1.Short
title; table of contents
(a)This Act may be cited
as the Continuing the Advancement of
Quality Improvement Act of 2007
.
(b)The table of contents of this Act is as follows:
Sec. 1. Short title; table of
contents.
Sec. 2. Responsibilities of utilization and quality control
peer review organizations.
Sec. 3. Priorities for selection of providers to provide
technical assistance.
Sec. 4. Data processing.
Sec. 5. Qualifications for utilization and quality control peer
review organizations.
Sec. 6. Funding.
Sec. 7. Improvements to annual reports.
2.Responsibilities
of utilization and quality control peer review organizations
(a)
(1)Section 1154 of the Social Security Act (42 U.S.C.
1320c–3) is amended by adding at the end the following new subsection:
(g)Notwithstanding
the preceding provisions of this section, beginning on August 1, 2009, any
utilization and quality control peer review organization entering into a
contract with the Secretary under this part shall only perform the function of
providing technical assistance for quality improvement and performance
measurement to providers, practitioners, and Medicare Advantage organizations
offering Medicare Advantage plans under part C of title XVIII, including the
following:
(1)Instruction on
how to collect, aggregate, and interpret data on measures that may be used for
internal quality improvement, public reporting, and payment.
(2)Instruction on
how to conduct root-cause analyses and deep case studies of sentinel events and
other problems.
(3)Assistance to
improve the validity and accuracy of data submitted by providers and
practitioners who participate in the program under title XVIII.
(4)Advice and
guidance on how to bring about, sustain, and diffuse internal system redesign
and process changes, particularly those redesign and process changes
that—
(A)are related to
the use of information technology for quality improvement; and
(B)promote care
coordination and efficiency through an episode of care.
(5)Promotion of best
practices identified by research, provider, and industry groups.
(6)Improvement of,
and provision of technical support for, the direct role of providers in the
education of individuals eligible for benefits under the program under title
XVIII as an integral component of improved care, better patient experience, and
patient self-management.
(7)Assistance with
bringing together and promoting cooperation among various stakeholders in
providing
care.
.
(2)Section 1154 of the Social Security Act (42 U.S.C.
1320c–3) is amended—
(A)in the heading,
by inserting and
other organizations
after organizations
; and
(B)in subsection
(a)—
(i)in
paragraph (1), in the matter preceding subparagraph (A)—
(I)by inserting
of such title
after part C
; and
(II)by inserting
of such title
after part D
; and
(ii)in
paragraph (17)—
(I)by inserting
of title XVIII
after part C
; and
(II)by inserting
of such title
after part D
.
(b)Transfer of
responsibilities for performing other functionsPart B of title
XI of the Social Security Act (42 U.S.C. 1320c et seq.) is amended by adding at
the end the following new section:
1164.Transfer of
responsibility for performing certain functions
(a)
(1)Not later than 6 months
after the date of enactment of this section, the Secretary shall develop and
transmit to the Committee on Finance of the Senate and the Committees on Energy
and Commerce and Ways and Means of the House of Representatives a transition
plan under which the functions of utilization and quality control peer review
organizations under section 1154, as in effect on the day before such date of
enactment, are transferred from the responsibility of such organizations to
other agencies and organizations (in this part referred to as Medicare
provider review organizations
). The transition plan shall include a
description of the steps the Secretary will take in implementing the plan and a
timeline for such implementation. The transition plan shall be developed in a
manner that will ensure that the intended beneficiaries of the functions
transferred will neither be harmed as a result of such transfer of
responsibility nor experience a disruption or decrease in services under
section 1154.
(2)Medicare
provider review organizationsIn determining which agency or
organization the responsibility for a function is transferred to under the
transition plan implemented under paragraph (1), the Secretary shall take into
account the following considerations:
(A)Whether the
agency or organization is comparable (in terms of experience, capabilities, and
capacity) to the organization that performed such responsibilities as of the
day before such date of enactment.
(B)Whether the
agency or organization is able to ensure that at least the same level of access
to services is available when responsibilities are transferred to the agency or
organization.
(C)Whether the
transfer of responsibility to the agency or organization will ensure the least
amount of disruption and minimize both the risk of harm to the intended
beneficiaries of the transferred responsibilities and the disruption or
decrease in services under section 1154.
