentsClose CommentsPermalink





‘(1) the facility agrees to provide the individual with a scholarship for each school year (not to exceed 4 school years) in which the individual is enrolled as a full-time student in a school of medicine or a school of osteopathic medicine; andCommentsClose CommentsPermalink





‘(2) the individual agrees--CommentsClose CommentsPermalink





‘(A) to maintain an acceptable level of academic standing;CommentsClose CommentsPermalink





‘(B) to complete a residency in a primary care field; andCommentsClose CommentsPermalink





‘(C) after completing the residency, to serve as a primary care physician at such facility in such field for a time period equal to the greater of--CommentsClose CommentsPermalink





‘(i) one year for each school year for which the individual was provided a scholarship under this section; orCommentsClose CommentsPermalink





‘(ii) two years.CommentsClose CommentsPermalink





‘(c) Amount-CommentsClose CommentsPermalink





‘(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.CommentsClose CommentsPermalink





‘(2) CONSIDERATIONS- In determining the amount of a scholarship to be provided to an individual under this section, a health facility may take into consideration the individual’s financial need, geographic differences, and educational costs.CommentsClose CommentsPermalink





‘(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.CommentsClose CommentsPermalink





‘(d) Application of Certain Provisions- The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.CommentsClose CommentsPermalink





‘(e) Definitions- In this section:CommentsClose CommentsPermalink





‘(1) 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), but has a critical shortage of physicians (as determined by the Secretary) in a primary care field.CommentsClose CommentsPermalink





‘(2) ELIGIBLE INDIVIDUAL- The term ‘eligible individual’ means an individual who is enrolled, or accepted for enrollment, as a full-time student in an accredited school of medicine or school of osteopathic medicine.CommentsClose CommentsPermalink

‘SEC. 340J. LOAN REPAYMENT PROGRAM.

‘(a) Purpose- It is the purpose of this section to alleviate critical shortages of primary care physicians and primary care providers.CommentsClose CommentsPermalink





‘(b) Loan Repayments- The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a program of entering into contracts with eligible individuals under which--CommentsClose CommentsPermalink





‘(1) the individual agrees to serve--CommentsClose CommentsPermalink





‘(A) as a primary care physician or primary care provider in a primary care field; andCommentsClose CommentsPermalink





‘(B) in an area that is not a health professional shortage area (as designated under section 332), but has a critical shortage of primary care physicians and primary care providers (as determined by the Secretary) in such field; andCommentsClose CommentsPermalink





‘(2) the Secretary agrees to pay, for each year of such service, not more than $35,000 of the principal and interest of the undergraduate or graduate educational loans of the individual.CommentsClose CommentsPermalink





‘(c) Service Requirement- A contract entered into under this section shall allow the individual receiving the loan repayment to satisfy the service requirement described in subsection (a)(1) through employment in a solo or group practice, a clinic, a public or private nonprofit hospital, or any other appropriate health care entity.CommentsClose CommentsPermalink





‘(d) Application of Certain Provisions- The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.CommentsClose CommentsPermalink





‘(e) Definition- In this section, the term ‘eligible individual’ means--CommentsClose CommentsPermalink





‘(1) an individual with a degree in medicine or osteopathic medicine; orCommentsClose CommentsPermalink





‘(2) a nurse practitioner.CommentsClose CommentsPermalink

‘SEC. 340K. LOAN REPAYMENTS FOR PHYSICIANS IN THE FIELDS OF OBSTETRICS AND GYNECOLOGY AND CERTIFIED NURSE MIDWIVES.

‘(a) Purpose- It is the purpose of this section to alleviate critical shortages of physicians in the fields of obstetrics and gynecology and certified nurse midwives.CommentsClose CommentsPermalink





‘(b) Loan Repayments- The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall establish a program of entering into contracts with eligible individuals under which--CommentsClose CommentsPermalink





‘(1) the individual agrees to serve--CommentsClose CommentsPermalink





‘(A) as a physician in the field of obstetrics and gynecology or as a certified nurse midwife; andCommentsClose CommentsPermalink





‘(B) in an area that is not a health professional shortage area (as designated under section 332), but has a critical shortage of physicians in the fields of obstetrics and gynecology or certified nurse midwives (as determined by the Secretary), respectively; andCommentsClose CommentsPermalink





‘(2) the Secretary agrees to pay, for each year of such service, not more than $35,000 of the principal and interest of the undergraduate or graduate educational loans of the individual.CommentsClose CommentsPermalink





‘(c) Service Requirement- A contract entered into under this section shall allow the individual receiving the loan repayment to satisfy the service requirement described in subsection (a)(1) through employment in a solo or group practice, a clinic, a public or private nonprofit hospital, or any other appropriate health care entity.CommentsClose CommentsPermalink





‘(d) Application of Certain Provisions- The provisions of subpart III of part D shall, except as inconsistent with this section, apply to the program established in subsection (a) in the same manner and to the same extent as such provisions apply to the National Health Service Corps Scholarship Program established in such subpart.CommentsClose CommentsPermalink





‘(e) Definition- In this section, the term ‘eligible individual’ means--CommentsClose CommentsPermalink





‘(1) a physician in the field of obstetrics and gynecology; orCommentsClose CommentsPermalink





‘(2) a certified nurse midwife.CommentsClose CommentsPermalink

‘SEC. 340L. REPORTS.

‘Not later than 18 months after the date of enactment of this section, and annually thereafter, the Secretary shall submit to Congress a report that describes the programs carried out under this subpart, including statements concerning--CommentsClose CommentsPermalink





‘(1) the number of enrollees, scholarships, loan repayments, and grant recipients;CommentsClose CommentsPermalink





‘(2) the number of graduates;CommentsClose CommentsPermalink





‘(3) the amount of scholarship payments and loan repayments made;CommentsClose CommentsPermalink





‘(4) which educational institution the recipients attended;CommentsClose CommentsPermalink





‘(5) the number and placement location of the scholarship and loan repayment recipients at health care facilities with a critical shortage of primary care physicians;CommentsClose CommentsPermalink





‘(6) the default rate and actions required;CommentsClose CommentsPermalink





‘(7) the amount of outstanding default funds of both the scholarship and loan repayment programs;CommentsClose CommentsPermalink





‘(8) to the extent that it can be determined, the reason for the default;CommentsClose CommentsPermalink





‘(9) the demographics of the individuals participating in the scholarship and loan repayment programs;CommentsClose CommentsPermalink





‘(10) the justification for the allocation of funds between the scholarship and loan repayment programs; andCommentsClose CommentsPermalink





‘(11) an evaluation of the overall costs and benefits of the programs.CommentsClose CommentsPermalink

‘SEC. 340M. AUTHORIZATION OF APPROPRIATIONS.

