[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6048 Introduced in House (IH)]








109th CONGRESS
  2d Session
                                H. R. 6048

 To amend title XVIII of the Social Security Act to provide incentives 
to Medicare participating suppliers and providers of services that are 
   outpatient physical therapy services (including outpatient speech-
   language pathology services) and occupational therapy services to 
report quality and efficiency measures and to provide for a value-based 
 purchasing program for payments for such services under the Medicare 
                    Program, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 7, 2006

  Mrs. Wilson of New Mexico introduced the following bill; which was 
 referred to the Committee on Energy and Commerce, and in addition to 
   the Committee on Ways and Means, for a period to be subsequently 
   determined by the Speaker, in each case for consideration of such 
 provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
 To amend title XVIII of the Social Security Act to provide incentives 
to Medicare participating suppliers and providers of services that are 
   outpatient physical therapy services (including outpatient speech-
   language pathology services) and occupational therapy services to 
report quality and efficiency measures and to provide for a value-based 
 purchasing program for payments for such services under the Medicare 
                    Program, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Outpatient Therapy Value-
Based Purchasing Act of 2006''.

SEC. 2. QUALITY AND EFFICIENCY MEASURES (Q & E MEASURES) AND VALUE-
              BASED PURCHASING PROGRAM FOR OUTPATIENT PHYSICAL THERAPY 
              SERVICES AND OCCUPATIONAL THERAPY SERVICES.

