# Public Health, Workforce, Quality, and Other Provisions in the Affordable Health Choices Act (S. 1679) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/crs%3AR40831 ## Record - **Collection:** Congressional research report - **Document type:** CRS Report - **Published:** September 25, 2009 - **Citation:** R40831 ## Text Public Health, Workforce, Quality, and Other Provisions in the Affordable Health Choices Act (S. 1679) (name redacted), Coordinator Specialist in Health and Aging Policy (name redacted), Coordinator Specialist in Health Policy September 25, 2009 Congressional Research Service 7-.... www.crs.gov R40831 CRS Report for Congress Prepared for Members and Committees of Congress Public Health, Workforce, Quality, and Other Provisions in S. 1679 Summary Health care reform is at the top of the domestic policy agenda for the 111th Congress, driven by concerns about the growing ranks of the uninsured and the unsustainable growth in spending on health care and health insurance. But efforts to improve access to care and control rising health care costs also will require changes to the health care delivery system. Experts point to a growing body of evidence of the health care system’s failure to consistently provide high-quality care to all Americans. Major challenges to the delivery of high-quality care include improving patient safety by eliminating medical errors, eradicating disparities in care, reducing the burden of chronic disease, and eliminating unnecessary and ineffective care that compromises quality, drives up costs, and neglects the needs of patients. The health reform debate has embraced a number of proposals to address these challenges and improve the delivery of health care services. They include initiatives to encourage individuals to adopt healthier lifestyles, and to change the way that physicians and other providers treat and manage disease. Delivery reform proposals focus on expanding the primary care workforce, encouraging the use of clinical preventive services, and strengthening the role of chronic care management. However, health care delivery reform cannot happen unless mechanisms are in place to drive change in the systems of care. Key drivers include performance measurement and the public dissemination of performance information, comparative effectiveness research, adoption of health information technology, and, most importantly, the alignment of payment incentives with high-quality care. Congress took an important first step toward reforming the health care delivery system when it enacted the American Recovery and Reinvestment Act (ARRA; P.L. 111-5) in February 2009. ARRA included $1.1 billion for comparative effectiveness research and established an interagency advisory panel to help coordinate and support the research. It also incorporated the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is intended to promote the widespread adoption of health information technology (HIT) for the electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders. Both the House and the Senate are now considering health reform legislation. America’s Affordable Health Choices Act of 2009 (H.R. 3200), introduced in the House and approved by the Committees on Ways and Means, Energy and Commerce, and Education and Labor, includes numerous provisions intended to increase the primary care and public health workforce, promote preventive services, and strengthen quality measurement, among other things. In the Senate, the Health, Education, Labor, and Pensions (HELP) Committee has approved the Affordable Health Choices Act (S. 1679), which addresses health care delivery reform issues such as expanding private health insurance coverage, improving health care quality and strengthening quality measurement, encouraging preventive services, expanding the health care workforce, preventing health care fraud and abuse, and improving access to medical therapies. This report summarizes the workforce, quality, prevention, and other selected provisions in S. 1679, as amended and adopted by the Senate HELP Committee. It will be updated to reflect future legislative actions. A companion product, CRS Report R40745, Public Health, Workforce, Quality, and Other Provisions in H.R. 3200, summarizes comparable provisions in the House health reform legislation, American’s Affordable Health Choices Act of 2009 (H.R. 3200). Congressional Research Service Public Health, Workforce, Quality, and Other Provisions in S. 1679 Contents Introduction ................................................................................................................................1 Health Care Delivery Reform................................................................................................1 Drivers of Reform.................................................................................................................2 American Recovery and Reinvestment Act............................................................................3 Overview of Report.....................................................................................................................3 Health Centers ............................................................................................................................4 Background and Issues..........................................................................................................4 Sec. 171. Spending for Community Health Centers .........................................................5 Sec. 172. Administrative Changes ...................................................................................5 Sec. 312. School-Based Health Clinics ............................................................................5 Sec. 428. Nurse-Managed Health Clinics.........................................................................6 Health Workforce........................................................................................................................6 Background and Issues..........................................................................................................6 National Health Service Corps ..............................................................................................7 Sec. 173. Designating Medically Underserved Populations and HPSAs ...........................7 Sec. 427. National Health Service Corps .........................................................................7 Promotion of Primary Care and Dentistry..............................................................................7 Sec. 421. Federally Supported Student Loan Funds .........................................................7 Sec. 423. Pediatric Specialist Loan Repayment Program .................................................8 Sec. 431. Primary Care Training and Enhancement .........................................................8 Sec. 432. Training Opportunities for Direct Care Workers ...............................................8 Sec. 433. Training in General, Pediatric, and Public Health Dentistry ..............................9 Sec. 434. Alternative Dental Health Care Provider Demonstration ...................................9 Sec. 456. Definition of Economic Hardship.....................................................................9 Nursing Workforce.............................................................................................................. 10 Sec. 422. Nursing Student Loan Program ...................................................................... 10 Sec. 435(c). Geriatric Education and Training ............................................................... 10 Sec. 438. Advanced Nursing Education Grants .............................................................. 10 Sec. 439. Nurse Education, Practice, and Retention Grants ............................................ 11 Sec. 440. Loan Repayment and Scholarship Program .................................................... 11 Sec. 441. Nurse Faculty Loan Program.......................................................................... 11 Sec. 442. Authorization of Appropriations ..................................................................... 11 Public Health Workforce ..................................................................................................... 12 Sec. 424. Public Health Workforce Loan Repayment Program....................................... 12 Sec. 426. Grants for State and Local Programs .............................................................. 12 Sec. 429. Elimination of Cap on Commissioned Corps .................................................. 12 Sec. 430. Establishing a Ready Reserve Corps .............................................................. 13 Sec. 443. Grants to Promote the Community Health Workforce ..................................... 13 Sec. 444. Youth Public Health Program ......................................................................... 13 Sec. 445. Fellowship Training in Public Health ............................................................. 13 Sec. 446. United States Public Health Sciences Track.................................................... 13 Workforce Diversity, Cultural Competency, and Interdisciplinary Care................................ 14 Sec. 435(a) and (b). Geriatric Education and Training.................................................... 15 Sec. 437. Cultural Competency, Prevention, and Disability Training.............................. 16 Sec. 451. Centers of Excellence..................................................................................... 16 Sec. 452. Health Care Professionals Training for Diversity ............................................ 16 Congressional Research Service Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 453. Interdisciplinary, Community-Based Linkages ............................................... 16 Sec. 454. Nursing Workforce Diversity ......................................................................... 17 Sec. 455. Primary Care Extension Program ................................................................... 17 Health Workforce Evaluation and Assessment ..................................................................... 17 Sec. 411. National Health Care Workforce Commission ................................................ 18 Sec. 412. State Health Care Workforce Development Grants ......................................... 18 Sec. 413. Health Care Workforce Program Assessment.................................................. 18 Other Workforce Provisions ................................................................................................ 19 Sec. 425. Allied Health Workforce Recruitment and Retention Programs....................... 19 Sec. 461. Reports .......................................................................................................... 19 Quality...................................................................................................................................... 19 Background and Issues........................................................................................................ 19 Quality Measurement .......................................................................................................... 20 Sec. 201. National Strategy ........................................................................................... 20 Sec. 202. Interagency Working Group on Health Care Quality....................................... 21 Sec. 203. Quality Measure Development ....................................................................... 21 Sec. 204. Quality Measure Endorsement; Public Reporting; Data Collection ................. 21 Sec. 205(a). Data for Quality and Resource Use Measures............................................. 22 Quality Improvement and Patient Safety ............................................................................. 23 Sec. 211. Patient Safety Research Center ....................................................................... 23 Sec. 216. Reducing and Reporting Hospital Readmissions............................................. 23 Sec. 220. Health Professional Education........................................................................ 24 Key Health Indicators ......................................................................................................... 24 Sec. 187. Key National Indicators ................................................................................. 25 Care Coordination............................................................................................................... 25 Sec. 212. Community Health Teams to Support Patient-Centered Medical Homes ......... 26 Sec. 213. Medication Management Services in Treatment of Chronic Disease ............... 26 Sec. 217. Program to Facilitate Shared Decisionmaking ................................................ 27 Sec. 223. Patient Navigator Program ............................................................................. 27 Comparative Effectiveness Research ................................................................................... 28 Sec. 219. Center for Health Outcomes Research and Evaluation .................................... 28 Health Information Technology................................................................................................. 28 HIPAA Administrative Simplification.................................................................................. 28 Sec. 222. Administrative Simplification......................................................................... 29 Legal Obstacles to HIT Adoption ........................................................................................ 29 Secs. 231-233. Safe Harbor and Stark Exception for HIT Products and Services ............ 30 Other HIT Provisions .......................................................................................................... 31 Sec. 185. Standards for Enrollment in Federal and State Programs................................. 31 Sec. 205(b). Quality Measures....................................................................................... 31 Prevention and Wellness............................................................................................................ 32 Background and Issues........................................................................................................ 32 Health Insurance Reform..................................................................................................... 34 Sec. 101. Amendments to the PHSA Regarding Insurance Coverage.............................. 34 Sec. 142. Affordable Health Choices ............................................................................. 35 Sec. 326. Encouraging Employer-Sponsored Wellness Programs ................................... 