1.Short title; table of
contents
(a)This Act may be cited as the Medicare Quality Improvement Organization Modernization
Act of 2007
.
(b)The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Quality improvement activities.
Sec. 3. Improved program administration.
Sec. 4. Data disclosure.
Sec. 5. Use of evaluation and competition.
Sec. 6. Quality improvement organization program
funding.
Sec. 7. Qualifications of QIOs.
Sec. 8. Conforming name to quality improvement
organizations
.
2.Quality
improvement activities
(a)Inclusion of
quality improvement functionsSection 1154(a) of the Social
Security Act (42 U.S.C. 1320c–3(a)) is amended by adding at the end the
following new paragraph:
(18)(A)The organization shall
offer quality improvement assistance to providers and practitioners who provide
health care items and services to individuals who are dually eligible for
benefits under titles XVIII and XIX, including such individuals with mental and
cognitive disabilities, and programs that provide items and services to such
individuals.
(B)In this paragraph, the term
quality improvement assistance
includes the following:
(i)Education on quality improvement
initiatives, strategies, and techniques.
(ii)Instruction on how to collect,
submit, aggregate, and interpret data on measures that may be used for quality
improvement, public reporting, and payment.
(iii)Technical assistance to support
quality improvement.
(iv)Technical assistance and
instruction in the conduct of root-cause analyses.
(v)Technical assistance for providers
and practitioners in beneficiary education to facilitate patient
self-management and improve patient health literacy.
(vi)Facilitating cooperation among
various local stakeholders in quality improvement.
(vii)Facilitating adoption of
procedures that encourage timely candid feedback from patients and their
families concerning perceived problems.
(viii)Guidance on redesigning clinical
processes, including the adoption and effective use of health information
technology, to improve the coordination, effectiveness, and safety of
care.
(ix)Assistance in improving the
quality of care delivered in rural and frontier areas and reducing health care
disparities among racial and ethnic minorities, as well as gender disparities,
including efforts to prevent or address any disparities or delays in the rate
of adoption of health information technology and in the effective use of such
technology among such entities that serve communities designated by the
Secretary as medically underserved communities or individuals dually eligible
for benefits under titles XVIII and XIX or that furnish such services in rural
areas.
(x)Assistance in improving
coordination of care as patients transition between providers and
practitioners, including developing the capacity to securely exchange
electronic health information and helping providers and practitioners to
effectively use secure electronic health information to improve quality.
(xi)Outreach to beneficiaries.
(C)(i)The organization should
give priority to funding quality improvement assistance described in
subparagraph (B)(iv).
(ii)In this paragraph, the term
root-cause analysis means the systematic examination of managerial
processes behind a series of actions that lead up to an
event.
.
(b)Medicare
quality accountability program and medical review audit
(1)Medicare
quality accountability programParagraph (14) of section 1154(a)
of such Act (42 U.S.C. 1320c–3(a)) is amended to read as follows:
(14)(A)The organization shall
conduct a review of all written 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 practitioner, plan, or person concerned with reasonable notice and
opportunity for discussion.
(B)The organization shall establish and
operate a Medicare quality accountability program consistent with the
following:
(i)The organization shall actively
educate Medicare beneficiaries of their right to bring quality concerns to
quality improvement organizations.
(ii)The organization shall report
findings of its investigations to the beneficiary involved or a representative
of such beneficiary, regardless of whether such findings involve a provider,
physician, or other practitioner. Such report shall describe 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 findings may not be used in any form in a medical malpractice
action.
(iii)The organization shall assist
providers, practitioners, and plans in adopting best practices for soliciting
and welcoming feedback about patient concerns, and assist providers,
practitioners, and plans in remedying patient-reported problems that are
confirmed by the organization and shall report findings of patient-reported
problems to the provider, practitioner, or plan involved before disclosing
investigation results to the patient or patient's representative.
(iv)The organization shall determine
whether the complaint allegations about clinical quality of care are confirmed
and assist providers, practitioners, and plans in remedying confirmed
complaints.
