,,ii #aacth ,,congress #b;d ,session ,s4 #aigh ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,january #cj1 #bjad,mr4 ,udall of ,new ,mexico introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to increase access to primary care services through training and accountability improvements4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,increasing ,primary ,care ,access ,act of #bjad4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,sec4 #b4 ,findings4,sec4 #c4 ,centers of ,excellence in ,primary ,care4,sec4 #d4 ,medicare ,indirect ,medical ,education 7,,ime7 performance adjustment and primary care training bonus4,sec4 #e4 ,increasing ,medicare graduate medical education transparency4,sec4 #f4 ,ensuring appropriate representation of primary care physicians on groups making recommendations regarding relative values under the ,medicare physician fee schedule4,sec4 #g4 ,primary care project4,sec4 #h4 ,regional centers for health workforce analysis4,sec4 #i4 ,payments for graduate medical education under the ,medicaid program4,sec4 #aj4 ,national ,center for ,health ,care ,workforce ,analysis4,sec4 #aa4 ,teaching health center reauthorization4,sec4 #ab4 ,,gao studies on graduate medical education4 #b4 ,findings ,congress makes the following findings3 7#a7 ,a well prepared1 effective primary care workforce can reduce health care costs and play a large role in the prevention and management of illness4 ,a one-unit increase in primary care physicians per #aj1jjj population is associated with improved health outcomes such as all-cause1 cancer1 heart disease1 and stroke mortality1 as well as increased life expectancy4 7#b7 ,primary care physicians include those trained in family medicine1 general internal medicine1 general pediatrics1 and in some cases1 gynecology4 ,one primary care physician will generate #f to #bc jobs in the community served by such physician1 #ijj1jjj to #a1bjj1jjj in wages1 salaries1 and benefits1 and nearly #ajj1jjj in ,state and local taxes4 7#c7 ,as of #bjaa1 only #cb percent of the physician workforce is comprised of primary care and only between #af to #ah percent of graduates of allopathic medical schools are likely to pursue a career in primary care4 7#d7 ,primary care supply has a positive effect on the entire population1 but the effect is greater in areas with higher income inequality and poverty1 such as rural areas4 ,only about #aj percent of physicians in ,america practice in rural areas while #bj percent of the ,united ,states population is located in rural areas4 7#e7 ,geographic areas with more general and family physicians per population have lower rates of mortality and hospitalization for conditions that should be preventable or detected early1 such as diabetes1 congestive heart failure1 and hypertension4 7#f7 ,as of ,may #bjaa1 there were #f1dai primary care health professional shortage areas1 comprised of #ff1cjj1jjj individuals4 ,it would take #ag1fcf practitioners to meet such individuals' need for primary care providers4 #c4 ,centers of ,excellence in ,primary ,care ,part ,c of title ,,vii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bick7 is amended by adding at the end the following3 ,,iii ,centers of ,excellence in ,primary ,care #gdi;,c4 ,centers of ,excellence in ,primary ,care 7a7 ,in general ,the ,secretary shall make grants to1 and enter into contracts with1 schools of medicine and osteopathic medicine for the purpose of assisting the schools in supporting programs of excellence in primary care4 7b7 ,eligible schools ,to be eligible to receive a grant under subsection 7a71 a school of medicine or osteopathic medicine shall submit an application at such time1 in such manner1 and containing such information as the ,secretary may require1 including a description of innovative ideas that applicants propose to increase recruitment and retention in primary care1 including pipeline1 admissions1 curriculum1 mentoring1 preparation for residency1 and related purposes4 7c7 ,selection of recipients 7#a7 ,in general ,the ,secretary shall award a grant under this section to not less than #f and not more than #aj eligible schools of medicine and osteopathic medicine4 ,such selected schools shall be designated as ,centers of ,excellence in ,primary ,care4 7#b7 ,requirements relating to rural and underserved areas ,of the schools designated under paragraph 7#a7-- 7,a7 not less than #d and not more than #g shall be located in a rural area2 and 7,b7 not less than #b and not more than #c shall be located in a medically underserved area4 7d7 ,use of funds ,a school of medicine or osteopathic medicine designated as a ,center of ,excellence under