‘To carry out sections 340I, 340J, and 340K there are authorized to be appropriated $55,000,000 for fiscal year 2010, $90,000,000 for fiscal year 2011, and $125,000,000 for fiscal year 2012, to be used solely for scholarships and loan repayment awards for primary care physicians and primary care providers.’.CommentsClose CommentsPermalink

SEC. 103. DEFERMENT OF LOANS DURING RESIDENCY AND INTERNSHIPS.

(a) Loan Requirements- Section 427(a)(2)(C)(i) of the Higher Education Act of 1965 (20 U.S.C. 1077(a)(2)(C)(i)) is amended by inserting ‘unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)’ after ‘residency program’.CommentsClose CommentsPermalink





(b) FFEL Loans- Section 428(b)(1)(M)(i) of the Higher Education Act of 1965 (20 U.S.C. 1078(b)(1)(M)(i)) is amended by inserting ‘unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)’ after ‘residency program’.CommentsClose CommentsPermalink





(c) Federal Direct Loans- Section 455(f)(2)(A) of the Higher Education Act of 1965 (20 U.S.C. 1087e(f)(2)(A)) is amended by inserting ‘unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)’ after ‘residency program’.CommentsClose CommentsPermalink





(d) Federal Perkins Loans- Section 464(c)(2)(A)(i) of the Higher Education Act of 1965 (20 U.S.C. 1087dd(c)(2)(A)(i)) is amended by inserting ‘unless the medical internship or residency program is in a primary care field (as defined in section 3(a)(5) of the Preserving Patient Access to Primary Care Act of 2009)’ after ‘residency program’.CommentsClose CommentsPermalink

SEC. 104. EDUCATING MEDICAL STUDENTS ABOUT PRIMARY CARE CAREERS.

Part C of title VII of the Public Health Service Act (42 U.S.C. 293k) is amended by adding at the end the following:CommentsClose CommentsPermalink

‘SEC. 749. EDUCATING MEDICAL STUDENTS ABOUT PRIMARY CARE CAREERS.

‘(a) In General- The Secretary shall award grants to eligible State and local government entities for the development of informational materials that promote careers in primary care by highlighting the advantages and rewards of primary care, and that encourage medical students, particularly students from disadvantaged backgrounds, to become primary care physicians.CommentsClose CommentsPermalink





‘(b) Announcement- The grants described in subsection (a) shall be announced through a publication in the Federal Register and through appropriate media outlets in a manner intended to reach medical education institutions, associations, physician groups, and others who communicate with medical students.CommentsClose CommentsPermalink





‘(c) Eligibility- To be eligible to receive a grant under this section an entity shall--CommentsClose CommentsPermalink





‘(1) be a State or local entity; andCommentsClose CommentsPermalink





‘(2) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.CommentsClose CommentsPermalink





‘(d) Use of Funds-CommentsClose CommentsPermalink





‘(1) IN GENERAL- An entity shall use amounts received under a grant under this section to support State and local campaigns through appropriate media outlets to promote careers in primary care and to encourage individuals from disadvantaged backgrounds to enter and pursue careers in primary care.CommentsClose CommentsPermalink





‘(2) SPECIFIC USES- In carrying out activities under paragraph (1), an entity shall use grants funds to develop informational materials in a manner intended to reach as wide and diverse an audience of medical students as possible, in order to--CommentsClose CommentsPermalink





‘(A) advertise and promote careers in primary care;CommentsClose CommentsPermalink





‘(B) promote primary care medical education programs;CommentsClose CommentsPermalink





‘(C) inform the public of financial assistance regarding such education programs;CommentsClose CommentsPermalink





‘(D) highlight individuals in the community who are practicing primary care physicians; orCommentsClose CommentsPermalink





‘(E) provide any other information to recruit individuals for careers in primary care.CommentsClose CommentsPermalink





‘(e) Limitation- An entity shall not use amounts received under a grant under this section to advertise particular employment opportunities.CommentsClose CommentsPermalink





‘(f) Authorization of Appropriations- There is authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2010 through 2013.’.CommentsClose CommentsPermalink

SEC. 105. TRAINING IN A FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, GENERAL GERIATRICS, GENERAL PEDIATRICS, PHYSICIAN ASSISTANCE, GENERAL DENTISTRY, AND PEDIATRIC DENTISTRY.

Section 747(e) of the Public Health Service Act (42 U.S.C. 293k) is amended by striking paragraph (1) and inserting the following:CommentsClose CommentsPermalink





‘(1) AUTHORIZATION OF APPROPRIATIONS- For the purpose of carrying out this section, there is authorized to be appropriated $198,000,000 for each of fiscal years 2010 through 2012.’.CommentsClose CommentsPermalink

SEC. 106. INCREASED FUNDING FOR NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS.

(a) In General- There is authorized to be appropriated $332,000,000 for the period of fiscal years 2010 through 2012 for the purpose of carrying out subpart III of part D of title III of the Public Health Service Act (42 U.S.C. 254l et seq.). Such authorization of appropriations is in addition to the authorization of appropriations in section 338H of such Act (42 U.S.C. 254q) and any other authorization of appropriations for such purpose.CommentsClose CommentsPermalink





(b) Allocation- Of the amounts appropriated under subsection (a) for the period of fiscal years 2010 through 2012, the Secretary shall obligate $96,000,000 for the purpose of providing contracts for scholarships and loan repayments to individuals who--CommentsClose CommentsPermalink





(1) are primary care physicians or primary care providers; andCommentsClose CommentsPermalink





(2) have not previously received a scholarship or loan repayment under subpart III of part D of title III of the Public Health Service Act (42 U.S.C. 254l et seq.).CommentsClose CommentsPermalink

TITLE II--MEDICAID RELATED PROVISIONSCommentsClose CommentsPermalink

SEC. 201. TRANSFORMATION GRANTS TO SUPPORT PATIENT CENTERED MEDICAL HOMES UNDER MEDICAID AND CHIP.