(v)The organization shall assist
providers, practitioners, and plans in preventing recurrence of quality
problems caused by unsafe processes of care, and refer to an appropriate
regulatory body providers, practitioners, or plans that are unwilling or unable
to improve.
(vi)The organization shall publish
annual reports on the quality of care provided to individuals entitled to
benefits for services under title XVIII in each State in which the organization
functions under a contract under this section, including aggregate complaint
data.
(vii)The organization shall promote
beneficiary awareness of standardized quality measures that may be used for
evaluating care and for choosing providers, practitioners, and plans.
(C)If an individual entitled to benefits
for services under title XVIII (or a person acting on the individual’s behalf)
makes a credible written request for additional review of a written complaint
submitted by such individual (or such a person) to the organization and
reviewed under subparagraph (A), the Secretary shall provide for prompt binding
independent review of the complaint determination made by the organization as a
result of such review.
(D)The Secretary shall monitor and report
to Congress, regarding—
(i)the reliability of complaint
determinations made by quality improvement organizations; and
(ii)the effect of the disclosure of
complaint findings on the availability of primary- and specialty-care physician
reviewers.
.
(2)Section 1156 of the Social Security Act (42 U.S.C. 1320c–5)
is amended by adding at the end the following new subsection:
(d)
(1)The Secretary,
acting through the Inspector General of the Department of Health and Human
Services, shall enter into a contract with an entity under which the entity
shall conduct a medical review audit to evaluate whether quality improvement
organizations are making appropriate determinations and recommendations to the
Secretary under subsection (b). Such audit shall be conducted in accordance
with the following requirements:
(A)The audit shall
consist of a medical review of a randomly selected sample of clinical records
involved in not less than 10 percent of all reviews of complaints about the
quality of services filed by an individual entitled to benefits for such
services under title XVIII (or a person acting on the individual’s behalf) that
are conducted by quality improvement organizations in 1 year during each 5-year
contract period beginning on or after the date of enactment of this subsection,
except that—
(i)not more than 50
of such complaint reviews conducted by each quality improvement organization
shall be selected for such medical review in the year; and
(ii)in the case
where a quality improvement organization conducted a total of 30 or less of
such complaint reviews during the sampling period, all such complaint reviews
conducted shall be selected for such medical review in the year.
(B)The complaint
reviews selected for medical review under subparagraph (A) with respect to a
year during a contract period shall be reviews which were initiated and with
respect to which action has been completed by the quality improvement
organization during that contract period.
(C)The Secretary
shall ensure that the entity the Secretary contracts with to conduct the
medical review audit under this paragraph retains appropriately qualified
individuals, in accordance with subsections (a)(7)(A) and (b) of section 1154,
to conduct the medical review of clinical records under subparagraph
(A).
(D)In evaluating
whether quality improvement organizations are making appropriate determinations
and recommendations to the Secretary under subsection (b), the entity the
Secretary contracts with to conduct the medical review audit under this
paragraph shall—
(i)rely on the
conclusions reached by a panel of physicians who have—
(I)reviewed the same
clinical information the quality improvement organization reviewed with respect
to each complaint review selected for the medical review under subparagraph
(A); and
(II)come to an
agreement with respect to whether a sanction recommendation was appropriate
with respect to each such complaint review selected; and
(ii)ensure that the
individuals conducting the medical review under subparagraph (A), and any other
individuals involved in the medical review audit process under this paragraph,
adhere to the procedures and rules applicable to entities that contracted with
quality improvement organizations at the time the complaint reviews selected
for such medical review were originally conducted by the quality improvement
organization.
(E)A quality
improvement organization shall disclose any data and information needed to
conduct the medical review audit under this paragraph to the entity the
Secretary contracts with to conduct such audit. Such disclosure shall be
considered necessary to carry out the purposes of this part and subject to the
exception to the prohibition against disclosure under section 1160(a)(1),
except that any subsequent disclosure of such data and information that
identifies a patient or practitioner by any individual associated with such
audit shall be subject to the prohibition against disclosure under section
1160(a).
