,,ii #aacth ,,congress #b;d ,session ,s4 #bgbh ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,july #ca1 #bjad ,mrs4 ,murray introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide community-based medical education payments to primary care teaching centers1 to provide for a ,medicare indirect medical education performance adjustment1 and to increase ,medicare graduate medical education transparency1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,community-,based ,medical ,education ,act of #bjad4 #b4 ,teaching health center extension 7a7 ,,thc 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 striking not to exceed #bcj1jjj1jjj1 for the period of fiscal years #bjaa through #bjae4 and inserting not to exceed--2 and 7,b7 by adding at the end the following3 7#a7 #bcj1jjj1jjj1 for the period of fiscal years #bjaa through #bjae2 and 7#b7 #dbj1jjj1jjj1 for the period of fiscal years #bjaf through #bjai4 2 and 7#b7 by adding at the end the following3 7k7 ,evaluation of program2 participation in primary care teaching program ,the ,secretary shall-- 7#a7 not later than ,december #ca1 #bjag1 conduct a comprehensive evaluation of the program under this section2 and 7#b7 establish a process by which qualified teaching health centers that have received payments under this section prior to the date on which the primary care teaching centers program is established under section #ahii;,b of the ,social ,security ,act may become eligible to participate in such primary care teaching program4 4 7b7 ,teaching health centers development grants ,section #gdi;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bicl-#a7 is amended-- 7#a7 in subsection 7a71 by inserting 1 based on demonstrated financial need1 after centers2 7#b7 in subsection 7b71 by striking #ejj1jjj and inserting #bej1jjj2 and 7#c7 in subsection 7g71 by striking fiscal year #bjaj1 #ej1jjj1jjj for fiscal year #bjaa1 #ej1jjj1jjj for fiscal year #bjab and inserting each of fiscal years #bjaf1 #bjag1 and #bjah4 #c4 ,community-,based ,medical ,education ,payments ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is amended by adding at the end the following new section3 #ahii;,b4 ,community-,based ,medical ,education ,payments 7a7 ,in general ,the ,secretary shall establish a program under which the ,secretary makes payments to primary care teaching centers 7as defined in subsection 7c77 under this section4 7b7 ,implementation ,the ,secretary shall establish the program under this section not later than ,january #a1 #bjai4 7c7 ,definitions 7#a7 ,definition of primary care teaching center ,in this section1 the term primary care teaching center means an entity described in paragraph 7#b7 that-- 7,a7 is accredited by the ,accreditation ,council on ,graduate ,medical ,education1 the ,american ,osteopathic ,association1 or the ,commission on ,dental ,accreditation2 and 7,b7 operates a community-based primary care residency program 7as defined in paragraph 7#e77 in a rural or underserved area4 7#b7 ,entity described ,the following entities are described in this paragraph3 7,a7 ,an entity that received payments under section #cdj;,h of the ,public ,health ,service ,act for a community based1 ambulatory patient care center which operates a primary care residency program or a related consortia recognized by the ,health ,resources and ,services ,administration4 7,b7 ,a community-based1 independent corporate entity collaborating with one or more hospitals in operating one or more primary care residency programs4 7,c7 ,a medical education entity established by one or more hospitals to develop and operate one or more primary care residency programs4 ,the hospital or hospitals may be the sole corporate members of the entity1 but the governing board of the entity shall include representatives of the community4 7,d7 ,a medical education entity that is independent of any hospital but collaborates with a hospital in operating one or more medical residency training programs4 ,the medical education entity may include a university or a school of medicine4 7,e7 ,a subsidiary of a hospital or independent corporation operating one or more primary care residency programs for the hospital with community participation in the governance of the organization4 7,f7 ,a rural training track program 7as defined in paragraph 7#f774 7#c7 ,inclusion of certain entities ,the term primary care teaching center includes the following3 7,a7 ,a ,federally qualified health center 7as defined in section #aije7l77#b77;,b774 7,b7 ,a community mental health center 7as defined in section #ahfa7;ff77#c77;,b774 7,c7 ,a rural health clinic1 as defined in section #ahfa7;aa74 7,d7 ,a health center operated by the ,indian ,health ,service1 an ,indian tribe or tribal organization1 or an urban ,indian organization 7as defined in section #d of the ,indian ,health ,care ,improvement ,act74 7,e7 ,an entity receiving funds under title ,x of the ,public ,health ,service ,act4 7,f7 ,a critical access hospital4 7,g7 ,an entity that collaborates to form a consortium that operates an accredited primary care residency program1 so long as the consortium is accredited in the primary care specialty and is listed as the institutional sponsor by the relevant accrediting body4 ,within the consortium1 a community-based ambulatory care center shall play an integral role in the academic1 financial1 and administrative operations of the primary care residency program4 7#d7 ,definition of primary care ,in this section1 the term primary care means family medicine1 internal medicine1 pediatrics1 internal medicine-pediatrics1 obstetrics and gynecology1 psychiatry1 general dentistry1 pediatric dentistry1 or geriatrics4 7#e7 ,definition of primary care residency program ,in this section1 the term primary care residency program means an approved medical residency training program 7as defined in section #ahhf7;h77#e77;,a77 in primary care4 7#f7 ,definition of rural training track program ,in this section1 the term rural training track program means an alternative training track integrated with a larger more urban or community hospital program and separately accredited