,i #aacth ,,congress #ast ,session ,h4 ,r4 #abja ,,in ,,the ,,house ,,of ,,representatives ,march #ad1 #bjac ,mr4 ,schock 7for himself and ,ms4 ,schwartz7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committee on ,energy and ,commerce1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide for the distribution of additional residency positions1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,training ,tomorrow's ,doctors ,today ,act4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,sec4 #b4 ,distribution of additional residency positions4 ,sec4 #c4 ,additional rules relating to application of #c-year rolling average for redistributed residency positions4 ,sec4 #d4 ,rules for determining full-time equivalent residents4 ,sec4 #e4 ,treatment of hospitals with rotating residents4 ,sec4 #f4 ,aggregation rules relating to applying limitation on number of residents4 ,sec4 #g4 ,period of board eligibility for residents who change programs4 ,sec4 #h4 ,medicare indirect medical education performance adjustment4 ,sec4 #i4 ,increasing graduate medical education transparency4 ,sec4 #aj4 ,,gao studies and reports4 #b4 ,distribution of additional residency positions 7a7 ,,dgme ,section #ahhf7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77 is amended-- 7#a7 in paragraph 7#d77;,f77i71 by striking paragraphs 7#g7 and 7#h7 and inserting paragraphs 7#g71 7#h71 and 7#i72 7#b7 in paragraph 7#d77;,h77i71 by striking paragraphs 7#g7 and 7#h7 and inserting paragraphs 7#g71 7#h71 and 7#i72 7#c7 in paragraph 7#g77;,e71 by inserting paragraph 7#i71 after paragraph 7#h712 and 7#d7 by adding at the end the following new paragraph3 7#i7 ,distribution of additional residency positions 7,a7 ,additional residency positions 7i7 ,in general ,for each of fiscal years #bjad through #bjah 7and succeeding fiscal years if the ,secretary determines that there are additional residency positions available to distribute under clause 7iv77,,ii771 the ,secretary shall1 subject to clause 7ii7 and subparagraph 7,d71 increase the otherwise applicable resident limit for each qualifying hospital that submits a timely application under this subparagraph by such number as the ,secretary may approve for portions of cost reporting periods occurring on or after ,july #a of the fiscal year of the increase4 7ii7 ,number available for distribution ,for each such fiscal year1 the ,secretary shall determine the total number of additional residency positions available for distribution under clause 7i7 in accordance with the following3 7,i7 ,allocation to hospitals already operating over resident limit ,one-third of such number shall be available for distribution only to hospitals described in subparagraph 7,b74 7,,ii7 ,aggregate limitation ,except as provided in clause 7iv77,i71 the aggregate number of increases in the otherwise applicable resident limit under this subparagraph shall be equal to #c1jjj in each such year4 7iii7 ,process for distributing positions 7,i7 ,rounds of applications ,the ,secretary shall initiate #e separate rounds of applications for an increase under clause 7i71 #a round with respect to each of fiscal years #bjad through #bjah4 7,,ii7 ,number available ,in each of such rounds1 the aggregate number of positions available for distribution in the fiscal year under clause 7ii7 shall be distributed1 plus any additional positions available under clause 7iv74 7,,iii7 ,timing ,the ,secretary shall notify hospitals of the number of positions distributed to the hospital under this paragraph as a result of an increase in the otherwise applicable resident limit by ,january #a of the fiscal year of the increase4 ,such increase shall be effective for portions of cost reporting periods beginning on or after ,july #a of that fiscal year4 7iv7 ,positions not distributed during the fiscal year 7,i7 ,in general ,if the number of resident full-time equivalent positions distributed under this paragraph in a fiscal year is less than the aggregate number of positions available for distribution in the fiscal year 7as described in clause 7ii71 including after application of this subclause71 the difference between such number distributed and such number available for distribution shall be added to the aggregate number of positions available for distribution in the following fiscal year4 7,,ii7 ,exception if positions not distributed by end of fiscal year #bjah ,if the aggregate number of positions distributed under this paragraph during the #e-year period of fiscal years #bjad through #bjah is less than #ae1jjj1 the ,secretary shall1 in accordance with the provisions of clause 7ii7 and subparagraph 7,d7 and the considerations and priority described in subparagraph 7,c71 conduct an application and distribution process in each subsequent fiscal year until such time as the aggregate amount of positions distributed under this paragraph is equal to #ae1jjj4 7,b7 ,allocation