[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3430 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 3430

  To establish a Medicare DSH pilot program under which participants 
   shall establish collaborative care networks to reduce the use of 
   emergency departments, inpatient and other expensive resources of 
   hospitals and other providers and provide more comprehensive and 
  coordinated care to low-income individuals, including those without 
   health insurance coverage, and to establish a Collaborative Care 
                            Network Center.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 30, 2009

Ms. Linda T. Sanchez of California (for herself, Mr. Lewis of Georgia, 
and Mr. Rush) introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, 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 establish a Medicare DSH pilot program under which participants 
   shall establish collaborative care networks to reduce the use of 
   emergency departments, inpatient and other expensive resources of 
   hospitals and other providers and provide more comprehensive and 
  coordinated care to low-income individuals, including those without 
   health insurance coverage, and to establish a Collaborative Care 
                            Network Center.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``DSH Collaborative Care Network Pilot 
Program Act of 2009''.

SEC. 2. MEDICARE DSH PILOT PROGRAM.

    (a) Establishment.--
            (1) In general.--The Secretary of Health and Human Services 
        (in this Act referred to as the ``Secretary'') shall carry out 
        a Medicare DSH pilot program (in this Act referred to as the 
        ``Pilot Program'') under which, for purposes of establishing 
        model projects described in paragraph (2), eligible DSH Program 
        participants shall, for discharges occurring during a cost 
        reporting period for which the participant is participating in 
        the Pilot Program, receive an amount in accordance with 
        paragraph (3) in addition to the amount the participant would 
        otherwise receive under section 1886(d)(5)(F) of the Social 
        Security Act (42 U.S.C. 1395ww(d)(5)(F)).
            (2) Model projects.--Model projects described in this 
        paragraph are projects to accomplish the following goals:
                    (A) To reduce unnecessary use of items and services 
                furnished in emergency departments of hospitals 
                (especially to ensure that individuals without health 
                insurance coverage or with inadequate health insurance 
                coverage do not use the services of such department 
                instead of the services of a primary care physician) 
                through methods such as--
                            (i) screening individuals who seek 
                        emergency department services for possible 
                        eligibility under relevant governmental health 
                        programs or for subsidies under such programs; 
                        and
                            (ii) providing such individuals referrals 
                        for follow-up care and chronic condition care.
                    (B) To manage chronic conditions to reduce their 
                severity, negative health outcomes, and expense.
                    (C) To encourage health care providers to 
                coordinate their efforts so that the most vulnerable 
                patient populations seek and obtain primary care.
                    (D) To provide more comprehensive and coordinated 
                care to low-income vulnerable individuals and 
                individuals without health insurance coverage or with 
                inadequate coverage.
                    (E) To provide mechanisms for improving both 
                quality and efficiency of care for low-income 
                individuals and families, with an emphasis on those 
                most likely to remain uninsured despite the existence 
                of government programs to make health insurance more 
                affordable.
                    (F) To increase preventive services, including 
                screening and counseling, to those who would otherwise 
                not receive such screening, in order to improve health 
                status and reduce long term complications and costs.
                    (G) To ensure the availability of community-wide 
                safety net services, including emergency and trauma 
                care.
            (3) Additional amount.--
                    (A) In general.--The Secretary shall specify the 
                additional amount each eligible DSH Program participant 
                shall receive for a cost reporting period from the pool 
                established under subparagraph (B) for the period 
                involved. Such amount shall be established, to the 
                maximum extent practicable, to retain or increase the 
                level of funding for such a participant from year to 
                year. The total of such payments for a period shall not 
                exceed the total amount of funds available under 
                subparagraph (B) for such period.
                    (B) Spending pool.--
                            (i) In general.--Subject to clause (ii), 
                        the amount described in this subparagraph for a 
                        fiscal year is equal to 2 percent of the total 
                        of all Medicare DSH payments for the fiscal 
                        year 2008 cost reporting period, the rate of 
                        increase (if any), for each succeeding fiscal 
                        year through the fiscal year involved, in 
                        Medicare DSH payments for the fiscal year, as 
                        estimated by the Secretary.
                            (ii) Treatment of decreases.--If because of 
                        a change in law or regulation there is a 
                        decrease total Medicare DSH payments for a 
                        fiscal year, 5 percent of the amount of such 
                        decreased payments shall be added to the amount 
                        otherwise computed under clause (i).