as such1 with a rural location1 a rural mission1 or a major rural service area1 in which the residents spend approximately two of three years in a place of practice separate and more rural or rurally focused than the larger program4 7d7 ,limitations on number of resident training positions 7#a7 ,limitation on total number under program ,subject to paragraph 7#c71 the ,secretary shall make payments under this section for not more than #a1ejj new full-time equivalent resident training positions to be distributed to primary care teaching centers at a rate of not more than #cjj per year until expended4 7#b7 ,limitation on total number for each primary care teaching center ,subject to paragraph 7#c71 no single primary care teaching center shall receive a total of more than #ej of the positions distributed under the program1 which must be in primary care specialties4 7#c7 ,exception for existing residents of teaching health centers ,the limitation under each of paragraphs 7#a7 and 7#b7 shall not apply with respect to a resident training position of a teaching health center that received payments under section #cdj;,h of the ,public ,health ,service ,act if the resident training position was in a medical residency training program operated by the teaching health center prior to the participation of the teaching health center as a primary care teaching center under this section4 ,the ,secretary shall make payments for a resident in a training position described in the preceding center under this section in accordance with subsection 7f74 7e7 ,preference for teaching health centers ,the ,secretary shall give preference to teaching health centers that received payments under section #cdj;,h of the ,public ,health ,service ,act that are seeking to participate as a primary care teaching center under this section4 7f7 ,payment of annual per resident payment amount 7#a7 ,methodology ,subject to paragraph 7#b7 and subsection 7i71 for each year of the program1 the ,secretary shall develop a methodology to determine the per resident payment amount for each full-time equivalent resident of a primary care teaching center under this section4 7#b7 ,minimum payment amount ,subject to subsection 7i71 the per resident payment amount for each full-time equivalent resident of a primary care teaching center under this section for a year shall be not less than-- 7,a7 for #bjad1 #aej1jjj2 and 7,b7 for each subsequent year1 the amount determined under this paragraph for the preceding year increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 for the #ab-month period ending with ,june of the preceding year4 7#c7 ,direct payment ,any payment under this section with respect to a full-time equivalent resident of a primary care teaching center shall be made directly to the primary care teaching center4 7g7 ,no effect on other payments or limitation on number of residents under section #ahhf ,nothing in this section shall effect payments under section #ahhf7;d77#e77;,b7 or section #ahhf7;h7 or the application of the limitation on the number of residents under section #ahhf7;h77#d77;,f74 7h7 ,requirements for entities receiving ,medicare graduate medical education payments ,in the case where a primary care residency program1 including a rural training track program1 funded by a hospital through payments under subsections 7d77#e77;,b7 and 7h7 of section #ahhf becomes a primary care teaching center under this section1 the hospital shall ensure1 during the #aj-year period beginning on the date of the transition1 that the total number of full-time equivalent residents of the hospital in primary care does not decrease4 ,the transition described in the preceding sentence shall begin on the date when the primary care teaching center receives its first payment under this section4 7i7 ,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 primary care teaching center would otherwise receive under this section for a year is adjusted based on the reporting of measures and the performance of the primary care teaching center on measures of population health priorities specified by the ,secretary4 7#b7 ,adjustments to begin in #bjba ,the adjustments shall apply to payments-- 7,a7 with respect to the adjustments for reporting under paragraph 7#g77;,a71 made for #bjba2 and 7,b7 with respect to the adjustments for performance under paragraph 7#g77;,b71 made for #bjbb and subsequent years4 7#c7 ,measures ,the measures of population health priorities specified by the ,secretary under this subsection shall be the measures specified by the ,secretary under section #ahhf7t74 7#d7 ,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 year 7as established under paragraph 7#e774 7#e7 ,performance period ,the ,secretary shall establish the performance period for a year4 ,such performance period shall begin and end prior to the beginning of such year4 7#f7 ,reporting of measures ,the procedures established and implemented under paragraph 7#a7 shall include a process under which primary care teaching centers 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#g7 ,adjustments 7,a7 ,reporting for #bjba ,for #bjba1 in the case of a primary care teaching center that does not submit1 to the ,secretary in accordance with this subsection1 data required to be submitted under paragraph 7#f7 for a period 7determined appropriate by the ,secretary7 for such year1 the total amount that the primary care teaching center would otherwise receive under this section for such year shall be reduced by #a percent4 7,b7 ,performance for #bjbb and subsequent years 7i7 ,in general ,subject to clause 7ii71 based on the performance of each primary care teaching center with respect to compliance with the measures for a performance period for a year 7beginning with #bjbb71 the ,secretary shall determine the amount of any adjustment under this subparagraph to payments to the primary care teaching center under this section for such year4 ,such adjustment may not exceed an amount equal to #a percent of the total amount that the primary care teaching center would otherwise receive under this section for such year4 7ii7 ,budget neutral ,in