What This Bill Does
This bill amends Medicare rules to create a new payment option for hospitals that train doctors (called residents) in rural areas. Hospitals can choose to receive special payments for medical residents who spend significant time training in rural locations. The bill aims to support physician workforce training programs in rural communities.
Who It Affects
Hospitals, critical access hospitals, sole community hospitals and rural emergency hospitals that run medical residency training programs. Medical residents who receive training in rural areas. Medicare (the federal health insurance program).
Key Provisions
• Hospitals can elect to receive special per-resident payments for doctors training in rural locations, starting one year after the law takes effect (Sec. 2(u)(2))
• Residents must spend at least 8 weeks training in a rural location, and the hospital must pay their salary and benefits during that time (Sec. 2(u)(5)(A))
• Hospitals running residency programs where more than 50 percent of training occurs in rural areas can receive the special payments for all residents in that program, regardless of where they actually train (Sec. 2(u)(5)(B))
• The payment amount equals the median national direct graduate medical education training costs from 2015, adjusted yearly for inflation (Sec. 2(u)(1)(B)(i))
• Residents counting toward these special payments do not count toward existing limits on the number of residents hospitals can train (Sec. 2(u)(3)(A))
What Changes
If this law passes, hospitals will have a new choice for how they receive Medicare payments for training rural doctors. Instead of only receiving standard graduate medical education payments, hospitals can opt into this new rural sustainability payment system. The total Medicare spending on graduate medical education payments must remain the same (budget neutral), meaning any new payments to hospitals choosing this option will be offset by adjustments elsewhere.
Important Definitions
"Rural training location" means a place where training happens that: is in a rural area according to census data, has a rural-urban commuting area code of 4.0 or higher, or is a sole community hospital or within 10 miles of one (Sec. 2(u)(7)(C))
"Applicable hospital" means a hospital, critical access hospital, sole community hospital or rural emergency hospital (Sec. 2(u)(7)(A))
"Resident" and "approved medical residency training program" have the same meanings as in existing Medicare medical education rules (Sec. 2(u)(7)(B))
Effective Date
The election to receive these special payments begins for cost reporting periods starting one year after the law is enacted (Sec. 2(u)(2)). The payment amount rules begin for cost reporting periods starting one year after enactment (Sec. 2(u)(1)(B)(i)).
II
118TH CONGRESS
1ST SESSION
S. 230
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
FEBRUARY 2, 2023
Mr. TESTER (for himself, Mr. BARRASSO, Ms. MURKOWSKI, Ms. COLLINS, Ms.
SINEMA, Mrs. HYDE-SMITH, Mr. CRAMER, Mr. KELLY, Mr. HEINRICH,
Mrs. CAPITO, and Ms. CORTEZ MASTO) 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 2023’’.
5
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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
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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
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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
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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
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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
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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
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‘‘(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
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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
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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
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‘‘(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
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(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
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[Text truncated for display. Full text available on Congress.gov.]