[Senate Report 108-189]
[From the U.S. Government Publishing Office]
Calendar No. 370
108th Congress Report
SENATE
1st Session 108-189
======================================================================
PHARMACY EDUCATION AID ACT OF 2003
_______
November 6, 2003.--Ordered to be printed
_______
Mr. Gregg, from the Committee on Health, Education, Labor, and
Pensions, submitted the following
R E P O R T
[To accompany S. 648]
The Committee on Health, Education, Labor, and Pensions, to
which was referred the bill (S. 648) to amend the Public Health
Service Act with respect to health professions programs
regarding the practice of pharmacy and having considered the
same, reports favorably thereon with an amendment in the nature
of a substitute and recommends that the bill (as amended) do
pass.
CONTENTS
Page
I. Purpose and need for legislation.................................1
II. Summary of the bill..............................................2
III. History of legislation and votes in committee....................2
IV. Explanation of bill and committee views..........................3
V. Cost estimate....................................................3
VI. Regulatory impact statement......................................6
VII. Application of law to the legislative branch.....................6
VIII.Section-by-section analysis......................................6
IX. Changes in existing law..........................................7
I. Purpose and Need for Legislation
Pharmacists are an important link in our Nation's health
care system and a shortage of pharmacists threatens the ability
of patients to pharmacies to provide important prescription
related services.
In the landmark report entitled ``To Err is Human: Building
a Safer Health System'', the Institute of Medicine reported
that medication errors can be partially attributed to factors
that are indicative of a shortage of pharmacists (such as too
many customers, numerous distractions, and staff shortages).
Congress acknowledged in the Healthcare Research and
Quality Act of 1999 (Public Law 106-129) the potential need for
pharmacists by requiring the Security of Health and Human
Services to conduct a study to determine whether there is a
shortage of pharmacists in the United States, and, if so, to
what extent.
As a result, the Secretary of Health and Human Services
published a report entitled ``The Pharmacist Workforce: A Study
in Supply and Demand for Pharmacists'' in December 2000 which
found, ``while the overall supply of pharmacists has increased
in the past decade, there has been an unprecedented demand for
pharmacists and for pharmaceutical care services, which has not
been met by the currently available supply'' and that the
``evidence clearly indicates the emergence of a shortage of
pharmacists over the past 2 years.''
The same study also found, ``the factors causing the
current shortage are of a nature not likely to abate in the
near future without fundamental changes in pharmacy practice
and education.'' The study projects that the number of
prescriptions filled by community pharmacists will increase by
20 percent by 2004.
Regarding access to pharmacy services in rural areas, the
study found, ``remoteness, isolation from other professionals,
lower economic returns, reduced opportunities for advancement
and other rural practice characteristics remain obstacles'' to
attracting pharmacists.
II. Summary of the Bill
The Pharmacy Education Aid Act of 2003 authorizes two new
student-loan repayment programs for pharmacists. The first
would repay the student loans of pharmacists who agree to
practice for at least 2 years in facilities that are facing
critical shortages of pharmacists, as defined by the Secretary
of Health and Human Services. The second would repay the loans
of students who agree to serve for at least 2 years as faculty
members at accredited schools of pharmacy.
III. History of Legislation and Votes in Committee
On December 11, 2001, Senator Reed, for himself and
Senators Enzi, Johnson, Chafee, Graham of Florida, Collins,
Landrieu, Hutchinson, Inouye, Cochran, and Wellstone,
introduced S. 1806, the Pharmacy Education Aid Act of 2001.
Senators Mikulski and Torricelli later joined as co-sponsors of
the act.
On September 30, 2002, the committee held an executive
session to consider S. 1806. After agreeing to an amendment in
the nature of a substitute, the committee approved S. 1806 by
unanimous voice vote.
On October 3, 2002, the Senate approved S. 1806 by
unanimous voice vote. On October 7, 2002, the House received S.
1806 and referred the act to the Committee on Energy and
Commerce.
There was no further action on S. 1806 in the 107th
Congress.
On March 18, 2003, Senator Reed, for himself and Senators
Enzi, Johnson, Warner, Landrieu, Collins, Inouye, and Roberts,
introduced S. 648, the Pharmacy Education Aid Act of 2003.
Senators Cochran, Lautenberg, Mikulski, and Stabenow later
joined as cosponsors of the act.