this section shall1 in using funds provided under the grant1 give funding priority to-- 7#a7 making medical school affordable for each admitted and graduated student1 including through significant tuition scholarships1 tuition remissions1 and stipends1 especially for low-income students1 and other provisions1 such as loan forgiveness for graduates who practice primary care for a specified duration of time2 7#b7 conducting admissions processes that favor students who will work in rural and medically underserved areas1 and consider factors such as rural birth1 minority status or upbringing1 and desire to serve rural and medically underserved populations2 7#c7 developing curricula models and innovations that expedite medical school training1 build needed skills for modern medical practice1 and enhance affinity of graduates for practice in rural and medically underserved areas 7which may include #c-year undergraduate medical education models1 rural and inner city rotations1 and mentoring with rural physicians72 7#d7 research whether students completing a service requirement in a rural or underserved area as part of the criteria for graduation improves access to care in such area2 7#e7 implement tracking systems that-- 7,a7 assess practice patterns of medical school graduates and require annual reports on this information for the duration of the grant program2 and 7,b7 track all loan repayment and scholarship disbursements to assure that program goals are being met with regard to recipients serving in desired locations with expected populations of need for a minimum required amount of time2 and 7#f7 having interprofessional primary care health professions community-based service learning models for primary care residents1 and include clerkships and continuity clinic experiences for medical1 nurse practitioner1 and physician assistant students interested in primary care4 4 #d4 ,medicare ,indirect ,medical ,education 7,,ime7 performance adjustment and primary care training bonus 7a7 ,in general ,section #ahhf7;d77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77 is amended-- 7#a7 by redesignating the clause 7x7 as added by section #eeje7;b7 of the ,patient ,protection and ,affordable ,care ,act as clause 7xi72 and 7#b7 by adding at the end the following new clauses3 7xii7 ,adjustment for performance 7,i7 ,in general ,the ,secretary1 in consultation with the advisory body under clause 7xiii71 shall establish and implement procedures under which the amount of payments that a hospital would otherwise receive for indirect medical education costs under this subparagraph for discharges occurring during an applicable period is adjusted based on the performance of the hospital on measures specified by the ,secretary4 7,,ii7 ,measures ,the measures specified by the ,secretary under this clause shall include measures on quality measurement and improvement1 evidence-based medicine1 interprofessional teamwork1 multidisciplinary teamwork1 care coordination1 and health information technology4 ,such measures shall include factors that promote training in primary care1 such as-- 7aa7 resident training in outpatient and community settings1 including ,federally qualified health centers1 rural health clinics1 teaching health centers1 rural medical practices1 facilities operated by the ,veterans ,administration1 ,indian ,health ,service facilities1 including primary care training sites that are carried out through self determination contracts and are located in a rural or primary care health professional shortage area2 7bb7 salary and loan conditions for primary care residents2 7cc7 the percentage of all graduates practicing primary care #e years after graduation2 7dd7 the percentage of all graduates practicing primary care in health professional shortage areas #e years after graduation2 7ee7 the percentage of all primary care graduates from underrepresented minority groups1 including ,african-,americans1 ,hispanic-,americans1 and ,native ,americans1 as well as other underserved populations2 7ff7 how the residency is responding to the workforce needs identified by ,state and regional centers for workforce analysis established under the ,national ,center for ,health ,care ,workforce ,analysis or the ,national ,health ,care ,workforce ,commission2 7gg7 the provision of service to all socioeconomic levels of patients1 including but not limited to ,medicaid program populations2 7hh7 mentoring curriculum in primary care2 7ii7 systems-based practice1 including training in new forms of delivery system models1 such as care coordination1 accountable care organizations1 and patient-centered medical homes2 and 7jj7 training