35 Public Health Systems......................................................................................................... 35 Sec. 301. National Prevention, Health Promotion and Public Health Council................. 35 Sec. 302. Prevention and Public Health Fund ................................................................ 35 Sec. 303. Clinical and Community Preventive Services Task Forces .............................. 36 Congressional Research Service Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 304. Education and Outreach Campaign Regarding Preventive Benefits................. 36 Access to Clinical Preventive Services ................................................................................ 37 Sec. 311. Right Choices Program .................................................................................. 37 Sec. 313. Oral Health Care Prevention Activities ........................................................... 38 Sec. 314. Oral Health Improvement............................................................................... 38 Community Preventive Services.......................................................................................... 39 Sec. 321. Community Transformation Grants ................................................................ 39 Sec. 322. Healthy Aging, Living Well............................................................................ 39 Sec. 323. Wellness for Individuals with Disabilities....................................................... 39 Sec. 324. Immunizations ............................................................................................... 40 Sec. 327. Demonstration Project Concerning Individualized Wellness Plan.................... 40 Sec. 328. Reasonable Break Time for Nursing Mothers ................................................. 41 Research, Information Management, and Education ............................................................ 41 Sec. 188. Report on Preventable Diseases in New Medicare Enrollees........................... 41 Sec. 331. Research on Optimizing the Delivery of Public Health Services ..................... 41 Sec. 332. Understanding Health Disparities: Data Collection and Analysis .................... 41 Sec. 333. Health Impact Assessments ............................................................................ 42 Sec. 334. CDC and Employer-Based Wellness Programs ............................................... 43 Sec. 335. Epidemiology and Laboratory Capacity Grants .............................................. 43 Sec. 336. Federal Messaging on Health Promotion and Disease Prevention ................... 44 Environmental Public Health Network ................................................................................ 45 Sec. 351. Coordinated Environmental Public Health Network ....................................... 45 Other Public Health Provisions ........................................................................................... 46 Sec. 221. Offices of Women’s Health ............................................................................ 46 Sec. 361. Sense of the Senate Concerning CBO Scoring................................................ 46 Sec. 362. Effectiveness of Federal Health and Wellness Initiatives................................. 46 Food and Drug Administration .................................................................................................. 47 Background and Issues........................................................................................................ 47 Prescription Drug Labeling ................................................................................................. 47 Sec. 218. Presentation of Prescription Drug Benefit and Risk Information ..................... 48 Nutrition Labeling............................................................................................................... 48 Sec. 325. Chain Restaurant Menus and Vending Machines ............................................ 48 Biosimilars.......................................................................................................................... 49 Sec. 602. Approval Pathway for Biosimilar Biological Products .................................... 49 Sec. 603. Savings .......................................................................................................... 51 Emergency Care........................................................................................................................ 51 Background and Issues........................................................................................................ 51 Sec. 175. Emergency Medical Services for Children...................................................... 52 Sec. 214. Regionalized Systems for Emergency Care .................................................... 52 Sec. 215. Trauma Care Centers...................................................................................... 52 Behavioral Health Care ............................................................................................................. 53 Background and Issues........................................................................................................ 53 Sec. 142. Applicability of Mental Health Parity to Qualified Plans ................................ 54 Sec. 176. Co-locating Care in Community-Based Mental Health Settings ...................... 54 Sec. 436. Mental and Behavioral Health Education and Training Grants ........................ 55 Pain Care and Management....................................................................................................... 55 Sec. 341. Institute of Medicine Conference on Pain ....................................................... 56 Sec. 342. Pain Research at National Institutes of Health ................................................ 56 Sec. 343. Pain Care Education and Training .................................................................. 56 Congressional Research Service Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 344. Public Awareness Campaign on Pain Management ......................................... 57 PHSA 340B Drug Pricing Program ........................................................................................... 57 Background and Issues........................................................................................................ 57 Sec. 611. Expanded Participation in 340B Program ....................................................... 58 Sec. 612. Improvements to 340B Program Integrity....................................................... 58 Sec. 613. GAO Study on Improving the 340B Program ................................................. 58 Miscellaneous ........................................................................................................................... 59 Sec. 174. Equity for Certain Eligible Survivors ............................................................. 59 Sec. 189. Transparency in Government.......................................................................... 59 Sec. 189A. Preserving the Solvency of Medicare and Social Security ............................ 59 Sec. 189B. Prohibition Against Discrimination on Assisted Suicide ............................... 59 Sec. 189C. Access to Therapies ..................................................................................... 60 Sec. 189D. Freedom Not to Participate in Federal Health Insurance Programs ............... 60 Appendixes Appendix. Acronyms Used in the Report................................................................................... 61 Contacts Author Contact Information ...................................................................................................... 63 Congressional Research Service Public Health, Workforce, Quality, and Other Provisions in S. 1679 Introduction Health care reform is at the top of the domestic policy agenda for the 111th Congress, driven by concerns about the growing ranks of the uninsured and the unsustainable growth in spending on health care and health insurance. Improving access to care and controlling rising costs will require changes to both the financing and delivery of health care. Experts point to a growing body of evidence of the health care system’s failure to consistently provide high-quality care to all Americans. In a November 2008 report outlining its goals for health reform, the National Priorities Partnership, representing all the major stakeholder groups in the health sector, identified four major challenges to the delivery of high-quality care.1 The first is to improve patient safety by eliminating medical errors and other adverse events. These errors mostly result from faulty systems, processes, and conditions that lead to mistakes. The second challenge is to eradicate disparities in care. Racial and ethnic minorities and low-income groups face disproportionately higher rates of disease, disability, and mortality, largely because of variations in access to care, and quality of care. The third challenge is to reduce the burden of chronic disease, which affects almost half of all Americans and accounts for three-quarters of health care spending. The final challenge is to eliminate unnecessary and ineffective care that compromises quality, drives up costs, and neglects the needs of patients. According to the Institute of Medicine (IOM), an estimated 30%-40% of health care spending is wasted on unnecessary and even unsafe care.2 Health Care Delivery Reform While primarily focused on health care financing issues, the health reform debate has embraced a number of proposals to address these challenges and improve the delivery of health care services. They include initiatives to encourage individuals to adopt healthier lifestyles, and to change the way that physicians and other providers treat and manage disease. Delivery reform proposals focus on (1) expanding the primary care workforce, (2) encouraging the use of clinical preventive services, and (3) strengthening the role of chronic care management. The current system places a high value on specialty care, rather than primary care. Patients with multiple chronic conditions often receive care from several providers in different settings. Among other things, this can compromise patients’ understanding of their conditions and ways to manage them. And the incomplete or inaccurate transfer of information among providers can lead to poor outcomes. Care coordination is seen as an important aspect of health care that helps avoid waste, and the over- and underuse of medications, diagnostic tests, and therapies. Health workforce policy has emerged as an important component of the health reform debate. Transforming the nation’s health care delivery system—from one that is focused on fragmented specialty care for acute illness to one that places a greater emphasis on primary care, disease prevention, and the coordination and management of care for chronic illness across settings—will require significant changes in health professions education and training. While some advisory 1 National Priorities Partnership, National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum, 2008. For more information on the work of the Partnership, go to http://www.nationalprioritiespartnership.org/. 2 Institute of Medicine, National Academy of Engineering, Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington, DC: National Academies Press, 2005. Congressional Research Service 1 Public Health, Workforce, Quality, and Other Provisions in S. 1679 groups have warned of a future physician shortage, based on the growing patient demand for services, others caution that simply adding more physicians to the current health care system will increase costs and not improve accessibility or quality. Currently, the number of physicians per capita varies significantly across the country. But that variation is largely driven by where physicians like to live and practice, rather than by patient need. Moreover, higher physician supply is not associated with better patient outcomes or satisfaction, or improved quality of care.3 Instead of focusing on overall physician supply, health policy analysts recommend a workforce policy that couples the training of more primary care physicians (and other primary care providers) with the promotion and development of integrated systems of care. Expanding the use of clinical preventive services is a key goal of delivery reform and often touted as having the potential to reduce health care costs. Such services include immunizations and other interventions that prevent the onset of disease (known as primary prevention), and screening tests that detect the presence of an incipient disease (known as secondary prevention). While there is clear evidence that clinical preventive services can improve health and may be cost-effective (i.e., providing good value for their cost), few of these interventions are cost-saving.4 Proponents of delivery reform have also embraced the concept of a medical home, intended to improve the quality of care through partnerships between patients and specially trained primary care physicians. The physician helps the patient manage his or her own care and coordinates services across settings (specialists’ offices, hospitals, and laboratories) and types of care (acute, chronic, and preventive). Concern about the rising costs of treating chronic disease and the lack of coordination of care also has generated keen interest in disease management programs. These programs, typically focused on a specific disease such as diabetes, help patients manage their own care. Program elements include patient education, symptom monitoring, and adherence to treatment plans. Disease management programs share similarities with the medical home concept. But whereas the medical home is built around a physician-patient partnership, disease management programs typically are run by health plans or specialized vendors. Drivers of Reform Health care delivery reform cannot happen unless mechanisms are in place to drive change in the systems of care. Key drivers include performance measurement and the public dissemination of performance information, comparative effectiveness research, adoption of health information technology, and, perhaps most importantly, alignment of payment incentives with high-quality care. Most health policy experts concede that improvements in the quality of health care will not be fully realized unless providers have financial incentives to change the way they deliver health care services. Under fee-for-service, the predominant method of payment, physicians are paid based on the volume of billable services, rather than the value or quality of care they provide. Increasingly, public and private payers are linking a portion of provider payments to their performance on a set of quality measures. Policymakers are interested in expanding these pay-forperformance initiatives to incentivize other changes to the health care delivery system. 