(2)Not later than
180 days after the date on which the medical review audit under paragraph (1)
is completed with respect to a year during the first contract period beginning
after the date of enactment of this subsection, the Inspector General of the
Department of Health and Human Services shall submit a report to the Committee
on Finance of the Senate and the Committee on Ways and Means and the Committee
on Energy and Commerce of the House of Representatives containing the results
of the medical review audit with respect to such year, including—
(A)a brief review of
the peer-reviewed literature relevant to such medical review audit that is
published prior to such year;
(B)a
characterization of the quality of care issues identified in complaints
selected for the medical review under paragraph (1)(A) with respect to such
year;
(C)a review of
published studies on consumer complaint behavior within and outside of the
health care field;
(D)a description of
actions taken by quality improvement organizations to address issues alleged in
complaints selected for such medical review with respect to such year
(including facilitated mediation, agreements with providers and practitioners,
referrals to State or Federal authorities for regulatory action, and any other
actions taken by such organizations to address such issues);
(E)information on
the extent to which—
(i)the panel of
physicians described in paragraph (1)(D)(i) comes to an agreement that a
sanction recommendation was appropriate with respect to such complaints;
and
(ii)such agreement
differs from the recommendations of the quality improvement organization that
originally reviewed such complaint;
(F)a description of
the disposition by the Secretary of recommendations received from quality
improvement organizations pursuant to subsection (b), including the reasons for
such disposition; and
(G)recommendations
for improving the sanction referral process with respect to complaints about
the quality of services that are filed with a quality improvement organization
by an individual entitled to benefits for such services under title XVIII (or a
person acting on the individual’s behalf).
(3)The Secretary
shall—
(A)take into
consideration the findings of the medical review audit under paragraph (1) in
evaluating the performance of a quality improvement organization during each
contract period beginning after the date enactment of this subsection;
and
(B)require that a
quality improvement organization take corrective action when
appropriate.
(4)The cost of
implementing the medical review audit under paragraph (1) (including the cost
of entering into a contract with an entity to conduct such medical review
audit) shall be payable as an expense under section
1159.
.
(c)Section 1154 of the Social Security Act (42 U.S.C.
1320c–3) is amended by adding at the end the following new subsection:
(d)(1)A quality improvement
organization may enter into business agreements with public or private
entities, including health care plans, providers, practitioners, and
purchasers, to provide quality improvement technical assistance or other
services, if—
(A)the services provided to a specific
business partner by the organization are not already being paid for under a
contract with the organization under this part; and
(B)the organization has a qualifying
arrangement under this subsection to avoid or mitigate potential conflicts of
interest.
(2)A quality improvement organization
shall be deemed to have a qualifying arrangement under this subsection that
permits the organization to enter into a business agreement with a public or
private entity without the Secretary’s approval if the arrangement satisfies 1
or more of the following criteria:
(A)The organization’s business agreement
is with an entity that is not subject to review by the organization under its
contract under this part.
(B)The organization’s business agreement
with the entity yields revenue of less than 5 percent of the total annual
revenue yielded by the organization under its contract under this part.
(C)The organization’s business agreement
is with an agency of local, State, or national government, including a nation
other than the United States, unless that agency is an individual provider or
practitioner that is subject to review by the organization under its contract
under this part.
(D)The organization’s business agreement
is with an association or other group of plans, providers, or practitioners
that represent a significant number of entities engaged in competition with one
another.
(E)The organization has arranged for
another quality improvement organization to make review determinations that may
arise pertaining to a plan, provider, or practitioner that is paying the
organization for services and which would otherwise be subject to review by the
organization under its contract under this part. Under such arrangement, review
determinations shall be made by reviewers that are licensed in the State where
the health care services under review are provided.