of distribution for positions to hospitals already operating over resident limit 7i7 ,in general ,subject to clauses 7ii7 and 7iii71 in the case of a hospital in which the reference resident level of the hospital 7as specified in subparagraph 7,g77iii77 is greater than the otherwise applicable resident limit1 the increase in the otherwise applicable resident limit under subparagraph 7,a7 for a fiscal year described in such subparagraph shall be an amount equal to the product of the total number of additional residency positions available for distribution under subparagraph 7,a77ii77,i7 for such fiscal year and the quotient of-- 7,i7 the number of resident positions by which the reference resident level of the hospital exceeds the otherwise applicable resident limit for the hospital2 and 7,,ii7 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 paragraph exceeds the otherwise applicable resident limit for such hospitals4 7ii7 ,requirements ,a hospital described in clause 7i7-- 7,i7 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 #aj and the hospital trains at least #cj percent of the full-time equivalent residents of the hospital in primary care and general surgery 7as of the date of enactment of this paragraph72 and 7,,ii7 shall continue to train at least #cj percent of the full-time equivalent residents of the hospital in primary care and general surgery for the #e-year period beginning on such date4 ,in the case where the ,secretary determines that a hospital described in clause 7i7 no longer meets the requirement of subclause 7,,ii71 the ,secretary may reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this subparagraph4 7iii7 ,clarification regarding eligibility for other additional residency positions ,nothing in this subparagraph shall be construed as preventing a hospital described in clause 7i7 from applying for and receiving additional residency positions under this paragraph that are not reserved for distribution under this subparagraph4 7,c7 ,distribution of other positions ,for purposes of determining an increase in the otherwise applicable resident limit under subparagraph 7,a7 7other than such an increase described in subparagraph 7,b771 the following shall apply3 7i7 ,considerations in distribution ,in determining for which hospitals such an increase is provided under subparagraph 7,a71 the ,secretary shall take into account the demonstrated likelihood of the hospital filling the positions made available under this paragraph within the first #e cost reporting periods beginning after the date the increase would be effective1 as determined by the ,secretary4 7ii7 ,priority for certain hospitals ,subject to clause 7iii71 in determining for which hospitals such an increase is provided1 the ,secretary shall distribute the increase in the following priority order3 7,i7 ,first1 to hospitals with approved medical residency training programs affiliated with medical schools that have at least #dj percent of graduates matched in primary care residency program in the #e years prior4 7,,ii7 ,second1 to hospitals in ,states with 7aa7 new medical schools that received ,candidate ,school status from the ,liaison ,committee on ,medical ,education or that received ,pre-,accreditation status from the ,american ,osteopathic ,association ,commission on ,osteopathic ,college ,accreditation on or after ,january #a1 #bjjj1 and that have achieved or continue to progress toward ,full ,accreditation status 7as such term is defined by the ,liaison ,committee on ,medical ,education7 or toward ,accreditation status 7as such term is defined by the ,american ,osteopathic ,association ,commission on ,osteopathic ,college ,accreditation71 or 7bb7 additional locations and branch campuses established on or after ,january #a1 #bjjj1 by medical schools with ,full ,accreditation status 7as such term is defined by the ,liaison ,committee on ,medical ,education7 or ,accreditation status 7as such term is defined by the ,american ,osteopathic ,association ,commission on ,osteopathic ,college ,accreditation74 7,,iii7 ,third1 to hospitals that are eligible for incentive payments under section #ahhf7n7 or #aijc7t7 as of the date the hospital submits an application for such increase under subparagraph 7,a74 7,,iv7 ,fourth1 to all other hospitals4 7iii7 ,distribution to hospitals in higher priority group prior to distribution in lower priority groups ,the ,secretary may only distribute such an increase to a lower priority group under clause 7ii7 if all qualifying hospitals in the higher priority group or groups have received the maximum number of increases under such subparagraph that the hospital is eligible for under this paragraph for the fiscal year4 7iv7 ,requirements for use of additional positions 7,i7 ,in general ,subject to subclause 7,,ii71 a hospital that receives such an increase shall ensure1 during the #e-year period beginning on the