3 David C. Goodman and Elliott S. Fisher, “Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription,” New England Journal of Medicine, vol. 358, no. 16 (April 17, 2008), pp. 1658-1661. 4 Joshua T. Cohen et al., “Does Preventive Care Save Money? Health Economics and the Presidential Candidates,” New England Journal of Medicine, vol. 358, no. 7 (February 14, 2008), pp. 661-663. Congressional Research Service 2 Public Health, Workforce, Quality, and Other Provisions in S. 1679 The use of performance measures to track the quality of care is growing in both the private and public health sectors, though concerns about the development and use of such data remain. The public reporting of quality information is seen as a necessary step in helping patients make informed choices about health care services and the organizations that provide them. American Recovery and Reinvestment Act Congress took one step toward reforming the health care delivery system when it enacted the American Recovery and Reinvestment Act (ARRA; P.L. 111-5) in February 2009. ARRA included $17 billion in supplemental funding for biomedical research, public health, and other health-related programs within the Department of Health and Human Services (HHS), including $1.1 billion for comparative effectiveness research. It also established an interagency advisory panel to help coordinate and support the research. In addition, ARRA incorporated the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is intended to promote the widespread adoption of health information technology (HIT) for the electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders. Included in the ARRA health funding was $2 billion to fund HIT grant programs authorized by the HITECH Act.5 HIT, which generally refers to the use of computer applications in medical practice, is widely viewed as a necessary and vital component of health care reform. It encompasses interoperable electronic health records (EHRs)—including computerized systems to order tests and medications, and support systems to aid clinical decision making—and the development of a national health information network to permit the secure exchange of electronic health information among providers. The promise of HIT comes not from automating existing practices, but rather its use as a tool to help overhaul the delivery of care. HIT has the potential to enable providers to render care more efficiently; for example, by eliminating the use of paper-based records and reducing the duplication of diagnostic tests. It can also improve the quality of care by identifying harmful drug interactions and helping physicians manage patients with multiple conditions. Moreover, the widespread use of HIT could provide large amounts of clinical data for comparative effectiveness research, performance measurement, and other activities aimed at improving health care quality. Overview of Report On September 17, 2009, Senator Harkin introduced a comprehensive health care reform bill entitled the Affordable Health Choices Act (S. 1679). The legislation is identical to the unnumbered health reform bill that was marked up and, on July 15, 2009, approved by the Senate Committee on Health, Education, Labor, and Pensions (HELP). The Affordable Health Choices Act (hereinafter referred to as the Senate HELP bill) consists of six titles. Title I addresses private health insurance, including the establishment of an insurance exchange and the creation of a public option. Title II includes provisions related to improving health care quality and service delivery, including strengthening quality measurement. Title III promotes preventive services. 5 See P.L. 111-5; for more information, see CRS Report R40181, Selected Health Funding in the American Recovery and Reinvestment Act of 2009, coordinated by (name redacted), and CRS Report R40161, The Health Information Technology for Economic and Clinical Health (HITECH) Act, by (name redacted). Congressional Research Service 3 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Title IV includes provisions to increase the primary care and public health workforce. Title V includes a series of provisions intended to prevent health care fraud and abuse. And Title VI addresses access to medical therapies, including creating a regulatory pathway for approving biosimilars and expanding participation in the Public Health Service Act (PHSA) 340B drug pricing program. This report summarizes the workforce, quality, prevention, and other provisions in Titles I, II, III, IV, and VI of the Senate HELP bill, as amended and adopted by the HELP Committee. The report groups the bill’s provisions under the following headings: (1) health centers; (2) health workforce, including programs authorized under the PHSA and under other statutes; (3) health care quality; (4) prevention and wellness; (5) Food and Drug Administration; (6) emergency care; (7) behavioral health care; (8) pain care and management; (9) PHSA 340B drug pricing program; and (10) miscellaneous. In most instances, each section begins with some background on current law and practice so as to provide context for the subsequent brief descriptions of the bill’s provisions. Unless otherwise stated, references to “the Secretary” refer to the Secretary of HHS. A list of all the acronyms used in the report is in the Appendix. This report will be updated to reflect future legislative actions. A companion report, CRS Report R40745, Public Health, Workforce, Quality, and Other Provisions in H.R. 3200, summarizes comparable provisions in the House health reform legislation, American’s Affordable Health Choices Act of 2009 (H.R. 3200). This legislation was jointly developed by the House Committees on Ways and Means, Energy and Commerce, and Education and Labor, which share jurisdiction over the federal health statutes. All three committees have held markups—in each case focusing on the titles in the bill that fall under the committee’s jurisdiction—and ordered the legislation to be reported, as amended. Health Centers Background and Issues PHSA Sec. 330 authorizes the health center program, which provides grants to Community Health Centers (CHCs), migrant health centers, health centers for the homeless, and health centers for residents of public housing. Health centers are a key component of the nation’s health care safety net and provide primary care and preventive services to the uninsured and underinsured. These centers are required to accept all patients regardless of ability to pay and must offer sliding scale fee arrangements for patients. Health centers are located in areas that are medically underserved and target populations with insufficient health care access. The Health Center program, which enjoys broad bipartisan support, has been expanded in recent years. In 2002, there were approximately 3,500 health center sites; in 2009, there are an estimated 9,000 sites.6 The program was reauthorized by the Health Care Safety Net Act of 2008.7 The Act also included the requirement that the Government Accountability Office (GAO) study the economic costs and benefits of school-based health clinics (SBHCs) and their impact on student health. SBHCs are not explicitly authorized in the PHSA, but have been established pursuant to 6 7 An individual health center may operate multiple sites. The health centers program is administered by HRSA. For more information, see http://bphc.hrsa.gov. Congressional Research Service 4 Public Health, Workforce, Quality, and Other Provisions in S. 1679 the general authority to establish community health centers. Studies show that health centers increase access to primary health care services, which helps reduce disparities and reduce costs by averting more expensive emergency room visits.8 Sec. 171. Spending for Community Health Centers This section would amend PHSA Sec. 330 by authorizing to be appropriated for the health center program the following amounts: $2,988,821,592 for FY2010; $3,862,107,440 for FY2011; $4,990,553,440 for FY2012; $6,448,713,307 for FY2013; $7,332,924,155 for FY2014; and $8,332,924,155 for FY2015. For FY2016 and subsequent years, the amount authorized to be appropriated for that year would be based on a specified formula that takes into account the preceding year’s appropriation, the per patient costs, and increases in the number of patients served by the health centers program. Nothing in this section should be construed to prevent a CHC from contracting with specified entities for the delivery of primary health care services that are available at the specified entity to individuals who would otherwise be eligible for free or reduced cost care if that individual were able to obtain that care at the CHC. Such services may be limited in scope to the primary health care services available at the facility. This section also specifies the criteria that the entities must meet in order to be eligible to receive contract funds from a CHC. Sec. 172. Administrative Changes This section would amend PHSA Sec. 330 to make several administrative changes to the health center programs. Among other changes, it would (1) expand the definition of health center to allow facilities to provide services at either facilities operated directly by the center and at other inpatient and outpatient settings; (2) allow facilities to be located outside of a medically underserved area if the location is accessible to and meets the needs of the service population; (3) allow the Secretary to permit grant applications for additional centers in an established center’s catchment area provided that certain specified criteria are met; (4) amend several grant application requirements as specified; (5) provide centers with greater flexibility to modify their budgets; (6) authorize the Secretary to carry out projects that allow centers to collaborate to establish joint purchasing agreements in order to reduce the costs of supplies; and (7) specify the procedures through which centers can correct a failure to meet grant conditions. Sec. 312. School-Based Health Clinics This section would create a new PHSA Sec. 399Z-1 requiring the Secretary to establish a SBHC grant program. To receive a grant, an SBHC would have to meet certain specified criteria unless granted a waiver for a specified time period, match 20% of the grant amount from nonfederal sources unless granted a waiver by the Secretary, agree to use grant funds for certain specified purposes (which may include facility construction), and agree to use grant funds to supplement and not supplant funds received from other sources. Additionally, SBHCs would only be permitted to provide age-appropriate services. The Secretary would be authorized to give preference to applicants who demonstrate ability to serve communities with specified barriers to 8 J. Hadley and P. Cunningham, “Availability of Safety Net Providers and Access to Care of Uninsured Persons,” Health Services Research, vol. 39, iss. 5 (August 2004), pp. 1527–46. Congressional Research Service 5 Public Health, Workforce, Quality, and Other Provisions in S. 1679 access. When determining grant amounts, the Secretary would be required to take into account the financial need of the SBHC, other funding sources available to the SBHC, and other factors determined appropriate by the Secretary. The section would authorize to be appropriated such sums as may be necessary (SSAN) for FY2010 through FY2014. Sec. 428. Nurse-Managed Health Clinics This section would create a new PHSA Sec. 330A-1 requiring the Secretary to establish a grant program to fund the development and operation of Nurse-Managed Health Clinics (NMHCs) that provide comprehensive primary health care and wellness services to vulnerable populations living in medically underserved communities, and to reduce the level of health disparities experienced by vulnerable populations. To be eligible to receive a grant, a NMHC would have to submit an application to the Secretary containing assurances that (1) nurses are a major provider of services at the NMHC, (2) the NMHC will provide care to all patients regardless of income or insurance status, and (3) the NMHC will establish a community advisory committee where the majority of members are individuals served by the NMHC. When determining grant amounts, the Secretary would be required to take into account the financial need of the NMHC, including other funding sources available to the NMHC, and other factors determined appropriate by the Secretary. The section would authorize to be appropriated $50 million for FY2010, and SSAN for each of FY2011 through FY2014. Health Workforce Background and Issues Existing health professions education and training programs authorized under PHSA Title VII provide funding to medical schools and other facilities to promote community-based and rural practice, primary care, and opportunities for minorities and disadvantaged students. In the early 1970s, annual funding for Title VII programs reached over $2.5 billion (in 2009 dollars); in recent years, it has been about $200 million. PHSA Title VIII authorizes a comparable set of programs to promote nursing education and training. Appropriations authority for most Title VII and VIII programs has expired, though many of them continue to receive funding. The National Health Service Corps (NHSC) program, authorized under PHSA Title III, provides scholarships and student loan repayments for medical students, nurse practitioners, physician assistants, and others who agree to a period of service as a primary care provider in a federally designated Health Professional Shortage Area (HPSA). NHSC clinicians may fulfill their service commitments in health centers, rural health clinics, public or nonprofit medical facilities, or within other community-based systems of care. However, there is far more demand for NHSC clinicians and there are many more clinicians interested in scholarships or loan repayment opportunities than can be met under the program’s budget. Currently, HHS estimates that the NHSC is filling only 8% of the total need for primary care practitioners in HPSAs.9 9 For more information on the NHSC program, see CRS Report R40533, Health Care Workforce: National Health Service Corps, by (name redacted). Congressional Research Service 6 Public Health, Workforce, Quality, and Other Provisions in S. 1679 National Health Service Corps Sec. 173. Designating Medically Underserved Populations and HPSAs This section would require the Secretary, through a negotiated rulemaking process, to establish a comprehensive methodology and criteria for designating medically underserved populations and HPSAs. The