[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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