effective date of such increase1 that-- 7aa7 not less than #ej percent of the positions attributable to such increase that are used in a given year during such #e-year period are used to train full-time equivalent residents in a shortage specialty residency program 7as defined in subparagraph 7,g77v771 as determined by the ,secretary at the end of such #e-year period2 7bb7 the total number of full-time equivalent residents1 excluding any additional positions attributable to such increase1 is not less than the average number of full-time equivalent residents during the #c most recent cost reporting periods ending on or before the effective date of such increase2 and 7cc7 the ratio of full-time equivalent residents in a shortage specialty residency program 7as so defined7 is not less than the average ratio of full-time equivalent residents in such a program during the #c most recent cost reporting periods ending on or before the effective date of such increase4 7,,ii7 ,redistribution of positions if hospital no longer meets certain requirements ,with respect to each fiscal year described in subparagraph 7,a71 the ,secretary shall determine whether or not a hospital described in subclause 7,i7 meets the requirements of such subclause4 ,in the case that the ,secretary determines that such a hospital does not meet such requirements1 the ,secretary shall-- 7aa7 reduce the otherwise applicable resident limit of the hospital by the amount by which such limit was increased under this paragraph2 and 7bb7 provide for the distribution of positions attributable to such reduction in accordance with the requirements of this paragraph4 7,d7 ,limitation ,a hospital may not receive more than #ge full-time equivalent additional residency positions under this paragraph for any fiscal year4 7,e7 ,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 paragraph1 the approved ,,fte per resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph 7#b77;,d7 for that hospital4 7,f7 ,permitting facilities to apply aggregation rules ,the ,secretary shall permit hospitals receiving additional residency positions attributable to the increase provided under this paragraph to1 beginning in the fifth year after the effective date of such increase1 apply such positions to the limitation amount under paragraph 7#d77;,f7 that may be aggregated pursuant to paragraph 7#d77;,h7 among members of the same affiliated group4 7,g7 ,definitions ,in this paragraph3 7i7 ,otherwise applicable resident limit ,the term otherwise applicable resident limit means1 with respect to a hospital1 the limit otherwise applicable under subparagraphs 7,f77i7 and 7,h7 of paragraph 7#d7 on the resident level for the hospital determined without regard to this paragraph but taking into account paragraphs 7#g77;,a71 7#g77;,b71 7#h77;,a71 and 7#h77;,b74 7ii7 ,primary care ,the term primary care means family medicine1 general internal medicine1 general pediatrics1 geriatrics1 preventive medicine1 obstetrics and gynecology1 general surgery1 and psychiatry4 7iii7 ,reference resident level ,except as otherwise provided in subclause 7,,ii71 the term reference resident level means1 with respect to a hospital1 the resident level for the most recent cost reporting period of the hospital ending on or before the date of enactment of this paragraph1 for which a cost report has been settled 7or1 if not1 submitted 7subject to audit771 as determined by the ,secretary4 7iv7 ,resident level ,the term resident level has the meaning given such term in paragraph 7#g77;,c77i74 7v7 ,shortage specialty residency program ,the term shortage specialty residency program means the following3 7,i7 ,prior to report on shortage specialties ,prior to the date on which the report is submitted under section #aj7;a7 of the ,training ,tomorrow's ,doctors ,today ,act1 any approved residency training program in a specialty identified in the report entitled ,the ,physician ,workforce3 ,projections and ,research into ,current ,issues ,affecting ,supply and ,demand1 issued in ,december #bjjh by the ,health ,resources and ,services ,administration1 as a specialty whose baseline physician requirements projections exceed the projected supply of total active physicians for the period of #bjje through #bjbj4 7,,ii7 ,after report on shortage specialities ,on or after the date on which the report is submitted under such section #e1 any approved residency training program in a physician specialty identified in such report as a specialty for which there is a shortage4 4 7b7 ,,ime ,section #ahhf7;d77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77 is amended-- 7#a7 in clause 7v71 in the second sentence1 by striking subsections 7h77#g7 and 7h77#h7 and inserting subsections 7h77#g71 7h77#h71 and 7h77#i72 7#b7 by redesignating clause 7x71 as added by section #eeje7;b7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 as clause 7xi7 and moving