S 973 ISCommentsClose CommentsPermalink

To amend title XVIII of the Social Security Act to provide for the distribution of additional residency positions, and for other purposes.CommentsClose CommentsPermalink

May 5, 2009CommentsClose CommentsPermalink

Mr. NELSON of Florida (for himself, Mr. REID, and Mr. SCHUMER) introduced the following bill; which was read twice and referred to the Committee on FinanceCommentsClose CommentsPermalink

To amend title XVIII of the Social Security Act to provide for the distribution of additional residency positions, 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.

This Act may be cited as the ‘Resident Physician Shortage Reduction Act of 2009’.CommentsClose CommentsPermalink

SEC. 2. 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 specified in clause (iii)) 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)), 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 emphasize 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. 3. COUNTING RESIDENT TIME IN OUTPATIENT SETTINGS.

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





(1) by striking ‘shall be counted and that all the time’ and inserting ‘shall be counted and that--CommentsClose CommentsPermalink





‘(i) effective for cost reporting periods beginning before July 1, 2009, all the time’;CommentsClose CommentsPermalink





(2) in clause (i), as inserted by paragraph (1), by striking the period at the end and inserting ‘; and’; andCommentsClose CommentsPermalink





(3) by inserting after clause (i), as so inserted, the following new clause:CommentsClose CommentsPermalink





‘(ii) effective for cost reporting periods beginning on or after July 1, 2009, all the time so spent by a resident shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, 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.’.CommentsClose CommentsPermalink





(b) IME- Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended--CommentsClose CommentsPermalink





(1) by striking ‘(iv) Effective for discharges occurring on or after October 1, 1997’ and inserting ‘(iv)(A) Effective for discharges occurring on or after October 1, 1997, and before July 1, 2009’; andCommentsClose CommentsPermalink





(2) by inserting after subparagraph (A), as inserted by paragraph (1), the following new subparagraph:CommentsClose CommentsPermalink





‘(B) Effective for discharges occurring on or after July 1, 2009, all the time spent by an intern or resident in patient care activities at an entity in a nonhospital setting shall be counted towards the determination of full-time equivalency if the hospital continues to incur the costs of the stipends and fringe benefits of the intern or resident during the time the intern or resident spends in that setting.’.CommentsClose CommentsPermalink





(c) Application- The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. 1395ww(h)).CommentsClose CommentsPermalink

SEC. 4. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.

(a) GME- Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)), as amended by section 3, is amended--CommentsClose CommentsPermalink





(1) in paragraph (4)(E)--CommentsClose CommentsPermalink





(A) by designating the first sentence as a clause (i) with the heading ‘IN GENERAL’ and appropriate indentation and by striking ‘Such rules’ and inserting ‘Subject to clause (ii), such rules’; andCommentsClose CommentsPermalink





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





‘(ii) TREATMENT OF CERTAIN NONHOSPITAL AND DIDACTIC ACTIVITIES- Such rules shall provide that all time spent by an intern or resident in an approved medical residency training program in a nonhospital setting that is primarily engaged in furnishing patient care (as defined in paragraph (5)(K)) in non-patient care activities, such as didactic conferences and seminars, but not including research not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall be counted toward the determination of full-time equivalency.’;CommentsClose CommentsPermalink





(2) in paragraph (4), by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(I) In determining the hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program on vacation, sick leave, or other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the normal duration of the program shall be counted toward the determination of full-time equivalency.’; andCommentsClose CommentsPermalink





(3) in paragraph (5), by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(K) NONHOSPITAL SETTING THAT IS PRIMARILY ENGAGED IN FURNISHING PATIENT CARE- The term ‘nonhospital setting that is primarily engaged in furnishing patient care’ means a nonhospital setting in which the primary activity is the care and treatment of patients, as defined by the Secretary.’.CommentsClose CommentsPermalink





(b) IME Determinations- Section 1886(d)(5)(B) of such Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following new clause:CommentsClose CommentsPermalink





‘(x)(I) The provisions of subparagraph (I) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.CommentsClose CommentsPermalink





‘(II) In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary, that occurs in the hospital shall be counted toward the determination of full-time equivalency if the hospital--CommentsClose CommentsPermalink





‘(aa) is recognized as a subsection (d) hospital;CommentsClose CommentsPermalink





‘(bb) is recognized as a subsection (d) Puerto Rico hospital;CommentsClose CommentsPermalink





‘(cc) is reimbursed under a reimbursement system authorized under section 1814(b)(3); orCommentsClose CommentsPermalink





‘(dd) is a provider-based hospital outpatient department.CommentsClose CommentsPermalink





‘(III) In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in research activities that are not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall not be counted toward the determination of full-time equivalency.’.CommentsClose CommentsPermalink