    (a) In General.--Section 1834 of the Social Security Act (42 U.S.C. 
1395m) is amended by adding at the end the following new subsections:
    ``(n) Quality and Efficiency Measures (Q & E Measures) for 
Outpatient Physical Therapy Services and Occupational Therapy 
Services.--
            ``(1) Submission of q & e measures to a national therapy 
        outcomes database.--
                    ``(A) In general.--For purposes of subsection 
                (o)(1), a covered provider of covered outpatient 
                therapy services may submit to a national therapy 
                outcomes database designated by the Secretary Q & E 
                performance information described in subparagraph (B). 
                Such information shall be submitted in a form and 
                manner and at a time specified by the Secretary.
                    ``(B) Q & e performance information described.--Q & 
                E performance information described in this 
                subparagraph is information on the performance of a 
                covered provider of covered outpatient therapy services 
                on the Q & E measures selected under paragraph (2), 
                with respect to each individual enrolled under this 
                part to whom such covered provider furnishes such 
                services.
            ``(2) Selection and development of q & e measures.--
                    ``(A) In general.--As part of the rulemaking 
                process for payments under subsection (k) for 2007 and 
                for purposes of this subsection and subsection (o), the 
                Secretary shall provide for the selection of Q measures 
                and E measures (referred to in such subsections as `Q & 
                E measures' collectively), with respect to covered 
                outpatient therapy services furnished by a covered 
                provider of such services to individuals enrolled under 
                this part. Q measures shall be measures that provide 
                for the assessment of the quality of such services. E 
                measures shall be measures that provide for the 
                assessment of the efficiency of utilization of such 
                services by such a covered provider.
                    ``(B) Development of measures.--Q & E measures 
                selected under subparagraph (A) shall be--
                            ``(i) developed through--
                                    ``(I) negotiated rulemaking; or
                                    ``(II) a consensus-building process 
                                coordinated by the National Quality 
                                Forum or a forum similar to the 
                                National Quality Forum; or
                            ``(ii) recognized by the National Quality 
                        Measures Clearinghouse of the Agency for Health 
                        Care Quality and Research.
                    ``(C) General characteristics of q & e measures.--
                To the extent feasible and practicable, Q & E measures 
                shall provide for the uniform reporting of therapy-
                specific data and shall--
                            ``(i) include a mixture of outcome 
                        measures, process measures (such as furnishing 
                        a service), and structural measures (such as 
                        the use of health information technology for 
                        submission of measures);
                            ``(ii) in the case of E measures, include 
                        efficiency measures related to clinical care 
                        (such as overuse, misuse, or underuse);
                            ``(iii) use a reporting mechanism, 
                        concurrent with the episode of care, that 
                        incorporates both the individual's and the 
                        applicable covered provider's input;
                            ``(iv) contribute to a national therapy 
                        outcomes database from which risk-adjusted 
                        thresholds for quality and efficiency 
                        measurements of covered providers of services 
                        involved can be established;
                            ``(v) promote interoperability of Q & E 
                        measures;
                            ``(vi) be evidence-based, if pertaining to 
                        clinical care;
                            ``(vii) be consistent, reliable, valid, 
                        responsive, practicable, and not overly 
                        burdensome to collect;
                            ``(viii) include measures that collectively 
                        provide a balanced measure of performance of 
                        the covered provider involved, with respect to 
                        the condition of the individual involved;
                            ``(ix) include measures that capture the 
                        individuals' involved assessment of clinical 
                        care furnished; and
                            ``(x) include measures that assess the 
                        relative use of resources, services, or 
                        expenditures (or any combination thereof) by 
                        the covered provider involved.
                    ``(D) Fairness.--To the extent feasible and 
                practicable, this paragraph shall be implemented in a 
                manner that--
                            ``(i) takes into account differences in the 
                        health status of each individual;
                            ``(ii) takes into account an individual's 
                        compliance with medical instructions related to 
                        the service involved;
                            ``(iii) does not directly or indirectly 
                        encourage patient selection or de-selection by 
                        covered providers of covered outpatient therapy 
                        services;
                            ``(iv) reduces health disparities across 
                        groups and areas; and
                            ``(v) uses appropriate statistical 
                        techniques to ensure valid results.
                    ``(E) Periodic review of q & e measures.--The 
                Secretary shall provide for the periodic revision and 
                selection of Q & E measures consistent with the 
                provisions of this paragraph and the application of 
                such revised Q & E measures on a prospective basis 
                beginning with a following year.
            ``(3) Public disclosure of covered providers' performance 
        on q & e measures.--