such clause #d ems to the left2 and 7#c7 by adding after clause 7xi71 as redesignated by subparagraph 7,a71 the following new clause3 7xii7 ,for discharges occurring on or after ,july #a1 #bjad1 insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection 7h77#i71 the indirect teaching adjustment factor shall be computed in the same manner as provided under clause 7ii7 with respect to such resident positions4 4 #c4 ,additional rules relating to application of #c-year rolling average for redistributed residency positions 7a7 ,elimination of #c-,year rolling average relating to redistributions after a hospital closes and under ,,ppaca redistributions 7#a7 ,,dgme 7,a7 ,redistribution of residency slots after a hospital closes 7i7 ,in general ,section #ahhf7;h77#d77;,h77vi7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#d77;,h77vi77 is amended by adding at the end the following new subclause3 7,,vi7 ,three-year rolling average inapplicable ,in applying subparagraph 7,g71 in the case of additional residency positions in a hospital attributable to the increase in the otherwise applicable resident limit provided under this paragraph pursuant to this clause1 the reference to the average of the actual full-time equivalent resident counts for the cost reporting period and the preceding two cost reporting periods shall be deemed to be a reference to the actual full-time equivalent residents count for the cost reporting period4 4 7ii7 ,effective date ,the amendment made by clause 7i7 shall apply with respect to hospitals with an approved medical residency program that closes on or after ,march #bc1 #bjjh4 7,b7 ,distribution of additional residency slots under ,,ppaca 7i7 ,in general ,section #ahhf7;h77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#h77 is amended by adding at the end the following new subparagraph3 7,j7 ,three-year rolling average inapplicable ,in applying paragraph 7#d77;,g71 in the case of additional residency positions in a hospital attributable to the increase in the otherwise applicable resident limit provided under this paragraph1 the reference to the average of the actual full-time equivalent resident counts for the cost reporting period and the preceding two cost reporting periods shall be deemed to be a reference to the actual full-time equivalent residents count for the cost reporting period4 4 7ii7 ,effective date ,the amendment made by clause 7i7 shall apply with respect to cost reporting periods occurring on or after ,july #a1 #bjaa4 7#b7 #c-year rolling average and ,intern and ,resident ,bed ratio cap inapplicable under ,,ime 7,a7 ,in general ,section #ahhf7;d77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b771 as amended by section #b7;b71 is further amended-- 7i7 in subclause 7,i7 of clause 7xi71 as redesignated by section #b7;b77#b71 by striking ,the provisions and inserting ,subject to clauses 7xiii7 and 7xiv72 and 7ii7 by adding at the end the following new clauses3 7xiii7 ,in the case of additional residency positions in a hospital attributable to the increase in the otherwise applicable resident limit provided under subsection 7h77#d77;,h77vi7 or 7h77#h71 the provisions of clause 7vi77,,ii7 shall be applied be deeming the reference to the average of the actual full-time equivalent resident count for the cost reporting period and the preceding two cost reporting periods to be a reference to the actual full-time equivalent resident count for the cost reporting period4 7xiv7 ,in the case of additional residency positions in a hospital attributable to the increase in the otherwise applicable resident limit provided under subsection 7h77#d77;,h77vi7 or 7h77#h71 the ratio of the hospital's full-time equivalent interns and residents to beds shall be equal to the ratio for the hospital's current cost reporting period4 4 7,b7 ,effective date ,the amendments made by subparagraph 7,a7 shall apply-- 7i7 to the extent such amendments relate to section #ahhf7;h77#d77;,h77vi7 of the ,social ,security ,act1 as if included in the enactment of section #eejf of the ,patient ,protection and ,affordable ,care ,act2 and 7ii7 to the extent such amendments relate to section #ahhf7;h77#h7 of the ,social ,security ,act1 as if included in the enactment of section #eejc of the ,patient ,protection and ,affordable ,care ,act4 7b7 ,elimination of #c-,year ,rolling ,average and ,intern and ,resident ,bed ,ratio ,cap beginning in #bjac 7#a7 ,,dgme ,section #ahhf7;h77#d77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#d77;,g77 is amended-- 7,a7 in clause 7i71 by inserting and before ,december #ca1 #bjab1 after ,october #a1 #aiig12 and 7,b7 by adding at the end the following new clause3 7iv7 ,current year count used to determine full-time equivalent resident count ,for cost reporting periods beginning on or after ,december #ca1 #bjab1 subject to the limit described in subparagraph 7,f71 the total number of