,,ii  #aac? ,,congress  #b;d ,session   
,s4 #bgbh  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,july #ca1 #bjad ,mrs4 
,murray introduc$ ! foll[+ bill2 :i* 0  
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
provide community-bas$ m$ical education 
paym5ts to prim>y c>e tea*+ c5t]s1 to   
provide = a ,m$ic>e indirect m$ical     
education p]=mance adju/m5t1 & to       
increase ,m$ic>e graduate m$ical        
education transp>5cy1 & = o!r purposes4 
#a4 ,%ort title  ,?is ,act may be cit$ z
 ! ,community-,bas$ ,m$ical ,education  
,act ( #bjad4  #b4 ,tea*+ heal? c5t]    
ext5sion  7a7 ,,?c program ,section     
#cdj;,h ( ! ,public ,heal? ,s]vice ,act 
7#db ,u4,s4,c4 #bef;h7 is am5d$-- 7#a7 9
 subsection 7g7-- 7,a7 by /rik+ n to    
exce$ #bcj1jjj1jjj1 = ! p]iod ( fiscal  
ye>s #bjaa ?r\gh #bjae4 & ins]t+ n to   
exce$--2 &  7,b7 by add+ at ! end !     
foll[+3  7#a7 #bcj1jjj1jjj1 = ! p]iod ( 
fiscal ye>s #bjaa ?r\gh #bjae2 &  7#b7  

#dbj1jjj1jjj1 = ! p]iod ( fiscal ye>s   
#bjaf ?r\gh #bjai4  2 &  7#b7 by add+ at
 ! end ! foll[+3  7k7 ,evaluation (     
program2 p>ticipation 9 prim>y c>e tea*+
 program ,! ,secret>y %all-- 7#a7 n lat]
 ?an ,decemb] #ca1 #bjag1 conduct a     
compreh5sive evaluation ( ! program "u  
?is section2 &  7#b7 e/abli% a process  
by :i* qualifi$ tea*+ heal? c5t]s t h   
receiv$ paym5ts "u ?is section prior to 
! date on :i* ! prim>y c>e tea*+ c5t]s  
program is e/abli%$ "u section #ahii;,b 
( ! ,social ,security ,act may become   
eligible to p>ticipate 9 su* prim>y c>e 
tea*+ program4  4  7b7 ,tea*+ heal?     
c5t]s developm5t grants ,section #gdi;,a
 ( ! ,public ,heal? ,s]vice ,act 7#db   
,u4,s4,c4 #bicl-#a7 is am5d$-- 7#a7 9   
subsection 7a71 by ins]t+ 1 bas$ on     
demon/rat$ f9ancial ne$1 aft] c5t]s2    
7#b7 9 subsection 7b71 by /rik+ #ejj1jjj
 & ins]t+ #bej1jjj2 &  7#c7 9 subsection
 7g71 by /rik+ fiscal ye> #bjaj1        
#ej1jjj1jjj = fiscal ye> #bjaa1         
#ej1jjj1jjj = fiscal ye> #bjab & ins]t+ 

ea* ( fiscal ye>s #bjaf1 #bjag1 & #bjah4
  #c4 ,community-,bas$ ,m$ical          
,education ,paym5ts ,title ,,xviii ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acie et seq47 is am5d$ by add+ at ! end
 ! foll[+ new section3  #ahii;,b4       
,community-,bas$ ,m$ical ,education     
,paym5ts  7a7 ,9 g5]al ,! ,secret>y %all
 e/abli% a program "u :i* ! ,secret>y   
makes paym5ts to prim>y c>e tea*+ c5t]s 
7z def9$ 9 subsection 7c77 "u ?is       
section4  7b7 ,implem5tation ,!         
,secret>y %all e/abli% ! program "u ?is 
section n lat] ?an ,janu>y #a1 #bjai4   
7c7 ,def9itions  7#a7 ,def9ition (      
prim>y c>e tea*+ c5t] ,9 ?is section1 ! 
t]m prim>y c>e tea*+ c5t] means an      
entity describ$ 9 p>agraph 7#b7 t-- 7,a7
 is accr$it$ by ! ,accr$itation ,c\ncil 
on ,graduate ,m$ical ,education1 !      
,am]ican ,o/eopa?ic ,association1 or !  
,commission on ,d5tal ,accr$itation2 &  
7,b7 op]ates a community-bas$ prim>y c>e
 resid5cy program 7z def9$ 9 p>agraph   
7#e77 9 a rural or und]s]v$ area4  7#b7 

