of 2005. Such report shall be submitted to Congress not later than the date that is 6 months after the date such surveys are collected and shall be made publicly available on an Internet website of the Department of Health and Human Services. Subtitle E—Public Reporting on Health Care- SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS. (a) IN GENERAL.-Title XI of the Social Security Act is amended by inserting after section 1138 the following section: "SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS. "(a) REPORTING REQUIREMENT. "(1) IN GENERAL.-The Secretary shall provide that a hospital (as defined in subsection (g)) or ambulatory surgical center meeting the requirements of titles XVIII or XIX may participate in the programs established under such titles (pursuant to the applicable provisions of law, including sections 1866(a)(1) and 1832(a)(1)(F)(i)) only if, in accordance with this section, the hospital or center reports such information on health care-associated infections that develop in the hospital or center (and such demographic information associated with such infections) as the Secretary specifies. "(2) REPORTING PROTOCOLS.- Such information shall be reported in accordance with reporting protocols established by the Secretary through the Director of the Centers for Disease Control and Prevention (in this section referred to as the 'CDC') and to the National Healthcare Safety Network of the CDC or under such another reporting system of such Centers as determined appropriate by the Secretary in consultation with such Director. "(3) COORDINATION WITH HIT.-The Secretary, through the Director of the CDC and the Office of the National Coordinator for Health Information Technology, shall ensure that the transmission of information under this subsection is coordinated with systems established under the HITECH Act, where appropriate. "(4) PROCEDURES TO ENSURE THE VALIDITY OF INFORMATION.-The Secretary shall establish procedures regarding the validity of the information submitted under this subsection in order to ensure that such information is appropriately compared across hospitals and centers. Such procedures shall address failures to report as well as errors in reporting. "(5) IMPLEMENTATION.-Not later than 1 year after the date of enactment of this section, the Secretary, through the Director of CDC, shall promulgate regulations to carry out this section. "(b) PUBLIC POSTING OF INFORMATION.-The Secretary shall promptly post, on the official public Internet site of the Department of Health and Human Services, the information reported under subsection (a). Such information shall be set forth in a manner that allows for the comparison of information on health care-associated infections "(1) among hospitals and ambulatory surgical centers; and "(2) by demographic information. "(c) ANNUAL REPORT TO CONGRESS.-On an annual basis the Secretary shall submit to the Congress a report that summarizes each of the following: "(1) The number and types of health care-associated infections reported under subsection (a) in hospitals and ambulatory surgical centers during such year. "(2) Factors that contribute to the occurrence of such infections, including health care worker immunization rates. "(3) Based on the most recent information available to the Secretary on the composition of the professional staff of hospitals and ambulatory surgical centers, the number of certified infection control professionals on the staff of hospitals and ambulatory surgical centers. "(4) The total increases or decreases in health care costs that resulted from increases or decreases in the rates of occurrence of each such type of infection during such year. "(5) Recommendations, in coordination with the Center for Quality Improvement established under section 931 of the Public Health Service Act, for best practices to eliminate the rates of occurrence of each such type of infection in hospitals and ambulatory surgical centers. "(d) NON-PREEMPTION OF STATE LAWS.-Nothing in this section shall be construed as preempting or otherwise affecting any provision of State law relating to the dis closure of information on health care-associated infections or patient safety procedures for a hospital or ambulatory surgical center. "(e) HEALTH CARE-ASSOCIATED INFECTION.-For purposes of this section: "(1) IN GENERAL.-The term 'health care-associated infection' means an infection that develops in a patient who has received care in any institutional setting where health care is delivered and is related to receiving health care. “(2) RELATED TO RECEIVING HEALTH CARE.-The term 'related to receiving health care', with respect to an infection, means that the infection was not incubating or present at the time health care was provided. "(f) APPLICATION TO CRITICAL ACCESS HOSPITALS.-For purposes of this section, the term 'hospital' includes a critical access hospital, as defined in section 1861(mm)(1).". (b) EFFECTIVE DATE.-With respect to section 1138A of the Social Security Act (as inserted by subsection (a) of this section), the requirement under such section that hospitals and ambulatory surgical centers submit reports takes effect on such date (not later than 2 years after the date of the enactment of this Act) as the Secretary of Health and Human Services shall specify. In order to meet such deadline, the Secretary may implement such section through guidance or other instructions. (c) GAO REPORT.-Not later than 18 months after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on the program established under section 1138A of the Social Security Act, as inserted by subsection (a). Such report shall include an analysis of the appropriateness of the types of information required for submission, compliance with reporting requirements, the success of the validity procedures established, and any conflict or overlap between the reporting required under such section and any other reporting systems mandated by either the States or the Federal Government. (d) REPORT ON ADDITIONAL DATA.-Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to the Congress a report on the appropriateness of expanding the requirements under such section to include additional information (such as health care worker immunization rates), in order to improve health care quality and patient safety. TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS. (a) IN GENERAL.-Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended (1) in paragraph (4)(F)(i), by striking "paragraph (7)" and inserting "paragraphs (7) and (8)"; (2) in paragraph (4)(H)(i), by striking “paragraph (7)” and inserting “paragraphs (7) and (8)"; (3) in paragraph (7)(E), by inserting "and paragraph (8)" after "this paragraph"; and (4) by adding at the end the following new paragraph: "(8) ADDITIONAL REDISTRIBUTION OF UNUSED RESIDENCY POSITIONS.— "(i) PROGRAMS SUBJECT TO REDUCTION.-If a hospital's reference resident level (specified in clause (ii)) is less than the otherwise applicable resident limit (as defined in subparagraph (C)(ii)), effective for portions of cost reporting periods occurring on or after July 1, 2011, the otherwise applicable resident limit shall be reduced by 90 percent of the difference between such otherwise applicable resident limit and such reference resident level. "(ii) REFERENCE RESIDENT LEVEL.— "(I) IN GENERAL.-Except as otherwise provided in a subsequent subclause, the reference resident level specified in this clause for a hospital is the highest resident level for any of the 3 most recent cost reporting periods (ending before the date of the enactment of this paragraph) of the hospital for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary. "(II) USE OF MOST RECENT ACCOUNTING PERIOD TO RECOGNIZE EXPANSION OF EXISTING PROGRAMS.-If a hospital submits a timely request to increase its resident level due to an expansion, or planned expansion, of an existing residency training program that is not reflected on the most recent settled or submitted cost report, after audit and subject to the discretion of the Secretary, subject to subclause (IV), the reference resident level for such hospital is the resident level that includes the additional residents attributable to such expansion or establishment, as determined by the Secretary. The Secretary is authorized to determine an alternative reference resident level for a hospital that submitted to the Secretary a timely request, before the start of the 2009-2010 academic year, for an increase in its reference resident level due to a planned expansion. "(III) SPECIAL PROVIDER AGREEMENT.-In the case of a hospital described in paragraph (4)(H)(v), the reference resident level specified in this clause is the limitation applicable under subclause (I) of such paragraph. "(IV) PREVIOUS REDISTRIBUTION.-The reference resident level specified in this clause for a hospital shall be increased to the extent required to take into account an increase in resident positions made available to the hospital under paragraph (7)(B) that are not otherwise taken into account under a previous subclause. "(iii) AFFILIATION.-The provisions of clause (i) shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) and to the extent the hospitals can demonstrate that they are filling any additional resident slots allocated to other hospitals through an affiliation agreement, the Secretary shall adjust the determination of available slots accordingly, or which the Secretary otherwise has permitted the resident positions (under section 402 of the Social Security Amendments of 1967) to be aggregated for purposes of applying the resident position limitations under this subsection. "(B) REDISTRIBUTION. "“(i) IN GENERAL. The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2011. The estimated aggregate number of increases in the otherwise applicable resident limit under this subparagraph may not exceed the Secretary's estimate of the aggregate reduction in such limits attributable to subparagraph (A). "(ii) REQUIREMENTS FOR QUALIFYING HOSPITALS.-A hospital is not a qualifying hospital for purposes of this paragraph unless the following requirements are met: "(I) MAINTENANCE OF PRIMARY CARE RESIDENT LEVEL.-The hospital maintains the number of primary care residents at a level that is not less than the base level of primary care residents increased by the number of additional primary care resident positions provided to the hospital under this subparagraph. For purposes of this subparagraph, the base level of primary care residents' for a hospital is the level of such residents as of a base period (specified by the Secretary), determined without regard to whether such positions were in excess of the otherwise applicable resident limit for such period but taking into account the application of subclauses (II) and (III) of subparagraph (A)(ii). “(II) DEDICATED ASSIGNMENT OF ADDITIONAL RESIDENT POSITIONS TO PRIMARY CARE.-The hospital assigns all such additional resident positions for primary care residents. "(III) ACCREDITATION.-The hospital's residency programs in primary care are fully accredited or, in the case of a residency training program not in operation as of the base year, the hospital is actively applying for such accreditation for the program for such additional resident positions (as determined by the Secretary). “(iii) CONSIDERATIONS IN REDISTRIBUTION.—In determining for which qualifying hospitals the increase in the otherwise applicable resident limit is provided under this subparagraph, the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2011, made available under this subparagraph, as determined by the Secretary. RITY "(iv) PRIORITY FOR CERTAIN HOSPITALS.-In determining for which qualifying hospitals the increase in the otherwise applicable resident limit is provided under this subparagraph, the Secretary shall dis tribute the increase to qualifying hospitals based on the following criteria: "(I) The Secretary shall give preference to hospitals that had a reduction in resident training positions under subparagraph (A). "(II) The Secretary shall give preference to hospitals with 3-year primary care residency training programs, such as family practice and general internal medicine. "(III) The Secretary shall give preference to hospitals insofar as they have in effect formal arrangements (as determined by the Secretary) that place greater emphasis upon training in Federally qualified health centers, rural health clinics, and other nonprovider settings, and to hospitals that receive additional payments under subsection (d)(5)(F) and emphasize training in an outpatient department. "(IV) The Secretary shall give preference to hospitals with a number of positions (as of July 1, 2009) in excess of the otherwise applicable resident limit for such period. "(V) The Secretary shall give preference to hospitals that place greater emphasis upon training in a health professional shortage area (designated under section 332 of the Public Health Service Act) or a health professional needs area (designated under section 2211 of such Act). "(VI) The Secretary shall give preference to hospitals in States that have low resident-to-population ratios (including a greater preference for those States with lower resident-to-population ratios). “(v) LIMITATION.