109 HR 6048 IH: To amend title XVIII of the Social Security Act to U.S. House of Representatives 2006-09-07 text/xml EN Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.

I 109th CONGRESS 2d Session H. R. 6048 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.

1.

Short title

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

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,.

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)..

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.

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.