(3)A quality improvement organization
may apply to the Secretary for approval of an arrangement for avoiding or
mitigating a potential conflict of interest that is not an arrangement
described in paragraph (2). If the Secretary does not formally respond to the
application in writing, accompanied by an explanation of the reasons for any
adverse decision, by not later than the 30th business day following receipt of
the application, the application shall be deemed approved. In the case where
the Secretary makes an adverse decision with respect to an application, the
organization may submit a revised application. If the Secretary does not
formally responded to the revised application in writing, accompanied by an
explanation of the reasons for any adverse decision, by not later than the 30th
business day following receipt of the revised application, the revised
application shall be deemed approved.
(4)The Secretary may be reimbursed from
funds available to administer the provisions of this part for the reasonable
costs—
(A)of training and maintaining qualified
personnel to review proposed arrangements to avoid or mitigate potential
conflicts of interest; and
(B)of establishing and maintaining
agreements with 1 or more independent review
entities.
.
3.Improved program
administrationPart B of title
XI of the Social Security Act is amended by adding at the end the following new
section:
1164.
(a)Improved
program management
(1)Report on
management of the qio programThe Comptroller General of the
United States shall submit to Congress reports on the implementation by the
Secretary and the Director of the Office of Management and Budget of this part
and their overall management of the program under this part, according to the
following schedule:
(A)Not later than 1
year after the date of enactment of this section, a report with respect to the
review conducted under subparagraphs (F), (G), and (I) of paragraph (2).
(B)Not later than 1
year following the end of the first statement of work that begins after the
date of enactment of this section, a report with respect to the review
conducted under subparagraphs (A), (B), (C), (D), (E), and (H) of such
paragraph.
(2)In accordance with the schedule under paragraph (1),
the reports under such paragraph shall include a review of the
following:
(A)Implementation of
the priorities, recommendations, and strategies of the strategic advisory
committee under subsection (c).
(B)Implementation of
appropriate program and quality improvement organization evaluation.
(C)Ensuring timely
issuance of statements of work.
(D)Ensuring timely
and priority QIO access to Medicare data for quality improvement
purposes.
(E)Ensuring timely
apportionment of funding.
(F)Ensuring funding
levels are commensurate with new work added to the QIO contract, as described
in the second sentence of section 1159(b)(1).
(G)The process of
developing the apportionment request and determining the funding allocation to
QIOs.
(H)The
identification of, and progress toward, measures of effective management by the
Secretary of the QIO program.
(I)A review of the
experience and qualifications of staff of the Centers for Medicare &
Medicaid Services in overseeing the program.
(3)The
Secretary shall ensure that quality improvement organizations are provided
flexibility in designing and applying intervention strategies for local quality
improvement, but must comply with national topic assignments and standardized
measures.
(b)The Secretary shall ensure that quality improvement
organizations have timely access to data for all parts of the program under
title XVIII that are pertinent to contract activities, in a form allowing the
data to be integrated and analyzed by such organizations according to the needs
of partners and Medicare beneficiaries in each jurisdiction.
(c)Determination
of strategic priorities
(1)Appointment of
strategic advisory committeeThe Secretary shall appoint an
independent strategic advisory committee chaired by the Director of the Agency
for Healthcare Research and Quality, composed of national quality measurement
and improvement experts and a diverse range of stakeholders, such as the
following:
(A)Medicare
beneficiaries.
(B)The Health
Resources and Services Administration.
(C)The Federal
Employee Health Benefits Program.
(D)The Indian Health
Service.
(E)The TRICARE
program.
(F)The Veterans
Health Affairs program.
(G)State Medicaid
programs.
(H)Private
purchasers.
(I)Health care
providers.
(J)Physicians.
(K)Pharmacists.
(L)Nurses.
(M)quality
improvement organizations.