full-time equivalent residents for determining a hospital's graduate medical education payment shall equal the actual full-time equivalent residents count for the hospital's cost reporting period4 4 7#b7 ,,ime ,section #ahhf7;d77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b771 as amended by subsection 7b71 is further amended by adding at the end the following new clauses3 7xv7 ,for cost reporting periods beginning on or after ,december #ca1 #bjab1 subject to the limits described in clauses 7iv7 and 7v71 the total number of full-time equivalent residents for payment purposes shall equal the actual full-time equivalent resident count for the hospital's cost reporting period4 7xvi7 ,for cost reporting periods beginning on or after ,december #ca1 #bjab1 the ratio of the hospital's full-time equivalent interns and residents to beds shall be equal to the ratio for the hospital's cost reporting period4 4 #d4 ,rules for determining full-time equivalent residents 7a7 ,,dgme ,section #ahhf7;h77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#d77 is amended-- 7#a7 in subparagraph 7,e71 by striking ,subject to subparagraphs 7,j7 and 7,k71 such rules and inserting ,subject to subparagraphs 7,j71 7,k71 and 7,l71 such rules2 7#b7 in subparagraph 7,j71 by striking ,such rules and inserting ,subject to subparagraph 7,l71 such rules 7#c7 in subparagraph 7,k71 by striking ,in determining and inserting ,subject to subparagraph 7,l71 in determining2 and 7#d7 by adding at the end the following new subparagraph3 7,l7 ,treatment of time spent in approved medical residency training program with respect to certain hospitals ,for purposes of cost reporting periods beginning on or after ,july #a1 #bjad1 in determining the number of full-time equivalent residents of the hospital for purposes of this paragraph1 all the time spent by an intern or resident in an approved medical residency training program1 regardless of setting1 shall be counted toward the determination of full-time equivalency1 and subparagraphs 7,j7 and 7,k7 shall not apply1 if the hospital-- 7i7 is recognized as a subsection 7d7 hospital2 7ii7 is recognized as a subsection 7d7 ,puerto ,rico hospital2 7iii7 is reimbursed under a reimbursement system authorized under section #ahad7;b77#c72 or 7iv7 is a provider-based hospital outpatient department4 4 7b7 ,,ime ,the second clause 7x7 of section #ahhf7;d77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77 is amended-- 7#a7 in subclause 7,,ii71 by striking ,in determining and inserting ,subject to subclause 7x77,,iv71 in determining2 7#b7 in subclause 7,,iii71 by striking ,in determining and inserting ,subject to subclause 7x77,,iv71 in determining2 and 7#c7 by adding at the end the following new subclause3 7,,iv7 ,the provisions of subparagraph 7,l7 of subsection 7h77#d7 shall apply under this subparagraph in the same manner as they apply under such subsection4 4 #e4 ,treatment of hospitals with rotating residents ,section #ahhf7;h77#b77;,f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#b77;,f77 is amended by adding at the end the following sentence3 ,in applying this subparagraph for cost reporting periods beginning on or after ,july #a1 #bjac1 the ,secretary shall not treat a cost reporting period for which a hospital trains residents participating in a program of another hospital as a period for which the hospital has an approved medical residency training program44 #f4 ,aggregation rules relating to applying limitation on number of residents 7a7 ,required rules ,to permit members of same affiliated group ,to elect ,to apply limitation on aggregate level ,section #ahhf7;h77#d77;,h77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#d77;,h77ii77 is amended by striking may and inserting shall4 7b7 ,election for new facilities ,such section is further amended by adding at the end the following new sentence3 ,such rules shall provide that all facilities established on or after ,january #a1 #bjjj1 whose resident limits are adjusted according to this subparagraph on or after ,january #a1 #aiig1 may elect to apply the limitation under subparagraph 7,f7 on an aggregate basis after a period specified by the ,secretary but that shall not exceed #e years from the date of such adjustment44 #g4 ,period of board eligibility for residents who change programs ,section #ahhf7;h77#e77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77#e77;,g77 is amended-- 7#a7 in clause 7i71 by striking 7iv71 and 7v7 and inserting 7iv71 7v71 and 7vi72 and 7#b7 by adding at the end the following new clause3 7vi7 ,in the case of a resident who changes residency specialties1 the period of board eligibility and the initial residency period shall be equal to the minimum number of years of formal training required to satisfy the requirements for the initial board eligibility of the program into which the resident transfers4 4 #h4 ,medicare indirect medical