    (b) Eligibility and Participant Selection.--
            (1) Eligible dsh program participant.--For purposes of this 
        section, the term ``eligible DSH Program participant'' means a 
        hospital described in section 1886(d)(5)(F)(i) of the Social 
        Security Act that is to be a member of a collaborative care 
        network described in subsection (d) and selected by the 
        Secretary under paragraph (3).
            (2) Application.--An applicant representing a collaborative 
        care network described in subsection (d) shall submit to the 
        Secretary an application in such form and manner and containing 
        such information as specified by the Secretary. Such 
        information shall at least--
                    (A) identify the health care providers 
                participating in the collaborative care network 
                proposed by the applicant and in the case a Federally-
                qualified health center is not included as such a 
                participant, the reason such a center is not so 
                included;
                    (B) include a description of how the providers plan 
                to collaborate to provide comprehensive and integrated 
                care for low-income individuals, including uninsured 
                and underinsured individuals;
                    (C) include a description of the organizational and 
                joint governance structure of the collaborative care 
                network in a manner so that it is clear how decisions 
                will be made;
                    (D) define the geographic areas and populations 
                that the network intends to serve;
                    (E) define the scope of services that the network 
                intends to provide and identify any reasons why such 
                services would not include a suggested core service 
                identified by the Secretary under paragraph (4);
                    (F) demonstrate the network's ability to meet the 
                requirements of this section; and
                    (G) provide assurances that (and include a plan 
                demonstrating how) funds received by an eligible DSH 
                Program participant under section 1886(d)(5)(F) of the 
                Social Security Act pursuant to the Pilot Program shall 
                be appropriately distributed among all health care 
                providers participating in the collaborative care 
                network.
            (3) Selection of participants.--The Secretary shall select 
        eligible DSH Program participants from applications submitted 
        under paragraph (2) on the basis of quality of the proposal 
        involved, geographic diversity (including different States and 
        regions served and urban and rural diversity), and the number 
        of low-income and uninsured individuals that the proposal 
        intends to serve. The Secretary shall give priority to 
        proposals from eligible DSH Program participants that serve a 
        high volume a low-income individuals, and in applying this 
        criteria, may consider whether the eligible DSH Program 
        participant meets the criteria set out under section 
        1923(b)(1)(B) of the Social Security Act. Subject to receiving 
        enough high quality applications under paragraph (2), the 
        Secretary shall select at least 5 such participants initially.
            (4) Suggested core services.--For purposes of paragraph 
        (2)(E), the Secretary shall develop a list of suggested core 
        services to be provided by a collaborative care network. The 
        Secretary may select an eligible DSH Program participant under 
        paragraph (3), the application of which does not include all 
        such services, if such application provides a reasonable 
        explanation why such services are not proposed to be included, 
        and the Secretary determines that the application is otherwise 
        high quality. Unless the Secretary determines otherwise, such 
        list of suggested core services should include primary care, 
        maternity care, and well-baby care.
            (5) Termination authority.--The Secretary may terminate 
        selection of a collaborative care network under this section 
        for good cause. Such good cause shall include a determination 
        that the network--
                    (A) has failed to provide a comprehensive range of 
                coordinated and integrated health care services as 
                required under subsection (d)(3);
                    (B) had failed to meet reasonable quality 
                standards;
                    (C) has misappropriated funds provided under this 
                section; or
                    (D) has failed to make progress toward 
                accomplishing goals set out in subsection (a)(2).
    (c) Use of Funds.--Funds provided under the Pilot Program shall be 
available to an eligible DSH Program participant (or consortium of 
participants) to create and support collaborative care networks 
(described in subsection (d)) that would carry out the following 
activities:
            (1) Assist low-income individuals without adequate health 
        care coverage to--
                    (A) access and appropriately use health services;
                    (B) enroll in applicable public or private health 
                insurance programs;
                    (C) obtain referrals to and see a primary care 
                provider in the case such an individual does not have a 
                primary care provider; and
                    (D) obtain appropriate care for chronic conditions.