(D)In the case where
the responsibility transferred is a review function required under section 1154
as of the day before such date of enactment, whether the agency or organization
is able, in the judgment of the Secretary, to perform such review function in a
manner consistent with the efficient and effective administration of this
part.
(E)Whether the
transferred responsibilities would be most effectively and efficiently
performed at a nationwide, Statewide, or regional level.
(F)Whether the
transfer of responsibility to the agency or organization will not result in a
conflict of interest.
(3)A
utilization and quality control peer review organization may not be a Medicare
provider review organization in any area in which the utilization and quality
control peer review organization provides technical assistance under section
1154(g).
(4)Transfer of
responsibilityNot later than July 31, 2009, the Secretary shall
fully implement the transition plan under this subsection and transfer the
functions described in paragraph (1) from utilization and quality control peer
review organizations to Medicare provider review organizations.
(b)Sharing of
information with utilization and quality control peer review
organizationsThe Secretary shall develop and implement a process
by which a Medicare provider review organization that, as a result of the
transfer of responsibility under subsection (a), conducts case review or has
responsibility for addressing beneficiary appeals or beneficiary complaints
shares information with utilization and quality control peer review
organizations for purposes of providing technical assistance for quality
improvement and performance measurement under section
1154(g).
.
(c)Medicare
provider review organizations addressing beneficiary complaints
(1)Section 1164 of the Social Security Act, as added by
subsection (b), is amended by adding at the end the following new
subsection:
(c)Medicare quality
accountability programOn or after the date on which the
transition plan is fully implemented under subsection (a), a Medicare provider
review organization that has responsibility for addressing beneficiary
complaints shall, instead of the requirements described in paragraph (14) of
section 1154(a), meet the following requirements:
(1)The Medicare provider review organization shall conduct a
review of all complaints about the quality of services (for which payment may
otherwise be made under title XVIII) not meeting professionally recognized
standards of health care, if the complaint is filed with the organization by an
individual entitled to benefits for such services under such title (or a person
acting on the individual’s behalf). Before the organization concludes that the
quality of services does not meet professionally recognized standards of health
care, the organization must provide the provider, practitioner, plan, or person
concerned with reasonable notice and opportunity for comment and
discussion.
(2)Medicare
quality accountability programThe Medicare provider review
organization shall establish and operate a Medicare quality accountability
program consistent with the following:
(A)The organization
shall actively educate Medicare beneficiaries in an efficient and effective
manner of their right to bring quality concerns to such Medicare provider
review organizations.
(B)The organization
shall report all findings of its investigations to the beneficiary involved or
a representative of such beneficiary, regardless of whether such findings
involve a provider, practitioner, or plan. Such reports shall describe, at a
minimum, whether the organization confirms the allegations in the complaint and
any actions taken by the provider, practitioner, or plan, respectively, with
respect to such findings. Such reports, and any other documentation prepared by
the organization during the course of investigating complaints, may not be used
in a tort claim or cause of action arising under State law.
(C)The organization
shall determine whether the complaint allegations about clinical quality of
care are confirmed. In the case where such allegations are confirmed, in whole
or in part, the organization shall (based on criteria issued by the Secretary)
refer the provider, practitioner, or plan to 1 or both of the following:
(i)A utilization and
quality control peer review organization with a contract with the Secretary
under this part for technical assistance under section 1154(g).
(ii)The appropriate
regulatory body for sanctions.
(D)The organization
shall publish and submit to the Secretary annual reports in each State in which
the organization operates. Such reports shall include aggregate complaint data
(including the number, nature, and disposition of complaints) and a description
of any follow-up activity conducted with respect to such complaints.
(E)The organization
shall promote beneficiary awareness of standardized quality measures that may
be used for evaluating care and for choosing providers, practitioners, and
plans.
.
(2)Section 1154(a)(14) of the Social Security Act (42
U.S.C. 1320c–3(a)(14)) is amended by striking The organization
and inserting Subject to section 1164(c), the
organization
.