On June 11, 2003, the committee held an executive session
to consider S. 648. After agreeing to an amendment in the
nature of a substitute offered by Senator Enzi for himself and
Senator Reed, the committee approved S. 648 by unanimous voice
vote.
A. AMENDMENT ADOPTED
The Enzi-Reed substitute amendment approved by the
committee requires schools of pharmacy conform to current law
and match federal contributions on a dollar-for-dollar basis in
the faculty loan repayment program. The substitute amendment
also removed a provision establishing a new information
technology grant program for schools of pharmacy.
IV. Explanation of Bill and Committee Views
The committee recognizes the important role that
pharmacists play in the American health care system. In
particular, the committee appreciates the role that pharmacists
play in rural areas, where the pharmacist can be one of the few
local health professionals with a permanent presence in the
community.
The demand for pharmacists will increase as prescription
drug use continues to grow. To help meet this demand, the
Pharmacy Education Aid Act of 2003 would establish programs
that help reduce the financial barriers faced by pharmacists
who would seek to practice in shortage areas or to serve as
pharmacy school faculty, two of the great demonstrated needs in
the pharmacist workforce.
The committee would be concerned if schools of pharmacy
were to use funds made available through this act for repaying
the educational loans of a faculty member to replace funds that
the school otherwise would have paid in salary or other
benefits to such faculty member. The committee intends for the
faculty loan repayment program to assist pharmacists who take
faculty positions in repaying their educational loans, since
faculty positions generally pay less than full-time practicing
positions in most areas. To that end, the committee expects the
Secretary to ensure that faculty loan repayments made by a
school of pharmacy are in addition to the compensation that the
individual would normally receive for serving as a member of
the faculty.
The committee expects that the Secretary will develop
regulations to implement this act, in particular the definition
of a ``facility with a critical shortage of pharmacists'', in
consultation with organizations representing residents of
medically underserved areas, facilities and pharmacists that
serve such residents, and schools of pharmacy.
V. Cost Estimate
U.S. Congress,
Congressional Budget Office,
Washington, DC, July 31, 2003.
Hon. Judd Gregg,
Chairman, Committee on Health, Education, Labor, and Pensions, U.S.
Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 648, the Pharmacy
Education Aid Act of 2003.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Alexis
Ahlstrom.
Sincerely,
Robert A. Sunshine
(for Douglas Holtz-Eakin, Director).
Enclosure.
S. 648--Pharmacy Education Aid Act of 2003
Summary: S. 648 would establish two pharmacy education
programs within the Health Services and Research Administration
(HRSA). The bill would authorize the agency to pay principal
and interest on education loans owed by pharmacists possessing
bachelor or doctorate degrees who agree to work for at least
two years in an area where there is a shortage of pharmacists.
S. 648 also would provide for loan repayments for students and
graduates who became members of the faculty of a pharmacy
school for a minimum of two years. In each case, payments for
an individual could not exceed $35,000 per year of service. The
bill would authorize the appropriation of such sums as
necessary for these activities from 2004 through 2008.
Assuming appropriation of the necessary amounts, CBO
estimates that implementing S. 648 would cost $2 million in
2004 and $51 million over the 2004-2008 period.
By authorizing assistance to certain pharmacists, S. 648
would effectively extend provisions of section 224 of the
Public Health Service act to those pharmacists who choose to
work in health centers that receive funding under section 330
of that act. That section authorizes settlements and awards for
tort claims to be paid out of the Treasury's Judgment Fund.
Those payments are considered direct spending, regardless of
whether the health program involved is an entitlement program
or subject to appropriations. CBO estimates that additional
payments under S. 648 would be less than $500,000 over the
2004-2008 period.
S. 648 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Any costs that public schools of pharmacy incur to assist
faculty members with loan payments would be voluntary.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 648 is shown in the following table. The
costs of this legislation fall within budget functions 550
(health) and 800 (general government).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------------------
2004 2005 2006 2007 2008
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATIONS \1\
Estimated Authorization Level............................ 3 8 13 18 22
Estimated Outlays........................................ 2 5 11 15 18
----------------------------------------------------------------------------------------------------------------
\1\ Enacting S. 648 also would increase direct spending, but the estimated cost would be less than $500,000 over
the 2004-2008 period.