            (2) Improve heath care by providing case management, 
        application assistance, and appropriate referrals such as 
        through methods to--
                    (A) create and meaningfully use a health 
                information network to track patients across 
                collaborative providers;
                    (B) perform health outreach, such as by using 
                ``promotoras''--neighborhood health workers who may 
                inform individuals about the availability of safety net 
                and primary care available through the collaborative 
                care network;
                    (C) provide for follow-up outreach to remind 
                patients of appointments or follow-up care 
                instructions;
                    (D) provide transportation to individuals to and 
                from the site of care;
                    (E) expand the capacity to provide care at any 
                provider participating in the collaborative care 
                network, including through hiring new staff, opening 
                new clinics or other provider sites after-hours, on 
                weekends, or otherwise providing an urgent care 
                alternative to an emergency department; and
                    (F) provide a primary care provider or medical home 
                for each network patient.
Nothing in this section shall be construed as requiring a collaborative 
care network to carry out all such activities.
    (d) Collaborative Care Networks.--
            (1) In general.--
                    (A) Description.--A collaborative care network 
                described in this subsection is a consortium of health 
                care providers with a joint governance structure that 
                provides a comprehensive range of coordinated and 
                integrated health care services for low-income patient 
                populations or medically underserved communities 
                (whether or not such individuals receive benefits under 
                title XVIII, XIX, or XXI of the Social Security Act, 
                private or other health insurance or are uninsured or 
                underinsured) that complies with any applicable minimum 
                eligibility requirements that the Secretary may 
                determine appropriate.
                    (B) Required inclusion.--Each such network shall 
                include--
                            (i) at least one eligible DSH program 
                        participant; and
                            (ii) at least one Federally-qualified 
                        health center (as defined in section 
                        1905(l)(2)(B) of such Act) unless no such a 
                        center serves the geographic area proposed to 
                        be served by the network; a center exists but 
                        refuses to participate; or a center places 
                        unreasonable conditions on such participation.
                    (C) Additional inclusions.--Each such network may 
                include any of the following additional providers:
                            (i) Another hospital.
                            (ii) A county or municipal department of 
                        health.
                            (iii) A rural health clinic.
                            (iv) A community clinic, including a mental 
                        health clinic, substance abuse clinic, or a 
                        reproductive health clinic.
                            (v) A private practice physician or group 
                        practice.
                            (vi) A nurse or physician assistant or 
                        group practice.
                            (vii) An adult day care center.
                            (viii) A home health provider.
                            (ix) Any other type of provider specified 
                        by the Secretary, which has a desire to serve 
                        low-income and uninsured patients.
                    (D) Construction.--Nothing in this section shall 
                prohibit a single entity from qualifying as 
                collaborative care network so long as such single 
                entity meets the criteria of a collaborative care 
                network. If the network does not include at least one 
                Federally-qualified health center (as defined in 
                section 1905(l)(2)(B) of the Social Security Act), the 
                application must explain the reason pursuant to 
                subparagraph (A)(ii).
            (2) Collaborative care network payment methodologies.--The 
        Secretary shall test alternative payment methodologies (which 
        the Secretary may apply under the Pilot Program in lieu of or 
        in addition to the increased payments under subsection (a)) to 
        provide reimbursements to members of collaborative care 
        networks for services that are provided by such members under 
        the Pilot Program and may adopt alternative payment 
        methodologies proposed by the members of the collaborative care 
        network in the Application submitted under Section (b)(2). Such 
        alternative methodologies may be paid to the eligible DSH 
        Program participant, to another member of the network, or to 
        the network itself, provided that the initial recipient is able 
        to adequately distribute the funds pursuant to assurances in 
        subsection (b)(2)(G). Such alternative payment methodologies 
        may include--
                    (A) bundled, capitated, or flat rate payments to 
                the collaborative care network or a member of the 
                network;
                    (B) shared savings programs;
                    (C) a transition from traditional cost-based 
                payments to alternative payment methodologies described 
                in this section after an initial period; and
                    (D) other payment methodologies designed to create 
                incentives for the collaborative care networks to 
                provide integrated and collaborative care and to reward 
                high quality, cost-efficient care.
            (3) Comprehensive range of coordinated and integrated 
        health care services.--The Secretary may define criteria for 
        evaluating the services offered by a collaborative care 
        network. Such criteria may include the following:
                    (A) Requiring collaborative care networks to 
                include at least the suggested core services identified 
                under subsection (b)(4), or whichever subset of the 
                suggested core services is applicable to a particular 
                network.
                    (B) Requiring such networks to assign each patient 
                of the network to a primary care provider responsible 
                for managing that patient's care.