                    ``(A) In general.--Not later than January 1, 2010, 
                the Secretary shall establish procedures to require 
                that information with respect to the quality and 
                efficiency demonstrated by a covered provider of 
                covered outpatient therapy services during a year 
                (based on the Q & E measures submitted under paragraph 
                (1)(A) by the covered provider involved for such year) 
                is made available to the public in a clear and 
                understandable form.
                    ``(B) Covered provider notification and opportunity 
                for comment; appeals process.--
                            ``(i) Notification and opportunity for 
                        comment.--
                                    ``(I) In general.--For purposes of 
                                subparagraph (A), before making the 
                                information described in such 
                                subparagraph available to the public 
                                with respect to a covered provider for 
                                years beginning with 2010, the 
                                Secretary shall notify the provider of 
                                the performance of the provider on the 
                                Q & E measures (including information 
                                on the performance of the provider in 
                                relation to the aggregate performance 
                                of the peers of such provider) and 
                                provide the opportunity for the 
                                provider to submit to the Secretary 
                                written comments with respect to such 
                                performance. The Secretary shall 
                                respond in writing to the comments and 
                                seek to reach agreement on the 
                                performance of the provider on the Q & 
                                E measures for the year involved.
                                    ``(II) Administrative provision.--
                                For purposes of subclause (I), 
                                notification provided by the Secretary 
                                and comments submitted by a provider 
                                shall be provided and submitted, 
                                respectively, in such manner and form 
                                and by such time as specified by the 
                                Secretary.
                                    ``(III) Peer defined.--For purposes 
                                of subclause (I), the term `peer' 
                                means, with respect to a covered 
                                provider that practices in a type of 
                                therapy, other covered providers that 
                                practice in the same type of therapy in 
                                the United States.
                            ``(ii) Appeals process.--The Secretary 
                        shall establish a formal appeals process for 
                        purposes of hearing cases in which agreements 
                        under clause (i)(I) cannot be reached. Upon 
                        conclusion of the appeals process, if the 
                        provider submits comments relating directly to 
                        the information made available under 
                        subparagraph (A) with respect to such provider, 
                        the Secretary shall make such comments 
                        available to the public with such information.
                    ``(C) Exceptions to public disclosure.--The 
                procedures established under subparagraph (A) shall 
                include exceptions to the requirement described in such 
                subparagraph. In providing for such exceptions, the 
                Secretary shall take into account whether or not the 
                covered provider involved was a new covered provider, 
                as specified by the Secretary, for covered outpatient 
                therapy services or otherwise had insufficient 
                information to provide to the Secretary for a 
                measurement of the quality and efficiency performance 
                of such covered provider.
            ``(4) National therapy outcomes database.--
                    ``(A) In general.--For purposes of this subsection 
                and subsection (o), the Secretary shall provide for at 
                least one national therapy outcomes database to analyze 
                Q & E provider information submitted under paragraph 
                (1)(A) and, based on such information, generate values 
                (that are adjusted for the risk characteristics of the 
                individuals provided covered outpatient therapy 
                services) for the following:
                            ``(i) How much functional improvement an 
                        individual is expected to experience over a 
                        designated period, with respect to services 
                        involved.
                            ``(ii) The period over which an individual 
                        with such characteristics is expected to 
                        experience the maximum functional improvement 
                        through the receipt of covered outpatient 
                        therapy services.
                    ``(B) Interoperability.--If the Secretary provides 
                for more than one national therapy outcomes database 
                under subparagraph (A), the Secretary shall ensure that 
                such databases are interoperable.
                    ``(C) Contracting authority.--For purposes of 
                subparagraph (A), the Secretary may enter into an 
                agreement with a private entity to use a database of 
                such entity that is capable of performing the functions 
                described in such subparagraph or to have such entity 
                establish and monitor such a database. For purposes of 
                selecting a private entity with which to enter into 
                such an agreement, the Secretary shall provide for a 
                process that ensures fair and open competition amongst 
                private entities.
            ``(5) Definitions.--For purposes of this subsection and 
        subsection (o):
                    ``(A) Covered outpatient therapy services.--The 
                term `covered outpatient therapy services' means--
                            ``(i) physical therapy services--