,entity describ$ ,! foll[+ entities are 
describ$ 9 ?is p>agraph3 7,a7 ,an entity
 t receiv$ paym5ts "u section #cdj;,h ( 
! ,public ,heal? ,s]vice ,act = a       
community bas$1 ambulatory pati5t c>e   
c5t] :i* op]ates a prim>y c>e resid5cy  
program or a relat$ consortia recogniz$ 
by ! ,heal? ,res\rces & ,s]vices        
,adm9i/ration4  7,b7 ,a community-bas$1 
indep5d5t corporate entity collaborat+ )
 "o or m hospitals 9 op]at+ "o or m     
prim>y c>e resid5cy programs4  7,c7 ,a  
m$ical education entity e/abli%$ by "o  
or m hospitals to develop & op]ate "o or
 m prim>y c>e resid5cy programs4 ,!     
hospital or hospitals may be ! sole     
corporate memb]s ( ! entity1 b ! gov]n+ 
bo>d ( ! entity %all include            
repres5tatives ( ! community4  7,d7 ,a  
m$ical education entity t is indep5d5t (
 any hospital b collaborates ) a        
hospital 9 op]at+ "o or m m$ical        
resid5cy tra9+ programs4 ,! m$ical      
education entity may include a univ]sity
 or a s*ool ( m$ic9e4  7,e7 ,a subsidi>y

 ( a hospital or indep5d5t corporation  
op]at+ "o or m prim>y c>e resid5cy      
programs = ! hospital ) community       
p>ticipation 9 ! gov]nance ( !          
organization4  7,f7 ,a rural tra9+ track
 program 7z def9$ 9 p>agraph 7#f774     
7#c7 ,inclusion ( c]ta9 entities ,! t]m 
prim>y c>e tea*+ c5t] includes ! foll[+3
 7,a7 ,a ,f$]ally qualifi$ heal? c5t] 7z
 def9$ 9 section #aije7l77#b77;,b774    
7,b7 ,a community m5tal heal? c5t] 7z   
def9$ 9 section #ahfa7;ff77#c77;,b774   
7,c7 ,a rural heal? cl9ic1 z def9$ 9    
section #ahfa7;aa74  7,d7 ,a heal? c5t] 
op]at$ by ! ,indian ,heal? ,s]vice1 an  
,indian tribe or tribal organization1 or
 an urban ,indian organization 7z def9$ 
9 section #d ( ! ,indian ,heal? ,c>e    
,improvem5t ,act74  7,e7 ,an entity     
receiv+ funds "u title ,x ( ! ,public   
,heal? ,s]vice ,act4  7,f7 ,a critical  
access hospital4  7,g7 ,an entity t     
collaborates to =m a consortium t       
op]ates an accr$it$ prim>y c>e resid5cy 
program1 s long z ! consortium is       

accr$it$ 9 ! prim>y c>e specialty & is  
li/$ z ! in/itutional sponsor by !      
relevant accr$it+ body4 ,)9 !           
consortium1 a community-bas$ ambulatory 
c>e c5t] %all play an integral role 9 ! 
academic1 f9ancial1 & adm9i/rative      
op]ations ( ! prim>y c>e resid5cy       
program4  7#d7 ,def9ition ( prim>y c>e  
,9 ?is section1 ! t]m prim>y c>e means  
family m$ic9e1 int]nal m$ic9e1          
p$iatrics1 int]nal m$ic9e-p$iatrics1    
ob/etrics & gynecology1 psy*iatry1 g5]al
 d5ti/ry1 p$iatric d5ti/ry1 or          
g]iatrics4  7#e7 ,def9ition ( prim>y c>e
 resid5cy program ,9 ?is section1 ! t]m 
prim>y c>e resid5cy program means an    
approv$ m$ical resid5cy tra9+ program 7z
 def9$ 9 section #ahhf7;h77#e77;,a77 9  
prim>y c>e4  7#f7 ,def9ition ( rural    
tra9+ track program ,9 ?is section1 !   
t]m rural tra9+ track program means an  
alt]native tra9+ track integrat$ ) a    
l>g] m urban or community hospital      
program & sep>ately accr$it$ z su*1 ) a 
rural location1 a rural mission1 or a   