in preventive care1 chronic disease management1 and population health and public health4 7,,iii7 ,initial measure development timeline 7aa7 ,proposed set of measures ,not later than ,january #a1 #bjaf1 the ,secretary shall publish in the ,federal ,register a proposed set of measures for use under this clause4 ,the ,secretary shall provide for a period of public comment on such measures4 7bb7 ,final set of measures ,not later than ,june #cj1 #bjaf1 the ,secretary shall publish in the ,federal ,register the final set of measures to be specified by the ,secretary for use under this clause4 7,,iv7 ,adjustment ,subject to subclause 7,v71 the ,secretary shall determine the amount of any adjustment under this clause to payments to a hospital under this subparagraph in an applicable period4 7,v7 ,budget-neutral with respect to payments that would otherwise be made ,in making adjustments under this clause1 the ,secretary shall ensure that the total amount of payments made to all hospitals under this subparagraph for an applicable period is equal to the total amount of payments that would have been made to such hospitals under this subparagraph in such period if this clause had not been enacted4 7,,vi7 ,primary care defined ,in this clause1 the term primary care means family medicine1 general internal medicine1 general pediatrics1 preventive medicine1 obstetrics and gynecology1 psychiatry1 and any other specialty which provides integrated1 accessible health care services and is accountable for addressing a large majority of health care needs1 developing a sustained partnership with patients1 and practicing in the context of family and community4 7,,vii7 ,applicable period defined ,in this clause1 the term applicable period means the #ab-month period beginning on ,july #a of each year 7beginning with #bjae74 7xiii7 ,use of advisory body 7,i7 ,in general ,subject to subclause 7,,iii71 the ,secretary shall establish an advisory group to advise the ,secretary on the application of clause 7xii71 including the development of the measures to be used1 how data on the measures may be collected1 which measures will be required in any given reporting period1 the applicable thresholds for the measures1 and the mechanisms to be used in order to determine whether a hospital has met a threshold4 7,,ii7 ,make-up of group ,the advisory group established under subclause 7,i7 shall include-- 7aa7 representatives of accrediting and certifying organizations2 7bb7 representatives of facilities that receive payments under this subparagraph2 7cc7 representatives of specialty boards and primary care boards2 7dd7 representatives of high-performing health care systems2 7ee7 experts in family medicine1 primary care1 and preventive medicine2 7ff7 representatives of public and private purchasers2 7gg7 representatives of consumer and patient organizations1 especially those from rural areas2 and 7hh7 other entities and individuals as determined by the ,secretary of ,health and ,human ,services4 7,,iii7 ,use of existing entity ,if the ,secretary determines that an existing entity is comprised of the individuals described in subclause 7,,ii7 and that such entity has the expertise to advise the ,secretary on the matters described in subclause 7,i71 the ,secretary may enter into an arrangement with such entity to advise the ,secretary on such matters rather than establishing a new advisory group under subclause 7,i74 4 7b7 ,,gao study and report 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study on the application of clause 7xii7 of section #ahhf7;d77#e77;,b7 of the ,social ,security ,act1 as added by subsection 7a71 including an analysis of any changes in workforce patterns as a result of the application of such clause4 7#b7 ,report ,not later than ,january #a1 #bjah1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report on the study conducted under paragraph 7#a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines to be appropriate4 #e4 ,increasing ,medicare 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 a report on the graduate medical education payments that hospitals and other facilities receive under the ,medicare program4 ,the report shall include the following information with respect to each hospital or facility that receives such payments3 7#a7 ,the direct graduate medical education payments made to the hospital or other facility under section #ahhf7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h774 7#b7 ,the indirect medical education payments made to the hospital or other facility under section #ahhf7;d77#e77;,b7 of such ,act 7#db ,u4,s4,c4 #acieww7d77#a77;,b774 7#c7 ,the number of residents