                                    ``(I) of the type described in 
                                section 1861(p), including speech-
                                language pathology services, furnished 
                                to individuals under this part; and
                                    ``(II) of such type that are 
                                furnished to individuals under this 
                                part by a physician (or as incident to 
                                physicians' services); and
                            ``(ii) occupational therapy services--
                                    ``(I) of the type that are 
                                described in section 1861(p) through 
                                the operation of section 1861(g) 
                                furnished to individuals under this 
                                part; and
                                    ``(II) of such type that are 
                                furnished to individuals under this 
                                part by a physician (or as incident to 
                                physicians' services).
                    ``(B) Covered provider.--The term `covered 
                provider' means a supplier or provider of services that 
                furnishes covered outpatient therapy services.
                    ``(C) National therapy outcomes database.--The term 
                `national therapy outcomes database' is a database 
                provided for under paragraph (4)(A).
                    ``(D) Q & e measure.--The term `Q & E measure' 
                means a measure selected under paragraph (2)(A).
    ``(o) Value-Based Purchasing Program for Outpatient Physical 
Therapy Services and Occupational Therapy Services.--
            ``(1) In general.--The Secretary shall establish and 
        implement, not later than January 1, 2010, a value-based 
        purchasing program, with respect to covered providers of 
        covered outpatient therapy services (as defined in subsection 
        (n)(5)(A)), under which--
                    ``(A) in the case of such a covered provider that 
                does not submit Q & E performance information in 
                accordance with subsection (n)(1)(A), the Secretary 
                shall not make payment under this part for such 
                services furnished by such provider; and
                    ``(B) in the case of such a covered provider that 
                submits Q & E performance information in accordance 
                with subsection (n)(1)(A)--
                            ``(i) if such provider furnishes high 
                        quality care (as determined under paragraph 
                        (2)(A)), the Secretary shall provide to such 
                        covered provider a payment in addition to the 
                        amount that would otherwise be paid under 
                        subsection (k) for such services;
                            ``(ii) if such provider furnishes low 
                        quality care (as determined under paragraph 
                        (2)(B)), the Secretary shall reduce the amount 
                        that would otherwise be paid to such covered 
                        provider under subsection (k) for such 
                        services; and
                            ``(iii) if such provider furnishes care 
                        that is neither high quality care nor low 
                        quality care, the Secretary shall provide to 
                        such provider the amount to be paid to such 
                        provider under subsection (k) for such 
                        services.
            ``(2) Determination of high quality care and low quality 
        care.--
                    ``(A) High quality care.--The Secretary shall 
                determine that a covered provider of covered outpatient 
                therapy services furnishes high quality care with 
                respect to such services furnished during a year if, 
                based on a comparison of the Q & E measures submitted 
                by such covered provider under paragraph (1)(A) of 
                subsection (n) with the appropriate values generated by 
                a national therapy outcomes database system under 
                paragraph (4) of such subsection, the Secretary finds 
                that the services furnished by the covered provider to 
                individuals under this part during the previous year 
                resulted in--
                            ``(i) a greater number of instances of 
                        functional improvement of such individuals than 
                        indicated by the value generated under 
                        paragraph (4)(A)(i) of such subsection; or
                            ``(ii) if the number of instances of 
                        functional improvement of individuals is the 
                        same as that indicated by the value generated 
                        under paragraph (4)(A)(i) of such subsection, 
                        more efficient utilization of such services 
                        than indicated by the value generated under 
                        paragraph (4)(A)(ii) of such subsection.
                    ``(B) Low quality care.--The Secretary shall 
                determine that a covered provider of covered outpatient 
                therapy services furnishes low quality care with 
                respect to services furnished during a year if, based 
                on a comparison of the Q & E measures submitted by such 
                covered provider under paragraph (1)(A) of subsection 
                (n) with the appropriate values generated by a national 
                therapy outcomes database under paragraph (4) of such 
                subsection, the Secretary finds that the services 
                furnished by the covered provider to individuals under 
                this part during the previous year resulted in--
                            ``(i) a fewer number of instances of 
                        functional improvement of such individuals than 
                        indicated by value generated under paragraph 
                        (4)(A)(i) of such subsection; or
                            ``(ii) if the number of instances of 
                        functional improvement of individuals is the 
                        same as that indicated by the value generated 
                        under paragraph (4)(A)(i) of such subsection, 
                        less efficient utilization of such services 
                        than indicated by the value generated under 
                        paragraph (4)(A)(ii) of such subsection.
            ``(3) Results-based payments.--