Secretary would be required to consider the availability, timeliness, and appropriateness of the data necessary to make the designation and the impact of the methodology and criteria on various populations, institutions, and stakeholders. The Secretary would be required to (1) appoint a rulemaking committee and receive timely reports from the committee; (2) publish an interim final rule, subject to public comment and subsequent revision, by July 1, 2010; and (3) publish a final rule by July 1, 2011. Sec. 427. National Health Service Corps This section would amend PHSA Sec. 338H(a) authorizing the following amounts for NHSC scholarships and loan repayments: $320,461,632 for FY2010; $414,095,394 for FY2011; $535,087,442 for FY2012; $691,431,432 for FY2013; $893,456,433 for FY2014; and $1,154,510,336 for FY2015. For FY2016 and subsequent fiscal years, the amount authorized to be appropriated would be based on the amount appropriated for the preceding fiscal year, adjusted by the product of the change in the costs of health professions education and the change in the number of individuals residing in HPSAs. Promotion of Primary Care and Dentistry PHSA Title VII, Part A, comprising Secs. 701-735, authorizes student loan programs for health professions students. Part C, comprising Secs. 747 and 748, authorizes grants for health professions schools to develop and operate training programs in family medicine, general internal medicine, general pediatrics, physician assistants, and general and pediatric dentistry. Funds may also be used to provide financial assistance to medical students, interns, residents, and faculty who are participants in such programs. Authority to fund those programs expired at the end of FY2002. The Senate HELP bill includes the following sections that would establish or amend existing programs to increase the supply of primary care providers. Sec. 421. Federally Supported Student Loan Funds This section would amend PHSA Sec. 723(a), requiring medical students who receive loan funds to practice in primary care for 10 years or until the loan is repaid, whichever comes first. For a medical student who fails to comply with such requirements, the loan would accrue interest at a rate of 2% per year higher than the initial rate. In addition, the Secretary would be prohibited from requiring parental financial information when determining a loan applicant’s financial need. Rather, the determination of whether to seek this information would be made at the discretion of the school loan officer. Congressional Research Service 7 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 423. Pediatric Specialist Loan Repayment Program This section would amend PHSA Title VII, Part E by adding a new “Subpart 3—Recruitment and Retention Programs” and, within that new subpart, create a new PHSA Sec. 775—“Investment in Tomorrow’s Pediatric Health Care Workforce.” The new section would require the Secretary to establish and implement a pediatric specialty loan repayment program under which eligible individuals would agree to work full-time for not less than two years in pediatric medicine or surgery, or in child and adolescent mental and behavioral health care (which could include substance abuse prevention and treatment). Eligible individuals, including pediatric medical specialists, pediatric surgical specialists, and child and adolescent mental and behavioral professionals, would have to work for a provider serving in a HPSA or medically underserved area, or among a medically underserved population. The program would pay up to $35,000 for each year of service, for a maximum of three years. There would be authorized to be appropriated (1) $30 million for each of FY2010 through FY2014 for loan repayments for pediatric medical specialists and pediatric surgical specialists, and (2) $20 million for each of FY2010 through FY2013 for loan repayments for child and adolescent mental and behavioral health professionals. Sec. 431. Primary Care Training and Enhancement This section would strike and replace PHSA Sec. 747 authorizing the Secretary to award grants or enter into contracts for a variety of activities to support training programs in primary care— defined as family medicine, general internal medicine, or general pediatrics—and for capacity building. Entities eligible for the training grants would include accredited public or nonprofit hospitals, schools of medicine or osteopathic medicine, accredited physician assistant training programs, or public or private nonprofit entities. However, only schools of medicine or osteopathic medicine would be eligible for capacity building grants. In awarding the grants or contracts, the Secretary would be required to give preference to qualified applicants proposing certain specified activities. The section would authorize to be appropriated $125 million for FY2010 and SSAN for each of FY2011 through FY2014, and require that 15% of the amount appropriated in each fiscal year be allocated to physician assistant training programs that prepare students for practice in primary care. For purposes of carrying out programs that integrate academic administrative units and programs, the section would authorize to be appropriated $750,000, out of the total amount authorized, for each of FY2010 through FY2014. Sec. 432. Training Opportunities for Direct Care Workers This section would add a new PHSA Sec. 747A that would require the Secretary to establish a grant program to provide new training opportunities for direct care workers employed in longterm care settings. Entities eligible for grants include accredited institutions of higher education that have established a partnership with a long-term care setting as specified. Eligible entities would be required to use grant funds to provide tuition and fee assistance for eligible individuals, defined as individuals who are enrolled in courses provided by an eligible entity. Individuals receiving assistance under this section would be required to work in one of the specified fields for a minimum of two years. There would be authorized to be appropriated $10 million for each of FY2011 through FY2013. Congressional Research Service 8 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 433. Training in General, Pediatric, and Public Health Dentistry This section would redesignate PHSA Sec. 748, as amended by Sec. 413 of this bill, as PHSA Sec. 749 and insert a new PHSA Sec. 748 authorizing the Secretary to make grants or enter into contracts with specified entities to conduct training, provide financial assistance, and fund projects for dental students, dental residents, dental hygienists, practicing dentists, or dental faculty in the fields of general dentistry, pediatric dentistry, or public health dentistry. The section also would establish a faculty loan repayment program under which individuals agree to serve full-time as faculty members in one of the specified dental fields, and the program agrees to pay specified percentages of the principal and interest on their outstanding student loans based on the number of years served as a full-time faculty member. Entities eligible for the programs under this section would include dental and dental hygiene schools and approved residency or advanced educational programs in the specified fields. Eligible entities also may partner with schools of public health so that dental residents or dental hygiene students may receive master’s-level training in public health. When making training awards, the Secretary would be required to give priority to certain qualified applicants. When making awards for both the training and faculty loan repayment programs, the Secretary would be required to give preference to applicants based on their record of providing care in underserved areas or to populations experiencing health disparities, including those eligible for Medicaid and the Children’s Health Insurance Program (CHIP), or to entities that in the two fiscal years prior to receiving the award had an increased rate of placing its graduates in settings that serve health disparity populations. The section would authorize to be appropriated $30 million for FY2010, and SSAN for each of FY2011 through FY2015. Sec. 434. Alternative Dental Health Care Provider Demonstration This section would add a new PHSA Sec. 340H that would authorize the Secretary to establish a demonstration program to train or employ alternative dental health care providers in order to increase access to dental health care services in rural and other underserved communities. Alternative dental health care providers include community dental health coordinators, advance practice dental hygienists, primary care physicians, and dental therapists. Entities eligible for this grant program include institutions of higher education, public-private partnerships, FQHCs, Indian tribes, Indian Health Service (IHS) or tribally operated facilities and Urban Indian organizations as specified, public hospitals or health systems, or other entities as specified. The Secretary would be authorized to award 15 grants of not less than $4 million over a five-year period. The section also specifies the funding disbursement formula for grants and states that demonstration projects would be required to begin within two years after enactment and to conclude not later than seven years after enactment. Additionally, this section would require the Secretary to contract with the IOM to conduct a study of the demonstration program, to include baseline and comparison data from each project funded by this program. Nothing in this section would prohibit an IHS-approved dental health aide training program from being eligible for a grant under this section. There would be authorized to be appropriated SSAN. Sec. 456. Definition of Economic Hardship This section would amend the Higher Education Act Sec. 435 by inserting new language restoring the “20/220 pathway,” which provides deferments of federal student loans to borrowers who are working full-time, have a federal educational debt burden that equals or exceeds 20% of their adjusted gross income, and where the difference between the borrower’s adjusted gross Congressional Research Service 9 Public Health, Workforce, Quality, and Other Provisions in S. 1679 income minus the borrower’s federal education debt burden is less than 220% of the greater of (1) minimum wage earnings, as defined, or (2) 150% of the poverty line adjusted for the borrower’s family size. 10 Nursing Workforce PHSA Title VIII, comprising Secs. 801-855, authorizes several programs to support nursing workforce development. These programs include funding for grant and scholarship programs for graduate and undergraduate nursing education in specified areas of nursing, including cultural competency, workforce diversity, nurse faculty members, advanced education nurses, and geriatric nursing. The Senate HELP bill would modify and reauthorize several of these existing programs. Sec. 422. Nursing Student Loan Program This section would amend PHSA Sec. 836 by increasing the annual maximum amount of loan funds a recipient can receive during FY2010 and FY2011 from $2,500 to $3,300; increasing the final two-year amounts from $4,000 to $5,200 per year; and increasing the total loan amount from $13,000 to $17,000. The section would provide, for loans made after FY2011, for a cost of attendance increase for the yearly and aggregate amounts. The section also would amend applicable dates to require that financial need be a criterion for receiving a loan after 2000. Additionally, it would provide for partial loan cancellation for loan recipients working as fulltime nurses in public or non-profit settings who received loan funds before September 29, 1995. Sec. 435(c). Geriatric Education and Training This subsection would amend PHSA Sec. 855 to include new language establishing traineeships for individuals preparing for advanced degrees in geriatric nursing or other nursing areas that specialize in elder care. It would authorize to be appropriated SSAN for each of FY2010 through FY2014. (Note: Subsections 435(a) and (b) of this bill amend the geriatric education and training provisions in PHSA Sec. 753; see below.) Sec. 438. Advanced Nursing Education Grants This section would amend PHSA Sec. 811 to establish separate authorizations for the support of nurse practitioner and nurse midwifery programs. It also would insert new language establishing expanded grant eligibility criteria for nurse midwifery programs. The section would delete the prohibition on obligating more than 10% of the traineeships for individuals in doctoral programs. 10 The College Cost Reduction and Access Act of 2007 (P.L. 110-84) made changes to the definition of “economic hardship” by repealing the 20/220 pathway, a specific type of economic hardship deferment (i.e., the temporary suspension of a borrower’s obligation to make payments on the principal of a loan for a period of time) that was commonly used by medical residents who were middle-income borrowers with large amounts of federal student loan debt. As of July 1, 2009, this deferment was no longer available. Medical residents and other eligible borrowers were able to obtain forbearance, whereby loan payments are temporarily suspended or reduced for a specified period of time; however, unlike a deferment, interest still accrues during the period of forbearance and the borrower is ultimately responsible for paying this interest. Congressional Research Service 10 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 439. Nurse Education, Practice, and Retention Grants This section would amend PHSA Sec. 831 by renaming the grant program “Nurse Education, Practice, and Quality Grants.” It also would delete the provision’s support for internship and residency programs to encourage mentoring and the development of specialties within nursing. The section would restate certain specified grant priority activities, and would redefine nursing schools to have the same meaning as the term in Sec. 801(2). The section would authorize to be appropriated SSAN for each of FY2010 through FY2014. Additionally, the section would add a new PHSA Sec. 831A—Nurse Retention Grants, authorizing the Secretary to provide funding to eligible entities for nurse retention and promotion (“career ladder”) programs. The Secretary would be required to give preference to entities that have not received a grant under this subsection, to entities that have not received a grant under the earlier nursing “career ladder” grant program, and to entities that address other high-priority areas as determined by the Secretary. The section would authorize to be appropriated SSAN to carry out grant programs in this section for each of FY2010 through FY2012. Sec. 440. Loan Repayment and Scholarship Program This section would amend PHSA Sec. 846 by expanding eligibility for