(d)Reference to
agencies and organizations performing transferred
functionsSection 1164 of the Social Security Act, as added by
subsection (b) and amended by subsection (c), is amended by adding at the end
the following new subsection:
(d)Reference to
agencies and organizations performing transferred functionsOn
and after the date on which the transition plan is fully implemented under
subsection (a), any reference in this Act to a utilization and quality control
peer review organization, a peer review organization, an organization, or
organizations with respect to the performance of functions for which
responsibility has been transferred under such subsection, shall be deemed a
reference to the Medicare provider review organization to which such
responsibility has been transferred. In the case where such a reference is
deemed a reference to a Medicare provider review organization, the Medicare
provider review organization shall not be required to meet—
(1)the definition of
a utilization and quality control peer review organization under section 1152
(as amended by section 5 of the Continuing
the Advancement of Quality Improvement Act of 2007); or
(2)contract
requirements applicable to a utilization and quality control peer review
organization under section 1153 (as amended by such section
5).
.
3.Priorities for
selection of providers to provide technical assistanceSection 1153 of the Social Security Act (42
U.S.C. 1320c–2) is amended by adding at the end the following new
subsection:
(j)The Secretary
shall establish priorities for utilization and quality control peer review
organizations to use in selecting providers and practitioners to provide
technical assistance under section 1154(g) in the event demand for such
assistance exceeds the available resources of such organizations. The
priorities established shall include—
(1)whether the
provider or practitioner is located in a rural or underserved area;
(2)the financial
needs of the provider or practitioner;
(3)low performance
in measures that may be used for public reporting and payment;
(4)whether there has
been a significant number of beneficiary complaints with respect to the
practitioner or provider; and
(5)such other
measures of performance or quality as are available to the
Secretary.
.
4.
(a)Section 1160 of the Social Security Act (42 U.S.C.
1320c–9) is amended—
(1)in subsection
(a)(3), by striking subsection (b)
and inserting
subsections (b) and (f)
; and
(2)by adding at the
end the following new subsection:
(f)(1)A utilization and quality control peer
review organization and a Medicare provider review organization may share
individual-specific data obtained from another provider or practitioner with a
provider or practitioner who is treating the individual, for quality
improvement and patient safety purposes.
(2)A utilization and quality control
peer review organization and a Medicare provider review organization may share
provider-specific data with the Secretary.
(3)The Secretary shall promulgate, not
later than 1 year after the date of the enactment of this subsection, a
regulation that—
(A)specifies the process for sharing data
under paragraphs (1) and (2); and
(B)includes safeguards to ensure the
confidentiality of the data shared.
(4)Nothing in this subsection shall be
construed to limit, alter, or affect the requirements imposed by the
regulations promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of
1996.
.
(b)
(1)The Secretary of Health and Human Services (in this
section referred to as the Secretary
) shall conduct a
comprehensive review of the data-sharing systems, processes, and regulations of
the Department of Health and Human Services in order to—
(A)identify best
practices and procedures, including abstraction of medical chart data;
and
(B)ensure that such
systems, processes, and regulations do not—
(i)restrict the
sharing of data by utilization and quality control peer review organizations
with a contract under part B of title XI of the Social Security Act (42 U.S.C.
1320c et seq.) for quality improvement and patient safety purposes; or
(ii)inhibit prompt
feedback to such organizations and to providers, practitioners, and Medicare
Advantage organizations offering Medicare Advantage plans under part C of title
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) on the performance of
such providers, practitioners, and organizations.
(2)Not
later than 6 months after the date of enactment of this Act, the Secretary
shall submit a detailed report to the Committee on Finance of the Senate and
the Committees on Energy and Commerce and Ways and Means of the House of
Representatives containing—
(A)the results of
the review conducted under paragraph (1);
(B)a timeline for
the implementation of any administrative action the Secretary determines to be
appropriate; and
(C)recommendations
for such legislation as the Secretary determines to be appropriate.
(c)Supporting
national reporting and integrating care dataThe Secretary shall
ensure that the program under part B of title XI of the Social Security Act, as
amended by this Act, supports the processes of national reporting of
performance measures, data aggregation, data analysis, and feedback.
5.Qualifications
for utilization and quality control peer review organizations
(a)Removal of
physician-access and physician-sponsored requirements
(1)Section 1152 of the Social Security Act (42 U.S.C.
1320c–1) is amended by striking paragraph (1) and inserting the
following:
(1)has expertise in
quality improvement and performance measurement;
and
.