Basis of estimate: For this estimate, CBO assumes that S.
648 will be enacted by the fall of 2003 and that the necessary
amounts to implement the bill will be appropriated each year.
CBO estimates that implementing S. 648 would require new
discretionary spending of about $51 million over the next five
years. Enacting the legislation also could increase direct
spending, but any such effects would not be significant.
Spending subject to appropriation
S. 648 would establish a loan repayment program for
individuals with a pharmacy degree who agree to work for a
minimum of two years in areas with a critical shortage of
pharmacists. The program would reimburse up to $35,000 per year
for loans covering tuition and living expenses, and would cover
the tax liability associated with those reimbursements.
Based on information from HRSA, CBO estimates that about 50
graduates would participate in 2004, rising to about 250
graduates each year by 2008. CBO estimates that annual loan
repayments, including payments for tax liability, would average
about $30,000 per participant in 2004, and that participants
would receive this aid for two to three years.
The bill would allow HRSA to recover payments to
individuals who fail to complete two years of service in an
area with a shortage of pharmacists. CBO estimates that the
percentage of pharmacists who fail to complete two years of
service would be between 5 percent and 15 percent, which is
similar to the experience of the National Health Service Corps
program.
CBO estimates that the cost of implementing this loan
repayment program would be less than $2 million in 2004 and $49
million over the 2004-2008 period, assuming the appropriation
of the necessary amounts.
The bill also would establish a loan repayment program for
pharmacy school graduates and near-graduates who serve on the
faculty of a pharmacy school. Under the bill, HRSA would enter
into contracts with students or graduates who have agreed to
work for a minimum of two years at a school of pharmacy. HRSA
would reimburse participants up to $35,000 per year for their
outstanding loans. The school hiring the participant would be
required to match federal payments, and would not be able to
reduce the faculty member's salary to account for the loan
repayments.
Based on information from HRSA, CBO expects that there
would not be much participation by pharmacy schools in the
faculty loan repayment program because of the matching
requirement. CBO estimates that the number of participants in
the loan repayment program would grow from 5 in 2004 to 30 in
2008. We assume that participants would receive loan
reimbursement for two years on average, in amounts averaging
between $22,000 and $25,000 per year over this period. CBO
estimates that implementing this program would cost less than
$500,000 in 2004 and $3 million over the 2004-2008 period,
assuming the appropriation of the necessary amounts.
Direct spending
Under current law, settlements and tort claims arising from
the actions of licensed health care providers in federally
funded health centers are paid from the Treasury's Judgment
Fund. The bill would expand that coverage to include tort
claims arising from the actions of licensed pharmacists
participating in the new loan repayment program. Based on past
experience with spending from the Judgment Fund for providers
covered under section 224 and the small number of pharmacists
who would likely be affected by this provision, CBO estimates
that any payments from the Fund would be less than $500,000
during the 2004-2008 period.
Intergovernmental and private-sector impact: S. 648
contains no intergovernmental or private-sector mandates as
defined in UMRA. Any costs that public schools of pharmacy
incur to assist faculty members with loan payments would be
voluntary.
Estimate prepared by: Federal Costs: Alexis Ahlstrom;
Impact on State, Local, and Tribal Governments: Leo Lex; and
Impact on the Private Sector: Daniel Wilmoth.
Estimate approved by: Robert A. Sunshine, Assistant
Director for Budget Analysis.
VI. Regulatory Impact Statement
The committee has determined that there will be minimal
increases in the regulatory burden imposed by this bill.
VII. Application of Law to the Legislative Branch
The Committee has determined that there is no legislative
impact.
VIII. Section-by-Section Analysis
Section 1. Short title
This bill may be referred to as the ``Pharmacy Education
Aid Act of 2003''.
Section 2. Findings
The findings describe the nature of the pharmacist
shortage, particularly as it impacts rural areas, and the need
both to educate a new generation of pharmacists and to
encourage new pharmacists to practice in underserved areas and
facilities.
Section 3. Health professions programs related to the practice of
pharmacy
The act amends Title VII of the Public Health Service Act
to create two student-loan repayment programs for pharmacists.
Loan repayment program for pharmacists serving in critical
shortage facilities
The act authorizes the Secretary of Health and Human
Services to repay the student loans of licensed pharmacists who
agree to serve for at least 2 years at a facility designated by
the Secretary as having a critical shortage of pharmacists.