the nursing student loan repayment and scholarship program to individuals who agree to serve as nurse faculty at an accredited school of nursing for two years or more. Sec. 441. Nurse Faculty Loan Program This section would amend PHSA Sec. 846A by renaming the nurse faculty loan program “School of Nursing Student Loan Fund.” It would add the requirement that loan fund agreements must be made with accredited schools of nursing. The section also would increase the annual loan limit from $30,000 to $35,500 for FY2010 and FY2011. Thereafter, the annual loan limit would be adjusted to provide for a cost-of-attendance increase. The bill would authorize to be appropriated SSAN for each of FY2010 through FY2014. Additionally, the section would create a new PHSA Sec. 847, authorizing the Secretary, acting through the Health Resources and Services Administrator (HRSA), to enter into an agreement with eligible individuals for the repayment of qualified education loans for the purpose of increasing the number of qualified nursing faculty. Award recipients would be required to serve as a faculty member at an accredited school of nursing for at least four of the six years after (1) the individual receives a qualifying degree or (2) the date the individual entered the agreement. Support of doctoral students would receive funding priority. There would be authorized to be appropriated SSAN for each of FY2010 through FY2014. Sec. 442. Authorization of Appropriations This section would amend PHSA Sec. 841 by authorizing to be appropriated $338 million in FY2010 for Title VIII Parts B, C, and D (i.e., Secs. 811, 821, and 831), and SSAN for each of FY2011 through FY2016. Congressional Research Service 11 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Public Health Workforce PHSA Title VII, Part E, Subpart 2, comprising Secs. 765-770, authorizes the Secretary to conduct programs for public health workforce development by providing grants or contracts to schools, state and local health agencies, and others to operate public health training and re-training programs. Programs include grants for Public Health Training Centers; tuition, fees, and stipends for traineeships in public health and in health administration; and residency programs in preventive medicine and dental public health. Appropriations authority for these programs has expired, though all except the health administration traineeships continue to receive funding. Sec. 424. Public Health Workforce Loan Repayment Program This section would create a new PHSA Sec. 776, requiring the Secretary, depending on appropriations, to establish a Public Health Workforce Loan Repayment Program for public health or health professionals who agree to work in a federal, state, local, or tribal public health agency or applicable fellowship after graduation. Among other contractual obligations, recipients would be required to serve for at least three years, or as determined by the Secretary. Annual repayment would be capped at $35,000 per individual, or one-third of total debt, whichever is less. The section would authorize the appropriation of $195 million for FY2010, and SSAN for each of FY2011 through FY2015. Sec. 426. Grants for State and Local Programs This section would amend PHSA Sec. 765 to add public health workforce loan repayment programs to the list of the allowable activities for public health workforce development grants. The section also would create a new PHSA Sec. 777, authorizing the Secretary to make awards to eligible educational entities to award scholarships for the training of mid-career professionals in public health and allied health. Eligible individuals would include federal, state, tribal, or local public health and allied health employees. There are no stated scholarship amounts or service obligations. The section would authorize the appropriation of $60 million for FY2010, and SSAN for each of FY2011 through FY2015. Appropriated funds would have to be evenly divided between programs for public health professionals and those for allied health professionals. Sec. 429. Elimination of Cap on Commissioned Corps Sec. 202 of P.L. 102-394, appropriations for Labor/HHS/Education for FY1993, capped the number of commissioned officers in the U.S. Public Health Service Regular Corps (versus the Reserve Corps) at 2,800 and prohibited the use of appropriations from that Act, or any subsequent appropriations act, to fund additional positions. 11 This section would amend Sec. 202 of P.L. 102394 by eliminating the cap. 11 The ceiling was raised to 4,000 in Sec. 222 of P.L. 111-8, the Omnibus Appropriations Act, 2009. Congressional Research Service 12 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 430. Establishing a Ready Reserve Corps This section would amend PHSA Sec. 203 to replace all mentions of the U.S. Public Health Service Reserve Corps with “Ready Reserve Corps.” In addition, members of the Reserve Corps serving on active duty would be deemed to be members of the Regular Corps. The Ready Reserve Corps would address a number of specified needs for additional commissioned personnel to assist the Regular Corps on short notice, for both routine public health and emergency response missions. The section would authorize the appropriation, for each of FY2010 through FY2014, of $5 million for recruitment and training, and $12.5 million for the Ready Reserve Corps. Sec. 443. Grants to Promote the Community Health Workforce This section would create a new PHSA Sec. 399U, requiring the Centers for Disease Control and Prevention (CDC) Director to award grants to eligible entities to serve medically underserved communities (as defined) through the use of community health workers (CHWs, as defined). Among other things, the Secretary would be required to establish guidelines for training and supervision of CHWs, monitor programs that receive grants, and provide technical assistance. The section would authorize the appropriation of SSAN through FY2014.12 Sec. 444. Youth Public Health Program This section would amend PHSA Sec. 751 with respect to an Area Health Education Center (AHEC) infrastructure development awards (as established by Sec. 453 of this bill, see below), by adding to the list of eligible activities programs to expose and recruit high school students into health careers, with a focus on public health. Sec. 445. Fellowship Training in Public Health This section would add a new PHSA Sec. 778, authorizing the Secretary to expand existing CDC public health training fellowships in epidemiology, laboratory science, and informatics; the Epidemic Intelligence Service (EIS); and other training programs that meet similar objectives. Participants could be placed in state and local health agencies, and states could receive federal assistance for loan repayment programs for such participants. The section would authorize, for each of FY2010 through FY2013, the appropriation of $24.5 million for EIS fellowships, and $5 million each for epidemiology, laboratory, and informatics fellowships. Sec. 446. United States Public Health Sciences Track This section would add a new PHSA Title II, Part D, “United States Public Health Sciences Track,” consisting of four new PHSA sections, as follows. New PHSA Sec. 271 would establish a science track at academic sites selected by the Secretary, to award degrees that emphasize teambased service, public health, epidemiology, and emergency preparedness and response. The track would be organized so as to graduate, annually, specified minimum numbers of students of 12 This section would also redesignate two existing PHSA sections sharing duplicate designations as Sec. 399R. Namely, Sec. 399R regarding an ALS registry would be redesignated as Sec. 399S, and Sec. 399R regarding prenatally and postnatally diagnosed conditions would be redesignated as Sec. 399T. Congressional Research Service 13 Public Health, Workforce, Quality, and Other Provisions in S. 1679 medicine, dentistry, nursing (including advanced nursing), public health, behavioral and mental health, physician assistance, and pharmacy. New PHSA Sec. 272 would delegate administration of the science track to the U.S. Surgeon General (SG), whose duties would include designating faculty and establishing their salary and benefits. The SG would be authorized to negotiate agreements to use appropriate federal and private accredited institutions to support the functions of the science track, and would be required to establish appropriate programs of continuing medical education. Also, the SG would, contingent upon available budget authority, be authorized to enter in contracts; award grants; accept gifts, grants, and voluntary services; and take such other specified actions as needed to administer the science track. Persons who provided voluntary services would be considered federal employees for the purposes of Chapter 81 of U.S.C. Title 5 (compensation for workrelated injuries) and Chapter 171 of U.S.C. Title 28 (tort claims), but not considered as federal employees for any other purpose. New PHSA Sec. 273 would establish requirements regarding selection of students for the science track and their service obligations. The SG would be required to develop selection procedures, giving priority to students from rural communities and underrepresented minorities. Subject to appropriations, the SG could provide students with funding (as established by the SG) for tuition and a stipend for up to four years, subject to specified contractual obligations, among them a requirement to serve in the Commissioned Corps of the Public Health Service for a period of two years for each year of supported student enrollment. The term of obligated service could be reduced for specified reasons, including service in a federal medical facility located in a HPSA. Students dropped from the science track for deficiencies of conduct or studies, or other reasons, would be liable to the U.S. government for tuition and stipend support provided. The SG would be required to emphasize community-based training and to give priority to institutions that jointly train different types of providers through a shared curriculum. In addition, the SG would be required to develop criteria for the appointment of promising science track faculty, students, and graduates to elite federal disaster preparedness teams to train and to respond to public health emergencies. New PHSA Sec. 274 would require the Secretary, beginning in FY2010, to transfer from the Public Health and Social Services Emergency Fund SSAN to carry out this new Part.13 Workforce Diversity, Cultural Competency, and Interdisciplinary Care PHSA Title VII, Part B, comprising Secs. 736-741, authorizes several programs intended to promote diversity in the health workforce. Sec. 736 requires that the Secretary award grants to establish Centers of Excellence (COEs) at health professions schools that recruit and train significant numbers of underrepresented minority students to help support and facilitate those activities. Funds are allocated to the various types of COEs according to a formula, which is based on whether the appropriation for a given fiscal year is (1) $24 million or less, (2) more than $24 million but less than $30 million, or (3) $30 million or more. Centers must maintain their prior level of nonfederal expenditures, and must first expend other federal funds before expending 13 The Public Health and Social Services Emergency Fund is an HHS account administered by the Secretary, which Congress has typically used to provide one-time funding for non-routine activities. Congressional Research Service 14 Public Health, Workforce, Quality, and Other Provisions in S. 1679 grant funds. Appropriations authority expired at the end of FY2002. Secs. 737 and 739 authorize scholarships and other educational assistance for students from disadvantaged backgrounds. Sec. 738 requires the Secretary to establish a loan repayment program for individuals from disadvantaged backgrounds with a health professions degree or in the final year of study who agree to serve as a faculty member in a health professions school. Eligible individuals may receive up to $20,000 of education loan repayment for each year they serve as faculty. Title VIII, Sec. 821 authorizes grants to increase nursing education opportunities for individuals from disadvantaged backgrounds. Title VII, Part D, comprising Secs. 750-758, authorizes several grant programs to support interdisciplinary, community-based health workforce training. Sec. 751 authorizes the AHEC program, which provides grants to medical and nursing schools to establish and maintain community-based, primary care training programs in off-campus rural and underserved areas. The AHEC program is intended to educate and train students to become culturally competent primary care health professionals who will provide care to underserved populations. Appropriations authority expired at the end of FY2002. Sec. 752 authorizes funding for health education and training centers. To receive funding, an entity must be otherwise eligible for an AHEC award and, among other things, address unmet health care needs along the border between the United States and Mexico, in Florida, and in other urban and rural areas with serious unmet health care needs. Sec. 753 authorizes funding for Geriatric Education Centers (GECs) to develop and provide training programs in geriatrics, and requires the Secretary to establish a faculty fellowship program in geriatrics. The Senate HELP bill includes the following sections that would amend and expand existing workforce diversity and interdisciplinary, community-based training programs. Sec. 435(a) and (b). Geriatric Education and Training Section 435(a) would amend PHSA Sec. 753 by adding two new subsections. The first subsection would require the Secretary to award grants or contracts for geriatric workforce development fellowship and training programs to qualified entities that operate a Geriatric Education Center (GEC). The awards would be used to (1) offer short-term intensive courses on geriatrics, chronic care management, and long-term care, and (2) offer family caregiver and direct care provider training, or develop and incorporate into all training courses best practices material on mental disorders among the elderly, medication safety issues for the elderly, and managing dementia. Each award would be $150,000 with no more that 24 GECs authorized to receive an award. There would be authorized to be appropriated $10.8 million for FY2011 through FY2014. The second new subsection would create incentive grants or contracts for certain qualified health professionals entering the field of geriatrics, long-term care, and chronic care management. Health professionals receiving this award would be required to teach or practice in one of the above fields for a minimum of five years. There would be authorized