[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1295 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1295

 To amend title XVIII of the Social Security Act to cover transitional 
  care services to improve the quality and cost effectiveness of care 
                      under the Medicare program.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 18, 2009

 Mrs. Shaheen (for herself, Ms. Collins, and Mrs. Lincoln) introduced 
the following bill; which was read twice and referred to the Committee 
                               on Finance

_______________________________________________________________________

                                 A BILL


 
 To amend title XVIII of the Social Security Act to cover transitional 
  care services to improve the quality and cost effectiveness of care 
                      under the Medicare program.

    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 ``Medicare Transitional Care Act of 
2009''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) More than 20 percent of older Americans suffer from 
        five or more chronic conditions and these older adults 
        typically require health care services from numerous providers 
        across several care settings each year.
            (2) Insufficient communication among older adults, family 
        caregivers, and health care providers contributes to poor 
        continuity of care, inadequate management of complex health 
        care needs, and preventable hospital admissions.
            (3) Research suggests that family caregivers often lack the 
        knowledge, skills, and resources to effectively address the 
        complex needs of older adults coping with multiple coexisting 
        conditions.
            (4) In 2005, health care services for Medicare 
        beneficiaries with five or more chronic conditions accounted 
        for 75 percent of total Medicare spending. The vast majority of 
        these costs were due to high rates of hospital admission and 
        readmission.
            (5) According to Medicare claims data from 2003-2004, 
        almost one-fifth (19.6 percent) of the 11,855,702 Medicare 
        beneficiaries who had been discharged from a hospital were 
        rehospitalized within 30 days, and 34.0 percent were 
        rehospitalized within 90 days.
            (6) A New England Journal of Medicine study estimates that 
        the cost to Medicare of unplanned rehospitalizations in 2004 
        was $17.4 billion.
            (7) The MetLife Caregiving Cost Study demonstrates that 
        American businesses lose an estimated $34 billion each year due 
        to employees' need to care for loved ones.
            (8) The Transitional Care Model, developed by the 
        University of Pennsylvania, is a care management strategy that 
        identifies patients' health goals, coordinates care throughout 
        acute episodes of illness, develops a streamlined plan of care 
        to prevent future hospitalizations, and prepares the 
        beneficiary and family caregivers to implement this care plan.
            (9) The major goal of the Transitional Care Model is to 
        interrupt cycles of avoidable hospitalizations and promote 
        longer-term positive health outcomes.
            (10) The Transitional Care Model has shown through multiple 
        randomized clinical trials to produce significant health 
        outcome improvements, reductions in health care costs among at-
        risk and chronically ill older adults, and increased patient 
        satisfaction.
            (11) Preliminary results from a clinical trial of the 
        Guided Care Model (based on a Medical Home which includes 
        transitional care) demonstrated reductions in hospital days, 
        skilled nursing facility days, and home health episodes, as 
        well as preliminary findings of net savings.
            (12) A clinical trial of the Care Transitions Intervention 
        demonstrated lower rehospitalization rates and lower hospital 
        costs per patient.

SEC. 3. MEDICARE COVERAGE OF TRANSITIONAL CARE.

    Title XVIII of the Social Security Act is amended by adding at the 
end the following new section:

