Rural Physician Workforce Production Act of 2019

II 116TH CONGRESS 1ST SESSION S. 289 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 JANUARY 31, 2019 Mr. GARDNER (for himself, Mr. TESTER, and Mrs. HYDE-SMITH) 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 2019’’. 5 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 2 •S 289 IS SEC. 2. ALTERNATIVE NATIONAL PER RESIDENT PAYMENT 1 FOR RESIDENTS TRAINING IN RURAL TRAIN- 2 ING 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) ALTERNATIVE NATIONAL PER RESIDENT PAY- 7 MENT AMOUNT FOR RESIDENTS TRAINING IN RURAL 8 TRAINING LOCATIONS.— 9 ‘‘(1) IN GENERAL.— 10 ‘‘(A) ESTABLISHMENT.—The Secretary 11 shall establish a national per resident payment 12 (NPRP) amount for time spent by residents 13 training in rural training locations in accord- 14 ance with paragraph (2). 15 ‘‘(B) ELECTION.—For cost reporting peri- 16 ods beginning on or after the date that is 1 17 year after the date of enactment of this sub- 18 section, an applicable hospital (as defined in 19 paragraph (6)(A)), may elect to receive the pay- 20 ment amount under this subsection for each 21 full-time-equivalent resident in an approved 22 medical residency training program that re- 23 ceives training in a rural training location in 24 accordance with paragraph (2). An applicable 25 hospital may make an election under the pre- 26 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 3 •S 289 IS ceding sentence regardless of whether the appli- 1 cable hospital is otherwise eligible for a pay- 2 ment or adjustment for indirect and direct 3 graduate medical education costs under sub- 4 sections (d)(5)(B) and (h) or section 1814(l), as 5 applicable, with respect to such residents. If the 6 applicable hospital is otherwise eligible for such 7 a payment or adjustment, the national per resi- 8 dent payment amount under this subsection 9 shall be in lieu of such payment or adjustment. 10 ‘‘(C) APPLICATION.—The provisions of this 11 subsection, or the application of such provisions 12 to an applicable hospital, shall not result in or 13 otherwise effect the following: 14 ‘‘(i) The establishment of a limitation 15 on the number of residents in allopathic or 16 osteopathic medicine for purposes of sub- 17 sections (d)(5)(B) and (h) with respect to 18 an approved medical residency training 19 program of an applicable hospital (or be 20 taken into account in determining such a 21 limitation during the cap building period of 22 an applicable hospital). 23 ‘‘(ii) The determination of— 24 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 4 •S 289 IS ‘‘(I) the additional payment 1 amount under subsection (d)(5)(B); 2 or 3 ‘‘(II) hospital-specific approved 4 FTE resident amounts under sub- 5 section (h). 6 ‘‘(iii) The counting of any resident 7 with respect to which the applicable hos- 8 pital receives a national per resident pay- 9 ment under this subsection towards the ap- 10 plication of the limitation described in 11 clause (i) for purposes of subsections 12 (d)(5)(B) and (h). 13 ‘‘(2) PAYMENT AMOUNT.— 14 ‘‘(A) BASE AMOUNT.—The national per 15 resident payment amount, with respect to full- 16 time equivalent residents training in rural 17 training locations, for cost reporting periods be- 18 ginning during the first year beginning on or 19 after the date of enactment of this subsection 20 shall be, based on the most recently available 21 data with respect to cost reporting periods be- 22 ginning during a preceding year (referred to in 23 this subparagraph as the ‘base cost reporting 24 period’), equal to the sum of the following: 25 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 5 •S 289 IS ‘‘(i) DIRECT GME.—The amount that, 1 out of all of the payment amounts (deter- 2 mined on a per resident basis) received by 3 hospitals under subsection (h) for such 4 base cost reporting period, is equal to the 5 national 85th percentile of such payment 6 amounts. 7 ‘‘(ii) INDIRECT GME.—The amount 8 that, out of all of the additional payment 9 amounts (determined on a per resident 10 basis) received by hospitals under sub- 11 section (d)(5)(B) for such base cost report- 12 ing period, is equal to the national 85th 13 percentile of such payment amounts. 14 ‘‘(B) UPDATING FOR SUBSEQUENT COST 15 REPORTING PERIODS.