making adjustments under this subparagraph1 the ,secretary shall ensure that the total amount of payments made to all primary care teaching centers under this section for a year is equal to the total amount of payments that would have been made to such centers under this section for such year if this subsection had not been enacted4 7#h7 ,no effect in subsequent years ,any adjustment under subparagraph 7,a7 or 7,b7 of paragraph 7#g7 shall apply only with respect to the year involved1 and the ,secretary shall not take into account any such adjustment in making payments to a primary care teaching center under this section in a subsequent year4 7j7 ,evaluation and report ,not later than ,january #a1 #bjba1 and every five years thereafter1 the ,secretary shall submit to ,congress a report on the implementation of the program under this section1 including-- 7#a7 the measure development procedures under subsection 7i71 including any barriers to measure development2 7#b7 the compliance with reporting on the performance measures under that subsection1 including any barriers to such compliance2 and 7#c7 recommendations to address any barriers described in subparagraph 7,a7 or 7,b74 7k7 ,funding ,for purposes of carrying out this section1 the ,secretary shall provide for the transfer1 from the ,federal ,hospital ,insurance ,trust ,fund under section #ahag and the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda 7in such proportion as the ,secretary determines appropriate71 of such sums as are necessary to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for fiscal year #bjai and each succeeding fiscal year4 ,amounts transferred under the preceding sentence shall remain available until expended4 4 #d4 ,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 population health 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 population health priorities specified by the ,secretary under this subsection shall include measures relating to-- 7,a7 the extent of training provided in-- 7i7 shortage specialties2 7ii7 a variety of settings and systems2 7iii7 the coordination of patient care across settings2 7iv7 interprofessional and multidisciplinary care teams2 7v7 methods for identifying system errors and implementing system solutions2 and 7vi7 the use of health information technology2 and 7,b7 the number of graduates practicing in shortage specialties #e years after graduation1 including in shortage specialties in health professional shortage areas4 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 schools 7allopathic and osteopathic74 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 #a 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 and every five years thereafter1 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 ,definitions ,in this subsection3 7,a7 ,hospital ,the term hospital means a hospital that receives payments under subsection 7d77#e77;,b74 7,b7 ,shortage specialty ,the term shortage specialty means the following specialties and subspecialties3 7i7 ,family medicine4 7ii7 ,geriatric medicine4 7iii7 ,general internal medicine4 7iv7 ,general surgery4 7v7 ,high priority pediatric subspecialties4 7vi7 ,psychiatry4 7vii7 ,other specialties and subspecialties determined appropriate by the ,secretary4 4 #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 and the ,national ,health ,care ,workforce ,commission a report on the graduate medical education payments that hospitals and primary health training programs receive under the ,medicare program4 7b7 ,requirements ,the report under subsection 7a7 shall include the following information with respect to each hospital or primary health training program 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 payments made to primary care teaching centers under section #ahii;,b of the ,social ,security ,act1 as added by section #c4 7#i7 ,the number of full-time-equivalent residents counted for purposes of making the payments described in paragraph 7#h74 7#aj7 ,the percentage of all graduates of a program for which payments described in paragraph 7#a7 or 7#c7 were made to the hospital that are practicing primary care #e years after graduation4 7#aa7 ,the percentage of all graduates of a program for which payments described in paragraph 7#a7 or 7#c7 were made to the hospital that are practicing primary care in health professional shortage areas #e years after graduation4 7#ab7 ,the percentage of all graduates of a primary care teaching center for which payments described in paragraph 7#h7 were made to the primary care teaching center that are practicing primary care #e years after graduation4 7#ac7 ,the percentage of all graduates of a primary care teaching center for which payments described in paragraph 7#h7 were made to the primary care teaching center that are practicing primary care in health professional shortage areas #e years after graduation4 7#ad7 ,other information determined appropriate by the ,secretary4 #f4 ,reauthorization of the ,health ,care ,workforce ,commission ,section #eaja7;h77#b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #bidq7h77#b77 is amended to read as follows3 7#b7 ,authorization of appropriations ,to carry out this section1 there are authorized to be appropriated #ad1jjj1jjj for the period of fiscal years #bjae through #bjai1 and such sums as may be necessary for each subsequent fiscal year4 4 #g4 ,reduction in ,medicare indirect graduate medical education 7,,ime7 payments 7a7 ,in general ,section #ahhf7;d77#e77;,b77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77ii77 is amended-- 7#a7 in subclause 7,,xi71 by striking and at the end2 7#b7 in subclause 7,,xii7-- 7,a7 by inserting and before ,october #a1 #bjaf1 after #bjjg12 and 7,b7 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subclause3 7,,xiii7 on or after ,october #a1 #bjaf1 c is equal to #a4cb4 4 7b7 ,conforming amendment relating to determination of standardized amount ,section #ahhf7;d77#b77;,c77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#b77;,c77i77 is amended by inserting or of section #g7;a7 of the ,community-,based ,medical ,education ,act of #bjad after ,act of #aiig4