                    ``(A) In general.--Subject to subparagraph (B), 
                additional payments under paragraph (1)(B)(i) and 
                reductions in payment under paragraph (1)(B)(ii) for 
                covered outpatient therapy services furnished by a 
                covered provider during a year shall be specified by 
                the Secretary.
                    ``(B) Limitations.--For purposes of subparagraph 
                (A), neither an additional payment under paragraph 
                (1)(B)(i) for services involved nor a reduction in 
                payment under paragraph (1)(B)(ii) for services 
                involved, may exceed an amount that is 10 percent of 
                the applicable fee schedule amount (as defined in 
                subsection (k)(3)) for such respective services.
                    ``(C) Construction.--An additional payment under 
                paragraph (1)(B)(i) and a reduction in payment under 
                paragraph (1)(B)(ii) shall apply only with respect to 
                the year involved, and the Secretary shall not take 
                into account such bonus or reduction in computing the 
                amount of a payment determined under subsection 
                (k)(1)(B) for a subsequent year.
            ``(4) Transitional program for exempt covered providers of 
        covered outpatient therapy services.--
                    ``(A) In general.--For purposes of section 
                1833(g)(5) and not later than July 1, 2007, the 
                Secretary shall establish and implement a program to 
                identify for any date during the period described in 
                subparagraph (B) covered providers of covered 
                outpatient therapy services that are exempt providers 
                on such date and to make available to the public the 
                names of such exempt providers in accordance with this 
                paragraph.
                    ``(B) Period of program described.--For purposes of 
                subparagraph (A), the period described in this 
                subparagraph is the period beginning on the date on 
                which the Secretary implements the program under such 
                subparagraph (A) (but not sooner than January 1, 2007) 
                and ending on the date on which the Secretary 
                implements the value-based purchasing program under 
                paragraph (1).
                    ``(C) Identification of exempt providers.--For 
                purposes of subparagraph (A), a covered provider of 
                covered outpatient therapy services may be identified 
                as an exempt provider on a date if during the 90-day 
                period immediately preceding such date the covered 
                provider--
                            ``(i) participates in the collection of Q & 
                        E performance information described in 
                        subsection (n)(1)(B) for covered outpatient 
                        therapy services, with respect to individuals 
                        under this part to whom such covered provider 
                        furnishes services;
                            ``(ii) submits to the Secretary, by not 
                        later than a date or dates specified by the 
                        Secretary, the information collected under 
                        clause (i) to be included in a national therapy 
                        outcomes database provided for under subsection 
                        (n)(4);
                            ``(iii) makes assurances satisfactory to 
                        the Secretary that Q & E performance 
                        information described in subsection (n)(1)(B) 
                        on functional outcomes for such services have 
                        been documented with respect to at least 70 
                        percent of the individuals under this part to 
                        whom such covered provider furnishes services; 
                        and
                            ``(iv) agrees to use the information 
                        collected from the Q & E measures to the 
                        greatest extent practicable in reaching 
                        clinical decisions with respect to covered 
                        outpatient therapy services furnished to 
                        individuals under this part.
                Such 90-day period may include dates before the period 
                described in subparagraph (B).
                    ``(D) Reference to exemption from therapy cap.--For 
                provision to exempt each exempt provider from the 
                provisions of 1833(g), see paragraph (6) of such 
                section.
            ``(5) Report to congress.--Not later than July 1, 2009, the 
        Secretary shall submit to Congress a report on--
                    ``(A) the interim results of the program 
                established under paragraph (4)(A), including a 
                description of--
                            ``(i) the completeness of the aggregate 
                        information collected under paragraph 
                        (4)(C)(i); and
                            ``(ii) the common characteristics among 
                        covered providers that submit information under 
                        paragraph (4)(C)(ii); and
                    ``(B) plans to implement the value-based purchasing 
                program under subsection (o), including a description 
                of--
                            ``(i) any recommendations, with respect to 
                        the implementation of the value-based 
                        purchasing program under subsection (o), based 
                        on the results described in subparagraph (A); 
                        and
                            ``(ii) methods and a timetable for such 
                        implementation.
            ``(6) Construction.--Unless Congress acts to prohibit the 
        implementation of the value-based purchasing program under 
        paragraph (1), the Secretary shall implement such program no 
        later than the date described in such paragraph.
            ``(7) Budget neutrality.--The Secretary shall ensure that 
        in no case shall the aggregate amount of Medicare expenditures 
        increase as a result of the implementation of the value-based 
        purchasing program established under paragraph (1) and the 
        transitional program under paragraph (4).''.
    (b) Conforming Amendment to Payments for Outpatient Therapy 
Services and for Outpatient Rehabilitation Services.--Section 
1834(k)(1)(B) of the Social Security Act (42 U.S.C. 1395m(k)(1)(B)) is 
amended by inserting ``subject to subsection (o),'' after ``subsequent 
year,''.