For each year of obligated service for which a pharmacist
contracts to serve, the Secretary may pay up to $35,000 of the
pharmacist's student loans.
Similar to the National Health Service Corps student loan
repayment program, the act authorizes the Secretary to
reimburse the pharmacist for tax liability resulting from the
student loan payments. To do so, the Secretary shall make
payments to the pharmacist in an amount equal to 39 percent of
the total amount of loan repayments made for the taxable year
involved.
In entering into student loan repayment agreements under
this section, the Secretary shall give preference to qualified
applicants with the greatest financial need.
The act requires the Secretary to report to Congress
annually on the program. The Secretary must also report to
Congress within 5 years after enactment on how the program
carried out under this section interacts with other Federal
loan repayment programs for pharmacists and the relative
effectiveness of such programs in increasing pharmacists
practicing in underserved areas.
A pharmacist who breaches his or her agreement under this
section shall be liable to the Federal Government for the
amount of the award and for interest on such amount.
The act authorizes such sums as may be necessary for fiscal
years 2003 through 2008.
Pharmacy faculty loan repayment program
The act authorizes the Secretary of Health and Human
Services to repay the student loans of pharmacists or pharmacy
students who agree to serve for at least 2 years as a faculty
member of a qualified school of pharmacy. To be qualified, a
school of pharmacy must provide clinical experience that
includes service provided for, or a facility that serves,
medically underserved citizens.
For each year of service, the Secretary may not pay more
than $35,000 of the principal and interest of the educational
loans of such individuals.
Eligible individuals include those who have a baccalaureate
degree in pharmacy or a Doctor of Pharmacy degree from an
accredited program, or are enrolled as a full-time student in
an accredited pharmacy program and are in the final year of a
course of study leading to a baccalaureate degree in pharmacy
or a Doctor of Pharmacy degree.
The Secretary may not enter into a loan-repayment contract
unless the individual involved has entered into a contract with
a school of pharmacy to serve as a member of the facility of
the school for not less than 2 years; and the contract provides
that the school will, for each year for which the individual
will serve as a member of the faculty under contract with the
school, make payments of the principal and interest due on the
educational loans of the individual for such year in an amount
equal to the amount of such payments made by the Secretary for
the year.
The payments made by the school must be in addition to the
compensation that the individual would otherwise receive for
serving as a member of the faculty.
The act authorizes such sums as may be necessary to carry
out the program in fiscal years 2004 through 2008.
IX. Changes in Existing Law
In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, the following provides a print of the
statute or the part or section thereof to be amended or
replaced (existing law proposed to be omitted is enclosed in
black brackets, new matter is printed in italic, existing law
in which no change is proposed is shown in roman):
PUBLIC HEALTH SERVICE ACT
* * * * * * *
TITLE VII--HEALTH PROFESSIONS EDUCATION
PART A--STUDENT LOANS
Subpart I--Insured Health Education Assistance Loans to Graduate
Students
SEC. 701. STATEMENT OF PURPOSE.
* * * * * * *
PART E--HEALTH PROFESSIONS AND PUBLIC HEALTH WORKFORCE
Subpart 1--Health Professions Workforce Information and Analysis
SEC. 761. HEALTH PROFESSIONS WORKFORCE INFORMATION AND ANALYSIS.
(a) Purpose.--* * *
* * * * * * *
``Subpart 3--Pharmacy Workforce Development
``SEC. 781. LOAN REPAYMENT PROGRAM FOR PHARMACISTS SERVING IN CRITICAL
SHORTAGE FACILITIES.
(a) In General.--In the case of any individual--
(1) who has received a baccalaureate degree in
pharmacy or a Doctor of Pharmacy degree from an
accredited program;
(2) who obtained an educational loan for pharmacy
education costs; and
(3) who is licensed without restrictions in the State
in which the designated health care facility is
located;
the Secretary may enter into an agreement with such individual
who agrees to serve as a full-time pharmacist for a period of
not less than 2 years at a designated health care facility, to
make payments in accordance with subsection (b), for and on
behalf of that individual, on the principal of and interest on
any loan of that individual described in paragraph (2) which is
outstanding on the date the individual begins such service.