(a) In General- Section 1903(z) of the Social Security Act (42 U.S.C. 1396b(z)) is amended--CommentsClose CommentsPermalink





(1) in paragraph (2), by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(G) Methods for improving the effectiveness and efficiency of medical assistance provided under this title and child health assistance 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 Preserving Patient Access to Primary Care Act of 2009 for medical practices to qualify as patient centered medical homes (as defined in paragraph (1) of such section).’; andCommentsClose CommentsPermalink





(2) in paragraph (4)--CommentsClose CommentsPermalink





(A) in subparagraph (A)--CommentsClose CommentsPermalink





(i) in clause (i), by striking ‘and’ at the end;CommentsClose CommentsPermalink





(ii) in clause (ii), by striking the period at the end and inserting ‘; and’; andCommentsClose CommentsPermalink





(iii) by inserting after clause (ii), the following new clause:CommentsClose CommentsPermalink





‘(iii) $25,000,000 for each of fiscal years 2010, 2011, and 2012.’; andCommentsClose CommentsPermalink





(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 2010, 2011, and 2012 shall be allocated among States that design programs to adopt the innovative methods described in paragraph (2)(G), with preference given to States that design programs involving multipayers (including under title XVIII and private health plans) test projects for implementation of the elements necessary to be recognized as a patient centered medical home practice under the National Committee for Quality Assurance Physicians Practice Connection--PCMH module (or any other equivalent process, as determined by the Secretary).’.CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by this section take effect on October 1, 2010.CommentsClose CommentsPermalink

TITLE III--MEDICARE PROVISIONSCommentsClose CommentsPermalink

Subtitle A--Primary CareCommentsClose CommentsPermalink

SEC. 301. REFORMING PAYMENT SYSTEMS UNDER MEDICARE TO SUPPORT PRIMARY CARE.

(a) Increasing Budget Neutrality Limits Under the Physician Fee Schedule To Account for Anticipated Savings Resulting From Payments for Certain Services and the Coordination of Beneficiary Care- Section 1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is amended--CommentsClose CommentsPermalink





(1) in clause (ii)(II), by striking ‘(iv) and (v)’ and inserting ‘(iv), (v), and (vii)’; andCommentsClose CommentsPermalink





(2) by adding at the end the following new clause:CommentsClose CommentsPermalink





‘(vii) INCREASE IN LIMITATION TO ACCOUNT FOR CERTAIN ANTICIPATED SAVINGS-CommentsClose CommentsPermalink





‘(I) IN GENERAL- Effective for fee schedules established beginning with 2010, the Secretary shall increase the limitation on annual adjustments under clause (ii)(II) by an amount equal to the anticipated savings under parts A, B, and D (including any savings with respect to items and services for which payment is not made under this section) which are a result of payments for designated primary care services and comprehensive care coordination services under section 1834(m) and the coverage of patient centered medical home services under section 1861(s)(2)(FF) (as determined by the Secretary).CommentsClose CommentsPermalink





‘(II) MECHANISM TO DETERMINE APPLICATION OF INCREASE- The Secretary shall establish a mechanism for determining which relative value units established under this paragraph for physicians’ services shall be subject to an adjustment under clause (ii)(I) as a result of the increase under subclause (I).CommentsClose CommentsPermalink





‘(III) ADDITIONAL FUNDING AS DETERMINED NECESSARY BY THE SECRETARY- In addition to any funding that may be made available as a result of an increase in the limitation on annual adjustments under subclause (I), there shall also be available to the Secretary, for purposes of making payments under this title for new services and capabilities to improve care provided to individuals under this title and to generate efficiencies under this title, such additional funds as the Secretary determines are necessary.’.CommentsClose CommentsPermalink





(b) Separate Medicare Payment for Designated Primary Care Services and Comprehensive Care Coordination Services-CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(n) Payment for Designated Primary Care Services and Comprehensive Care Coordination Services-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall pay for designated primary care services and comprehensive care coordination services furnished to an individual enrolled under this part.CommentsClose CommentsPermalink





‘(2) PAYMENT AMOUNT- The Secretary shall determine the amount of payment for designated primary care services and comprehensive care coordination services under this subsection.CommentsClose CommentsPermalink





‘(3) DOCUMENTATION REQUIREMENTS- The Secretary shall propose appropriate documentation requirements to justify payments for designated primary care services and comprehensive care coordination services under this subsection.CommentsClose CommentsPermalink





‘(4) DEFINITIONS-CommentsClose CommentsPermalink





‘(A) COMPREHENSIVE CARE COORDINATION SERVICES- The term ‘comprehensive care coordination services’ means care coordination services with procedure codes established by the Secretary (as appropriate) which are furnished to an individual enrolled under this part by a primary care provider or principal care physician.CommentsClose CommentsPermalink





‘(B) DESIGNATED PRIMARY CARE SERVICES- The term ‘designated primary care service’ means a service which the Secretary determines has a procedure code which involves a clinical interaction with an individual enrolled under this part that is inherent to care coordination, including interactions outside of a face-to-face encounter. Such term includes the following:CommentsClose CommentsPermalink





‘(i) Care plan oversight.CommentsClose CommentsPermalink





‘(ii) Evaluation and management provided by phone.CommentsClose CommentsPermalink





‘(iii) Evaluation and management provided using internet resources.CommentsClose CommentsPermalink





‘(iv) Collection and review of physiologic data, such as from a remote monitoring device.CommentsClose CommentsPermalink





‘(v) Education and training for patient self management.CommentsClose CommentsPermalink





‘(vi) Anticoagulation management services.CommentsClose CommentsPermalink





‘(vii) Any other service determined appropriate by the Secretary.’.CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendment made by this section shall apply to items and services furnished on or after January 1, 2010.CommentsClose CommentsPermalink

SEC. 302. COVERAGE OF PATIENT CENTERED MEDICAL HOME SERVICES.

(a) In General- Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended--CommentsClose CommentsPermalink





(1) in subparagraph (DD), by striking ‘and’ at the end;CommentsClose CommentsPermalink





(2) in subparagraph (EE), by inserting ‘and’ at the end; andCommentsClose CommentsPermalink





(3) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(FF) patient centered medical home services (as defined in subsection (hhh)(1));’.CommentsClose CommentsPermalink





(b) Definition of Patient Centered Medical Home Services- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink

‘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.CommentsClose CommentsPermalink





‘(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 Primary Care Act of 2009).’.CommentsClose CommentsPermalink





(c) Monthly Fee for Patient Centered Medical Home Services- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(p) Monthly Fee for Patient Centered Medical Home Services-CommentsClose CommentsPermalink





‘(1) MONTHLY FEE-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Not later than January 1, 2012, the Secretary shall establish a payment methodology for patient centered medical home services (as defined in paragraph (1) of section 1861(hhh)). Under such payment methodology, the Secretary shall pay qualified patient 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 home. Such fee shall be paid on a prospective basis.CommentsClose CommentsPermalink





‘(B) CONSIDERATIONS- The Secretary shall take into account the results of the Medicare medical home demonstration project under section 204 of the Medicare Improvement and Extension Act of 2006 (42 U.S.C. 1395b-1 note; division B of Public Law 109-432) in establishing the payment methodology under subparagraph (A).CommentsClose CommentsPermalink