to be appropriated $10 million for this program for FY2011 through FY2013. Sec. 435(b) would further amend PHSA Sec. 753 by expanding eligibility for geriatric academic career awards to qualified faculty at any accredited health professions school, as determined by the Secretary. Entities receiving an award must meet specified targets and use award funds to supplement and not supplant funds otherwise available to the GEC. Congressional Research Service 15 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 437. Cultural Competency, Prevention, and Disability Training This section would amend Title VII, Part B by adding at the end a new PHSA Sec. 742—Cultural Competency, Prevention and Public Health, and Individuals with Disabilities Training. The new section would require the Secretary to support the development and evaluation of model curricula for use in health professions schools and continuing education programs for providing training in cultural competency, prevention and public health proficiency, and working with individuals with disabilities. The Secretary would be required to evaluate the adoption and implementation of these curricula, which would be available through the Internet. To carry out the section, there would be authorized to be appropriated SSAN for each of FY2010 through FY2015. Sec. 451. Centers of Excellence This section would amend PHSA Sec. 736, modifying the COE funding formula by adding an additional set of specifications for allocating funds among the various types of COEs when the appropriation is $40 million or more. It would authorize to be appropriated for the COE program $50 million for each of FY2010 through FY2015, and SSAN for each subsequent fiscal year. Sec. 452. Health Care Professionals Training for Diversity This section would amend PHSA Sec. 738 by increasing the annual limit on the loan repayment amount to $30,000. In addition, the section would amend PHSA Sec. 740 by authorizing the following appropriations: (1) for Sec. 737 scholarships, $51 million for FY2010, and SSAN for each of FY2011 through FY2014; (2) for Sec. 738 loan repayments and fellowships, $5 million for each of FY2010 through FY2014; and (3) for Sec. 739 educational assistance, $60 million for FY2010, and SSAN for each of FY2011 through FY2014. Sec. 453. Interdisciplinary, Community-Based Linkages This section would amend PHSA Sec. 751—Area Health Education Centers, replacing the existing provisions with new language. The new section would expand the current AHEC program and require the Secretary to award (1) infrastructure development grants to medical and nursing schools to plan, develop, and operate AHEC programs, and (2) point of service maintenance and enhancement grants to maintain and improve the effectiveness of existing AHEC programs. As with the current AHEC program, the new section would require a nonfederal match, set the minimum award at $250,000, and place certain time limits on the award period. It would authorize to be appropriated $125 million for each of FY2010 through FY2014. It would be the sense of Congress that every state has an AHEC program. In addition, the section would replace the existing section with a new PHSA Sec. 752— Continuing Education Support for Health Professionals Serving in Underserved Communities, requiring the Secretary to award grants to health professions schools, academic health centers, and state or local governments, among others, to fund innovative activities to enhance education through distance learning, continuing education, collaborative conferences, and telehealth, with a focus on primary care. It would authorize to be appropriated $5 million for each of FY2010 through FY2014, and SSAN for each subsequent year. Congressional Research Service 16 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Sec. 454. Nursing Workforce Diversity This section would amend PHSA Sec. 821 by expanding the allowable uses of diversity grants to include stipends for diploma or associated degree nurses to enter a bridge or degree completion program, student scholarships or stipends for accelerated nursing degree programs, and advanced education preparation. In lieu of the existing consultation requirements, it would require the Secretary to take into account the recommendations of the National Advisory Council on Nurse Education and Practice and consult with nursing associations including the National Coalition of Ethnic Minority Nurse Associations and other appropriate organizations. Sec. 455. Primary Care Extension Program This section would add a new PHSA Sec. 399V—Primary Care Extension Program, to fund the creation of local Primary Care Extension Agencies to support and educate primary care providers about preventive medicine, health promotion, chronic disease management, mental health services, and evidence-based therapies. Primary care providers would work with communitybased health connectors, referred to as “Health Extension Agents.” These agents would be any local, community-based health worker who provides assistance by implementing quality improvement or system redesign that incorporates the principles of the patient-centered medical home, provides guidance to patients in culturally and linguistically appropriate ways, and links practices to diverse health system resources. The Secretary would be required to award competitive grants to states to establish Primary Care Extension Program State Hubs, consisting of the state health department and other specified entities. Hubs would be required to contract with and provide grant funds to county or local entities to serve as Primary Care Extension Agencies and organize statewide or multistate networks of such agencies to share information. Primary Care Extension Agencies would be required to (1) assist primary care providers to implement a patient-centered medical home; (2) develop and support primary care learning communities; (3) participate in a national network of hubs and proposed how best practices can be shared; and (4) develop a plan for financial sustainability after the initial six-year period of funding under this section is completed. The section would authorize both six-year program grants for entities that submit a fully developed hub plan, and two-year planning grants for entities to develop such a plan. A state receiving a program grant would be evaluated at the end of the grant period. After the sixth year of a grant, a state may receive additional support if its program receives a satisfactory evaluation. There would be authorized to be appropriated $120 million for each of FY2010 and FY2011, and SSAN for FY2013 and FY2014. Health Workforce Evaluation and Assessment PHSA Title VII, Part E, Subpart 1, comprising Secs. 761-763, establishes various projects to support health professions workforce information and analysis, including grants to entities in order to develop analysis of and information on the health workforce, an Advisory Council on Graduate Medical Education, and an evaluation of the number of pediatric rheumatologists. Other advisory groups established under PHSA Title VII include the Advisory Committee on Training in Primary Care Medicine and Dentistry and the Advisory Committee on Interdisciplinary, Community-based Linkages (established under Secs. 748 and 756, respectively). In addition, PHSA Title VIII, Part G (Sec. 845) establishes a National Advisory Council on Nurse Education Congressional Research Service 17 Public Health, Workforce, Quality, and Other Provisions in S. 1679 and Practice. Federal leadership for health workforce analysis is provided by HRSA’s National Center for Health Workforce Analysis (NCHWA), which is not explicitly authorized in the PHSA. The Senate HELP bill includes two sections that would add new language establishing a National Health Care Workforce Commission and a state health care workforce development grants program. A third section would replace existing PHSA provisions with new language creating in statute a NCHWA, establishing State and Regional Centers for Health Workforce Analysis, and increasing grant amounts for longitudinal evaluations of specified individuals who have received assistance from certain PHSA Title VII programs. Sec. 411. National Health Care Workforce Commission This section would establish a National Health Care Workforce Commission to serve as a national resource that focuses on evaluating and meeting the need for health care workers. The Commission would be composed of 15 members appointed by the Comptroller General of the United States. It would (1) review specified health care workforce supply and distribution information and make two annual reports with recommendations to Congress; (2) review implementation progress reports and report on the state health care workforce development grants program (established by Sec. 412 of this bill); (3) study effective mechanisms for financing education and training for careers in health care; (4) make recommendations about improving health care workers’ safety and protections; and (5) assess reports from the NCHWA (established by Sec. 413 of this bill). This section would authorize to be appropriated SSAN. Sec. 412. State Health Care Workforce Development Grants This section would establish a competitive health care workforce development grants program for the purpose of enabling state partnerships to plan and implement activities leading to coherent and comprehensive health care workforce development strategies at the state and local levels. HRSA would be responsible for administering the program, in consultation with the Commission (established by Sec. 411 of this bill). HRSA would also provide technical assistance to grantees and report performance information to the Commission. For planning grants, it would authorize to be appropriated $8 million for FY2010, and SSAN for each subsequent fiscal year. For implementation grants, it would authorize to be appropriated $150 million for FY2010, and SSAN for each subsequent fiscal year. Sec. 413. Health Care Workforce Program Assessment This section would amend PHSA Sec. 761 by requiring the Secretary to (1) establish a National Center for Health Workforce Analysis; (2) establish State and Regional Centers for Health Workforce Analysis; and (3) increase grant amounts for longitudinal evaluations of specified individuals who have received education, training, or financial assistance from programs under PHSA Title VII. The section also would authorize the following appropriations: (1) for National Centers, $5 million for each of FY2010 through FY2011, $10 million for each of FY2012 through FY2014, and SSAN for each subsequent fiscal year; (2) for State and Regional Centers, $4.5 million for each of FY2010 through FY2014, and SSAN for each subsequent fiscal year; and (3) for grants for longitudinal evaluations, SSAN for each of FY2010 through FY2014. Funds could be authorized to be carried over from one fiscal year to another without obtaining approval from the Secretary; however, funds would not be carried over for more than three years. This section Congressional Research Service 18 Public Health, Workforce, Quality, and Other Provisions in S. 1679 also would require that all responsibilities of HRSA’s existing NCHWA be transferred to the new National Center no later than 180 days after enactment. The section amends PHSA Sec. 791 by adding new language that would require the Secretary to give preference in awarding grants or contracts under Secs. 747 and 750 to any qualified applicant that utilizes a longitudinal evaluation and reports data from such system to a national workforce database. It would also amend Secs. 748, 756, and 762 to include additional duties regarding performance measures and guidelines for longitudinal evaluations for the Advisory Committee on Training in Primary Care Medicine and Dentistry; the Advisory Committee on Interdisciplinary, Community-based Linkages; and the Advisory Council on Graduate Medical Education. Other Workforce Provisions Sec. 425. Allied Health Workforce Recruitment and Retention Programs This section would amend Sec. 428K of the Higher Education Act of 1965 to include, among those eligible for a loan forgiveness program, an individual who is employed full-time as an allied health professional in a federal, state, local and tribal public health agency. Additional qualified employment locations would include acute care and ambulatory care facilities, and settings located in HPSAs, medically underserved areas or among medical underserved populations, as recognized by the Secretary. The section would define the term “allied health professional,” as described in PHSA Sec. 799B(5), as an individual who has graduated and received an allied health professions degree or certificate from an institution of higher education and is employed with a federal, state, local, or tribal public health agency, or other qualified employment location. Sec. 461. Reports This section would require the Secretary to submit an annual report to the appropriate congressional committees. The report would include the activities carried out under the amendments made by Title IV of this bill, and their effectiveness. The Secretary would be authorized to require, as a condition of receiving funds under the amendments made by Title IV, that recipients of such funds submit reports on activities carried out under the amendments and the effectiveness of those activities. Quality Background and Issues Numerous stakeholders, including policymakers, have engaged in a wide range of efforts to try to address the issue of health care quality. These efforts have generally focused on improving and refining metrics for measuring the quality of care delivered in a number of settings; publicly reporting comparative information on quality performance; and, in some cases, using metrics as the basis for payment policies to demand provider accountability (value-based purchasing). Congressional Research Service 19 Public Health, Workforce, Quality, and Other Provisions in S. 1679 However, these efforts have not generally been guided by a single federal strategy, entity, or set of priorities or goals, nor have they benefitted from a coordinated infrastructure specifically devoted to improving health care quality. The following describes provisions in the Senate HELP bill that would address the issues of quality measurement, patient safety/quality improvement, care coordination, and comparative effectiveness research. Quality Measurement There are no provisions in current law that require the development of national priorities for performance improvement (directed either at the Secretary or the Agency for Healthcare Research and Quality, AHRQ). However, the Secretary is required by law to have in effect a contract with a consensus-based entity to perform a number of duties, including to synthesize evidence and convene