counted for purposes of making the payments described in paragraph 7#a74 7#d7 ,the number of residents counted for purposes of making the payments described in paragraph 7#b74 7#e7 ,the number of residents1 if any1 that are not counted for purposes of making payments described in paragraph 7#a74 7#f7 ,the number of residents1 if any1 that are not counted for purposes of making payments described in paragraph 7#b74 7#g7 ,the percent that the payments described in paragraphs 7#a7 and 7#b7 that are made to the hospital or other facility make up of the total costs that the hospital or other facility incurs in providing graduate medical education1 including salaries1 benefits1 operational expenses1 and all other patient care costs4 7#h7 ,the number of residents training in each specialty4 7#i7 ,a list that identifies any training partners and the sponsoring institutions for each residency program4 #f4 ,ensuring appropriate representation of primary care physicians on groups making recommendations regarding relative values under the ,medicare physician fee schedule ,section #ahdh7;c77#b77;,b77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77iii77 is amended by adding at the end the following new sentence3 ,the ,secretary may not consult with an organization representing physicians if the organization uses a group to formulate recommendations regarding adjustments under clause 7i7 unless at least #dj percent of the members of the group are physicians who are board certified and actively practicing in family medicine1 general internal medicine1 general pediatrics1 preventive medicine1 obstetrics and gynecology1 or psychiatry44 #g4 ,primary care project 7a7 ,in general ,the ,secretary of ,health and ,human ,services 7referred to in this section as the ,secretary7 shall establish a pilot program to provide funding for graduate medical residency training programs in primary care4 7b7 ,application and selection of sites 7#a7 ,in general ,an entity shall be eligible to participate in the project under this section if such entity-- 7,a7 is-- 7i7 a community-based corporate entity collaborating with #a or more hospitals to operate a primary care residency program2 7ii7 a medical education entity established by #a or more hospitals to operate a primary care residency program2 7iii7 a hospital subsidiary or independent corporation operating a primary care residency program2 7iv7 a medical education entity1 independent of a hospital1 collaborating with a primary care residency program2 or 7v7 another type of entity as determined appropriate by the ,secretary2 and 7,b7 submits an application at such time1 in such manner1 and containing such information as the ,secretary may require4 7#b7 ,selection of participants ,the ,secretary shall select1 from the eligible entities under paragraph 7#a71 #d entities to participate in the project4 ,not less than #a selected entity shall be an entity that is not a hospital4 7c7 ,activities under the project ,in carrying out the project1 the ,secretary shall-- 7#a7 structure the funding of the project such that payments are made directly to the entity participating in the project2 7#b7 support primary care training in all sites where care is delivered1 including non-hospital settings such as ,federally qualified health centers 7as defined in section #ahfa7;aa7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa7772 7#c7 7,a7 increase funding for the primary care residency programs of the participating entities such that those primary care residency programs are funded at the #ijth percentile of all residency programs nationally and are funded at levels that equal at least #ajj1jjj per resident involved2 and 7,b7 ensure that entities participating in the project use the funding under the project to provide infrastructure support and recruitment and retention support for faculty and residents of the primary care residency program1 including loan repayment for such residents2 7#d7 require training in rural and medically underserved areas1 and with medically underserved populations 7as defined in section #ccj7;b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b7b777 and service in such areas for a minimum of two rotations of not less than four weeks each year2 and 7#e7 permit the primary care residency program of the participating entities to qualify for payment under section #ahhf7;d77#e77;,b77xii7 of the ,social ,security ,act 7as added by section #d7 if such entities receive an appropriate score 7as determined by the ,secretary7 on the measures specified by the ,secretary under such section4 7d7 ,term of project ,the ,secretary shall carry out the project under this