education performance adjustment ,section #ahhf of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7 is amended-- 7#a7 in subsection 7d77#e77;,b71 in the matter preceding clause 7i71 by inserting subject to subsection 7t7 and before except as follows2 and 7#b7 by adding at the end the following new subsection3 7t7 ,indirect medical education performance adjustments 7#a7 ,in general ,subject to the succeeding provisions of this subsection1 the ,secretary shall establish and implement procedures under which the amount of payments that a hospital 7as defined in paragraph 7#aa77 would otherwise receive for indirect medical education costs under subsection 7d77#e77;,b7 for discharges occurring during a fiscal year is adjusted based on the reporting of measures and the performance of the hospital on measures of patient care priorities specified by the ,secretary4 7#b7 ,adjustments to begin in fiscal year #bjah ,the adjustments shall apply to payments for discharges occurring-- 7,a7 with respect to the adjustments for reporting under paragraph 7#h77;,a71 during fiscal year #bjah2 and 7,b7 with respect to the adjustments for performance under paragraph 7#h77;,b71 on or after ,october #a1 #bjah4 7#c7 ,measures ,the measures of patient care priorities specified by the ,secretary under this subsection shall include the extent of training provided in-- 7,a7 the delivery of services categorized as evaluation and management codes by the ,centers for ,medicare ,medicaid ,services2 7,b7 a variety of settings and systems2 7,c7 the coordination of patient care across settings2 7,d7 the relevant cost and value of various diagnostic and treatment options2 7,e7 interprofessional and multidisciplinary care teams2 7,f7 methods for identifying system errors and implementing system solutions2 and 7,g7 the use of health information technology4 7#d7 ,measure development process 7,a7 ,in general ,the measures of patient care specified by the ,secretary under this subsection-- 7i7 shall-- 7,i7 be measures that have been adopted or endorsed by an accrediting organization 7such as the ,accreditation ,council for ,graduate ,medical ,education or ,american ,osteopathic ,association72 and 7,,ii7 be measures that the ,secretary identifies as having used a consensus-based process for developing such measures2 and 7ii7 may include measures that have been submitted by teaching hospitals and medical schools4 7,b7 ,proposed set of initial measures ,not later than ,july #a1 #bjae1 the ,secretary shall publish in the ,federal ,register a proposed initial set of measures for use under this subsection4 ,the ,secretary shall provide for a period of public comment on such measures4 7,c7 ,final set of initial measures ,not later than ,january #a1 #bjaf1 the ,secretary shall publish in the ,federal ,register the set of initial measures to be specified by the ,secretary for use under this subsection4 7,d7 ,update of measures ,the ,secretary may1 through notice and comment rulemaking1 periodically update the measures specified under this subsection pursuant to the requirements under subparagraph 7,a74 7#e7 ,performance standards ,the ,secretary shall establish performance standards with respect to measures specified by the ,secretary under this subsection for a performance period for a fiscal year 7as established under paragraph 7#f774 7#f7 ,performance period ,the ,secretary shall establish the performance period for a fiscal year4 ,such performance period shall begin and end prior to the beginning of such fiscal year4 7#g7 ,reporting of measures ,the procedures established and implemented under paragraph 7#a7 shall include a process under which hospitals shall submit data on the measures specified by the ,secretary under this subsection to the ,secretary in a form and manner1 and at a time1 specified by the ,secretary for purposes of this subsection4 7#h7 ,adjustments 7,a7 ,reporting for fiscal year #bjah ,for fiscal year #bjah1 in the case of a hospital that does not submit1 to the ,secretary in accordance with this subsection1 data required to be submitted under paragraph 7#g7 for a period 7determined appropriate by the ,secretary7 for such fiscal year1 the total amount that the hospital would otherwise receive under subsection 7d77#e77;,b7 for discharges in such fiscal year shall be reduced by #j4e percent4 7,b7 ,performance for fiscal year #bjai and subsequent fiscal years 7i7 ,in general ,subject to clause 7ii71 based on the performance of each hospital with respect to compliance with the measures for a performance period for a fiscal year 7beginning with fiscal year #bjai71 the ,secretary shall determine the amount of any adjustment under this subparagraph to payments to the hospital under subsection 7d77#e77;,b7 for discharges in such fiscal year4 ,such adjustment may not exceed an amount equal to #b percent of the total amount that the hospital would otherwise