major rural s]vice area1 9 :i* !        
resid5ts sp5d approximately two ( ?ree  
ye>s 9 a place ( practice sep>ate & m   
rural or rurally focus$ ?an ! l>g]      
program4  7d7 ,limitations on numb] (   
resid5t tra9+ positions  7#a7           
,limitation on total numb] "u program   
,subject to p>agraph 7#c71 ! ,secret>y  
%all make paym5ts "u ?is section = n m  
?an #a1ejj new full-"t equival5t resid5t
 tra9+ positions to be di/ribut$ to     
prim>y c>e tea*+ c5t]s at a rate ( n m  
?an #cjj p] ye> until exp5d$4  7#b7     
,limitation on total numb] = ea* prim>y 
c>e tea*+ c5t] ,subject to p>agraph     
7#c71 no s+le prim>y c>e tea*+ c5t] %all
 receive a total ( m ?an #ej ( !        
positions di/ribut$ "u ! program1 :i*   
mu/ be 9 prim>y c>e specialties4  7#c7  
,exception = exi/+ resid5ts ( tea*+     
heal? c5t]s ,! limitation "u ea* (      
p>agraphs 7#a7 & 7#b7 %all n apply )    
respect to a resid5t tra9+ position ( a 
tea*+ heal? c5t] t receiv$ paym5ts "u   
section #cdj;,h ( ! ,public ,heal?      

,s]vice ,act if ! resid5t tra9+ position
 0 9 a m$ical resid5cy tra9+ program    
op]at$ by ! tea*+ heal? c5t] prior to ! 
p>ticipation ( ! tea*+ heal? c5t] z a   
prim>y c>e tea*+ c5t] "u ?is section4 ,!
 ,secret>y %all make paym5ts = a resid5t
 9 a tra9+ position describ$ 9 ! prec$+ 
c5t] "u ?is section 9 accordance )      
subsection 7f74  7e7 ,pref]5ce = tea*+  
heal? c5t]s ,! ,secret>y %all give      
pref]5ce to tea*+ heal? c5t]s t receiv$ 
paym5ts "u section #cdj;,h ( ! ,public  
,heal? ,s]vice ,act t are seek+ to      
p>ticipate z a prim>y c>e tea*+ c5t] "u 
?is section4  7f7 ,paym5t ( annual p]   
resid5t paym5t am\nt  7#a7 ,me?odology  
,subject to p>agraph 7#b7 & subsection  
7i71 = ea* ye> ( ! program1 ! ,secret>y 
%all develop a me?odology to det]m9e !  
p] resid5t paym5t am\nt = ea* full-"t   
equival5t resid5t ( a prim>y c>e tea*+  
c5t] "u ?is section4  7#b7 ,m9imum      
paym5t am\nt ,subject to subsection 7i71
 ! p] resid5t paym5t am\nt = ea* full-"t
 equival5t resid5t ( a prim>y c>e tea*+ 

c5t] "u ?is section = a ye> %all be n   
less ?an-- 7,a7 = #bjad1 #aej1jjj2 &    
7,b7 = ea* subsequ5t ye>1 ! am\nt       
det]m9$ "u ?is p>agraph = ! prec$+ ye>  
increas$ by ! p]c5tage increase 9 !     
consum] price index = all urban consum]s
 7,unit$ ,/ates city av]age7 = !        
#ab-mon? p]iod end+ ) ,june ( ! prec$+  
ye>4  7#c7 ,direct paym5t ,any paym5t "u
 ?is section ) respect to a full-"t     
equival5t resid5t ( a prim>y c>e tea*+  
c5t] %all be made directly to ! prim>y  
c>e tea*+ c5t]4  7g7 ,no effect on o!r  
paym5ts or limitation on numb] (        
resid5ts "u section #ahhf ,no?+ 9 ?is   
section %all effect paym5ts "u section  
#ahhf7;d77#e77;,b7 or section #ahhf7;h7 
or ! application ( ! limitation on !    
numb] ( resid5ts "u section             
#ahhf7;h77#d77;,f74  7h7 ,requirem5ts = 
entities receiv+ ,m$ic>e graduate m$ical
 education paym5ts ,9 ! case :]e a      
prim>y c>e resid5cy program1 includ+ a  
rural tra9+ track program1 fund$ by a   
hospital ?r\gh paym5ts "u subsections   