(2)Such committee shall—
(A)advise the
Secretary on methods to ensure that the quality measures used under the program
under this part are—
(i)the same as or
coordinated with measures under other Federal and non-Federal quality programs;
and
(ii)reliable and
valid (as used under the program for measuring the quality of care provided and
the performance of quality improvement organizations);
(B)advise the
Secretary as to how the function and structure of the program under this part
may be made to better correspond with the strategic priorities for improvement
in the quality of care recommended by the Institute of Medicine’s 6 aims for
health care improvement, including safety, effectiveness, patient centeredness,
timeliness, efficiency, and equity;
(C)advise the
Secretary as to how evaluation of quality improvement organizations under the
program under this part may be improved, taking into account—
(i)the value of
longitudinal tracking of performance and comparison groups in assessing change
attributable to the program;
(ii)the value of
stakeholder partnerships;
(iii)the activities
of stakeholders that may affect evaluation of the performance of those
partnering with quality improvement organizations;
(iv)the availability
of timely, valid, and reliable data for evaluating the performance of quality
improvement organizations; and
(v)the cost of such
performance evaluation; and
(D)prepare and
provide for public comment a draft statement of work for each program
cycle.
(3)The
Secretary shall apportion funds for the strategic advisory committee under this
subsection from the Federal Hospital Insurance Trust Fund and the Federal
Supplementary Medical Insurance Trust Fund in the same manner, and in addition
to, the amounts that would otherwise be apportioned for contracts with
organizations under section 1159(b).
(d)Taking into
account recommendations from stakeholders in statements of
workEach statement of work under this part for a contract period
beginning on or after August 1, 2008, shall include a task for the contracting
quality improvement organization to convene stakeholders to identify high
priority quality problems for work in the next contract period that are
relevant to Medicare beneficiaries in the State. Each such organization shall
propose, to be incorporated as part of such statement, 1 or more projects to
the Secretary taking into consideration the recommendations of such
stakeholders, along with suggested performance measures to evaluate progress on
such projects.
(e)quality improvement organizations holding contracts
under this part shall be an integral part of Federal performance improvement
initiatives and each organization’s activities shall be coordinated with
initiatives developed by the Secretary and other Federal
agencies.
.
4.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)An organization with a
contract with the Secretary under this part may share individual-specific data
with a physician treating the individual, for quality improvement and patient
safety purposes.
(2)The Secretary shall promulgate, not
later than 180 days after the date of the enactment of this subsection, a
regulation that permits the sharing of data under paragraph (1).
(3)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.
.
5.Use of
evaluation and competitionSection 1153 of the Social Security Act (42
U.S.C. 1320c–2) is amended—
(1)by amending
paragraph (3) of subsection (c) to read as follows:
(3)contract terms
are consistent with subsection
(j);
;
(2)in subsection
(c)(1), by inserting , at the sole discretion of the
organization,
after or may subcontract
;
(3)in subsection (e), by striking paragraph
(1) and inserting the following:
(1)Contracting authority of the Secretary
under this section shall be carried out in accordance with the Federal
Acquisition Regulation issued in accordance with section 25 of the Office of
Federal Procurement Policy Act (41 U.S.C.
421).
;
and
(4)by adding at the
end the following new subsections:
(j)(1)Subject to the
succeeding provisions of this subsection, each contract with an organization
under this section shall be for an initial term of 5 years, beginning and
ending on a common date for all quality improvement organizations as required
under this subsection and shall be renewable for 5 year terms
thereafter.
(2)Before publishing a request for
proposals for a contract period, the Secretary shall, in consultation with the
strategic advisory committee appointed under section 1164(c)(1) establish
measurable goals for each task to be included in such proposal. The contract
shall include performance thresholds by which an organization holding a
contract under this section may demonstrate excellent performance. The
Secretary may not establish such performance thresholds in such a way as to
predetermine or limit either the number or percentage of organizations which
may demonstrate excellent performance.
(3)In evaluating proposals from bidders
for a contract under this section, the Secretary shall consider the performance
of the incumbent contractor bidding in each State, and if the incumbent
contractor has demonstrated excellent performance (as defined under the process
described in paragraph (2)) in fulfilling the terms of the contract during the
previous contract period, the Secretary shall add to the score of the technical
proposal of such contractor a bonus equivalent to 10 percent of the total
possible score for the proposal.
(4)The Secretary shall publish the
request for proposals not later than 4 months prior to the beginning of each
contract period.