(c) Effective Dates; Application-CommentsClose CommentsPermalink





(1) IN GENERAL- Except as otherwise provided, the Secretary of Health and Human Services shall implement the amendments made by this section in a manner so as to apply to cost reporting periods beginning on or after January 1, 1983.CommentsClose CommentsPermalink





(2) DIRECT GME- Section 1886(h)(4)(E)(ii) of the Social Security Act, as added by subsection (a)(1)(B), shall apply to cost reporting periods beginning on or after July 1, 2008.CommentsClose CommentsPermalink





(3) IME- Section 1886(d)(5)(B)(x)(III) of the Social Security Act, as added by subsection (b), shall apply to cost reporting periods beginning on or after October 1, 2001. Such section, as so added, shall not give rise to any inference on how the law in effect prior to such date should be interpreted.CommentsClose CommentsPermalink





(4) APPLICATION- The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act or for direct graduate medical education costs under section 1886(h) of such Act.CommentsClose CommentsPermalink

SEC. 5. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED AND ACQUIRED HOSPITALS.

(a) GME- Section 1886(h)(4)(H) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)) is amended by adding at the end the following new clauses:CommentsClose CommentsPermalink





‘(vi) REDISTRIBUTION OF RESIDENCY SLOTS AFTER A HOSPITAL CLOSES-CommentsClose CommentsPermalink





‘(I) IN GENERAL- Subject to the succeeding provisions of this clause, the Secretary shall, by regulation, establish a process under which, in the case where a hospital with an approved medical residency program closes on or after the date of enactment of the Balanced Budget Act of 1997, the Secretary shall increase the otherwise applicable resident limit under this paragraph for other hospitals in accordance with this clause.CommentsClose CommentsPermalink





‘(II) PRIORITY FOR HOSPITALS IN CERTAIN AREAS- Subject to the succeeding provisions of this clause, in determining for which hospitals the increase in the otherwise applicable resident limit is provided under such process, the Secretary shall distribute the increase to hospitals located in the following priority order (with preference given within each category to hospitals that are members of the same affiliated group (as defined by the Secretary under clause (ii)) as the closed hospital):CommentsClose CommentsPermalink

‘(aa) First, to hospitals located in the same core-based statistical area as, or a core-based statistical area contiguous to, the hospital that closed.CommentsClose CommentsPermalink

‘(bb) Second, to hospitals located in the same State as the hospital that closed.CommentsClose CommentsPermalink

‘(cc) Third, to hospitals located in the same region of the country as the hospital that closed.CommentsClose CommentsPermalink

‘(dd) Fourth, to all other hospitals.CommentsClose CommentsPermalink

‘(III) REQUIREMENT HOSPITAL LIKELY TO FILL POSITION WITHIN CERTAIN TIME PERIOD- The Secretary may only increase the otherwise applicable resident limit of a hospital under such process if the Secretary determines the hospital has demonstrated a likelihood of filling the positions made available under this clause within 3 years.CommentsClose CommentsPermalink





‘(IV) LIMITATION- The aggregate number of increases in the otherwise applicable resident limits for hospitals under this clause shall be equal to the number of resident positions in the approved medical residency programs that closed on or after the date described in subclause (I).CommentsClose CommentsPermalink





‘(vii) SPECIAL RULE FOR ACQUIRED HOSPITALS-CommentsClose CommentsPermalink





‘(I) IN GENERAL- In the case of a hospital that is acquired (through any mechanism) by another entity with the approval of a bankruptcy court, during a period determined by the Secretary (but not less than 3 years), the applicable resident limit of the acquired hospital shall, except as provided in subclause (II), be the applicable resident limit of the hospital that was acquired (as of the date immediately before the acquisition), without regard to whether the acquiring entity accepts assignment of the Medicare provider agreement of the hospital that was acquired, so long as the acquiring entity continues to operate the hospital that was acquired and to furnish services, medical residency programs, and volume of patients similar to the services, medical residency programs, and volume of patients of the hospital that was acquired (as determined by the Secretary) during such period.CommentsClose CommentsPermalink





‘(II) LIMITATION- Subclause (I) shall only apply in the case where an acquiring entity waives the right as a new provider under the program under this title to have the otherwise applicable resident limit of the acquired hospital re-established or increased.’.CommentsClose CommentsPermalink





(b) IME- Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended by section 3, is amended by striking ‘subsections (h)(7) and (h)(8)’ and inserting ‘subsections (h)(4)(H)(vi), (h)(4)(H)(vii), (h)(7), and (h)(8)’.CommentsClose CommentsPermalink





(c) Application- The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs under section 1886(h) of such Act (42 U.S.C. Section 1395ww(h)).CommentsClose CommentsPermalink





(d) No Effect on Temporary FTE Cap Adjustments- The amendments made by this section shall not effect any temporary adjustment to a hospital’s FTE cap under section 413.79(h) of title 42, Code of Federal Regulations (as in effect on the date of enactment of this Act).CommentsClose CommentsPermalink