                    (C) Requiring the services provided by a 
                collaborative care network to include support services 
                appropriate to meet the health needs of low-income 
                populations in the network's community, which may 
                include chronic care management, nutritional 
                counseling, transportation, language services, 
                enrollment counselors, social services and other 
                services as proposed by the network.
                    (D) Providing that the services provided by a 
                collaborative care network may also include long term 
                care services and other services not specified in this 
                subsection.
                    (E) Providing for the approval by the Secretary of 
                a scope of collaborative care network services for each 
                network that addresses an appropriate minimum scope of 
                work consistent with the setting of the network and the 
                health professionals available in the community the 
                network serves.
            (4) Clarification.--Participation in a collaborative care 
        network under the Pilot Program shall not disqualify a health 
        care provider from reimbursement under title XVIII, XIX, or XXI 
        of the Social Security Act with respect to services otherwise 
        reimbursable under such title. Nothing in this section shall 
        prevent a collaborative care network that is otherwise eligible 
        to contract with Medicare, a private health insurer, or any 
        other appropriate entity to provide care under Medicare, under 
        health insurance coverage offered by the insurer, or otherwise.
    (e) Evaluations.--
            (1) Participant reports.--Each eligible DSH Program 
        participant shall submit to the Secretary, for each year of the 
        participant's participation in the Pilot Program beginning in 
        the third year following the date of implementation of the 
        Pilot Program, an evaluation on the activities carried out by 
        the collaborative care network of such participant under the 
        Pilot Program and shall include--
                    (A) the number of people served;
                    (B) the most common health problems treated;
                    (C) any reductions in emergency department use;
                    (D) an accounting of how amounts received pursuant 
                to the Pilot Program were used; and
                    (E) to the extent requested by the Secretary, any 
                quality measures or any other measures specified by the 
                Secretary.
            (2) Program reports.--The Secretary shall submit to 
        Congress an annual evaluation (beginning not later than 6 
        months after the first reports under paragraph (1) are 
        submitted) on the extent to which emergency department use was 
        reduced as a result of the activities carried out by the 
        participant under the Pilot Program. Each such evaluation shall 
        also include information on--
                    (A) the prevalence of certain chronic conditions in 
                various populations, including a comparison of such 
                prevalence in the general population versus in the 
                population of individuals with inadequate health 
                insurance coverage;
                    (B) demographic characteristics of the population 
                of uninsured and underinsured individuals served by the 
                collaborative care network involved; and
                    (C) the conditions of such individuals for whom 
                services were requested at such emergency departments 
                of participating hospitals.
            (3) Audit authority.--The Secretary may conduct periodic 
        audits and request periodic spending reports of participants 
        under the Pilot Program.
            (4) MedPAC evaluation.--In its annual reports to Congress, 
        the Medicare Payment Advisory Commission shall include its 
        evaluation of the Pilot Program.
    (f) Clarification.--Nothing in this section or section 3 requires a 
provider to report individually identifiable information of an 
individual to government agencies, unless the individual consents, 
consistent with HIPAA privacy and security law, as defined in section 
3009(a)(2) of the Public Health Service Act.

SEC. 3. CREATION OF A COLLABORATIVE CARE NETWORK CENTER WITHIN HHS.

    (a) In General.--The Secretary shall create within the Department 
of Health and Human Services a Collaborative Care Network Center (in 
this section referred to as the ``Center'').
    (b) Duties.--The Center shall carry out the following duties:
            (1) Provide technical assistance and other implementation 
        support to collaborative care networks.
            (2) Develop and disseminate collaborative care network best 
        practice models and facilitate networking and information 
        sharing among collaborative care networks.
            (3) Develop and assist in the development of pilot programs 
        under title XVIII, XIX, or XXI of the Social Security Act to 
        test new payment models and delivery system innovations, such 
        as bundling, shared savings models, capitated payments, and 
        incentive payment structures.
            (4) Evaluate the effectiveness of such pilots programs.
            (5) Evaluate the performance of collaborative care networks 
        based on an aggregation of the quality measures the network's 
        providers are to report under section 2(e)(1)(E).
            (6) Advise Congress, the Secretary, and other relevant 
        agencies regarding proposed changes to statutory or regulatory 
        barriers to collaborative care network success.
            (7) Carry out other activities as determined by the 
        Secretary to be necessary for the development or improvement of 
        collaborative care networks.
    (c) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as are necessary to carry out this section.
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