7d77#e77;,b7 & 7h7 ( section #ahhf      
becomes a prim>y c>e tea*+ c5t] "u ?is  
section1 ! hospital %all ensure1 dur+ ! 
#aj-ye> p]iod beg9n+ on ! date ( !      
transition1 t ! total numb] ( full-"t   
equival5t resid5ts ( ! hospital 9 prim>y
 c>e does n decrease4 ,! transition     
describ$ 9 ! prec$+ s5t5ce %all beg9 on 
! date :5 ! prim>y c>e tea*+ c5t]       
receives its fir/ paym5t "u ?is section4
  7i7 ,p]=mance adju/m5ts  7#a7 ,9 g5]al
 ,subject to ! succe$+ provisions ( ?is 
subsection1 ! ,secret>y %all e/abli% &  
implem5t proc$ures "u :i* ! am\nt (     
paym5ts t a prim>y c>e tea*+ c5t] w\ld  
o!rwise receive "u ?is section = a ye>  
is adju/$ bas$ on ! report+ ( measures &
 ! p]=mance ( ! prim>y c>e tea*+ c5t] on
 measures ( population heal? priorities 
specifi$ by ! ,secret>y4  7#b7          
,adju/m5ts to beg9 9 #bjba ,! adju/m5ts 
%all apply to paym5ts--  7,a7 ) respect 
to ! adju/m5ts = report+ "u p>agraph    
7#g77;,a71 made = #bjba2 &  7,b7 )      
respect to ! adju/m5ts = p]=mance "u    

p>agraph 7#g77;,b71 made = #bjbb &      
subsequ5t ye>s4  7#c7 ,measures ,!      
measures ( population heal? priorities  
specifi$ by ! ,secret>y "u ?is          
subsection %all be ! measures specifi$  
by ! ,secret>y "u section #ahhf7t74     
7#d7 ,p]=mance /&>ds ,! ,secret>y %all  
e/abli% p]=mance /&>ds ) respect to     
measures specifi$ by ! ,secret>y "u ?is 
subsection = a p]=mance p]iod = a ye> 7z
 e/abli%$ "u p>agraph 7#e774  7#e7      
,p]=mance p]iod ,! ,secret>y %all       
e/abli% ! p]=mance p]iod = a ye>4 ,su*  
p]=mance p]iod %all beg9 & end prior to 
! beg9n+ ( su* ye>4  7#f7 ,report+ (    
measures ,! proc$ures e/abli%$ &        
implem5t$ "u p>agraph 7#a7 %all include 
a process "u :i* prim>y c>e tea*+ c5t]s 
%all submit data on ! measures specifi$ 
by ! ,secret>y "u ?is subsection to !   
,secret>y 9 a =m & mann]1 & at a "t1    
specifi$ by ! ,secret>y = purposes ( ?is
 subsection4  7#g7 ,adju/m5ts  7,a7     
,report+ = #bjba ,= #bjba1 9 ! case ( a 
prim>y c>e tea*+ c5t] t does n submit1  

to ! ,secret>y 9 accordance ) ?is       
subsection1 data requir$ to be submitt$ 
"u p>agraph 7#f7 = a p]iod 7det]m9$     
appropriate by ! ,secret>y7 = su* ye>1 !
 total am\nt t ! prim>y c>e tea*+ c5t]  
w\ld o!rwise receive "u ?is section =   
su* ye> %all be r$uc$ by #a p]c5t4  7,b7
 ,p]=mance = #bjbb & subsequ5t ye>s  7i7
 ,9 g5]al ,subject to clause 7ii71 bas$ 
on ! p]=mance ( ea* prim>y c>e tea*+    
c5t] ) respect to compliance ) !        
measures = a p]=mance p]iod = a ye>     
7beg9n+ ) #bjbb71 ! ,secret>y %all      
det]m9e ! am\nt ( any adju/m5t "u ?is   
subp>agraph to paym5ts to ! prim>y c>e  
tea*+ c5t] "u ?is section = su* ye>4    
,su* adju/m5t may n exce$ an am\nt equal
 to #a p]c5t ( ! total am\nt t ! prim>y 
c>e tea*+ c5t] w\ld o!rwise receive "u  
?is section = su* ye>4  7ii7 ,budget    
neutral ,9 mak+ adju/m5ts "u ?is        
subp>agraph1 ! ,secret>y %all ensure t !
 total am\nt ( paym5ts made to all      
prim>y c>e tea*+ c5t]s "u ?is section = 
a ye> is equal to ! total am\nt (       