(b) Manner of Payments.--
(1) In general.--The payments described in subsection
(a) may consist of payment, in accordance with
paragraph (2), on behalf of the individual of the
principal, interest, and related expenses on government
and commercial loans received by the individual
regarding the undergraduate or graduate education of
the individual (or both), which loans were made for--
(A) tuition expenses;
(B) all other reasonable educational
expenses, including fees, books, and laboratory
expenses, incurred by the individual; or
(C) reasonable living expenses as determined
by the Secretary.
(2) Payments for years served.--
(A) In general.--For each year of obligated
service that an individual contracts toserve
under subsection (a) the Secretary may pay up to $35,000 on behalf of
the individual for loans described in paragraph (1). In making a
determination of the amount to pay for a year of such service by an
individual, the Secretary shall consider the extent to which each such
determination--
(i) affects the ability of the
Secretary to maximize the number of
agreements that may be provided under
this section from the amounts
appropriated for such agreements;
(ii) provides an incentive to serve
in areas with the greatest shortages of
pharmacists; and
(iii) provides an incentive with
respect to the pharmacist involved
remaining in the area and continuing to
provide pharmacy services after the
completion of the period of obligated
service under agreement.
(B) Repayment schedule.--Any arrangement made
by the Secretary for the making of loan
repayments in accordance with this subsection
shall provide that any repayments for a year of
obligated service shall be made not later than
the end of the fiscal year in which the
individual completes such year of service.
(3) Tax liability.--For the purpose of providing
reimbursements for tax liability resulting from
payments under paragraph (2) on behalf of an
individual--
(A) the Secretary shall, in addition to such
payments, make payments to the individual in an
amount equal to 39 percent of the total amount
of loan repayments made for the taxable year
involved; and
(B) may make such additional payments as the
Secretary determines to be appropriate with
respect to such purpose.
(4) Payment schedule.--The Secretary may enter into
an agreement with the holder of any loan for which
payments are made under this section to establish a
schedule for the making of such payments.
(c) Preferences.--In entering into agreements under
subsection (a), the Secretary shall give preference to
qualified applicants with the greatest financial need.
(d) Reports.--
(1) Annual report.--Not later than 18 months after
the date of enactment of the Pharmacy Education Aid
Act, and annually thereafter, the Secretary shall
prepare and submit to Congress a report describing the
program carried out under this section, including
statements regarding--
(A) the number of applicants and contract
recipients;
(B) the amount of loan repayments made;
(C) which educational institution the
recipients attended;
(D) the number and practice locations of the
loan repayment recipients at health care
facilities with a critical shortage of
pharmacists;
(E) the default rate and actions required;
(F) the amount of outstanding default funds
of the loan repayment program;
(G) to the extent that it can be determined,
the reason for the default;
(H) the demographics of the individuals
participating in the loan repayment program;
and
(I) an evaluation of the overall costs and
benefits of the program.
(2) 5-year report.--Not later than 5 years after the
date of enactment of the Pharmacy Education Aid Act,
the Secretary shall prepare and submit to Congress a
report on how the program carriedout under this section
interacts with other Federal loan repayment programs for pharmacists
and determining the relative effectiveness of such programs in
increasing pharmacists practicing in underserved areas.
(e) Application of Certain Provisions.--
(1) In general.--The provisions of section 338C,
338G, and 338I shall apply to the program established
under this section in the same manner and to the same
extent as such provisions apply to the National Health
Service Corps Loan Repayment Program under subpart III
of part D of title III, including the applicability of
provisions regarding reimbursements for increased tax
liability and bankruptcy.
(2) Breach of agreement.--An individual who enters
into an agreement under subsection (a) shall be liable
to the Federal Government for the amount of the award
under such agreement (including amounts provided for
expenses related to such attendance), and for interest
on such amount at the maximum legal prevailing rate, if
the individual fails to provide health services in
accordance with the program under this section for the
period of time applicable under the program.
(3) Waiver or suspension of liability.--In the case
of an individual or health facility making an agreement
for purposes of subsection (a), the Secretary shall
provide for the waiver or suspension of liability under
paragraph (2) if compliance by the individual or the
health facility, as the case may be, with the agreement
involved is impossible, or would involve extreme
hardship to the individual or facility, and if
enforcement of the agreements with respect to the
individual or facility would be unconscionable.
