1.This Act may be cited as
the Medicare Payment Improvement Act
of 2009
.
2.Value index
under the Medicare physician fee schedule
(a)Section 1848(e)(5) of
the Social Security Act (42 U.S.C. 1395w–4(e)) is amended by adding at the end
the following new paragraph:
(6)
(A)The Secretary shall determine a value index for each
hospital referral area (as defined by the Secretary). The value index shall be
the ratio of the quality component under subparagraph (B) to the cost component
under subparagraph (C) for that hospital referral area.
(B)
(i)The quality component shall be based on a composite score
that reflects quality measures available on a State or hospital referral area
(as so defined) basis. The measures shall reflect health outcomes and health
status for the Medicare population, patient safety, and patient satisfaction.
The Secretary shall use the best data available, after consultation with the
Agency for Healthcare Research and Quality and with private entities that
compile quality data.
(ii)
(I)Not later than 60 days after the date of enactment of the
Medicare Payment Improvement Act of
2009, the Secretary shall establish a group of experts and
stakeholders to make consensus recommendations to the Secretary regarding
development of the quality component. The membership of the advisory group
shall at least reflect providers, purchasers, health plans, researchers,
relevant Federal agencies, and individuals with technical expertise on health
care quality.
(II)In
the development of recommendations with respect to the quality component, the
group established under subclause (I) shall consider at least the following
areas:
- (aa)High variation
and high cost per capita utilization of resources, including rates of
hospitalizations, number of visits and subspecialty referrals, and number of
procedures (as determined by data under this title).
- (bb)Health outcomes
and functional status of patients.
- (cc)The continuity,
management, and coordination of health care and care transitions, including
episodes of care, for patients across the continuum of providers, health care
settings, and health plans.
- (dd)Patient,
caregiver, and authorized representative experience, quality and relevance of
information provided to patients, caregivers, and authorized representatives,
and use of information by patients, caregivers, and authorized representatives
to inform decision making.
- (ee)The safety,
effectiveness, and timeliness of care.
- (ff)The appropriate
use of health care resources and services.
- (gg)Other items
determined appropriate by the Secretary.
(iii)In
establishing the quality component under this subparagraph, the Secretary
shall—
(I)take into account
the recommendations of the group established under clause (ii)(I); and
(II)provide for an
open and transparent process for the activities conducted pursuant to the
convening of such group with respect to the development of the quality
component.
(iv)The
quality component for each hospital referral area (as so defined) shall be the
ratio of the quality score for such area to the national average quality
score.
(v)If the quality component for a hospital referral area
(as so defined) does not rank in the top 25th percentile as compared to the
national average (as determined by the Secretary) and the amount of
reimbursement for services under this section is greater than the amount of
reimbursement for such services that would have applied under this section if
the amendments made by section 2 of the Medicare Payment Improvement Act of 2009 had
not been enacted, this section shall be applied as if such amendments had not
been enacted.
(vi)In
the case of a hospital referral area (as so defined) that is less than an
entire State, if available quality data is not sufficient to measure quality at
the sub-State level, the quality component for a sub-State hospital referral
area shall be the quality component for the entire State.
(C)
(i)The cost component shall be total annual per beneficiary
Medicare expenditures under part A and this part for the hospital referral area
(as so defined). The Secretary may use total per beneficiary expenditures under
such parts in the last two years of life as an alternative measure if the
Secretary determines that such measure better takes into account severity
differences among hospital referral areas.
(ii)The
cost component for a hospital referral area (as so defined) shall be the ratio
of the cost per beneficiary for such area to the national average cost per
beneficiary.
.
(b)Section 1848 of the Social Security Act (42 U.S.C.
1395w–4) is amended—
(1)in subsection
(b)(1)(C), by striking geographic
and inserting
geographic and value
; and
(2)in subsection
(e)—
(A)in paragraph
(1)—
(i)in
the heading, by inserting and value
after geographic
;
(ii)in
subparagraph (A), by striking clause (iii) and inserting the following new
clause:
(iii)a value index
(as defined in paragraph (6)) applicable to physician
work.
;
(iii)in subparagraph
(C), by inserting and value
after geographic
in
the first sentence;
(iv)in
subparagraph (D), by striking physician work effort
and
inserting value
;
(v)by
striking subparagraph (E); and
(vi)by
striking subparagraph (G);
(B)by striking
paragraph (2) and inserting the following new paragraph:
(2)Computation of
geographic and value adjustment factorFor purposes of subsection
(b)(1)(C), for all physicians’ services for each hospital referral area (as
defined by the Secretary) the Secretary shall establish a geographic and value
adjustment factor equal to the sum of the geographic cost-of-practice
adjustment factor (specified in paragraph (3)), the geographic malpractice
adjustment factor (specified in paragraph (4)), and the value adjustment factor
(specified in paragraph (5)) for the service and the
area.
;
and
(C)by striking
paragraph (5) and inserting the following new paragraph:
(5)Physician work
value adjustment factorFor purposes of paragraph (2), the
physician work value adjustment factor
for a service for a
hospital referral area (as defined by the Secretary), is the product of—
(A)the proportion of
the total relative value for the service that reflects the relative value units
for the work component; and
(B)the value index
score for the area, based on the value index established under paragraph
(6).
.
(c)Availability of
quality component prior to implementationThe Secretary of Health
and Human Services shall make the quality component described in section
1848(c)(6)(B) of the Social Security Act, as added by subsection (a), for each
hospital referral area (as defined by the Secretary) available to the public by
not later than July 1, 2011.
(d)Subject to subsection
(e), the amendments made by this section shall apply to the Medicare physician
fee schedule for 2012 and each subsequent year.
(e)Notwithstanding
the amendments made by the preceding provisions of this section, the Secretary
of Health and Human Services shall provide for an appropriate transition to the
amendments made by this section. Under such transition, in the case of payments
under such fee schedule for services furnished during—
(1)2012, 25 percent
of such payments shall be based on the amount of payment that would have
applied to the services if such amendments had not been enacted and 75 percent
of such payment shall be based on the amount of payment that would have applied
to the services if such amendments had been fully implemented;
(2)2013, 50 percent
of such payment shall be based on the amount of payment that would have applied
to the services if such amendments had not been enacted and 50 percent of such
payment shall be based on the amount of payment that would have applied to the
services if such amendments had been fully implemented; and
(3)2014 and
subsequent years, 100 percent of such payment shall be based on the amount of
payment that is applicable under such amendments.