‘(2) AMOUNT OF PAYMENT-CommentsClose CommentsPermalink





‘(A) CONSIDERATIONS- In determining the amount of such fee, subject to paragraph (3), the Secretary shall consider the following:CommentsClose CommentsPermalink





‘(i) The clinical work and practice expenses involved in providing care coordination services consistent with the patient centered medical home model (such as providing increased access, care coordination, disease population management, and education) for which payment is not made under this section as of the date of enactment of this subsection.CommentsClose CommentsPermalink





‘(ii) Ensuring that the amount of payment is sufficient to support the acquisition, use, and maintenance of clinical information systems which--CommentsClose CommentsPermalink





‘(I) are needed by a qualified patient centered medical home; andCommentsClose CommentsPermalink





‘(II) have been shown to facilitate improved outcomes through care coordination.CommentsClose CommentsPermalink





‘(iii) The establishment of a tiered monthly care management fee that provides for a range of payment depending on how advanced the capabilities of a qualified patient centered medical home are in having the information systems needed to support care coordination.CommentsClose CommentsPermalink





‘(B) RISK-ADJUSTMENT- The Secretary shall use appropriate risk-adjustment in determining the amount of the monthly fee under this paragraph.CommentsClose CommentsPermalink





‘(3) FUNDING-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall determine the aggregate estimated savings for a calendar year as a result of the implementation of this subsection on reducing preventable hospital admissions, duplicate testing, medication errors and drug interactions, and other savings under this part and part A (including any savings with respect to items and services for which payment is not made under this section).CommentsClose CommentsPermalink





‘(B) FUNDING- Subject to subparagraph (C), the aggregate amount available for payment of the monthly fee under this subsection during a calendar year shall be equal to the aggregate estimated savings (as determined under subparagraph (A)) for the calendar year (as determined by the Secretary).CommentsClose CommentsPermalink





‘(C) ADDITIONAL FUNDING- In the case where the amount of the aggregate actual savings during the preceding 3 years exceeds the amount of the aggregate estimated savings (as determined under subparagraph (A)) during such period, the aggregate amount available for payment of the monthly fee under this subsection during the calendar year (as determined under subparagraph (B)) shall be increased by the amount of such excess.CommentsClose CommentsPermalink





‘(D) ADDITIONAL FUNDING AS DETERMINED NECESSARY BY THE SECRETARY- In addition to any funding made available under subparagraphs (B) and (C), there shall also be available to the Secretary, for purposes of effectively implementing this subsection, such additional funds as the Secretary determines are necessary.CommentsClose CommentsPermalink





‘(4) PERFORMANCE-BASED BONUS PAYMENTS- The Secretary shall establish a process for paying a performance-based bonus to qualified patient centered medical homes which meet or achieve substantial improvements in performance (as specified under clinical, patient satisfaction, and efficiency benchmarks established by the Secretary). Such bonus shall be in an amount determined appropriate by the Secretary.CommentsClose CommentsPermalink





‘(5) NO EFFECT ON PAYMENTS FOR EVALUATION AND MANAGEMENT SERVICES- The monthly fee under this subsection shall have no effect on the amount of payment for evaluation and management services under this title.’.CommentsClose CommentsPermalink





(d) Coinsurance- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--CommentsClose CommentsPermalink





(1) by striking ‘and’ before ‘(W)’; andCommentsClose CommentsPermalink





(2) by inserting before the semicolon at the end the following: ‘, and (X) with respect to patient centered medical home services (as defined in section 1861(hhh)(1)), the amount paid shall be (i) in the case of such services which are physicians’ services, the amount determined under subparagraph (N), and (ii) in the case of all other such services, 80 percent of the lesser of the actual charge for the service or the amount determined under a fee schedule established by the Secretary for purposes of this subparagraph’.CommentsClose CommentsPermalink





(e) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2012.CommentsClose CommentsPermalink

SEC. 303. MEDICARE PRIMARY CARE PAYMENT EQUITY AND ACCESS PROVISION.

(a) In General- Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by section 302(c), is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(q) Primary Care Payment Equity and Access-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Not later than January 1, 2010, the Secretary shall develop a methodology, in consultation with primary care physician organizations and primary care provider organizations, the Medicare Payment Advisory Commission, and other experts, to increase payments under this section for designated evaluation and management services provided by primary care physicians, primary care providers, and principal care providers through 1 or more of the following:CommentsClose CommentsPermalink





‘(A) A service-specific modifier to the relative value units established for such services.CommentsClose CommentsPermalink





‘(B) Service-specific bonus payments.CommentsClose CommentsPermalink





‘(C) Any other methodology determined appropriate by the Secretary.CommentsClose CommentsPermalink





‘(2) INCLUSION OF PROPOSED CRITERIA- The methodology developed under paragraph (1) shall include proposed criteria for providers to qualify for such increased payments, including consideration of--CommentsClose CommentsPermalink





‘(A) the type of service being rendered;CommentsClose CommentsPermalink





‘(B) the specialty of the provider providing the service; andCommentsClose CommentsPermalink





‘(C) demonstration by the provider of voluntary participation in programs to improve quality, such as participation in the Physician Quality Reporting Initiative (as determined by the Secretary) or practice-level qualification as a patient centered medical home.CommentsClose CommentsPermalink





‘(3) FUNDING-CommentsClose CommentsPermalink





‘(A) DETERMINATION- The Secretary shall determine the aggregate estimated savings for a calendar year as a result of such increased payments on reducing preventable hospital admissions, duplicate testing, medication errors and drug interactions, Intensive Care Unit admissions, per capita health care expenditures, and other savings under this part and part A (including any savings with respect to items and services for which payment is not made under this section).CommentsClose CommentsPermalink





‘(B) FUNDING- The aggregate amount available for such increased payments during a calendar year shall be equal to the aggregate estimated savings (as determined under subparagraph (A)) for the calendar year (as determined by the Secretary).CommentsClose CommentsPermalink





‘(C) ADDITIONAL FUNDING AS DETERMINED NECESSARY BY THE SECRETARY- In addition to any funding made available under subparagraph (B), there shall also be available to the Secretary, for purposes of effectively implementing this subsection, such additional funds as the Secretary determines are necessary.’.CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by this section shall apply to services furnished on or after January 1, 2010.CommentsClose CommentsPermalink

SEC. 304. ADDITIONAL INCENTIVE PAYMENT PROGRAM FOR PRIMARY CARE SERVICES FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.