(4) Date certain for recovery.--Subject to paragraph
(3), any amount that the Federal Government is entitled
to recover under paragraph (2) shall be paid to the
United States not later than the expiration of the 3-
year period beginning on the date the United States
becomes so entitled.
(5) Availability.--Amounts recovered under paragraph
(2) with respect to a program under this section shall
be available for the purposes of such program, and
shall remain available for such purposes until
expended.
(f) Definition.--In this section, the term ``health care
facility'' means a facility with a critical shortage of
pharmacists as determined by the Secretary.
(g) Authorization of Appropriations.--For the purpose of
payments under agreements entered into under subsection (a),
there are authorized to be appropriated such sums as may be
necessary for each of fiscal years 2004 through 2008.
SEC. 782. PHARMACY FACULTY LOAN REPAYMENT PROGRAM.
(a) Establishment of Program.--The Secretary shall
establish a program under which the Secretary will enter into
contracts with individuals described in subsection (b) and such
individuals will agree to serve as faculty members of schools
of pharmacy in consideration of the Federal Government agreeing
to pay, for each year of such service, not more than $35,000 of
the principal and interest of the educational loans of such
individuals.
(b) Eligible Individuals.--An individual is described in
this subsection if such individual--
(1) has a baccalaureate degree in pharmacy or a
Doctor of Pharmacy degree from an accredited program;
or
(2) is enrolled as a full-time student--
(A) in an accredited pharmacy program; and
(B) in the final year of a course of a study
or program, offered by such institution
andapproved by the Secretary, leading to a baccalaureate degree in
pharmacy or a Doctor of Pharmacy degree from such a school.
(c) Requirements Regarding Faculty Positions.--The
Secretary may not enter into a contract under subsection (a)
unless--
(1) the individual involved has entered into a
contract with a school of pharmacy to serve as a member
of the faculty of the school for not less than 2 years;
and
(2) the contract referred to in paragraph (1)
provides that--
(A) the school will, for each year for which
the individual will serve as a member of the
faculty under contract with the school, make
payments of the principal and interest due on
the educational loans of the individual for
such year in an amount equal to the amount of
such payments made by the Secretary for the
year;
(B) the payments made by the school pursuant
to subparagraph (A) on behalf of the individual
will be in addition to the compensation that
the individual would otherwise receive for
serving as a member of such faculty; and
(C) the school, in making a determination of
the amount of compensation to be provided by
the school to the individual for serving as a
member of the faculty, will make the
determination without regard to the amount of
payments made (or to be made) to the individual
by the Federal Government under subsection (a).
(d) Applicability of Certain Provisions.--The provisions of
sections 338C, 338G, and 338I shall apply to the program
established in subsection (a) to the same extent and in the
same manner as such provisions apply to the National Health
Service Corps Loan Repayment Program established in subpart III
of part D of title III, including the applicability of
provisions regarding reimbursements for increased tax liability
and regarding bankruptcy.
(e) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2004 through 2008.
SEC. 783. DEFINITIONS.
In this subpart:
(1) School of pharmacy.--the term ``school of
pharmacy'' means a college or school of pharmacy (as
defined in section 799B) that, in providing clinical
experience for students, requires that the
studentsserve in a clinical rotation in which pharmacist services (as
defined in section 331(a)(3)(E)) are provided at or for--
(A) a medical facility that serves a
substantial number of individuals who reside in
or are members of a medically underserved
community (as so defined);
(B) an entity described in any of
subparagraphs (A) through (L) of section
340B(a)(4) (relating to the definition of
covered entity);
(C) a health care facility of the Department
of Veterans Affairs or of any of the Armed
Forces of the United States;
(D) a health care facility of the Bureau of
Prisons;
(E) a health care facility operated by, or
with funds received from, the Indian Health
Service; or
(F) a disproportionate share hospital under
section 1923 of the Social Security Act.
(2) Pharmacist services.--The term ``pharmacist
services'' includes drug therapy management services
furnished by a pharmacist, individually or on behalf of
a pharmacy provider, and such services and supplies
furnished incident to the pharmacist's drug therapy
management services, that the pharmacist is legally
authorized to perform (in the State in which the
individual performs such services) in accordance with
State law (or the State regulatory mechanism provided
for by State law).
* * * * * * *