(5)The Secretary shall utilize the
strategic advisory committee appointed under section 1164(c)(1) to qualify the
performance measures to be used in evaluating the performance of the quality
improvement organizations on a program-wide basis and individually.
(6)The Secretary may not reduce the
amount of a contract award below the amount proposed by the bidder prevailing
in a competitive bidding process unless the scope of work has been reduced. In
the case where the scope of work has been reduced, any reduction in the
contract award shall be commensurate with the reduction in the scope of
work.
(7)The Secretary shall design the
process for performance evaluation of contracts under this section—
(A)to hold harmless and not penalize
quality improvement organizations when performance is impaired or delayed by
failures of the Secretary, personnel of the Department of Health and Human
Services, or entities or individuals that contract with the Secretary, to
provide timely deliverables;
(B)to use a continuous measurement
strategy with provision for frequent performance updates for evaluating interim
progress; and
(C)to require that evaluation metrics be
monitored and permit their adjustment based on experience or evolving science
over the course of a contract cycle, subject to subparagraph (A).
(k)(1)Notwithstanding the
provisions of section 1153(c)(3), the Secretary shall extend each contract
under this section for which the contract period began on or after August 1,
2005, to ensure that the subsequent contract period for all quality improvement
organizations begins on October 1, 2009.
(2)The Secretary shall apportion
adequate funding so that organizations with contracts extended under this
subsection can perform existing and new tasks, as determined by the Secretary,
during the period of the contract extension.
(3)There are authorized to be
appropriated such sums as are necessary to respond to increased personnel
requirements resulting from starting all contracts simultaneously, as provided
under this
subsection.
.
6.Quality
improvement organization program fundingSection 1159 of the Social Security Act (42
U.S.C. 1320c–8) is amended—
(1)by inserting
(a)
before Expenses incurred
; and
(2)by adding at the
end the following new subsections:
(b)(1)The aggregate annual
funding for contracts under this part that begin after August 1, 2008, shall
not be less than $421,666,000. In addition, there are authorized to be
apportioned for contract periods in subsequent years such additional amounts as
may be necessary to adequately fund any resource needs in excess of the amount
provided under the previous sentence.
(2)The Secretary shall determine the
total program resource needs for a contract period. The determination shall
take into account factors including any new work added via contract
modification during the course of the contract period or added from 1 contract
cycle to the next cycle. New work includes—
(A)additional core contract tasks,
requirements, deliverables, and performance thresholds;
(B)technical assistance for additional
providers, practitioners, and health plans and in additional provider
settings;
(C)increased outreach and communications
to Medicare beneficiaries, providers, practitioners, and plans; and
(D)increased volume of medical
reviews.
Nothing in this paragraph shall be construed as
limiting the ability of the Secretary to negotiate contracts under this part
individually with each quality improvement organization.(3)With respect to the apportionment of
funds under this part for a contract period—
(A)the Secretary shall submit a proposed
apportionment to the Director of the Office of Management and Budget not later
than 1 year before the first date of the contract period;
(B)such Director shall approve an
apportionment not later than 9 months before the first date of such contract
period;
(C)for tasks the Secretary proposes to
continue from the previous contract period, if the apportionment is not
authorized by the deadline specified in subparagraph (B), funding shall
continue for the next contract period at a level no less than the level for the
previous contract period, increased by the percentage increase in the consumer
price index for all urban consumers during the most recent 12-month
period.
(4)A
quality improvement organization shall have the ability to meet the terms of
its contract under this part by allocating funds to the functions provided
under such contract at its discretion. The Secretary shall review whether the
organization met the functions and goals set out for the organization, without
regard to the allocation of funds at the time of the initial acceptance of the
contract.
(5)Organizations with a contract under
this part may utilize funding allocated to such contracts to pay for food costs
at meetings and conferences if—
(A)meals and refreshments are incidental
to the meeting or conference;
(B)attendance at the meals and when
refreshments are provided is important for the host agency to ensure full
participation in essential discussions, lectures, or speeches concerning the
purpose of the meeting or conference; and
(C)the meals and refreshments are part of
a formal conference that includes (in addition to the meals and refreshment)
discussions, speeches, or other business that may take place when the meals and
refreshments are served and also includes substantial functions occurring
separately from when the food is served.
