Rural Physician Workforce Production Act of 2021

II 117TH CONGRESS 1ST SESSION S. 1893 To amend title XVIII of the Social Security Act to support rural residency training funding that is equitable for all States, and for other purposes. IN THE SENATE OF THE UNITED STATES MAY 27, 2021 Mr. TESTER (for himself and Mr. BARRASSO) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to support rural residency training funding that is equitable for all States, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Rural Physician Work- 4 force Production Act of 2021’’. 5 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 2 •S 1893 IS SEC. 2. ELECTIVE RURAL SUSTAINABILITY PER RESIDENT 1 PAYMENT FOR RESIDENTS TRAINING IN 2 RURAL TRAINING LOCATIONS. 3 (a) IN GENERAL.—Section 1886 of the Social Secu- 4 rity Act (42 U.S.C. 1395ww) is amended by adding at the 5 end the following new subsection: 6 ‘‘(u) ELECTIVE RURAL SUSTAINABILITY PER RESI- 7 DENT PAYMENT AMOUNT FOR RESIDENTS TRAINING IN 8 RURAL TRAINING LOCATIONS.— 9 ‘‘(1) DETERMINATION OF ELECTIVE RURAL 10 SUSTAINABILITY PER RESIDENT PAYMENT 11 AMOUNT.— 12 ‘‘(A) IN GENERAL.—The elective rural sus- 13 tainability per resident payment amount deter- 14 mined under this subsection for an applicable 15 hospital (as defined in paragraph (7)(A)) that 16 makes an election under paragraph (2), with re- 17 spect to each full-time-equivalent resident in an 18 approved medical residency training program 19 that receives training in a rural training loca- 20 tion (as defined in paragraph (7)(C)), is an 21 amount equal to the difference between— 22 ‘‘(i) the total elective rural sustain- 23 ability amount determined under subpara- 24 graph (B) (or, in the case of an applicable 25 hospital not located in a rural area, the 26 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 3 •S 1893 IS total elective rural sustainability amount or 1 urban total elective rural sustainability 2 amount, as applicable, determined under 3 such subparagraph); and 4 ‘‘(ii) the amount (if any) the applica- 5 ble hospital otherwise receives for direct 6 graduate medical education costs under 7 subsection (h) or section 1814(l), as appli- 8 cable, with respect to each such resident. 9 ‘‘(B) TOTAL ELECTIVE RURAL SUSTAIN- 10 ABILITY AMOUNT.— 11 ‘‘(i) ESTABLISHMENT FOR INITIAL 12 COST REPORTING PERIODS.— 13 ‘‘(I) IN GENERAL.—Subject to 14 subclause (II), for cost reporting peri- 15 ods beginning during the first year be- 16 ginning on or after the date of the en- 17 actment of this subsection, the Sec- 18 retary shall establish a total elective 19 rural sustainability amount for time 20 spent by each full-time-equivalent resi- 21 dent in an approved medical residency 22 training program that receives train- 23 ing in a rural training location. Such 24 amount shall be the amount that the 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 4 •S 1893 IS Secretary determines is equal to the 1 median national direct GME training 2 costs per full-time equivalent resident 3 for 2015 described in table 9 on page 4 33 of the March 2018 GAO report on 5 Physician Workforce (GAO–18–240), 6 updated for each subsequent year 7 through the first year beginning on or 8 after the date of the enactment of this 9 subsection, by the annual percentage 10 increase in the consumer price index 11 for all urban consumers (all items; 12 United States city average). 13 ‘‘(II) APPLICATION TO URBAN 14 HOSPITALS.—For cost reporting peri- 15 ods beginning during the first year be- 16 ginning on or after the date of the en- 17 actment of this subsection, in the case 18 of an applicable hospital that is not 19 located in a rural area— 20 ‘‘(aa) with respect to such 21 residents that receive training in 22 a rural track or an integrated 23 rural track, the total elective 24 rural sustainability amount per 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 5 •S 1893 IS resident shall be equal to the 1 amount established under sub- 2 clause (I); and 3 ‘‘(bb) with respect to such 4 residents that receive training in 5 a rural training location and who 6 are not participating in a rural 7 track or an integrated rural 8 track, the total elective rural sus- 9 tainability amount per resident 10 shall be equal to 50 percent of 11 the amount established under 12 subclause (I) (referred to in this 13 subsection as the ‘urban total 14 elective rural sustainability 15 amount’). 16 ‘‘(ii) UPDATING FOR SUBSEQUENT 17 COST REPORTING PERIODS.