   ``coverage of transitional care services for qualified individuals

    ``Sec. 1899.  (a) Coverage Under Part B.--
            ``(1) In general.--In the case of a qualified individual 
        (as defined in subsection (b)), the Secretary shall provide 
        under part B for benefits for transitional care services (as 
        defined in subsection (c)) furnished by a transitional care 
        clinician (as defined in subsection (d)) acting as an employee 
        of (or pursuant to a contract with) a qualified transitional 
        care entity (as defined in paragraph (3)(A)) in accordance with 
        this section during the transitional care period (as defined in 
        paragraph (3)(B)) for the qualified individual.
            ``(2) Initial implementation.--The Secretary shall first 
        implement this section for services furnished on or after 
        January 1, 2010.
            ``(3) General definitions.--In this section:
                    ``(A) Qualified transitional care entity.--The term 
                `qualified transitional care entity' means--
                            ``(i) a hospital or a critical care 
                        hospital;
                            ``(ii) a home health agency;
                            ``(iii) a primary care practice;
                            ``(iv) a Federally qualified health center; 
                        or
                            ``(v) another entity approved by the 
                        Secretary for purposes of this section.
                    ``(B) Transitional care period.--The term 
                `transitional care period' means, with respect to a 
                qualified individual, the period--
                            ``(i) beginning on the date the individual 
                        is admitted to a subsection (d) hospital (as 
                        defined for purposes of section 1886) for 
                        inpatient hospital services, or is admitted to 
                        a critical care hospital for inpatient critical 
                        access hospital services, for which payment may 
                        be made under this title; and
                            ``(ii) ending on the last day of the 90-day 
                        period beginning on the date of the 
                        individual's discharge from such hospital or 
                        critical care hospital.
    ``(b) Qualified Individuals.--
            ``(1) Limiting first phase of implementation to high-risk 
        individuals.--Except as provided in this subsection, qualified 
        individuals are limited to individuals who--
                    ``(A) have been admitted to a subsection (d) 
                hospital (as defined for purposes of section 1886) for 
                inpatient hospital services or to a critical care 
                hospital for inpatient critical access hospital 
                services; and
                    ``(B) are identified by the Secretary as being at 
                highest risk for readmission or for a poor transition 
                from such a hospital to a post-hospital site of care.
        The identification under subparagraph (B) shall be based on 
        achieving a minimum hierarchical condition category score 
        (specified by the Secretary) in order to target eligibility for 
        benefits under this section to individuals with multiple 
        chronic conditions and other risk factors, such as cognitive 
        impairment, depression, or a history of multiple 
        hospitalizations.
            ``(2) Second phase of implementation.--After submitting to 
        Congress the evaluation under subsection (i)(2) and considering 
        any cost-savings and quality improvements from the prior 
        implementation of this section, the Secretary may expand 
        eligibility of qualified individuals to include moderate-risk 
        and lower-risk individuals, as determined in accordance with 
        eligibility criteria specified by the Secretary. In expanding 
        eligibility, the Secretary may modify or scale transitional 
        care services to meet the specific needs of moderate- and 
        lower-risk individuals.
            ``(3) Avoiding duplication of services.--The Secretary 
        shall ensure that qualified individuals receiving transitional 
        care services are not receiving duplicative services under this 
        title.
    ``(c) Transitional Care Services Defined.--In this section, the 
term `transitional care services' means services that support a 
qualified individual during the transitional care period and includes 
the following:
            ``(1) A comprehensive assessment prior to discharge 
        including an assessment of the individual's physical and mental 
        condition, cognitive and functional capacities, medication 
        regimen and adherence, social and environmental needs, and 
        primary caregiver needs and resources.
            ``(2) Development of a comprehensive, evidenced-based plan 
        of transitional care for the individual developed with the 
        individual and the individual's primary caregiver and other 
        health team members, identifying potential health risks, 
        treatment goals, current therapies, and future services for 
        both the individual and any primary caregiver.
            ``(3) A visit at the care setting within 24 hours after 
        discharge from the hospital or critical access hospital.
            ``(4) Home visits to implement the plan of care.
            ``(5) Implementation of the plan of care, including--
                    ``(A) addressing symptoms;