section for a term of at least #f years4 7e7 ,evaluation 7#a7 ,in general ,not later than #a year after the commencement of the project1 and each year thereafter1 the ,secretary shall conduct an of evaluation the project4 7#b7 ,content ,the ,secretary shall conduct the evaluation under paragraph 7#a7 using the following criteria3 7,a7 ,the percentage of graduates from the primary care residency programs of the participating entities that are practicing primary care #b years after graduation1 and longer4 7,b7 ,the percentage of graduates from the primary care residency programs of the participating entities that are practicing in a health professional shortage area 7as defined in section #ccb of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;e77 #b years after graduation1 and longer4 7,c7 ,other criteria as determined appropriate by the ,secretary4 7f7 ,authorization of appropriation ,there are authorized to be appropriated to carry out this section #c1fjj1jjj for each of fiscal years #bjae through #bjai4 #h4 ,regional centers for health workforce analysis 7a7 ,in general ,section #gfa7;c7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bidn7c77 is amended by adding at the end the following-- 7#c7 ,establishment of new ,centers and funding to primary care residency programs 7,a7 ,establishment of new ,centers 7i7 ,in general ,not later than #a year after the date of enactment of the ,increasing ,primary ,care ,access ,act of #bjad1 the ,secretary shall award grants to1 or enter into contracts with1 not less than #f and not more than #h additional eligible entities1 as described in paragraph 7#a74 7ii7 ,requirements ,in awarding grants or entering into contracts under clause 7i71 the ,secretary shall-- 7,i7 ensure that each ,regional ,center for ,health ,workforce ,analysis established under this paragraph is located in the geographic region that the ,center covers2 and 7,,ii7 seek to award such grants or enter into contracts with eligible entities that are multi-,state consortia4 7,b7 ,distribution of funding to primary care residency programs 7i7 ,in general ,each ,regional ,center for ,health ,workforce ,analysis established pursuant to a grant or contract under subparagraph 7,a7 shall1 from the funds described in subparagraph 7,d71 allocate funding to primary care residency programs-- 7,i7 within the region served by the ,regional ,center for ,health ,workforce ,analysis2 and 7,,ii7 that the ,center has identified as a primary care residency program in need4 7,c7 ,consultation ,each ,regional ,center for ,health ,workforce ,analysis established pursuant to a grant or contract under this subsection shall establish a consortium of academic institutions with which the ,center shall consult in determining allocations under subparagraph 7,b74 7,d7 ,funding 7i7 ,authorization of appropriations ,for each fiscal year1 there is authorized to be appropriated to carry out this paragraph #d1jjj1jjj1 of which not less than #ejj1jjj shall be allocated to each ,regional ,center for ,health ,workforce ,analysis established under this paragraph4 7ii7 ,use of funds to establish new ,centers ,each entity receiving funds under this paragraph may use a portion of such funding to establish the ,regional ,center for ,health ,workforce ,analysis4 4 7b7 ,conforming amendment ,section #gfa7;e77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bidn7e77#b77 is amended by striking subsection 7c7 and inserting paragraphs 7#a7 and 7#b7 of subsection 7c74 #i4 ,payments for graduate medical education under the ,medicaid program 7a7 ,in general ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d71 is amended by adding at the end the following new subsection3 7ee7 ,increased ,,fmap for targeted graduate medical education in ,expansion ,states 7#a7 ,in general ,the term medical assistance includes payment for costs of graduate medical education consistent with this subsection1 whether provided in or outside of a hospital4 7#b7 ,increased ,,fmap for ,expansion ,states that expand targeted graduate medical education ,notwithstanding subsection 7b71 with respect to amounts expended by an ,expansion ,state for medical assistance for targeted graduate medical education that is above the level of expenditures made by the ,expansion ,state for such graduate medical education for #bjad1 the ,federal medical assistance percentage shall be equal to-- 7,a7 #ajj percent for amounts expended in calendar quarters in #bjae1 #bjaf1 or #bjag2 7,b7 #ie percent for amounts expended in calendar quarters in #bjah2 7,c7 #id percent for amounts expended in calendar quarters in #bjai2 7,d7 #ic percent for amounts expended in calendar