(2)Section 1153(b)(1) of the Social Security Act (42
U.S.C. 1320c–2(b)(1)) is amended by striking the second sentence.
(b)Part
B of title XI of the Social Security Act (42 U.S.C. 1320c), as amended by
section 3, is amended—
(1)in section
1152—
(A)by striking
paragraph (2);
(B)by redesignating
paragraph (3) as paragraph (2); and
(C)in paragraph (2),
as redesignated by subparagraph (B), by inserting and, beginning on the
date that is 1 year after the date of enactment of the
Continuing the Advancement of Quality
Improvement Act of 2007, that meets the requirements described in
section 1153(k)(1)
before the period at the end; and
(2)in section 1153,
by adding at the end the following new subsection:
(k)(1)The requirements described in this
paragraph are as follows:
(A)The governing board of the utilization and
quality control peer review organization is appropriately diverse, has
relationships with providers and stakeholders within the State, and provides
for transparency.
(B)(i)Subject to clause (ii), the governing board
of the utilization and quality control peer review organization is made up of
individuals from diverse areas, disciplines, and expertise, including—
(I)quality improvement and performance
measurement professionals from within and outside of the health care
field;
(II)providers of services under the program
under title XVIII, including physicians and other health care
practitioners;
(III)public or population health
professionals;
(IV)information technology implementation,
management, and oversight professionals;
(V)certified public accountants, auditors, and
attorneys; and
(VI)Medicare beneficiary and consumer
groups.
(ii)A
majority of the members of the governing board of the utilization and quality
control peer review organization do not come from any 1 of the 5 areas,
disciplines, and expertise described in subclauses (I) through (V) of clause
(i).
(C)The governing board of the utilization and
quality control peer review organization has—
(i)developed and implemented a
compliance program that includes—
(I)written policies, procedures, and
standards of conduct that articulate the organization’s commitment to comply
with all applicable Federal and State standards;
(II)effective compliance training and
education for employees, managers, and members of the governing board;
(III)the designation of—
- (aa)a compliance officer; and
- (bb)a compliance committee comprised of a
majority of members who are independent of the governing board and to which the
governing board refers issues of conflicts of interest, ethics, program
integrity, and the compensation (including benefits) and travel costs of senior
executive staff and members of the governing board;
(IV)effective lines of communication between
the compliance officer designated under subclause (III)(aa) and the
organization’s employees;
(V)enforcement of policies, procedures, and
standards of conduct through publicized disciplinary guidelines;
(VI)procedures for periodic internal
monitoring and auditing;
(VII)procedures for ensuring prompt response
to detected offenses and the development of corrective action initiatives;
and
(VIII)such other requirements as the
Secretary determines to be necessary for ensuring appropriate governance;
and
(ii)set overall policy and direction
for the organization and has retained oversight responsibility over the
organization.
(D)The governing board of the utilization and
quality control peer review organization and the utilization and quality
control peer review organization comply with the following requirements for
transparency and accountability:
(i)The governing board of the utilization and
quality control peer review organization discloses to the public information
regarding the board, including—
(I)the
size of the board;
(II)the
length of appointment of members to the board;
(III)any
cap on the length of service as a member of the board;
(IV)when
appointments to the board are made;
(V)what
portion of the board is typically appointed each year;
(VI)names, affiliation, and compensation of
board members; and
(VII)such other disclosure requirements as
the Secretary determines to be appropriate.
(ii)The governing board of the
utilization and quality control peer review organization meets contract
requirements developed by the Secretary—
(I)with respect to the length of service,
independence, and duties of board members; and
(II)with respect to compliance officer and
compliance committee duties.
(iii)The governing board of the
utilization and quality control peer review organization complies with
guidelines developed by the Secretary as to what constitutes reasonable
compensation for members of the governing board of a utilization and quality
control peer review organization (including the chief executive officer, chief
operating officer, and chief financial officer).
(iv)The utilization and quality control peer
review organization has in place formal and documented procedures for
addressing potential board member and executive conflicts of interests, ethical
issues, and program integrity.
(v)The utilization and quality control peer
review organization implements formal and documented procedures to evaluate
individual board member actions and activities and overall board performance
not less frequently than on an annual basis.
