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.