-In no case shall more than 20 full-time equivalent additional residency positions be made available under this subparagraph with respect to any hospital. "(vi) APPLICATION OF PER RESIDENT AMOUNTS FOR PRIMARY CARE.— With respect to additional residency positions in a hospital attributable to the increase provided under this subparagraph, the approved FTE resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital. "(vi) DISTRIBUTION.-The Secretary shall distribute the increase in resident training positions to qualifying hospitals under this subparagraph not later than July 1, 2011. “(Č) RESIDENT LEVEL AND LIMIT DEFINED.—In this paragraph: “(i) The term 'resident level has the meaning given such term in paragraph (7)(C)(i). "(ii) The term 'otherwise applicable resident limit' means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph but taking into account paragraph (7)(A). "(D) MAINTENANCE OF PRIMARY CARE RESIDENT LEVEL.-In carrying out this paragraph, the Secretary shall require hospitals that receive additional resident positions under subparagraph (B) (b) IME. "(i) to maintain records, and periodically report to the Secretary, on the number of primary care residents in its residency training programs; and "(ii) as a condition of payment for a cost reporting period under this subsection for such positions, to maintain the level of such positions at not less than the sum of "(I) the base level of primary care resident positions (as determined under subparagraph (B)(ii)(I)) before receiving such additional positions; and "(II) the number of such additional positions.". (1) IN GENERAL.-Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the third sentence, is amended (A) by striking "subsection (h)(7)" and inserting "subsections (h)(7) and (h)(8)"; and (B) by striking "it applies" and inserting "they apply". (2) CONFORMING PROVISION.-Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following clause: "(x) For discharges occurring on or after July 1, 2011, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(8)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions.". (c) CONFORMING AMENDMENT.-Section 422(b)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173) is amended by striking "section 1886(h)(7)" and all that follows and inserting "paragraphs (7) and (8) of subsection (h) of section 1886 of the Social Security Act.". SEC. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS. (a) DIRECT GME.-Section 1886(h)(4)(E) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended (1) by designating the first sentence as a clause (i) with the heading "IN GENERAL.-" and appropriate indentation; (2) by striking "shall be counted and that all the time" and inserting “shall be counted and that "(I) effective for cost reporting periods beginning before July 1, 2009, all the time"; (3) in subclause (I), as inserted by paragraph (1), by striking the period at the end and inserting "; and”; and (A) by inserting after subclause (I), as so inserted, the following: "(II) effective for cost reporting periods beginning on or after July 1, 2009, all the time so spent by a resident shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, if the hospital incurs the costs of the stipends and fringe benefits of the resident during the time the resident spends in that setting. Any hospital claiming under this subparagraph for time spent in a nonprovider setting shall maintain and make available to the Secretary records regarding the amount of such time and such amount in comparison with amounts of such time in such base year as the Secretary shall specify.". (b) IME.-Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended (1) by striking "(iv) Effective for discharges occurring on or after October 1, 1997" and inserting "(iv)(I) Effective for discharges occurring on or after October 1, 1997, and before July 1, 2009"; and (2) by inserting after subclause (I), as inserted by paragraph (1), the following new subclause: "(II) Effective for discharges occurring on or after July 1, 2009, all the time spent by an intern or resident in patient care activities at an entity in a nonprovider setting shall be counted towards the determination of full-time equivalency if the hospital incurs the costs of the stipends and fringe benefits of the intern or resident during the time the intern or resident spends in that setting.". (c) OIG STUDY ON IMPACT ON TRAINING.-The Inspector General of the Department of Health and Human Services shall analyze the data collected by the Secretary of Health and Human Services from the records made available to the Secretary under section 1886(h)(4)(E) of the Social Security Act, as amended by subsection (a), in order to assess the extent to which there is an increase in time spent by medical residents in training in nonprovider settings as a result of the amendments made by this section. Not later than 4 years after the date of the enactment of this Act, the Inspector General shall submit a report to Congress on such analysis and assessment. (d) DEMONSTRATION PROJECT FOR APPROVED TEACHING HEALTH CENTERS. (1) IN GENERAL.-The Secretary of Health and Human Services shall conduct a demonstration project under which an approved teaching health center (as defined in paragraph (3)) would be eligible for payment under subsections (h) and (k) of section 1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts for its own direct costs of graduate medical education activities for primary care residents, as well as for the direct costs of graduate medical education activities of its contracting hospital for such residents, in a manner similar to the manner in which such payments would be made to a hospital if the hospital were to operate such a program. (2) CONDITIONS.-Under the demonstration project (A) an approved teaching health center shall contract with an accredited teaching hospital to carry out the inpatient responsibilities of the primary care residency program of the hospital involved and is responsible for pay |