paym5ts t w\ld h be5 made to su* c5t]s  
"u ?is section = su* ye> if ?is         
subsection _h n be5 enact$4  7#h7 ,no   
effect 9 subsequ5t ye>s ,any adju/m5t "u
 subp>agraph 7,a7 or 7,b7 ( p>agraph    
7#g7 %all apply only ) respect to ! ye> 
involv$1 & ! ,secret>y %all n take into 
acc\nt any su* adju/m5t 9 mak+ paym5ts  
to a prim>y c>e tea*+ c5t] "u ?is       
section 9 a subsequ5t ye>4  7j7         
,evaluation & report ,n lat] ?an ,janu>y
 #a1 #bjba1 & e five ye>s !reaft]1 !    
,secret>y %all submit to ,congress a    
report on ! implem5tation ( ! program "u
 ?is section1 includ+--  7#a7 ! measure 
developm5t proc$ures "u subsection 7i71 
includ+ any b>ri]s to measure           
developm5t2  7#b7 ! compliance ) report+
 on ! p]=mance measures "u t subsection1
 includ+ any b>ri]s to su* compliance2 &
  7#c7 recomm5dations to address any    
b>ri]s describ$ 9 subp>agraph 7,a7 or   
7,b74  7k7 ,fund+ ,= purposes ( c>ry+   
out ?is section1 ! ,secret>y %all       
provide = ! transf]1 f ! ,f$]al         

,hospital ,insurance ,tru/ ,fund "u     
section #ahag & ! ,f$]al ,supplem5t>y   
,m$ical ,insurance ,tru/ ,fund "u       
section #ahda 79 su* proportion z !     
,secret>y det]m9es appropriate71 ( su*  
sums z are necess>y to ! ,c5t]s =       
,m$ic>e  ,m$icaid ,s]vices ,program     
,managem5t ,acc\nt = fiscal ye> #bjai & 
ea* succe$+ fiscal ye>4 ,am\nts         
transf]r$ "u ! prec$+ s5t5ce %all rema9 
available until exp5d$4  4  #d4 ,m$ic>e 
indirect m$ical education p]=mance      
adju/m5t ,section #ahhf ( ! ,social     
,security ,act 7#db ,u4,s4,c4 #acieww7  
is am5d$--  7#a7 9 subsection           
7d77#e77;,b71 9 ! matt] prec$+ clause   
7i71 by ins]t+ subject to subsection 7t7
 & be=e except z foll[s2 &  7#b7 by add+
 at ! end ! foll[+ new subsection3  7t7 
,indirect m$ical education p]=mance     
adju/m5ts  7#a7 ,9 g5]al ,subject to !  
succe$+ provisions ( ?is subsection1 !  
,secret>y %all e/abli% & implem5t       
proc$ures "u :i* ! am\nt ( paym5ts t a  
hospital 7z def9$ 9 p>agraph 7#aa77 w\ld

 o!rwise receive = indirect m$ical      
education co/s "u subsection            
7d77#e77;,b7 = dis*>ges occurr+ dur+ a  
fiscal ye> is adju/$ bas$ on ! report+ (
 measures & ! p]=mance ( ! hospital on  
measures ( population heal? priorities  
specifi$ by ! ,secret>y4  7#b7          
,adju/m5ts to beg9 9 fiscal ye> #bjah ,!
 adju/m5ts %all apply to paym5ts =      
dis*>ges occurr+--  7,a7 ) respect to ! 
adju/m5ts = report+ "u p>agraph         
7#h77;,a71 dur+ fiscal ye> #bjah2 &     
7,b7 ) respect to ! adju/m5ts = p]=mance
 "u p>agraph 7#h77;,b71 on or aft]      
,octob] #a1 #bjah4  7#c7 ,measures ,!   
measures ( population heal? priorities  
specifi$ by ! ,secret>y "u ?is          
subsection %all include measures relat+ 
to-- 7,a7 ! ext5t ( tra9+ provid$ 9--   
7i7 %ortage specialties2  7ii7 a v>iety 
( sett+s & sy/ems2  7iii7 ! coord9ation 
( pati5t c>e across sett+s2  7iv7       
int]pr(essional & multidiscipl9>y c>e   
teams2  7v7 me?ods = id5tify+ sy/em     
errors & implem5t+ sy/em solutions2 &   