                    ``(B) teaching and promoting self-management skills 
                for the individual and any primary caregiver;
                    ``(C) teaching and counseling the individual and 
                the individual's primary caregiver (as appropriate) to 
                assure adherence to medications and other therapies and 
                avoid adverse events;
                    ``(D) promoting individual access to primary care 
                and community-based services;
                    ``(E) coordinating services provided by other 
                health team members and community caregivers; and
                    ``(F) facilitating transitions to palliative or 
                hospice care, where appropriate.
            ``(6) Accompanying the individual to follow-up physician 
        visits, as appropriate.
            ``(7) Providing information and resources about conditions 
        and care.
            ``(8) Educating and assisting the individual and the 
        individual's primary caregiver to arrange and coordinate 
        clinician visits and health care services.
            ``(9) Informing providers of services and suppliers of 
        those items and services that have been ordered for and 
        received by the individual from other providers.
            ``(10) Working with providers of services and suppliers to 
        assure appropriate referrals to specialists, tests, and other 
        services.
            ``(11) Educating and assisting the individual and the 
        individual's primary caregiver with arranging and coordinating 
        community resources and support services (such as medical 
        equipment, meals, homemaker services, assistance with daily 
        activities, shopping, and transportation).
            ``(12) Providing to the qualified individual, primary 
        caregiver, and appropriate clinicians and qualified 
        transitional care entity providing ongoing care at the 
        conclusion of the transitional care period a written summary 
        that includes the goals established in the plan of care 
        described in paragraph (2), progress in achieving such goals, 
        and remaining treatment needs.
            ``(13) Other services that the Secretary determines are 
        appropriate.
The Secretary shall determine and update the services to be included in 
transitional care services as appropriate, based on the evidence of 
their effectiveness in reducing hospital readmissions and improving 
health outcomes.
    ``(d) Transitional Care Clinicians.--
            ``(1) In general.--In this section, the term `transitional 
        care clinician' means, with respect to a qualified individual, 
        a nurse or other health professional who--
                    ``(A) has received specialized training in the 
                clinical care of people with multiple chronic 
                conditions (including medication management) and 
                communication and coordination with multiple providers 
                of services, suppliers, patients, and their primary 
                caregivers;
                    ``(B) is supported by an interdisciplinary team in 
                a manner that assures continuity of care throughout a 
                transitional care period and across care settings 
                (including the residences of qualified individuals);
                    ``(C) is employed by (or has a contract with) with 
                a qualified transitional care entity for the furnishing 
                of transitional care services; and
                    ``(D) meets such participation criteria as the 
                Secretary may specify consistent with this subsection.
            ``(2) Participation criteria.--In establishing 
        participation criteria under paragraph (1)(C), the Secretary 
        shall assure that transitional care clinicians meet relevant 
        experience and training requirements and have the ability to 
        meet the individual needs of qualified individuals.
            ``(3) Encouragement of hit.--The Secretary may provide for 
        an additional payment to encourage transitional care clinicians 
        and qualified transitional care entities to use health 
        information technology in the provision of transitional care 
        services.
    ``(e) Payment.--
            ``(1) In general.--The Secretary shall determine the method 
        of payment for transitional care services under this section, 
        including appropriate risk adjustment that reflects the 
        differences in resources needed to provide transitional care 
        services to individuals with differing characteristics and 
        circumstances and, when applicable, the performance measures 
        under subsection (f). The payment amount shall be sufficient to 
        ensure the provision of necessary transitional care services 
        throughout the transitional care period. The payment shall be 
        structured in a manner to explicitly recognize transitional 
        care as an episode of services that crosses multiple care 
        settings, providers of services, and suppliers. The payment 
        with respect to transitional care services furnished by a 
        transitional care clinician shall be made, notwithstanding any 
        other provision of this title, to the qualified transitional 
        care entity which employs, or has a contract with, the 
        clinician for the furnishing of such services.
            ``(2) No cost-sharing.--Notwithstanding section 1833, there 
        shall be no deductible or cost-sharing applicable to payment 
        under this section for transitional care services.