(a) In General- Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(x) Additional Incentive Payments for Primary Care Services Furnished in Health Professional Shortage Areas-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of primary care services furnished on or after January 1, 2010, by a primary care physician or primary care provider in an area that is designated (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area as identified by the Secretary prior to the beginning of the year involved, in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service under this part.CommentsClose CommentsPermalink





‘(2) DEFINITIONS- In this subsection:CommentsClose CommentsPermalink





‘(A) PRIMARY CARE PHYSICIAN; PRIMARY CARE PROVIDER- The terms ‘primary care physician’ and ‘primary care provider’ have the meaning given such terms in paragraphs (6) and (7), respectively, of section 3(a) of the Preserving Patient Access to Primary Care Act of 2009.CommentsClose CommentsPermalink





‘(B) PRIMARY CARE SERVICES- The term ‘primary care services’ means procedure codes for services in the category of the Healthcare Common Procedure Coding System, as established by the Secretary under section 1848(c)(5) (as of December 31, 2008, and as subsequently modified by the Secretary) consisting of evaluation and management services, but limited to such procedure codes in the category of office or other outpatient services, and consisting of subcategories of such procedure codes for services for both new and established patients.CommentsClose CommentsPermalink





‘(3) JUDICIAL REVIEW- There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the identification of primary care physicians, primary care providers, or primary care services under this subsection.’.CommentsClose CommentsPermalink





(b) Conforming Amendment- Section 1834(g)(2)(B) of the Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by adding at the end the following sentence: ‘Section 1833(x) shall not be taken into account in determining the amounts that would otherwise be paid pursuant to the preceding sentence.’.CommentsClose CommentsPermalink

SEC. 305. PERMANENT EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is amended by striking ‘and before January 1, 2010,’.CommentsClose CommentsPermalink

SEC. 306. PERMANENT EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR PHYSICIAN SCARCITY AREAS.

Section 1833(u) of the Social Security Act (42 U.S.C. 1395l(u)) is amended--CommentsClose CommentsPermalink





(1) in paragraph (1)--CommentsClose CommentsPermalink





(A) by inserting ‘or on or after July 1, 2009’ after ‘before July 1, 2008’; andCommentsClose CommentsPermalink





(B) by inserting ‘(or, in the case of services furnished on or after July 1, 2009, 10 percent)’ after ‘5 percent’; andCommentsClose CommentsPermalink





(2) in paragraph (4)(D), by striking ‘before July 1, 2008’ and inserting ‘before January 1, 2010’.CommentsClose CommentsPermalink

SEC. 307. HHS STUDY AND REPORT ON THE PROCESS FOR DETERMINING RELATIVE VALUE UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

(a) Study- The Secretary shall conduct a study on the process used by the Secretary for determining relative value under the Medicare physician fee schedule under section 1848(c) of the Social Security Act (42 U.S.C. 1395w-4(c)). Such study shall include an analysis of the following:CommentsClose CommentsPermalink





(1)(A) Whether the existing process includes equitable representation of primary care physicians (as defined in section 3(a)(6)); andCommentsClose CommentsPermalink





(B) any changes that may be necessary to ensure such equitable representation.CommentsClose CommentsPermalink





(2)(A) Whether the existing process provides the Secretary with expert and impartial input from physicians in medical specialties that provide primary care to patients with multiple chronic diseases, the fastest growing part of the Medicare population; andCommentsClose CommentsPermalink





(B) any changes that may be necessary to ensure such input.CommentsClose CommentsPermalink





(3)(A) Whether the existing process includes equitable representation of physician medical specialties in proportion to their relative contributions toward caring for Medicare beneficiaries, as determined by the percentage of Medicare billings per specialty, percentage of Medicare encounters by specialty, or such other measures of relative contributions to patient care as determined by the Secretary; andCommentsClose CommentsPermalink





(B) any changes that may be necessary to reflect such equitable representation.CommentsClose CommentsPermalink





(4)(A) Whether the existing process, including the application of budget neutrality rules, unfairly disadvantages primary care physicians, primary care providers, or other physicians who principally provide evaluation and management services; andCommentsClose CommentsPermalink





(B) any changes that may be necessary to eliminate such disadvantages.CommentsClose CommentsPermalink





(b) Report- Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink

Subtitle B--Preventive ServicesCommentsClose CommentsPermalink

SEC. 311. ELIMINATING TIME RESTRICTION FOR INITIAL PREVENTIVE PHYSICAL EXAMINATION.

(a) In General- Section 1862(a)(1)(K) of the Social Security Act (42 U.S.C. 1395y(a)(1)(K)) is amended by striking ‘more than’ and all that follows before the comma at the end and inserting ‘more than one time during the lifetime of the individual’.CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2010.CommentsClose CommentsPermalink

SEC. 312. ELIMINATION OF COST-SHARING FOR PREVENTIVE BENEFITS UNDER THE MEDICARE PROGRAM.

(a) Definition of Preventive Services- Section 1861(ddd) of the Social Security Act (42 U.S.C. 1395w(dd)) is amended--CommentsClose CommentsPermalink





(1) in the heading, by inserting ‘; Preventive Services’ after ‘Services’;CommentsClose CommentsPermalink





(2) in paragraph (1), by striking ‘not otherwise described in this title’ and inserting ‘not described in subparagraphs (A) through (N) of paragraph (3)’; andCommentsClose CommentsPermalink





(3) by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(3) The term ‘preventive services’ means the following:CommentsClose CommentsPermalink





‘(A) Prostate cancer screening tests (as defined in subsection (oo)).CommentsClose CommentsPermalink





‘(B) Colorectal cancer screening tests (as defined in subsection (pp)).CommentsClose CommentsPermalink





‘(C) Diabetes outpatient self-management training services (as defined in subsection (qq)).CommentsClose CommentsPermalink





‘(D) Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)).CommentsClose CommentsPermalink





‘(E) Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)).CommentsClose CommentsPermalink





‘(F) An initial preventive physical examination (as defined in subsection (ww)).CommentsClose CommentsPermalink





‘(G) Cardiovascular screening blood tests (as defined in subsection (xx)(1)).CommentsClose CommentsPermalink





‘(H) Diabetes screening tests (as defined in subsection (yy)).CommentsClose CommentsPermalink





‘(I) Ultrasound screening for abdominal aortic aneurysm for certain individuals (as described in subsection (s)(2)(AA)).CommentsClose CommentsPermalink





‘(J) Pneumococcal and influenza vaccine and their administration (as described in subsection (s)(10)(A)).CommentsClose CommentsPermalink





‘(K) Hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)).CommentsClose CommentsPermalink





‘(L) Screening mammography (as defined in subsection (jj)).CommentsClose CommentsPermalink





‘(M) Screening pap smear and screening pelvic exam (as described in subsection (s)(14)).CommentsClose CommentsPermalink





‘(N) Bone mass measurement (as defined in subsection (rr)).CommentsClose CommentsPermalink