—For each sub- 18 sequent cost reporting period, the total 19 elective rural sustainability amount under 20 clause (i)(I) and clause (i)(II)(aa) and the 21 urban total elective rural sustainability 22 amount under clause (i)(II)(bb), respec- 23 tively, are equal to such amounts deter- 24 mined under such clause for the previous 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 6 •S 1893 IS cost reporting period updated, through the 1 midpoint of the period, by projecting the 2 estimated percentage change in the con- 3 sumer price index for all urban consumers 4 (all items; United States city average) dur- 5 ing the 12-month period ending at that 6 midpoint, with appropriate adjustments to 7 reflect previous under- or over-estimations 8 under this clause in the projected percent- 9 age change in the consumer price index for 10 medical care services. 11 ‘‘(C) CLARIFICATION.—The total elective 12 rural sustainability amount, the urban total 13 elective rural sustainability amount, and the 14 elective rural sustainability per resident pay- 15 ment amount determined under this paragraph 16 shall not be discounted or otherwise adjusted 17 based on the Medicare patient load (as defined 18 in subsection (h)(3)(C)) of an applicable hos- 19 pital or discharges in a diagnosis-related group. 20 ‘‘(2) ELECTION.—For cost reporting periods 21 beginning on or after the date that is 1 year after 22 the date of the enactment of this subsection, an ap- 23 plicable hospital may elect to receive the elective 24 rural sustainability per resident payment amount for 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 7 •S 1893 IS each full-time-equivalent resident in an approved 1 medical residency training program that receives 2 training in a rural training location in accordance 3 with this subsection. An applicable hospital may 4 make an election under the preceding sentence re- 5 gardless of whether the applicable hospital is other- 6 wise eligible for a payment or adjustment for indi- 7 rect and direct graduate medical education costs 8 under subsections (d)(5)(B) and (h) or section 9 1814(l), as applicable, with respect to such resi- 10 dents. 11 ‘‘(3) APPLICATION.—The provisions of this sub- 12 section, or the application of such provisions to an 13 applicable hospital— 14 ‘‘(A) shall not result in— 15 ‘‘(i) the establishment of a limitation 16 on the number of residents in allopathic or 17 osteopathic medicine for purposes of sub- 18 sections (d)(5)(B) and (h) with respect to 19 an approved medical residency training 20 program of an applicable hospital (or be 21 taken into account in determining such a 22 limitation during the cap building period of 23 an applicable hospital); or 24 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 8 •S 1893 IS ‘‘(ii) the counting of any resident with 1 respect to which the applicable hospital re- 2 ceives an elective rural sustainability per 3 resident payment amount under this sub- 4 section towards the application of the limi- 5 tation described in clause (i) for purposes 6 of subsections (d)(5)(B) and (h); and 7 ‘‘(B) shall not have any effect on the de- 8 termination of— 9 ‘‘(i) the additional payment amount 10 under subsection (d)(5)(B); or 11 ‘‘(ii) hospital-specific approved FTE 12 resident amounts under subsection (h). 13 ‘‘(4) ALLOCATION OF PAYMENTS.—In providing 14 for payments under this subsection, the Secretary 15 shall provide for an allocation of such payments be- 16 tween parts A and part B (and the trust funds es- 17 tablished under the respective parts) as reasonably 18 reflects the proportion of such costs associated with 19 the provision of services under each respective part. 20 ‘‘(5) ELIGIBILITY FOR PAYMENT.— 21 ‘‘(A) IN GENERAL.—An applicable hospital 22 shall be eligible for payment of the elective 23 rural sustainability per resident payment 24 amount under this subsection for time spent by 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 9 •S 1893 IS a resident training in a rural training location 1 if the following requirements are met: 2 ‘‘(i) The resident spends the equiva- 3 lent of at least 8 weeks over the course of 4 their training in a rural training location. 5 ‘‘(ii) The hospital pays the salary and 6 benefits of the resident for the time spent 7 training in a rural training location. 8 ‘‘(B) TREATMENT OF TIME SPENT IN 9 RURAL TRACKS OR INTEGRATED RURAL 10 TRACKS.