quarters in #bjbj2 and 7,e7 #ij percent for amounts expended in calendar quarters in #bjba or in each year thereafter4 7#c7 ,definitions ,in this subsection3 7,a7 ,expansion ,state ,the term ,expansion ,state means a ,state that elects in accordance with the amendments made by the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 to this title to provide medical assistance to individuals described in subclause 7,,viii7 of section #aijb7;a77#aj77;,a77i74 7,b7 ,targeted graduate medical education ,the term targeted graduate medical education means graduate medical education for community-based1 interprofessional primary care residents and other health care students1 located in a rural area or an area that is designated 7under section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act7 as a health professional shortage area1 or for other workforce needs identified by ,state and regional centers for workforce analysis established under the ,national ,center for ,health ,workforce ,analysis4 7,c7 ,primary care ,the term primary care means family medicine1 general internal medicine1 general pediatrics1 preventive medicine1 obstetrics and gynecology1 psychiatry1 and any other specialty which provides integrated1 accessible health care services and is accountable for addressing a large majority of health care needs1 developing a sustained partnership with patients1 and practicing in the context of family and community4 4 7b7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjae4 ,nothing in this section shall be construed as affecting payments made before such date under a ,state plan under title ,,xix of the ,social ,security ,act for graduate medical education4 #aj4 ,national ,center for ,health ,care ,workforce ,analysis ,section #gfa7;b77#b77;,a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bidn7b77#b77;,a77 is amended by inserting before the semicolon1 the following3 1 including national and regional workforce issues related to spending under the ,medicaid program under title ,,xix of the ,social ,security ,act4 #aa4 ,teaching health center reauthorization 7a7 ,reauthorization of the teaching health centers program ,section #cdj;,h of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bef;h7 is amended-- 7#a7 in subsection 7g7-- 7,a7 by inserting before the period the following3 1 and not to exceed #hjj1jjj1jjj1 for the period of fiscal years #bjaf through #bjbj2 and 7,b7 by adding at the end the following3 ,any amounts appropriated under this subsection for any of fiscal years #bjaa through #bjbj and remaining unexpended at the end of the fiscal year involved may be used in subsequent fiscal years to carry out this section42 7#b7 in subsection 7h77#b7-- 7,a7 in the paragraph heading1 by adding at the end the following3 2 submission to ,congress2 and 7,b7 by adding at the end the following3 7,c7 ,submission to ,congress ,the ,secretary shall annually submit to ,congress a report that contains a compilation of the data submitted to the ,secretary under paragraph 7#a7 for the year involved4 2 7#c7 by redesignating subsections 7h7 through 7j7 as subsections 7i7 through 7k71 respectively2 and 7#d7 by inserting after subsection 7g71 the following3 7h7 ,limitation ,the ,secretary shall establish a minimum per resident per year payment amount for funding of all approved teaching health center graduate medical education positions under this section that shall be not less than the per resident per year payment amount as of ,january #a1 #bjac1 and ensure that not less than such amount is provided to all teaching health center graduate medical education programs for all approved positions4 4 7b7 ,teaching health centers development grants ,section #gdi;,a7g7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bicl-#a7;g77 is amended by striking each fiscal year thereafter and inserting each of fiscal years #bjac through #bjbj and each fiscal year thereafter4 #ab4 ,,gao studies on graduate medical education 7a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study on each of the following3 7#a7 ,the potential of making graduate medical education payments under the ,medicare program for mid-level health providers 7such as physician assistants and nurse practitioners7 in order to allow physicians and other health care providers to perform to their full scope of practice4 7#b7 ,the actual costs involved in training residents in different residency specialty types4 7b7 ,report ,not later than one year after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report on each of the studies conducted under subsection 7a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines to be appropriate4