‘(O) Additional preventive services (as determined under paragraph (1)).’.CommentsClose CommentsPermalink





(b) Coinsurance-CommentsClose CommentsPermalink





(1) GENERAL APPLICATION-CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 302, is amended--CommentsClose CommentsPermalink





(i) in subparagraph (T), by striking ‘80 percent’ and inserting ‘100 percent’;CommentsClose CommentsPermalink





(ii) in subparagraph (W), by striking ‘80 percent’ and inserting ‘100 percent’;CommentsClose CommentsPermalink





(iii) by striking ‘and’ before ‘(X)’; andCommentsClose CommentsPermalink





(iv) by inserting before the semicolon at the end the following: ‘, and (Y) with respect to preventive services described in subparagraphs (A) through (O) of section 1861(ddd)(3), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the fee schedule that applies to such services under this part’.CommentsClose CommentsPermalink





(2) ELIMINATION OF COINSURANCE FOR SCREENING SIGMOIDOSCOPIES AND COLONOSCOPIES- Section 1834(d) of the Social Security Act (42 U.S.C. 1395m(d)) is amended--CommentsClose CommentsPermalink





(A) in paragraph (2)--CommentsClose CommentsPermalink





(i) in subparagraph (A), by inserting ‘, except that payment for such tests under such section shall be 100 percent of the payment determined under such section for such tests’ before the period at the end; andCommentsClose CommentsPermalink





(ii) in subparagraph (C)--CommentsClose CommentsPermalink





(I) by striking clause (ii); andCommentsClose CommentsPermalink





(II) in clause (i)--CommentsClose CommentsPermalink

(aa) by striking ‘(i) IN GENERAL- Notwithstanding’ and inserting ‘Notwithstanding’;CommentsClose CommentsPermalink

(bb) by redesignating subclauses (I) and (II) as clauses (i) and (ii), respectively, and moving such clauses 2 ems to the left; andCommentsClose CommentsPermalink

(cc) in the flush matter following clause (ii), as so redesignated, by inserting ‘100 percent of’ after ‘based on’; andCommentsClose CommentsPermalink

(B) in paragraph (3)--CommentsClose CommentsPermalink





(i) in subparagraph (A), by inserting ‘, except that payment for such tests under such section shall be 100 percent of the payment determined under such section for such tests’ before the period at the end; andCommentsClose CommentsPermalink





(ii) in subparagraph (C)--CommentsClose CommentsPermalink





(I) by striking clause (ii); andCommentsClose CommentsPermalink





(II) in clause (i)--CommentsClose CommentsPermalink

(aa) by striking ‘(i) IN GENERAL- Notwithstanding’ and inserting ‘Notwithstanding’; andCommentsClose CommentsPermalink

(bb) by inserting ‘100 percent of’ after ‘based on’.CommentsClose CommentsPermalink

(3) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS-CommentsClose CommentsPermalink





(A) EXCLUSION FROM OPD FEE SCHEDULE- Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking ‘and diagnostic mammography’ and inserting ‘, diagnostic mammography, and preventive services (as defined in section 1861(ddd)(3))’.CommentsClose CommentsPermalink





(B) CONFORMING AMENDMENTS- Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended--CommentsClose CommentsPermalink





(i) in subparagraph (F), by striking ‘and’ after the semicolon at the end;CommentsClose CommentsPermalink





(ii) in subparagraph (G)(ii), by adding ‘and’ at the end; andCommentsClose CommentsPermalink





(iii) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(H) with respect to preventive services (as defined in section 1861(ddd)(3)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(W) or (1)(X), as applicable;’.CommentsClose CommentsPermalink





(c) Waiver of Application of Deductible- The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended--CommentsClose CommentsPermalink





(1) in clause (1), by striking ‘items and services described in section 1861(s)(10)(A)’ and inserting ‘preventive services (as defined in section 1861(ddd)(3))’;CommentsClose CommentsPermalink





(2) by inserting ‘and’ before ‘(4)’; andCommentsClose CommentsPermalink





(3) by striking ‘, (5)’ and all that follows up to the period at the end.CommentsClose CommentsPermalink

SEC. 313. HHS STUDY AND REPORT ON FACILITATING THE RECEIPT OF MEDICARE PREVENTIVE SERVICES BY MEDICARE BENEFICIARIES.

(a) Study- The Secretary, in consultation with provider organizations and other appropriate stakeholders, shall conduct a study on--CommentsClose CommentsPermalink





(1) ways to assist primary care physicians and primary care providers (as defined in section 3(a)) in--CommentsClose CommentsPermalink





(A) furnishing appropriate preventive services (as defined in section 1861(ddd)(3) of the Social Security Act, as added by section 312) to individuals enrolled under part B of title XVIII of such Act; andCommentsClose CommentsPermalink





(B) referring such individuals for other items and services furnished by other physicians and health care providers; andCommentsClose CommentsPermalink





(2) the advisability and feasability of making additional payments under the Medicare program to physicians and primary care providers for--CommentsClose CommentsPermalink





(A) the work involved in ensuring that such individuals receive appropriate preventive services furnished by other physicians and health care providers; andCommentsClose CommentsPermalink





(B) incorporating the resulting clinical information into the treatment plan for the individual.CommentsClose CommentsPermalink





(b) Report- Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink

Subtitle C--Other ProvisionsCommentsClose CommentsPermalink

SEC. 321. HHS STUDY AND REPORT ON IMPROVING THE ABILITY OF PHYSICIANS AND PRIMARY CARE PROVIDERS TO ASSIST MEDICARE BENEFICIARIES IN OBTAINING NEEDED PRESCRIPTIONS UNDER MEDICARE PART D.

(a) Study- The Secretary, in consultation with physician organizations and other appropriate stakeholders, shall conduct a study on the development and implementation of mechanisms to facilitate increased efficiency relating to the role of physicians and primary care providers in Medicare beneficiaries obtaining needed prescription drugs under the Medicare prescription drug program under part D of title XVIII of the Social Security Act. Such study shall include an analysis of ways to--CommentsClose CommentsPermalink





(1) improve the accessibility of formulary information;CommentsClose CommentsPermalink





(2) streamline the prior authorization, exception, and appeals processes, through, at a minimum, standardizing formats and allowing electronic exchange of information; andCommentsClose CommentsPermalink





(3) recognize the work of the physician and primary care provider involved in the prescribing process, especially work that may extend beyond the amount considered to be bundled into payment for evaluation and management services.CommentsClose CommentsPermalink





(b) Report- Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink

SEC. 322. HHS STUDY AND REPORT ON IMPROVED PATIENT CARE THROUGH INCREASED CAREGIVER AND PHYSICIAN INTERACTION.