(c)(1)Not later than 180 days
after the date of enactment of this subsection, the Secretary shall enter into
an arrangement under which the Institute of Medicine of the National Academy of
Sciences (in this subsection referred to as the Institute
) shall
conduct a study on—
(A)the adequacy of overall funding of the
program under this part to meet program goals, based on the most recent
statement of work for which the Office of Management and Budget has made a
funding decision;
(B)a recommended national percentage of
funding for quality improvement organizations, to be used for the core contract
work with providers, practitioners, plans, and beneficiaries and on national
initiatives established by the Secretary;
(C)a recommended national percentage of
such funding to be used for local initiatives, identified by quality
improvement organizations in consultation with stakeholders in each State;
and
(D)a recommended national percentage of
overall funds under the program under this part that will not be available for
the work of quality improvement organizations in the field and that may be used
by the Secretary for central management of the program.
(2)Not later than 2 years after the date
of enactment of this subsection, the Institute shall submit a report to the
Committee on Finance of the Senate and the Committees on Ways and Means and
Energy and Commerce of the House of Representatives, containing the results of
the study conducted under paragraph (1) together with recommendations for such
legislation and administrative action as the Institute determines
appropriate.
(3)(A)On or before the date
that the proposal for each statement of work is submitted to the Office of
Management and Budget, the Secretary shall enter into an arrangement under
which the Institute shall conduct a study on the issues described in
subparagraphs (A) through (D) of paragraph (1).
(B)Not later than 180 days after the
date on which the proposal for each statement of work is submitted to the
Office of Management and Budget, the Institute shall submit a report to the
Committee on Finance of the Senate and the Committees on Ways and Means and
Energy and Commerce of the House of Representatives, containing the results of
the studies conducted under subparagraph (A) and paragraph (1) together with
recommendations for such legislation and administrative action as the Institute
determines appropriate.
(4)The Secretary shall apportion funds
for the studies conducted by the Institute of Medicine under this subsection
from the Federal Hospital Insurance Trust Fund and the Federal Supplementary
Medical Insurance Trust Fund in the same manner, and in addition to, the
amounts that would otherwise be apportioned for contracts with organizations
under subsection
(b).
.
7.
(a)Subsection (b) of section 1153 of the Social Security Act
(42 U.S.C. 1320c–2) is amended by adding at the end the following new
paragraph:
(4)(A)The Secretary shall not
enter into or renew a contract under this section with an entity unless the
entity has demonstrated success in facilitating clinical and administrative
system redesign to improve the coordination, effectiveness, and safety of
health care, and in facilitating cooperation among stakeholders in quality
improvement.
(B)The Secretary shall ensure that the
entity complies with standards to ensure organizational integrity,
including—
(i)appropriate representation of
consumers, quality assurance experts, and stakeholders in the composition of
the governing body;
(ii)market-based compensation of board
members and executives;
(iii)avoidance and mitigation of board
member conflict of interest; and
(iv)safeguards to ensure appropriate
travel expenses.
To the extent practicable, the Secretary shall utilize
standards developed in the private sector for purposes of carrying out this
subparagraph and shall conduct audits as necessary to ensure compliance with
such
standards..
(b)Use of States
for geographic areasSubsection (a) of such section is amended to
read as follows:
(a)The Secretary
shall designate each State as a geographic area with respect to which contracts
under this part will be
made.
.
(c)Removal of
physician-access and physician-sponsored requirements for
organizations
(1)Section 1152 of the Social Security Act (42 U.S.C.
1320c–1) is amended by striking paragraph (1).
(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.
(d)The amendments made by this section shall apply to contract
periods beginning after the date of the enactment of this Act.
8.Conforming name
to quality improvement organizations
Part C of title XI of the Social Security
Act is amended by striking utilization and quality control peer
review
(and peer review
) each place it appears before
organization
or organizations
and inserting
quality improvement
.