7vi7 ! use ( heal? in=mation te*nology2 
&  7,b7 ! numb] ( graduates practic+ 9  
%ortage specialties #e ye>s aft]        
graduation1 includ+ 9 %ortage           
specialties 9 heal? pr(essional %ortage 
areas4  7#d7 ,measure developm5t process
  7,a7 ,9 g5]al ,! measures ( pati5t c>e
 specifi$ by ! ,secret>y "u ?is         
subsection--  7i7 %all--  7,i7 be       
measures t h be5 adopt$ or endors$ by an
 accr$it+ organization 7su* z !         
,accr$itation ,c\ncil = ,graduate       
,m$ical ,education or ,am]ican          
,o/eopa?ic ,association72 &  7,,ii7 be  
measures t ! ,secret>y id5tifies z hav+ 
us$ a cons5sus-bas$ process = develop+  
su* measures2 &  7ii7 may include       
measures t h be5 submitt$ by tea*+      
hospitals & m$ical s*ools 7allopa?ic &  
o/eopa?ic74  7,b7 ,propos$ set ( initial
 measures ,n lat] ?an ,july #a1 #bjae1 !
 ,secret>y %all publi% 9 ! ,f$]al       
,regi/] a propos$ initial set ( measures
 = use "u ?is subsection4 ,! ,secret>y  
%all provide = a p]iod ( public comm5t  

on su* measures4  7,c7 ,f9al set (      
initial measures ,n lat] ?an ,janu>y #a1
 #bjaf1 ! ,secret>y %all publi% 9 !     
,f$]al ,regi/] ! set ( initial measures 
to be specifi$ by ! ,secret>y = use "u  
?is subsection4  7,d7 ,update ( measures
 ,! ,secret>y may1 ?r\gh notice & comm5t
 rulemak+1 p]iodically update ! measures
 specifi$ "u ?is subsection pursuant to 
! requirem5ts "u subp>agraph 7,a74  7#e7
 ,p]=mance /&>ds ,! ,secret>y %all      
e/abli% p]=mance /&>ds ) respect to     
measures specifi$ by ! ,secret>y "u ?is 
subsection = a p]=mance p]iod = a fiscal
 ye> 7z e/abli%$ "u p>agraph 7#f774     
7#f7 ,p]=mance p]iod ,! ,secret>y %all  
e/abli% ! p]=mance p]iod = a fiscal ye>4
 ,su* p]=mance p]iod %all beg9 & end    
prior to ! beg9n+ ( su* fiscal ye>4     
7#g7 ,report+ ( measures ,! proc$ures   
e/abli%$ & implem5t$ "u p>agraph 7#a7   
%all include a process "u :i* hospitals 
%all submit data on ! measures specifi$ 
by ! ,secret>y "u ?is subsection to !   
,secret>y 9 a =m & mann]1 & at a "t1    

specifi$ by ! ,secret>y = purposes ( ?is
 subsection4  7#h7 ,adju/m5ts  7,a7     
,report+ = fiscal ye> #bjah ,= fiscal   
ye> #bjah1 9 ! case ( a hospital t does 
n submit1 to ! ,secret>y 9 accordance ) 
?is subsection1 data requir$ to be      
submitt$ "u p>agraph 7#g7 = a p]iod     
7det]m9$ appropriate by ! ,secret>y7 =  
su* fiscal ye>1 ! total am\nt t !       
hospital w\ld o!rwise receive "u        
subsection 7d77#e77;,b7 = dis*>ges 9 su*
 fiscal ye> %all be r$uc$ by #a p]c5t4  
7,b7 ,p]=mance = fiscal ye> #bjai &     
subsequ5t fiscal ye>s  7i7 ,9 g5]al     
,subject to clause 7ii71 bas$ on !      
p]=mance ( ea* hospital ) respect to    
compliance ) ! measures = a p]=mance    
p]iod = a fiscal ye> 7beg9n+ ) fiscal   
ye> #bjai71 ! ,secret>y %all det]m9e !  
am\nt ( any adju/m5t "u ?is subp>agraph 
to paym5ts to ! hospital "u subsection  
7d77#e77;,b7 = dis*>ges 9 su* fiscal    
ye>4 ,su* adju/m5t may n exce$ an am\nt 
equal to #b p]c5t ( ! total am\nt t !   
hospital w\ld o!rwise receive "u su*    