SEC. 3. TREATMENT OF MEDICARE THERAPY CAP.

    (a) Exception for Exempt Providers During 2007, 2008, and 2009 and 
Replacement of Therapy Cap With Value-Based Purchasing Program in 
2010.--Section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)), 
as amended by section 5107 of the Deficit Reduction Act of 2005, is 
further amended--
            (1) in each of paragraphs (1) and (3), by striking 
        ``paragraphs (4) and (5)'' and inserting ``paragraphs (4), (5), 
        (6), and (7)''; and
            (2) by adding at the end the following new paragraphs:
    ``(6) Subject to paragraph (7), paragraphs (1) and (3) shall not 
apply to expenses incurred with respect to such services furnished 
during the period described in subparagraph (B) of section 1834(o)(4) 
if such services are furnished by a covered provider during a period in 
which such provider is identified as an exempt provider under 
subparagraph (C) of such section.
    ``(7) This subsection shall cease to have effect on the date the 
Secretary implements the value-based purchasing program under section 
1834(o)(1).''.
    (b) Expansion of Services Covered by Therapy Cap After 
Implementation of Exempt Providers Program and Before Implementation of 
Value-Based Purchasing Program.--Section 1833(g) of such Act, as 
amended by subsection (a), is further amended--
            (1) in paragraph (1), by striking ``, in the case of 
        physical therapy services'' and all that follows through 
        ``subsections (a) and (b).'' and inserting a dash and the 
        following:
                    ``(A) in the case of physical therapy services 
                (including outpatient speech-language pathology 
                services) of the type described in section 1861(p), but 
                not described in section 1833(a)(8)(B), and physical 
                therapy services of such type which are furnished by a 
                physician or as incident to physicians' services, with 
                respect to expenses incurred before the date on which 
                the program under section 1834(o)(4)(A) is implemented, 
                and
                    ``(B) in the case of physical therapy services 
                (including outpatient speech-language pathology 
                services) of the type described in section 1861(p) and 
                physical therapy services of such type which are 
                furnished by a physician or as incident to physicians' 
                services, with respect to expenses incurred within the 
                period described in section 1834(o)(4)(B),
        no more than the amount specified in paragraph (2) for the year 
        shall be considered as incurred expenses for purposes of 
        subsections (a) and (b).''; and
            (2) in paragraph (3), by striking ``, in the case of 
        occupational therapy services'' and all that follows through 
        ``subsections (a) and (b).'' and inserting a dash and the 
        following:
                    ``(A) in the case of occupational therapy services 
                (of the type that are described in section 1861(p) (but 
                not described in section 1833(a)(8)(B)) through the 
                operation of section 1861(g) and of such type which are 
                furnished by a physician or as incident to physicians' 
                services), with respect to expenses incurred before the 
                date on which the program under section 1834(o)(4)(A) 
                is implemented, and
                    ``(B) in the case of occupational therapy services 
                of the type that are described in section 1861(p) 
                through the operation of section 1861(g) and of such 
                type which are furnished by a physician or as incident 
                to physicians' services, with respect to expenses 
                incurred within the period described in section 
                1834(o)(4)(B),
        no more than the amount specified in paragraph (2) for the year 
        shall be considered as incurred expenses for purposes of 
        subsections (a) and (b).''.

SEC. 4. REQUIRING LICENSING OF PHYSICAL OR OCCUPATIONAL THERAPISTS WHO 
              FURNISH MEDICARE THERAPY SERVICES AS INCIDENT TO 
              PHYSICIANS' SERVICES.

    (a) In General.--Section 1862(a)(20) of the Social Security Act (42 
U.S.C. 1395y(a)(20)) is amended by striking ``(other than any licensing 
requirement specified by the Secretary)''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 2007.

SEC. 5. SENSE OF CONGRESS REGARDING ASSIGNMENT OF UNIQUE SUPPLIER 
              NUMBERS FOR THERAPISTS.

    It is the sense of Congress that the Secretary of Health and Human 
Services shall develop a system under which, beginning not later than 
January 1, 2010, each covered provider of covered outpatient therapy 
services (as such terms are defined in section 1834(n)(5) of the Social 
Security Act, as added by section 2(a)) participating in the Medicare 
program has a unique supplier identification number in order to enable 
the Secretary to monitor the quality and efficiency of such services 
furnished by such provider.
                                 <all>