stakeholders to make recommendations on an integrated national strategy and priorities for health care performance measurement in all applicable settings. AHRQ has significant existing statutory authorities under PHSA Title IX with respect to the development of quality measures. This includes promoting health care quality improvement by conducting and supporting research that develops and presents scientific evidence regarding all aspects of health care, including methods for measuring quality and strategies for improving quality. In addition, AHRQ’s role includes the ongoing development, testing, and dissemination of quality measures, including measures of health and functional outcomes, and the compilation and dissemination of health care quality measures developed in the private and public sector. Current law does not set forth a process for, or require, multi-stakeholder input into the selection of quality measures by the Secretary for use in the Centers for Medicare and Medicaid’s (CMS’s) quality programs, such as Medicare’s Physician Quality Reporting Initiative (PQRI) or the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. The Senate HELP bill includes the following five sections addressing quality measurement, which would require the development of an explicit national strategy for quality improvement; establish an interagency working group to advance quality efforts at the national level; develop a comprehensive repertoire of quality measures; and formalize quality measure endorsement, data collection methods, and public reporting of quality information. Sec. 201. National Strategy This section would create in Title III a new PHSA Part S, “Health Care Quality Programs,” Subpart I, “National Strategy for Quality Improvement in Health Care.” It would include a new Sec. 399HH, which would require the Secretary to establish a national strategy for healthcare quality improvement to improve the delivery of health care services, outcomes, and population health, and to identify national priorities for quality improvement. This section would require the Secretary to ensure that the national priorities would address health care provided to patients with high-cost chronic diseases; improve the adoption of strategies for quality improvement that represent best practices; have the greatest potential for improving health outcomes, efficiency, and patient-centeredness of care; reduce health disparities; and address gaps in quality and health outcomes measures, comparative effectiveness information, and data aggregation techniques, among others. The national strategy would be required to include a comprehensive strategic plan to achieve the national priorities for quality improvement. The Secretary would also be required Congressional Research Service 20 Public Health, Workforce, Quality, and Other Provisions in S. 1679 to publish an annual national health care quality report card and create a website to make public the national priorities, the annual national health care quality report card, and other information the Secretary deems appropriate. Sec. 202. Interagency Working Group on Health Care Quality This section would require the President to convene a working group to be known as the Interagency Working Group on Health Care Quality. The goals of this group would include achieving collaboration, cooperation, and consultation between federal departments and agencies with respect to quality improvement activities, avoiding duplication of quality improvement efforts, and developing a streamlined process for quality reporting and compliance requirements. The Working Group would be composed of senior-level representatives of specified federal agencies and departments, the Secretary would serve as the Chair, and Members would serve as Vice Chair, on a rotating basis. The Working Group would be required to submit a report describing its progress and recommendations to relevant committees of Congress and to make this report publicly available. Sec. 203. Quality Measure Development This section would create in Title IX a new PHSA Part D, “Health Care Quality Improvement,” Subpart I, “Quality Measure Development.” It would include a new PHSA Sec. 931, which would require the Director of AHRQ to identify gaps where no quality measures exist or where existing measures need improvement, updating or expansion consistent with the national strategy under Sec. 399HH. In identifying these gaps, the Director would be required to consider the gaps identified by a qualified consensus-based entity under Sec. 399JJ. The Director would be required to make a report on any gaps identified, and the process used to identify the gaps, available to the public. This section would also require the Director to fund or enter into agreements with eligible entities for purposes of developing, improving, updating, or expanding quality measures in gap areas. The Director would be required to give priority to the development of quality measures that allow for the assessment of health outcomes and functional status of patients; the continuity, management, and coordination of health care and care transitions; health disparities; and the appropriate use of health care resources and services, among other things. An entity receiving funds under this section would be required to use the funds to develop quality measures that allow, to the extent practicable, data on measures to be collected using HIT, that are free of charge to users, and that are publicly available, among other things. The funds under this section would be able to be used by the Director to update and test quality measures endorsed by a qualified consensus-based entity. This section would authorize to be appropriated $75 million for each fiscal year through FY2014. Sec. 204. Quality Measure Endorsement; Public Reporting; Data Collection This section would create in Title III, Part S, a new Subpart II, “Health Care Quality Programs.” It would include Secs. 399JJ, 399KK, and 399LL, as described below. Sec. 399JJ would permit a qualified consensus-based entity to receive a grant or contract to make recommendations to the Secretary for national priorities for performance improvement; identify gaps in endorsed quality measures; identify and endorse quality measures, including measures that address gaps; update endorsed measures; make endorsed measures publicly available and have a plan for wide-spread dissemination; and transmit endorsed measures to the Secretary. An Congressional Research Service 21 Public Health, Workforce, Quality, and Other Provisions in S. 1679 entity that receives funding under this section would be required to convene multi-stakeholder groups to make recommendations for national priorities for performance improvement and to provide guidance on the selection of individual or composite measures for use in reporting performance information to the public or for use in federal health programs. This section would permit the Secretary to make a determination under regulation or otherwise to use a quality measure that has been endorsed by the qualified consensus-based entity only after taking into account the guidance of multi-stakeholder groups. The Secretary would be permitted to make a determination to use a quality measure that has not been endorsed under certain circumstances, and if there is no adequate alternative, the Secretary would be required to support the development of such an alternative measure. This section would require the Secretary to review quality measures used by the Secretary and determine whether to maintain or phase out each measure. This section would authorize to be appropriated $50 million for each fiscal year through FY2014. Sec. 399KK would require the Secretary to implement a system for the reporting of quality measures that protects patient privacy and, where appropriate, assesses health outcomes and functional status of patients; coordination of care; patient experience and patient caregiver and family engagement; the safety, effectiveness, and timeliness of care; and health disparities. This section would require the Secretary to make available to the public performance information summarizing data on quality measures through a series of standardized websites. Performance information on these websites would be required to be made available by clinical condition and, where appropriate, would be provider-specific to meet the needs of patients with different clinical conditions. Sec. 399LL would require the Comptroller General of the United States to conduct periodic evaluations of the implementation of the data collection processes for quality measures to be used by the Secretary. Sec. 205(a). Data for Quality and Resource Use Measures This subsection would add a new PHSA Sec. 399MM, which would provide for the development of reports to improve the quality and efficiency of health care and make available to the public provider-identifiable performance information. This section would require the Secretary to establish a process to collect, and validate, aggregate data on quality measures, as well as to ensure the collection and aggregation of consistent data on quality and resource use measures, to facilitate and implement public reporting of performance information, and would require the Secretary to award grants or contracts to eligible entities to support this activity. This section would also require the Secretary to support the development, validation, implementation, and refinement of nationally consistent methods used to support quality measurement and reporting through the awarding of grants or contracts to eligible quality data entities. The Secretary would be required to make aggregated data and reports on quality and resource use measures available to health care providers and the public. Finally, this section would require the Secretary to allow certain researchers to report on the performance of health care providers and suppliers, including in a provider-identifiable format. This section would authorize to be appropriated $90 million for each fiscal year through 2014. Congressional Research Service 22 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Quality Improvement and Patient Safety The PHSA, Title IX, provides AHRQ with broad general authority to conduct and support research on health care quality, including ways in which patients, consumers, purchasers, and practitioners acquire new information about best practices and health benefits, and the determinants and impact of their use of this information. In addition, AHRQ has the authority to provide financial assistance for meeting the costs of planning and establishing new centers for multidisciplinary health services research, demonstration projects, evaluations, training, and policy analysis. Under PHSA Sec. 301, the Secretary has general authority to conduct and promote the coordination of research, investigations, experiments, demonstrations, and studies related to the causes, diagnosis, treatment, control, and prevention of physical and mental diseases affecting individuals and to award grants for public health purposes, including for training; to award grants for training of health professionals under Part C of Title VII; and to conduct research and disseminate information regarding health care quality under Title IX; among other things. Sec. 211. Patient Safety Research Center This section would create a new Subpart II, “Health Care Quality Improvement Programs,” and would include a new PHSA Sec. 933, which would establish the Patient Safety Research Center in AHRQ. The general functions of this Center would include, among others (1) identifying providers that deliver consistently high-quality, efficient health care services and employ best practices that are adaptable and scalable to diverse health care settings; (2) assessing research, evidence, and knowledge about what strategies and methodologies are most effective in improving health care delivery; (3) finding ways to translate such information rapidly and effectively; (4) creating strategies for quality improvement through the development of tools, methodologies, and interventions that can successfully reduce variation in the delivery of health care; and (5) building capacity at the state and community level to lead quality and safety efforts through education, training and mentoring programs. The Center would be required to support research on health care delivery system improvement and the development of tools to facilitate the adoption of best practices. This section would require the Director to make the research findings of the Center available to the public and to ensure that research findings and results generated by the Center would be shared with HHS Office of the National Coordinator for HIT (ONCHIT) section would authorize to be appropriated $20 million for each fiscal year through 2014. This section would also add a new PHSA Sec. 934 which would require the Director, through the Center, to award technical assistance funding to specified eligible entities. Funds would provide technical support to institutions that deliver health care so that such institutions understand, adapt, and implement the models and practices identified in the research conducted by the Center. Funds would also support implementation awards to eligible entities to implement these models and practices. Sec. 216. Reducing and Reporting Hospital Readmissions This section would add a new PHSA Sec. 399NN, with the purpose of improving the quality and value of inpatient hospital services in order to improve the coordination of care and appropriately reduce inefficiency and waste, such as unnecessary hospital readmissions. This section would Congressional Research Service 23 Public Health, Workforce, Quality, and Other Provisions in S. 1679 require the Secretary to analyze and calculate hospital-specific and national applicable readmissions rates and to establish procedures to provide for the confidential disclosure, to hospitals receiving funds under this proposed law, of information on the hospital-specific and national applicable readmission rates. No later than two years after enactment, the Secretary would also be required to make publicly available information on applicable readmission rates of hospitals receiving funds under the PHSA. This section would require the Secretary to establish a program for eligible hospitals to improve their readmission rates through the use of patient safety organizations. Eligible hospitals would be defined as a hospital that the Secretary would determine to have a severity adjusted readmission rate, for the selected conditions, among the highest 25% of all hospitals nationally. Eligible hospitals and patient safety organizations working with those hospitals would be required to report to the Secretary on the processes employed by the hospital to improve readmission