subsection = dis*>ges 9 su* fiscal ye>4 
7ii7 ,budget neutral ,9 mak+ adju/m5ts  
"u ?is subp>agraph1 ! ,secret>y %all    
ensure t ! total am\nt ( paym5ts made to
 all hospitals "u subsection            
7d77#e77;,b7 = dis*>ges 9 a fiscal ye>  
is equal to ! total am\nt ( paym5ts t   
w\ld h be5 made to su* hospitals "u su* 
subsection = dis*>ges 9 su* fiscal ye>  
if ?is subsection _h n be5 enact$4  7#i7
 ,no effect 9 subsequ5t fiscal ye>s ,any
 adju/m5t "u subp>agraph 7,a7 or 7,b7 ( 
p>agraph 7#h7 %all apply only ) respect 
to ! fiscal ye> involv$1 & ! ,secret>y  
%all n take into acc\nt any su* adju/m5t
 9 mak+ paym5ts to a hospital "u ?is    
section 9 a subsequ5t fiscal ye>4  7#aj7
 ,evaluation ( submission ( p]=mance    
measures ,n lat] ?an ,janu>y #a1 #bjah1 
& e five ye>s !reaft]1 ! ,secret>y %all 
submit to ,congress a report on !       
implem5tation ( ?is subsection1         
includ+--  7,a7 ! measure developm5t    
proc$ures1 includ+ any b>ri]s to measure
 developm5t2  7,b7 ! compliance )       

report+ on ! p]=mance measures1 includ+ 
any b>ri]s to su* compliance2 &  7,c7   
recomm5dations to address any b>ri]s    
describ$ 9 subp>agraph 7,a7 or 7,b74    
7#aa7 ,def9itions ,9 ?is subsection3    
7,a7 ,hospital ,! t]m hospital means a  
hospital t receives paym5ts "u          
subsection 7d77#e77;,b74  7,b7 ,%ortage 
specialty ,! t]m %ortage specialty means
 ! foll[+ specialties & subspecialties3 
7i7 ,family m$ic9e4  7ii7 ,g]iatric     
m$ic9e4  7iii7 ,g5]al int]nal m$ic9e4   
7iv7 ,g5]al surg]y4  7v7 ,high priority 
p$iatric subspecialties4  7vi7          
,psy*iatry4  7vii7 ,o!r specialties &   
subspecialties det]m9$ appropriate by ! 
,secret>y4  4  #e4 ,increas+ ,m$ic>e    
graduate m$ical education transp>5cy    
7a7 ,9 g5]al ,n lat] ?an #b ye>s aft] ! 
date ( ! enactm5t ( ?is ,act1 & annually
 !reaft]1 ! ,secret>y ( ,heal? & ,human 
,s]vices %all submit to ,congress & !   
,national ,heal? ,c>e ,work=ce          
,commission a report on ! graduate      
m$ical education paym5ts t hospitals &  

prim>y heal? tra9+ programs receive "u !
 ,m$ic>e program4  7b7 ,requirem5ts ,!  
report "u subsection 7a7 %all include ! 
foll[+ in=mation ) respect to ea*       
hospital or prim>y heal? tra9+ program t
 receives su* paym5ts3  7#a7 ,! direct  
graduate m$ical education paym5ts made  
to ! hospital "u section #ahhf7;h7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7h774  7#b7 ,! total co/s (      
direct graduate m$ical education to !   
hospital z report$ on ! annual ,m$ic>e  
,co/ ,reports4  7#c7 ,! indirect m$ical 
education paym5ts made to ! hospital "u 
section #ahhf7;d77#e77;,b7 ( su* ,act   
7#db ,u4,s4,c4 #acieww7d77#a77;,b774    
7#d7 ,! numb] ( full-"t-equival5t       
resid5ts c\nt$ = purposes ( mak+ !      
paym5ts describ$ 9 p>agraph 7#a74  7#e7 
,! numb] ( full-"t-equival5t resid5ts   
c\nt$ = purposes ( mak+ ! paym5ts       
describ$ 9 p>agraph 7#c74  7#f7 ,! numb]
 ( full-"t-equival5t resid5ts1 if any1 t
 are n c\nt$ = purposes ( mak+ paym5ts  
describ$ 9 p>agraph 7#a74  7#g7 ,! numb]