(a) Study- The Secretary, in consultation with appropriate stakeholders, shall conduct a study on the development and implementation of mechanisms to promote and increase interaction between physicians or primary care providers and the families of Medicare beneficiaries, as well as other caregivers who support such beneficiaries, for the purpose of improving patient care under the Medicare program. Such study shall include an analysis of--CommentsClose CommentsPermalink





(1) ways to recognize the work of physicians and primary care providers involved in discussing clinical issues with caregivers that relate to the care of the beneficiary; andCommentsClose CommentsPermalink





(2) regulations under the Medicare program that are barriers to interactions between caregivers and physicians or primary care providers and how such regulations should be revised to eliminate such barriers.CommentsClose CommentsPermalink





(b) Report- Not later than 12 months after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink

SEC. 323. IMPROVED PATIENT CARE THROUGH EXPANDED SUPPORT FOR LIMITED ENGLISH PROFICIENCY (LEP) SERVICES.

(a) Additional Payments for Primary Care Physicians and Primary Care Providers- Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section 304, is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(y) Additional Payments for Providing Services to Individuals With Limited English Proficiency-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of primary care physicians and primary care providers’ services furnished on or after January 1, 2010, to an individual with limited English proficiency by a provider, in addition to the amount of payment that would otherwise be made for such services under this part, there shall also be paid an appropriate amount (as determined by the Secretary) in order to recognize the additional time involved in furnishing the service to such individual.CommentsClose CommentsPermalink





‘(2) JUDICIAL REVIEW- There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting the determination of the amount of additional payment under this subsection.’.CommentsClose CommentsPermalink





(b) National Clearinghouse- Not later than 180 days after the date of enactment of this Act, the Secretary shall establish a national clearinghouse to make available to the primary care physicians, primary care providers, patients, and States translated documents regarding patient care and education under the Medicare program, the Medicaid program, and the State Children’s Health Insurance Program under titles XVIII, XIX, and XXI, respectively, of the Social Security Act.CommentsClose CommentsPermalink





(c) Grants To Support Language Translation Services in Underserved Communities-CommentsClose CommentsPermalink





(1) AUTHORITY TO AWARD GRANTS- The Secretary shall award grants to support language translation services for primary care physicians and primary care providers in medically underserved areas (as defined in section 3(c)).CommentsClose CommentsPermalink





(2) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated to the Secretary to award grants under this subsection, such sums as are necessary for fiscal years beginning with fiscal year 2010.CommentsClose CommentsPermalink

SEC. 324. HHS STUDY AND REPORT ON USE OF REAL-TIME MEDICARE CLAIMS ADJUDICATION.

(a) Study- The Secretary shall conduct a study to assess the ability of the Medicare program under title XVIII of the Social Security Act to engage in real-time claims adjudication for items and services furnished to Medicare beneficiaries.CommentsClose CommentsPermalink





(b) Consultation- In conducting the study under subsection (a), the Secretary consult with stakeholders in the private sector, including stakeholders who are using or are testing real-time claims adjudication systems.CommentsClose CommentsPermalink





(c) Report- Not later than January 1, 2011, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.CommentsClose CommentsPermalink

SEC. 325. ONGOING ASSESSMENT BY MEDPAC OF THE IMPACT OF MEDICARE PAYMENTS ON PRIMARY CARE ACCESS AND EQUITY.

The Medicare Payment Advisory Commission, beginning in 2010 and in each of its subsequent annual reports to Congress on Medicare physician payment policies, shall provide an assessment of the impact of changes in Medicare payment policies in improving access to and equity of payments to primary care physicians and primary care providers. Such assessment shall include an assessment of the effectiveness, once implemented, of the Medicare payment-related reforms required by this Act to support primary care as well as any other payment changes that may be required by Congress to improve access to and equity of payments to primary care physicians and primary care providers.CommentsClose CommentsPermalink

SEC. 326. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.

(a) In General- Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended--CommentsClose CommentsPermalink





(1) in paragraph (4)(F)(i), by striking ‘paragraph (7)’ and inserting ‘paragraphs (7) and (8)’;CommentsClose CommentsPermalink





(2) in paragraph (4)(H)(i), by striking ‘paragraph (7)’ and inserting ‘paragraphs (7) and (8)’; andCommentsClose CommentsPermalink





(3) by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS-CommentsClose CommentsPermalink





‘(A) ADDITIONAL RESIDENCY POSITIONS-CommentsClose CommentsPermalink





‘(i) REDUCTION IN LIMIT BASED ON UNUSED POSITIONS-CommentsClose CommentsPermalink





‘(I) IN GENERAL- The Secretary shall reduce the otherwise applicable resident limit for a hospital that the Secretary determines had residency positions that were unused for all 5 of the most recent cost reporting periods ending prior to the date of enactment of this paragraph by an amount that is equal to the number of such unused residency positions.CommentsClose CommentsPermalink





‘(II) EXCEPTION FOR RURAL HOSPITALS AND CERTAIN OTHER HOSPITALS- This subparagraph shall not apply to a hospital--CommentsClose CommentsPermalink

‘(aa) located in a rural area (as defined in subsection (d)(2)(D)(ii));CommentsClose CommentsPermalink

‘(bb) that has participated in a voluntary reduction plan under paragraph (6); orCommentsClose CommentsPermalink

‘(cc) that has participated in a demonstration project approved as of October 31, 2003, under the authority of section 402 of Public Law 90-248.CommentsClose CommentsPermalink

‘(ii) NUMBER AVAILABLE FOR DISTRIBUTION- The number of additional residency positions available for distribution under subparagraph (B) shall be an amount that the Secretary determines would result in a 15 percent increase in the aggregate number of full-time equivalent residents in approved medical training programs (as determined based on the most recent cost reports available at the time of distribution). One-third of such number shall only be available for distribution to hospitals described in subclause (I) of subparagraph (B)(ii) under such subparagraph.CommentsClose CommentsPermalink





‘(B) DISTRIBUTION-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after the date of enactment of this paragraph. The aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to the number of additional residency positions available for distribution under subparagraph (A)(ii).CommentsClose CommentsPermalink





‘(ii) DISTRIBUTION TO HOSPITALS ALREADY OPERATING OVER RESIDENT LIMIT-CommentsClose CommentsPermalink





‘(I) IN GENERAL- Subject to subclause (II), in the case of a hospital in which the reference resident level of the hospital (as defined in clause (ii)) is greater than the otherwise applicable resident limit, the increase in the otherwise applicable resident limit under this subparagraph shall be an amount equal to the product of the total number of additional residency positions available for distribution under subparagraph (A)(ii) and the quotient of--CommentsClose CommentsPermalink