(2)Each contract with a utilization and
quality control peer review organization under this part shall require that the
organization comply with a system established by the Secretary to identify,
cure (by resolving or waiving), and report conflicts of interest with respect
to the governing board of such an organization, such organization, and entities
that subcontract with such organization. Such system shall include the
following:
(A)Guidelines as to what constitutes a
conflict of interest, including a member of the governing board receiving
compensation from the organization, directly or indirectly, for the provision
of services outside the scope of their duties and responsibilities as a member
of the governing board.
(B)The requirement to disclose any potential
conflicts of interest.
(C)A
process by which conflicts of interest shall be disclosed.
(D)Methods by which conflicts of interest
shall be resolved or waived.
(3)Each contract with a utilization and
quality control peer review organization under this part shall require that the
organization meet requirements pertaining to the development and conduct or
implementation of—
(A)annual performance evaluations for members
of the governing board of such an organization (including the chief executive
officer, chief operating officer, and chief financial officer);
(B)an
annual self-assessment to be conducted by the governing board of such an
organization; and
(C)an
overall performance improvement plan for the governing board of such an
organization.
.
(c)Duration of
contracts, selection criteria, and ensuring valueSection 1153 of the Social Security Act (42
U.S.C. 1320c–2) is amended—
(1)by
striking paragraph (3) of subsection (c) and inserting the following new
paragraph:
(3)contract terms are
consistent with subsection (i);
;
and
(2)by striking
subsection (i) and inserting the following new subsection:
(i)(1)Subject to the succeeding provisions of
this subsection, each contract with a utilization and quality control peer
review organization under this part shall be for an initial term of 5 years,
beginning and ending on a common date for all contractors as required under
this subsection and shall be renewable for 5-year terms thereafter.
(2)Each contract with a utilization and
quality control peer review organization under this part—
(A)shall be bid on through a competitive
process; and
(B)shall not be renewed without going through
a competitive process.
(3)The Secretary shall use criteria for
selecting utilization and quality control peer review organizations to enter
into a contract with under this part that takes into consideration—
(A)any previous experience and performance of
the organization under a contract under this part;
(B)whether the organization has demonstrated a
capacity to support quality improvement and performance measurement; and
(C)the financial integrity of the
organization.
(4)The Secretary shall develop performance
measures, including interim and final goals, for the functions to be performed
by the utilization and quality control peer review organization under the
contract. The performance measures shall be based on nationwide priorities
developed or adopted by the Secretary. Such measures shall be made available to
utilization and quality control peer review organizations during the bidding
process. The Secretary shall provide financial incentives and penalties that
reward high performance and penalize poor performance under such contracts,
taking into consideration the measures developed under this paragraph.
(5)The Secretary shall develop
procedures for the conduct of interim and final evaluations to assess the
performance of the utilization and quality control peer review organization
under the contract against the performance measures developed under paragraph
(4). Such procedures shall provide for 3 types of evaluations to be conducted
at each of the following levels:
(A)The program under this part as a
whole.
(B)Individual utilization and quality
control peer review organizations with respect to the contract entered into
with such organization under this part.
(C)Selected quality improvement
interventions implemented by such organizations.
(6)The Secretary shall enter into a
contract with an entity to conduct an independent external evaluation of the
overall contributions of the program under this part toward quality improvement
and performance measurement. Such an evaluation shall be conducted not less
frequently than once during each contract cycle.
(7)The Secretary shall extend each
contract with a utilization and quality control peer review organization under
this part the contract period for which began on or after August 1, 2005, and
on or before February 1, 2006, so that the subsequent contract period begins on
August 1,
2009.
.
(d)Section 1153 of the
Social Security Act (42 U.S.C. 1320c–2), as amended by subsections (b) and (c),
is amended—
(1)in paragraph (3)
of subsection (c), by striking subsection (i)
and inserting
subsections (i) and (l)
; and
(2)by adding at the
end the following new subsection:
(l)(1)The scope of work
required under a contract with a utilization and quality control peer review
organization under this part shall reflect the priorities of—
(A)quality improvement in individual
provider settings and across multiple-provider settings; and
(B)performance measurement which may be
used for purposes of public reporting and payment under title XVIII.