rates and the impact of such processes on readmission rates. This section would require the Secretary to identify and select at least eight high-volume and high-readmissions conditions or procedures to be analyzed under this section. It would also require the Secretary to select readmissions, for analysis under this section, that must have been reasonably preventable by the provision of care consistent with evidence-based guidelines during the prior admission or the post discharge follow-up period, and they must have been for a condition or procedure related to the care provided during the prior admission or post discharge follow-up period. The Comptroller General of the United States would be required to conduct a study on the impact of this section on care furnished to consumers, expenditures under federal health programs, and the cost and quality of care furnished by hospitals. This section would also require the Secretary to seek to enter into an agreement with the IOM to submit a report to Congress with recommendations on how to reduce unnecessary hospital readmissions. Sec. 220. Health Professional Education This section would allow the Secretary to award grants to eligible entities or consortia to develop and implement academic curricula that integrate quality improvement and patient safety into the clinical education of health professionals. A grant could be awarded under this section only if the receiving entity or consortium were to agree to make available nonfederal contributions toward the costs of the program in an amount that is not less than $1 for each $5 of federal funds. This section would also require the Secretary to evaluate the projects funded under this section and publish, make publicly available, and disseminate the results of such evaluations on as wide a basis as is practicable. Finally, this section would require the Secretary to submit a report to specified congressional committees that would describe the specific projects supported under this section and provide recommendations to Congress. Key Health Indicators There are a number of current efforts, some required by law, to collect and disseminate health statistics on the U.S. population. Those activities are primarily directed by AHRQ and the CDC National Center for Health Statistics (NCHS). AHRQ is required to submit two annual reports to Congress: one on national trends in the quality of health care provided to the American people, and the other on prevailing disparities in health care delivery as they relate to racial and socioeconomic factors in priority populations. NCHS conducts and supports statistical and epidemiological activities for the purpose of improving the effectiveness, efficiency, and quality Congressional Research Service 24 Public Health, Workforce, Quality, and Other Provisions in S. 1679 of health services in the United States. NCHS collects statistics on (1) the extent and nature of illness and disability in the U.S. population; (2) the impact of illness and disability of the population on the U.S. economy; (3) environmental, social, and other health hazards; (4) determinants of health; (5) health resources; (6) utilization of health care; (7) health care costs and financing; and (8) family formation, growth, and dissolution. Sec. 187. Key National Indicators This section would establish the Commission on Key National Indicators (“Commission”) appointed equally by the majority and minority leaders of the Senate and the Speaker and minority leader of the House of Representatives. The Commission would have the following responsibilities: (1) conduct comprehensive oversight of the newly established key national indicator system; (2) make recommendations on how to improve the key national indicator system; (3) coordinate with federal government users and information providers to ensure access to relevant and quality data; and (4) enter into contracts with the National Academy of Sciences (“Academy”). The Commission would be required to enter into an arrangement with the Academy to review available public and private sector research on key national indicator set selection and determine how to best establish a key national indicator system. The Academy would establish the key national indicator system by either creating its own institutional capability, or partnering with an independent, private, non-profit organization as an Institute. The Academy would be required to identify and select all criterion and methodologies to establish and operate the key national indicator system. This entails issues to be represented, measures to utilize, and data to populate the system. The Academy would be required to design, publish, and maintain a public website for public access to key national indicators. Also, the Academy would develop a quality assurance framework to ensure rigorous and independent processes and quality data selection. The Comptroller General of the United States would be required to conduct a study of previous work conducted by a range of entities with respect to best practices for a key national indicator system, and would be required to submit this study to the appropriate authorizing committees of Congress. This section would authorize to be appropriated $10 million for FY2010, and $7.5 million for each of fiscal years 2011 through 2018, with amounts appropriated to remain available until expended. Care Coordination Care coordination is seen as an important aspect of health care that helps avoid waste by reducing the over- and underuse of medications, diagnostic tests, and therapies. The current health care system places a high value on specialty care, rather than primary care, and patients with multiple chronic conditions often receive care from several providers in different settings. Among other things, this can compromise patients’ understanding of their conditions and ways to manage them, and may also result in deficiencies in the quality of care provided to these patients. A number of provisions in the Senate HELP bill address issues relating to the coordination of care by supporting medical homes, medication management services, patient navigator services, and the empowerment of patients through education about methods for managing their chronic conditions. Sec. 204 of the Tax Relief and Health Care Act of 2006 mandated a demonstration in up to eight states to provide targeted, accessible, continuous and coordinated care to Medicare beneficiaries with chronic or prolonged illnesses requiring regular medical monitoring, advising, or treatment. This model is commonly referred to as a medical home. Sec. 133 of the Medicare Improvements Congressional Research Service 25 Public Health, Workforce, Quality, and Other Provisions in S. 1679 for Patients and Providers Act of 2008 allowed the Secretary to expand the demonstration project as appropriate (subject to certain limitations). Currently, Medicare Part D sponsors are required to establish medication therapy management (MTM) programs, in cooperation with licensed pharmacists, to ensure that covered Part D drugs are used appropriately and reduce adverse drug interactions. Part D plans have significant flexibility in structuring their MTM programs and deciding which targeted populations are appropriate for MTM services. In a July 2008 study, CMS examined the attributes and features of MTM models currently in use and concluded that it is too soon to tell how the various MTM models contribute to clinical outcomes. Sec. 340A of the PHSA authorizes the Secretary to make grants to eligible entities for the development and operation of demonstration programs to provide patient navigator services. Patient navigators must have direct knowledge of the communities they serve, and perform the following duties, among others: (1) facilitate involvement of community organizations in assisting individuals with chronic diseases to receive better access to high-quality health care services; (2) help patients to overcome barriers in the health care system to ensure prompt resolution of an abnormal finding of a chronic disease; and (3) coordinate with relevant health insurance entities to provide information to individuals with chronic diseases about health coverage. Sec. 212. Community Health Teams to Support Patient-Centered Medical Homes This section would require the Secretary to implement a grant program for the purpose of establishing health teams to provide support to primary care providers, and providing capitated payments to these providers. Eligible grantees would be a state (or designee), Indian tribe, or tribal organization that submits a plan for financial sustainability and for incorporating prevention initiatives, patient education, and care management resources into care delivery, and that ensures that the health team includes a multi-disciplinary team of specified providers. “Medical home” would be defined as a mode of care that includes (1) personal physicians; (2) whole-person orientation; (3) coordinated and integrated care; (4) safe and high quality care though evidenceinformed medicine, appropriate use of health information technology, and continuous quality improvements; (5) expanded access to care; and (6) payment that recognizes added value from additional components of patient-centered care. A health team would be required to carry out 10 specific activities, including establishing contractual agreements with primary care providers to provide support services; developing plans that integrate preventive services for patients; providing 24-hour care management and support during transitions in care settings; and others. Primary care providers who contracted with these teams would be required to provide care plans for patient participants, provide access to participant health records and primary care practices, and meet regularly with the care team to ensure integration of care. Sec. 213. Medication Management Services in Treatment of Chronic Disease This section would add a new PHSA Sec. 935, which would require the Secretary, acting through the Patient Safety Research Center established in Sec. 933, to provide grants to support MTM services provided by licensed pharmacists. The section would require the Secretary to establish an MTM grant program. Grantees would have to provide various specified MTM services to targeted individuals, such as (1) assessing patients’ health and functional status; (2) formulating a medical Congressional Research Service 26 Public Health, Workforce, Quality, and Other Provisions in S. 1679 treatment plan; (3) administering appropriate medication therapy; (4) monitoring and evaluating patient response to therapy; (5) documenting the care delivered and communicating essential aspects to appropriate care providers; (6) providing education and training to enhance the appropriate use of medications; and (7) coordinating and integrating MTM services in broader health care management. MTM services provided by licensed pharmacists under this program would be targeted at individuals who take four or more prescribed medications, take high-risk medications, have two or more chronic diseases, or have undergone a transition of care or other factors that are likely to create a high risk of medication-related problems. The Secretary would be required to assess and evaluate specified aspects of the program and report to Congress. Sec. 217. Program to Facilitate Shared Decisionmaking This section would add a new PHSA Sec. 936 to facilitate shared decision making between patients and caregivers and their clinicians, by engaging the patient in clinical decision making, providing information on trade-offs among treatment options, and incorporating patient preferences and values into the medical plan. The Secretary would be required to enter into a contract with a qualified consensus-based organization to develop and identify standards for patient decision aids, to review patient decision aids, and develop a certification process for determining whether patient decision aids meet those standards. The Secretary, acting through the Director of AHRQ, would be required to award grants or contracts to develop, update, and produce patient decision aids, to test such materials to ensure they are balanced and evidencebased, and to educate providers on their use. The Secretary would be required to award grants for establishing Shared Decision Making Resource Centers to develop and disseminate best practices to speed adoption and effective use of patient decisions aids and shared decision making. The Secretary also would be required to award grants to providers for the development and implementation of shared decision-making techniques. Finally, the Secretary would be required to adopt quality measures for shared decision making. Providers receiving a grant would have to report to the Secretary data on those quality measures, and the Secretary would have to provide feedback to those providers. This section would authorize to be appropriated SSAN for FY2010, and each subsequent fiscal year. Sec. 223. Patient Navigator Program This section would amend PHSA Sec. 340A to prohibit the Secretary from awarding a grant to an entity under this section unless the entity provides assurances that patient navigators recruited, assigned, trained, or employed using these grant funds meet certain minimum core proficiencies. These proficiencies would be defined by the entity that submits the application and would be tailored for the main focus or intervention of the navigator involved. This section would authorize the appropriation of $3.5 million for FY2010, and SSAN for each of fiscal years 2011 through 2015. Congressional Research Service 27 Public Health, Workforce, Quality, and Other Provisions in S. 1679 Comparative Effectiveness Research ARRA provided $1.1 billion for comparative effectiveness research and created the Federal Coordinating Council for Comparative Effectiveness Research (FCCCER), an interagency advisory group that is required to report to the President and Congress annually.14 Sec. 219. Center for Health Outcomes Research and Evaluation The section would add a new PHSA, Sec. 937, which would require the Secretary to establish a Center for Health Outcomes Research and Evaluation (“Center”) within AHRQ. This section would direct the Center to conduct research relevant to the comparative health outcomes and effectiveness of the full spectrum of health care treatments. Responsibilities would cover systematic reviews of clinical research, research to identify benefits and risks of treatments specific to individuals’ genetic makeup and coexisting conditions, and research that leads to reduction in treatment disparities among populations. The Center would be required to use a broad range of methodologies, create informational [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR40831. Public record. Not legal advice.