‘(aa) the number of resident positions by which the reference resident level of the hospital exceeds the otherwise applicable resident limit for the hospital; andCommentsClose CommentsPermalink

‘(bb) the number of resident positions by which the reference resident level of all such hospitals with respect to which an application is approved under this subparagraph exceeds the otherwise applicable resident limit for such hospitals.CommentsClose CommentsPermalink

‘(II) REQUIREMENTS- A hospital described in subclause (I)--CommentsClose CommentsPermalink

‘(aa) is not eligible for an increase in the otherwise applicable resident limit under this subparagraph unless the amount by which the reference resident level of the hospital exceeds the otherwise applicable resident limit is not less than 10 and the hospital trains at least 25 percent of the full-time equivalent residents of the hospital in primary care and general surgery (as of the date of enactment of this paragraph); andCommentsClose CommentsPermalink

‘(bb) shall continue to train at least 25 percent of the full-time equivalent residents of the hospital in primary care and general surgery for the 10-year period beginning on such date.CommentsClose CommentsPermalink

In the case where the Secretary determines that a hospital no longer meets the requirement of item (bb), the Secretary may reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this clause.CommentsClose CommentsPermalink





‘(III) CLARIFICATION REGARDING ELIGIBILITY FOR OTHER ADDITIONAL RESIDENCY POSITIONS- Nothing in this clause shall be construed as preventing a hospital described in subclause (I) from applying for additional residency positions under this paragraph that are not reserved for distribution under this clause.CommentsClose CommentsPermalink





‘(iii) REFERENCE RESIDENT LEVEL-CommentsClose CommentsPermalink





‘(I) IN GENERAL- Except as otherwise provided in subclause (II), the reference resident level specified in this clause for a hospital is the resident level for the most recent cost reporting period of the hospital ending on or before the date of enactment of this paragraph, for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary.CommentsClose CommentsPermalink





‘(II) USE OF MOST RECENT ACCOUNTING PERIOD TO RECOGNIZE EXPANSION OF EXISTING PROGRAM OR ESTABLISHMENT OF NEW PROGRAM- If a hospital submits a timely request to increase its resident level due to an expansion of an existing residency training program or the establishment of a new residency training program that is not reflected on the most recent cost report that has been settled (or, if not, submitted (subject to audit)), after audit and subject to the discretion of the Secretary, the reference resident level for such hospital is the resident level for the cost reporting period that includes the additional residents attributable to such expansion or establishment, as determined by the Secretary.CommentsClose CommentsPermalink





‘(C) CONSIDERATIONS IN REDISTRIBUTION- In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B) (other than an increase under subparagraph (B)(ii)), the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2010, made available under this paragraph, as determined by the Secretary.CommentsClose CommentsPermalink





‘(D) PRIORITY FOR CERTAIN AREAS- In determining for which hospitals the increase in the otherwise applicable resident limit is provided under subparagraph (B) (other than an increase under subparagraph (B)(ii)), the Secretary shall distribute the increase to hospitals based on the following criteria:CommentsClose CommentsPermalink





‘(i) The Secretary shall give preference to hospitals that submit applications for new primary care and general surgery residency positions. In the case of any increase based on such preference, a hospital shall ensure that--CommentsClose CommentsPermalink





‘(I) the position made available as a result of such increase remains a primary care or general surgery residency position for not less than 10 years after the date on which the position is filled; andCommentsClose CommentsPermalink





‘(II) the total number of primary care and general surgery residency positions in the hospital (determined based on the number of such positions as of the date of such increase, including any position added as a result of such increase) is not decreased during such 10-year period.CommentsClose CommentsPermalink





In the case where the Secretary determines that a hospital no longer meets the requirement of subclause (II), the Secretary may reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this paragraph.CommentsClose CommentsPermalink





‘(ii) The Secretary shall give preference to hospitals that emphasizes training in community health centers and other community-based clinical settings.CommentsClose CommentsPermalink





‘(iii) The Secretary shall give preference to hospitals in States that have more medical students than residency positions available (including a greater preference for those States with smaller resident-to-medical-student ratios). In determining the number of medical students in a State for purposes of the preceding sentence, the Secretary shall include planned students at medical schools which have provisional accreditation by the Liaison Committee on Medical Education or the American Osteopathic Association.CommentsClose CommentsPermalink





‘(iv) The Secretary shall give preference to hospitals in States that have low resident-to-population ratios (including a greater preference for those States with lower resident-to-population ratios).CommentsClose CommentsPermalink





‘(E) LIMITATION-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Except as provided in clause (ii), in no case may a hospital (other than a hospital described in subparagraph (B)(ii)(I), subject to the limitation under subparagraph (B)(ii)(III)) apply for more than 50 full-time equivalent additional residency positions under this paragraph.CommentsClose CommentsPermalink





‘(ii) INCREASE IN NUMBER OF ADDITIONAL POSITIONS AVAILABLE FOR DISTRIBUTION- The Secretary shall increase the number of full-time equivalent additional residency positions a hospital may apply for under this paragraph if the Secretary determines that the number of additional residency positions available for distribution under subparagraph (A)(ii) exceeds the number of such applications approved.CommentsClose CommentsPermalink





‘(F) APPLICATION OF PER RESIDENT AMOUNTS FOR PRIMARY CARE AND NONPRIMARY CARE- With respect to additional residency positions in a hospital attributable to the increase provided under this paragraph, the approved FTE resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital.CommentsClose CommentsPermalink





‘(G) DISTRIBUTION- The Secretary shall distribute the increase to hospitals under this paragraph not later than 2 years after the date of enactment of this paragraph.’.CommentsClose CommentsPermalink





(b) IME-CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, is amended--CommentsClose CommentsPermalink





(A) by striking ‘subsection (h)(7)’ and inserting ‘subsections (h)(7) and (h)(8)’; andCommentsClose CommentsPermalink





(B) by striking ‘it applies’ and inserting ‘they apply’.CommentsClose CommentsPermalink





(2) CONFORMING PROVISION- Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following clause:CommentsClose CommentsPermalink





‘(x) For discharges occurring on or after the date of enactment of this clause, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(8)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions.’.CommentsClose CommentsPermalink

SEC. 327. COUNTING RESIDENT TIME IN OUTPATIENT SETTINGS.

(a) D-GME- Section 1886(h)(4)(E) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(E)) is amended--CommentsClose CommentsPermalink





(1) by striking ‘under an approved medical residency training program’; andCommentsClose CommentsPermalink





(2) by striking ‘if the hospital incurs all, or substantially all, of the costs for the training program in that setting’ and inserting ‘if the hospital continues to incur the costs of the stipends and fringe benefits of the resident during the time the resident spends in that setting’.