receive under such subsection for discharges in such fiscal year4 7ii7 ,budget neutral ,in making adjustments under this subparagraph1 the ,secretary shall ensure that the total amount of payments made to all hospitals under subsection 7d77#e77;,b7 for discharges in a fiscal year is equal to the total amount of payments that would have been made to such hospitals under such subsection for discharges in such fiscal year if this subsection had not been enacted4 7#i7 ,no effect in subsequent fiscal years ,any adjustment under subparagraph 7,a7 or 7,b7 of paragraph 7#h7 shall apply only with respect to the fiscal year involved1 and the ,secretary shall not take into account any such adjustment in making payments to a hospital under this section in a subsequent fiscal year4 7#aj7 ,evaluation of submission of performance measures ,not later than ,january #a1 #bjah1 the ,secretary shall submit to ,congress a report on the implementation of this subsection1 including-- 7,a7 the measure development procedures1 including any barriers to measure development2 7,b7 the compliance with reporting on the performance measures1 including any barriers to such compliance2 and 7,c7 recommendations to address any barriers described in subparagraph 7,a7 or 7,b74 7#aa7 ,definition of hospital ,in this subsection1 the term hospital means a hospital that receives payments under subsection 7d77#e77;,b74 4 #i4 ,increasing graduate medical education transparency 7a7 ,in general ,not later than #b years after the date of the enactment of this ,act1 and annually thereafter1 the ,secretary of ,health and ,human ,services shall submit to ,congress and the ,national ,health ,care ,workforce ,commission a report on the graduate medical education payments that hospitals receive under the ,medicare program4 ,the report shall include the following information with respect to each hospital that receives such payments3 7#a7 ,the direct graduate medical education payments made to the hospital under section #ahhf7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h774 7#b7 ,the total costs of direct graduate medical education to the hospital as reported on the annual ,medicare ,cost ,reports4 7#c7 ,the indirect medical education payments made to the hospital under section #ahhf7;d77#e77;,b7 of such ,act 7#db ,u4,s4,c4 #acieww7d77#a77;,b774 7#d7 ,the number of full-time-equivalent residents counted for purposes of making the payments described in paragraph 7#a74 7#e7 ,the number of full-time-equivalent residents counted for purposes of making the payments described in paragraph 7#c74 7#f7 ,the number of full-time-equivalent residents1 if any1 that are not counted for purposes of making payments described in paragraph 7#a74 7#g7 ,the number of full-time-equivalent residents1 if any1 that are not counted for purposes of making payments described in paragraph 7#c74 7#h7 ,the factors contributing to the higher costs of patient care provided by the hospital1 including-- 7,a7 the costs of trauma1 burn1 other standby services2 7,b7 translation services for disabled or non-,english speaking patients2 7,c7 the cost of uncompensated care2 7,d7 financial losses with respect to ,medicaid patients2 and 7,e7 uncompensated costs of clinical research4 #aj4 ,,gao studies and reports 7a7 ,on physician workforce 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study on the physician workforce4 ,such study shall include the identification of physician specialties for which there is a shortage1 as defined by the ,comptroller ,general4 7#b7 ,report ,not later than ,january #a1 #bjae1 the ,comptroller ,general shall submit to ,congress a report on the study conducted under subsection 7a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 7b7 ,on strategies for increasing diversity 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study on strategies for increasing the diversity of the health professional workforce4 ,such study shall include an analysis of strategies for increasing the number of health professionals from rural1 lower income1 and under-represented minority communities1 including which strategies are most effective for achieving such goal4 7#b7 ,report ,not later than #b years after the date of enactment of this ,act1 the ,comptroller ,general shall submit to ,congress a report on the study conducted under subsection 7a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 7c7 ,on protecting older adults 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study that addresses the competency of the physician workforce to care for older adults upon the completion of such workforce's residency training4 7#b7 ,report ,not later than #b years after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to ,congress a report on such study1 including such recommendations for legislation and administrative action as the ,comptroller ,general determines appropriate based on such study4