—For each subsequent 16 cost reporting period, the national per resident 17 payment amount is equal to such amount deter- 18 mined under this paragraph for the previous 19 cost reporting period updated, through the mid- 20 point of the period, by projecting the estimated 21 percentage change in the consumer price index 22 during the 12-month period ending at that mid- 23 point, with appropriate adjustments to reflect 24 previous under- or over-estimations under this 25 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 6 •S 289 IS subparagraph in the projected percentage 1 change in the consumer price index. 2 ‘‘(C) CLARIFICATION.—The national per 3 resident payment amount shall not be dis- 4 counted or otherwise adjusted based on the 5 Medicare patient load (as defined in subsection 6 (h)(3)(C)) of an applicable hospital or dis- 7 charges in a diagnosis-related group. 8 ‘‘(3) ALLOCATION OF PAYMENTS.—In providing 9 for payments under this subsection, the Secretary 10 shall provide for an allocation of such payments be- 11 tween parts A and part B (and the trust funds es- 12 tablished under the respective parts) as reasonably 13 reflects the proportion of such costs associated with 14 the provision of services under each respective part. 15 ‘‘(4) ELIGIBILITY FOR PAYMENT.— 16 ‘‘(A) IN GENERAL.—An applicable hospital 17 shall be eligible for payment of the national per 18 resident payment amount under this subsection 19 for time spent by a resident training in a rural 20 training location if the following requirements 21 are met: 22 ‘‘(i) The resident spends the equiva- 23 lent of at least 8 weeks over the course of 24 their training in a rural training location. 25 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 7 •S 289 IS ‘‘(ii) The hospital pays the salary and 1 benefits of the resident for the time spent 2 training in a rural training location. 3 ‘‘(B) TREATMENT OF TIME SPENT IN 4 RURAL TRACKS.—An applicable hospital shall 5 be eligible for payment of the national per resi- 6 dent payment amount under this subsection for 7 all time spent by residents in an approved med- 8 ical residency program (or separately defined 9 track within a program) that provides 50 per- 10 cent or more of the total residency training 11 time in rural training locations (as defined in 12 paragraph (6)(C)), regardless of where the 13 training occurs and regardless of specialty. 14 ‘‘(5) DETERMINATION OF FULL-TIME-EQUIVA- 15 LENT RESIDENTS.—The determination of full-time- 16 equivalent residents for purposes of this subsection 17 shall be made in the same manner as the determina- 18 tion of full-time-equivalent residents under sub- 19 section (h)(4). 20 ‘‘(6) DEFINITIONS.—In this subsection: 21 ‘‘(A) APPLICABLE HOSPITAL.—The term 22 ‘applicable hospital’ means a hospital or critical 23 access hospital. 24 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 8 •S 289 IS ‘‘(B) APPROVED MEDICAL RESIDENCY 1 TRAINING PROGRAM; DIRECT GRADUATE MED- 2 ICAL EDUCATION COSTS; RESIDENT.—The 3 terms ‘approved medical residency training pro- 4 gram’, ‘direct graduate medical education 5 costs’, and ‘resident’ have the meanings given 6 those terms in subsection (h)(5). 7 ‘‘(C) RURAL TRAINING LOCATION.—The 8 term ‘rural training location’ means a location 9 in which training occurs that, based on the 10 2010 census or any subsequent census adjust- 11 ment, meets one or more of the following cri- 12 teria: 13 ‘‘(i) The training occurs in a location 14 that is a rural area (as defined in section 15 1886(d)(2)(D)). 16 ‘‘(ii) The training occurs in a location 17 that has a rural-urban commuting area 18 code equal to or greater than 4.0. 19 ‘‘(iii) The training occurs in a location 20 that is within 10 miles of a sole community 21 hospital (as defined in subsection 22 (d)(5)(D)(iii))). 23 ‘‘(7) BUDGET NEUTRALITY REQUIREMENT.— 24 The Secretary shall ensure that aggregate payments 25 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 9 •S 289 IS for direct medical education costs and indirect med- 1 ical education costs under this title, including any 2 payments under this subsection, for each year (effec- 3 tive beginning on or after the date that is 1 year 4 after the date of enactment of this subsection) are 5 not greater than the aggregate payments for such 6 costs that would have been made under this title for 7 the year without the application of this subsection. 