—An applicable hospital shall be eligi- 11 ble for payment of the elective rural sustain- 12 ability per resident payment amount under this 13 subsection for all time spent by residents in an 14 approved medical residency program (or sepa- 15 rately defined track within a program) that pro- 16 vides more than 50 percent of the total resi- 17 dency training time in rural training locations, 18 regardless of where the training occurs and re- 19 gardless of specialty. 20 ‘‘(6) DETERMINATION OF FULL-TIME-EQUIVA- 21 LENT RESIDENTS.—The determination of full-time- 22 equivalent residents for purposes of this subsection 23 shall be made in the same manner as the determina- 24 tion of full-time-equivalent residents under sub- 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 10 •S 1893 IS section (h)(4), but not taking into account the limi- 1 tation under subparagraph (F) of such subsection. 2 ‘‘(7) DEFINITIONS.—In this subsection: 3 ‘‘(A) APPLICABLE HOSPITAL.—The term 4 ‘applicable hospital’ means a hospital, critical 5 access hospital, sole community hospital (as de- 6 fined in subsection (d)(5)(D)(iii)), or rural 7 emergency hospital (as defined in section 8 1861(kkk)(2)). 9 ‘‘(B) APPROVED MEDICAL RESIDENCY 10 TRAINING PROGRAM; DIRECT GRADUATE MED- 11 ICAL EDUCATION COSTS; RESIDENT.—The 12 terms ‘approved medical residency training pro- 13 gram’, ‘direct graduate medical education 14 costs’, and ‘resident’ have the meanings given 15 those terms in subsection (h)(5). 16 ‘‘(C) RURAL TRAINING LOCATION.—The 17 term ‘rural training location’ means a location 18 in which training occurs that, based on the 19 2010 census or any subsequent census adjust- 20 ment, meets one or more of the following cri- 21 teria: 22 ‘‘(i) The training occurs in a location 23 that is a rural area (as defined in section 24 1886(d)(2)(D)). 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 11 •S 1893 IS ‘‘(ii) The training occurs in a location 1 that has a rural-urban commuting area 2 code equal to or greater than 4.0. 3 ‘‘(iii) The training occurs in a sole 4 community hospital (as defined in sub- 5 section (d)(5)(D)(iii)) or in a location that 6 is within 10 miles of a sole community hos- 7 pital. 8 ‘‘(8) BUDGET NEUTRALITY REQUIREMENT.— 9 The Secretary shall ensure that aggregate payments 10 for direct medical education costs and indirect med- 11 ical education costs under this title, including any 12 payments under this subsection, for each year (effec- 13 tive beginning on or after the date that is 1 year 14 after the date of enactment of this subsection) are 15 not greater than the aggregate payments for such 16 costs that would have been made under this title for 17 the year without the application of this subsection. 18 For purposes of carrying out the budget neutrality 19 requirement under the preceding sentence, the Sec- 20 retary may make appropriate adjustments to the 21 amount of such payments for direct graduate med- 22 ical education costs and indirect medical education 23 costs under subsections (h) and (d)(5)(B), respec- 24 tively.’’. 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 12 •S 1893 IS (b) TREATMENT OF CRITICAL ACCESS HOSPITALS 1 AND SOLE COMMUNITY HOSPITALS.— 2 (1) CRITICAL ACCESS HOSPITALS.—Section 3 1814(l) of the Social Security Act (42 U.S.C. 4 1395f(l)) is amended by adding at the end the fol- 5 lowing new paragraph: 6 ‘‘(6) For cost reporting periods beginning on or after 7 the date that is 1 year after the date of enactment of this 8 paragraph, the following shall apply: 9 ‘‘(A) A critical access hospital may elect to be 10 treated as a hospital or as a non-provider setting for 11 purposes of counting resident time for indirect med- 12 ical education costs and direct graduate medical edu- 13 cation costs for the time spent by the resident in 14 that setting under subsections (d)(5)(B) and (h), re- 15 spectively, of section 1886. 16 ‘‘(B) Medical education costs shall not be con- 17 sidered reasonable costs of a critical access hospital 18 for purposes of payment under paragraph (1), to the 19 extent that the critical access hospital is treated as 20 a non-provider setting of another hospital or another 21 hospital receives payment for such costs for the time 22 spent by the resident in that setting pursuant to 23 subsection (d)(5)(B), subsection (h), or subsection 24 (u) of section 1886.’’. 25 VerDate Sep 11 2014 23:51 Jun 15, 2021 Jkt 019200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S1893.IS S1893 kjohnson on DSK79L0C42PROD with BILLS 13 •S 1893 IS (2) SOLE COMMUNITY H [Text truncated for display. 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