    ``(f) Performance Measures.--
            ``(1) Accountability.--
                    ``(A) In general.--The Secretary shall establish a 
                method whereby qualified transitional care entities 
                responsible for furnishing transitional care services 
                would be held accountable for process and outcome 
                performance measures specified by the Secretary from 
                those that have been endorsed by the National Quality 
                Forum.
                    ``(B) Development and endorsement of performance 
                measure set.--For purposes of carrying out subparagraph 
                (A), the Secretary shall enter into an arrangement--
                            ``(i) with the National Quality Forum for 
                        the evaluation, endorsement, and recommendation 
                        of an appropriate set of performance measures 
                        for transitional care services and for the 
                        identification of gaps in available measures; 
                        and
                            ``(ii) with the Agency for Healthcare 
                        Research and Quality to support measure 
                        development, to fill gaps in available 
                        measures, and to provide for the ongoing 
                        maintenance of the set of performance measures 
                        for transitional care services.
            ``(2) Pay for performance.--As soon as practicable after 
        reliable process and outcome performance measures have been 
        endorsed and specified under subparagraph (A), the Secretary 
        shall provide that the payment amounts under subsection (e) for 
        transitional care services shall be linked to performance on 
        such measures.
            ``(3) Public reporting.--The Secretary shall establish a 
        mechanism to publicly report on a qualifying entity's 
        transitional care performance on such measures, including 
        providing benchmarks to identify high performers and those 
        practices that contribute to lower hospital readmission rates.
            ``(4) Dissemination of information on best practices.--The 
        Secretary shall disseminate information on best practices used 
        by transitional care clinicians and qualifying transitional 
        care entities in furnishing transitional care services for 
        purposes of application in other settings, such as in 
        conditions of participation under this title, under the Quality 
        Improvement Organization (QIO) Program under part B of title 
        XI, and public-private quality alliances, such as the Hospital 
        Quality Alliance.
    ``(g) Notification of Eligibility and Coordination With Hospital 
Discharge Planning.--In establishing standards for discharge planning 
under section 1861(ee)(1), the Secretary shall require each subsection 
(d) hospital and each critical care hospital--
            ``(1) to identify, as soon as practicable after admission, 
        those patients who are qualified individuals under this 
        section; and
            ``(2) to provide to such patients and their primary 
        caregivers a list of qualified transitional care entities 
        available to arrange for the provision of transitional care 
        services, a list of transitional services provided under this 
        section, and a notice that the transitional care service 
        benefit is provided to qualified individuals with no deductible 
        or cost-sharing.
Nothing in this section shall be construed as preventing such a 
hospital from entering into an agreement with a qualified transitional 
care entity or a transitional care clinician for the furnishing of 
transitional care services to the hospital's patients.
    ``(h) Prevention of Inappropriate Steering.--The Secretary shall 
promulgate such regulations as the Secretary deems necessary to address 
any protections needed, beyond those otherwise provided under law and 
regulations, to prevent inappropriate steering of qualified individuals 
to providers of services, suppliers, qualified transitional care 
entities, or transitional care clinicians, under this section or 
inappropriate limitations on access to needed transitional care 
services under this section.
    ``(i) Evaluation of Benefit.--
            ``(1) In general.--The Secretary shall evaluate the 
        performance of the transitional care benefit under this section 
        by measuring the following (for those receiving transitional 
        care services and those not receiving such services):
                    ``(A) Admission rates to health care facilities.
                    ``(B) Hospital readmission rates.
                    ``(C) Cost of transitional care and all other 
                health care services.
                    ``(D) Quality of transitional care experiences.
                    ``(E) Measures of quality and efficiency.
                    ``(F) Beneficiary, primary caregiver, and provider 
                experience.
                    ``(G) Health outcomes.
                    ``(H) Reductions in expenditures under this title 
                over time.
            ``(2) Report.--The Secretary shall submit a report to 
        Congress no later than April 1, 2013, on the performance 
        measures achieved by the transitional care benefit in the first 
        2 years of implementation. After submitting such report, the 
        Secretary may expand the benefit to moderate-risk and lower-
        risk individuals in accordance with subsection (b)(2).''.
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