8 For purposes of carrying out the budget neutrality 9 requirement under the preceding sentence, the Sec- 10 retary may make appropriate adjustments to the 11 amount of such payments for direct graduate med- 12 ical education costs and indirect medical education 13 costs under subsections (h) and (d)(5)(B), respec- 14 tively.’’. 15 (b) TREATMENT OF CRITICAL ACCESS HOSPITALS 16 AND SOLE COMMUNITY HOSPITALS.— 17 (1) CRITICAL ACCESS HOSPITALS.—Section 18 1814(l) of the Social Security Act (42 U.S.C. 19 1395f(l)) is amended by adding at the end the fol- 20 lowing new paragraph: 21 ‘‘(6) For cost reporting periods beginning on or after 22 the date that is 1 year after the date of enactment of this 23 paragraph, the following shall apply: 24 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 10 •S 289 IS ‘‘(A) A critical access hospital may elect to be 1 treated as a hospital or as a non-provider setting for 2 purposes of counting resident time for indirect med- 3 ical education costs and direct graduate medical edu- 4 cation costs for the time spent by the resident in 5 that setting under subsections (d)(5)(B) and (h), re- 6 spectively, of section 1886. 7 ‘‘(B) Medical education costs shall not be con- 8 sidered reasonable costs of a critical access hospital 9 for purposes of payment under paragraph (1), to the 10 extent that the critical access hospital or another 11 hospital receives payment for such costs for the time 12 spent by the resident in that setting pursuant to 13 subsection (d)(5)(B), subsection (h), or subsection 14 (u) of section 1886.’’. 15 (2) SOLE COMMUNITY HOSPITALS.—Section 16 1886(d)(5)(D) of the Social Security Act (42 U.S.C. 17 1395ww(d)(5)(D)) is amended by adding at the end 18 the following new clause: 19 ‘‘(vi) For cost reporting periods beginning on or after 20 the date that is 1 year after the date of enactment of this 21 paragraph, the hospital-specific payment amount deter- 22 mined under clause (i)(I) with respect to a sole community 23 hospital shall not include medical education costs, to the 24 extent that the sole community hospital receives payment 25 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 11 •S 289 IS for such costs for the time spent by the resident in that 1 setting pursuant to subsection (u).’’. 2 (c) CONFORMING AMENDMENTS.— 3 (1) Section 1886 of the Social Security Act (42 4 U.S.C. 1395ww) is amended— 5 (A) in subsection (d)(5)(B), in the matter 6 preceding clause (i), by striking ‘‘The Sec- 7 retary’’ and inserting ‘‘Subject to subsection 8 (u), the Secretary’’; and 9 (B) in subsection (h)— 10 (i) in paragraph (1), by inserting 11 ‘‘subject to subsection (u)’’ after 12 ‘‘1861(v),’’; and 13 (ii) in paragraph (3), in the flush 14 matter following subparagraph (B), by 15 striking ‘‘subsection (k)’’ and inserting 16 ‘‘subsection (k) or subsection (u)’’. 17 SEC. 3. SUPPORTING NEW, EXPANDING, AND EXISTING 18 RURAL TRAINING TRACK RESIDENCIES. 19 (a) DIRECT GRADUATE MEDICAL EDUCATION.—Sec- 20 tion 1886(h) of the Social Security Act (42 U.S.C. 21 1395ww(h)) is amended— 22 (1) in paragraph (4)— 23 (A) in subparagraph (F)(i)— 24 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 12 •S 289 IS (i) by striking ‘‘130 percent’’ and in- 1 serting ‘‘for cost reporting periods begin- 2 ning on or after October 1, 1997, and be- 3 fore the date that is 1 year after the date 4 of enactment of the Rural Physician Work- 5 force Production Act of 2019, 130 per- 6 cent’’; and 7 (ii) by adding at the end the fol- 8 lowing: ‘‘For cost reporting periods begin- 9 ning on or after the date that is 1 year 10 after the date of enactment of the Rural 11 Physician Workforce Production Act of 12 2019, such rules shall provide that any 13 full-time-equivalent resident in an ap- 14 proved medical residency program (or sep- 15 arately defined track within a program) 16 that provides 50 percent or more of the 17 total residency training time in rural train- 18 ing locations (as defined in subsection 19 (u)(6)(C)), regardless of where the training 20 occurs and regardless of specialty, shall 21 not be taken into account for purposes of 22 applying the limitation under this subpara- 23 graph.’’; and 24 (B) in subparagraph (H)— 25 VerDate Sep 11 2014 00:02 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S289.IS S289 pamtmann on DSKBFK8HB2PROD with BILLS 13 •S [Text truncated for display. 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