 ( full-"t-equival5t resid5ts1 if any1 t
 are n c\nt$ = purposes ( mak+ paym5ts  
describ$ 9 p>agraph 7#c74  7#h7 ,!      
paym5ts made to prim>y c>e tea*+ c5t]s  
"u section #ahii;,b ( ! ,social         
,security ,act1 z add$ by section #c4   
7#i7 ,! numb] ( full-"t-equival5t       
resid5ts c\nt$ = purposes ( mak+ !      
paym5ts describ$ 9 p>agraph 7#h74  7#aj7
 ,! p]c5tage ( all graduates ( a program
 = :i* paym5ts describ$ 9 p>agraph 7#a7 
or 7#c7 7 made to ! hospital t are      
practic+ prim>y c>e #e ye>s aft]        
graduation4  7#aa7 ,! p]c5tage ( all    
graduates ( a program = :i* paym5ts     
describ$ 9 p>agraph 7#a7 or 7#c7 7 made 
to ! hospital t are practic+ prim>y c>e 
9 heal? pr(essional %ortage areas #e    
ye>s aft] graduation4  7#ab7 ,! p]c5tage
 ( all graduates ( a prim>y c>e tea*+   
c5t] = :i* paym5ts describ$ 9 p>agraph  
7#h7 7 made to ! prim>y c>e tea*+ c5t] t
 are practic+ prim>y c>e #e ye>s aft]   
graduation4  7#ac7 ,! p]c5tage ( all    
graduates ( a prim>y c>e tea*+ c5t] =   

:i* paym5ts describ$ 9 p>agraph 7#h7 7  
made to ! prim>y c>e tea*+ c5t] t are   
practic+ prim>y c>e 9 heal? pr(essional 
%ortage areas #e ye>s aft] graduation4  
7#ad7 ,o!r in=mation det]m9$ appropriate
 by ! ,secret>y4  #f4 ,reau?orization ( 
! ,heal? ,c>e ,work=ce ,commission      
,section #eaja7;h77#b7 ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #bidq7h77#b77 is am5d$ to read
 z foll[s3  7#b7 ,au?orization (        
appropriations ,to c>ry out ?is section1
 !re are au?oriz$ to be appropriat$     
#ad1jjj1jjj = ! p]iod ( fiscal ye>s     
#bjae ?r\gh #bjai1 & su* sums z may be  
necess>y = ea* subsequ5t fiscal ye>4  4 
#g4 ,r$uction 9 ,m$ic>e indirect        
graduate m$ical education 7,,ime7       
paym5ts  7a7 ,9 g5]al ,section          
#ahhf7;d77#e77;,b77ii7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,b77ii77 is am5d$-- 7#a7
 9 subclause 7,,xi71 by /rik+ & at !    
end2  7#b7 9 subclause 7,,xii7-- 7,a7 by
 ins]t+ & be=e ,octob] #a1 #bjaf1 aft]  

#bjjg12 &  7,b7 by /rik+ ! p]iod at !   
end & ins]t+ 2 &2 &  7#c7 by add+ at !  
end ! foll[+ new subclause3  7,,xiii7 on
 or aft] ,octob] #a1 #bjaf1 c is equal  
to #a4cb4  4  7b7 ,con=m+ am5dm5t relat+
 to det]m9ation ( /&>diz$ am\nt ,section
 #ahhf7;d77#b77;,c77i7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#b77;,c77i77 is am5d$ by     
ins]t+ or ( section #g7;a7 ( !          
,community-,bas$ ,m$ical ,education ,act
 ( #bjad aft] ,act ( #aiig4