(2)In advance of each contract cycle,
the Secretary shall conduct an assessment of the need for technical assistance
for quality improvement and performance measurement by obtaining feedback from
providers within each provider setting under the program under title XVIII. The
feedback obtained shall be on applicable areas, including the following:
(A)Internal capacities of providers for
quality improvement and performance measurement.
(B)Past and current quality improvement
and performance measurement activities.
(C)Technical assistance that providers
are currently receiving on quality improvement and performance
measurement.
(D)Current gaps in technical assistance
for quality improvement and performance
measurement.
.
(e)Except as provided in subsection (b)(1)(C), the amendments
made by this section shall apply to contracts entered into on or after August
1, 2009.
6.
(a)
(1)Section 1159 of the Social Security Act (42
U.S.C. 1320c–8) is amended—
(A)in the matter
preceding paragraph (1), by inserting (a)
before Expenses
incurred
; and
(B)by adding at the
end the following new subsections:
(b)Subject to
subsection (c), funding for contracts under this part shall be used solely for
providing technical assistance for quality improvement and performance
measurement. The decision whether to fund such contracts under this part shall
be based on the results of evaluations conducted by the Secretary to
determine—
(1)the overall
impact of the program under this part on quality improvement and performance
measurement;
(2)the specific
quality improvement methods and techniques used by an organization;
(3)which
organizations that the Secretary contracts with under this part are most
successful; and
(4)whether there is
continued demand for technical assistance for quality improvement and
performance measurement, as demonstrated by—
(A)demand by
providers for such assistance;
(B)the activities of
utilization and quality control peer review organizations; and
(C)referrals made by
the Secretary, Medicare provider review organizations, and other agencies and
organizations (including contractors) for such assistance.
(c)Expenses incurred
by Medicare provider review organizations in carrying out functions the
responsibility for which was transferred under section 1164(a) shall be payable
from funds authorized under subsection
(a).
(2)The amendments made by this subsection shall apply to
contracts entered into on or after August 1, 2009.
(b)Limitations on
use and reduction of funding
(1)Section 1159 of the Social Security Act (42 U.S.C.
1320c–8), as amended by subsection (a), is amended—
(A)in subsection
(b), by striking subsection (c)
and inserting subsections
(c) and (d)
; and
(B)by adding at the
end the following new subsections:
(d)Funding for
contracts under this part may not be used for either of the following
purposes:
(1)To pay dues for
membership in an organization that engages in lobbying activities (as defined
in section 3 of the Lobbying Disclosure Act of 1995 (2 U.S.C. 1602)).
(2)To pay fees to
any individual for lobbying activities (as so defined).
(e)The Secretary may not reduce the amount of
funding under a contract under this part unless the scope of work has been
reduced. In the case where the scope of work has been reduced, any reduction in
contract funding shall be commensurate with the reduction in the scope of
work.
.
(2)The amendments made by this subsection shall take effect on
the date that is 1 year after the date of enactment of this Act.
7.Improvements to
annual reportsSection 1161 of
the Social Security Act (42 U.S.C. 1320c–1) is amended—
(1)in the matter
preceding paragraph (1), by striking the Congress
and inserting
the Committee on Finance of the Senate and the Committees on Energy and
Commerce and Ways and Means of the House of Representatives
;
(2)by redesignating
paragraphs (4), (5), and (6) as paragraphs (5), (6), and (7), respectively;
and
(3)by inserting
after paragraph (3) the following new paragraph:
(4)in the case of
reports submitted on or after April 1, 2010—
(A)the number and
type of practitioners and providers that are provided technical assistance for
quality improvement and performance measurement under section 1154(g);
(B)the performance
of organizations under a contract under this part against performance measures,
including interim and final goals, developed under section 1153(i)(4);
(C)the number and
nature of complaints investigated by Medicare provider review organizations,
and the disposition of such complaints by such organizations;
(D)a compilation of
the data contained in quality reports submitted to the Secretary under section
1164(c)(2)(D);
(E)the amount and
apportionment of funding from the Federal Hospital Insurance Trust Fund and the
Federal Supplementary Medical Insurance Trust Fund to administer this part
under section 1159, including how such funds were allocated based on the
recipient, purpose, and amount; and
(F)any weaknesses
identified in audits conducted with respect to the financial statements of
utilization and quality control peer review organizations and Medicare provider
review
organizations.
.