Women's medical home demonstration project

(a)

Definitions

In this Act: (1)

Advisory Council

The term Advisory Council means the advisory council established under subsection (c). (2)

CHIP

The term CHIP means the State Children's Health Insurance Program established under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.). (3)

Eligible individuals

(A)

In general

The term eligible individual means a woman who is receiving assistance under Medicaid or CHIP. (B)

Priority for certain women

In enrolling eligible individuals in a demonstration project conducted under this section, the eligible entity conducting the project shall give special consideration to enrolling eligible individuals receiving services described in any of clauses (i) through (ix) of paragraph (8)(G). (4)

Eligible entity

The term eligible entity means a State, an entity or organization receiving payments under Medicaid or CHIP, an entity or organization that is receiving assistance under section 330 of the Public Health Service Act (42 U.S.C. 254b), a federally qualified health center (as defined in subsection (l)(2)(C) of section 1905 of the Social Security Act (42 U.S.C. 1396d), a rural health clinic (as defined in subsection (l)(1) of such section), or an entity that receives assistance under title X or XX of the Public Health Service Act (42 U.S.C. 300 et seq., 300z et seq.), that submits an approved application to the Secretary to conduct a demonstration project under this section. (5)

Medicaid

The term Medicaid means the Federal and State program for medical assistance established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). (6)

Principal women’s health provider

The term principal women's health provider means: (A)A physician (as defined in section 1861(r)(1) of the Social Security Act (42 U.S.C. 1395x(r)(1)) who meets the following requirements: (i)The physician is a board certified physician who specializes in women’s health issues, such as obstetrics and gynecology, and who provides continuous and comprehensive care for individuals under the physician's care. (ii)The physician has the staff and resources to manage the comprehensive and coordinated health care of each such individual. (iii)The physician practices in a practice or health center recognized to be a women’s medical home. (iv)Such other requirements as are defined by the Secretary in consultation with the Advisory Council. (B)An advance practice nurse, including a certified nurse-midwife (CNM) or certified midwife (CM) certified by the American Midwifery Certification Board, or physician assistant, who meets the following requirements: (i)The advance practice nurse or physician assistant specializes in women’s health issues, such as obstetrics and gynecology, and provides continuous and comprehensive care for patients. (ii)The advance practice nurse or physician assistant has the staff and resources to manage the comprehensive and coordinated health care of each such individual. (iii)The advance practice nurse or physician assistant practices in a practice or health center recognized to be a women’s medical home. (iv)Such other requirements as are defined by the Secretary in consultation with the Advisory Council. (7)

Secretary

The term Secretary means the Secretary of Health and Human Services. (8)

Women’s medical home

The term women's medical home means a physician-led practice, or advanced practice nurse-directed practice in those States in which independent practice is included in the scope of practice of licensed advanced practice nurses, that uses practice innovations to improve the management and coordination of women’s health care and that meets the following standards: (A)The practice, health center, or clinic is able to provide or coordinate a continuum of care for women across their life spans, including wellness care, preconception care, prenatal care, family planning, medical care, mental and behavioral health care, screening, and followup care for health needs later in life. (B)The practice, health center, or clinic applies standards for access to care and communication with eligible individuals participating in the demonstration project established under this section, including direct and ongoing access to the principal women’s health provider who accepts responsibility for providing continuous care, including coordination for comprehensive health care to the whole person, in collaboration with teams of other health professionals, including other nurses, primary care and specialist physicians, and mental health professionals, as needed and appropriate. Care is patient and family centered, culturally and linguistically appropriate, structured to ensure women receive complete and accurate health information to make their own health care decisions, and structured to assure confidentiality so that teens and women may seek needed care in a timely way. (C)The practice, health center, or clinic has readily accessible, clinically useful information on eligible individuals participating in the demonstration project established under this section that enables the practice to treat such individuals comprehensively and systematically. (D)The practice, health center, or clinic maintains continuous relationships with eligible individuals participating in the demonstration project established under this section by implementing evidence-based guidelines and applying them to the identified needs of such individuals over time and with the intensity needed by such individuals. (E)The practice, health center, or clinic provides ongoing assistance and encouragement in patient management. The practice— (i)collaborates with eligible individuals participating in the demonstration project established under this section to pursue their goals for optimal achievable health; and (ii)assesses patient-specific barriers to communication and conducts activities to support patient self-management. (F)The practice, health center, or clinic has in place the resources and processes necessary to achieve improvements in the management and coordination of care for eligible individuals participating in the demonstration project established under this section, including— (i)providing training programs for personnel involved in the coordination of care; and (ii)utilizing information technology to support optimal patient care, performance measurement, patient education, and enhanced communication. (G)The practice, health center, or clinic is able to provide 1 or more of the following services: (i)Treats women who are deemed at risk for premature birth. (ii)Provides services related to prevention of cervical cancer by immunization, periodic cervical cytology and early treatment of precursor lesions. (iii)Provides and coordinates care for women with breast or gynecologic cancer. (iv)Provides and coordinates services for women experiencing menopause, perimenopause and related issues such as osteoporosis, fracture prevention, and mental health concerns. (v)Provides family planning care. (vi)Provides and coordinates postpartum health services, including care for women experiencing perinatal depression. (vii)Provides and coordinates care for women who are members of a minority population that experiences health disparities. (viii)Provides and coordinates care for chronic conditions. (ix)Any other services specified by the Secretary, in consultation with the Advisory Council. (H)The practice, health center, or clinic monitors its clinical process and performance (including process and outcome measures) and provides information in a form and manner specified by the Secretary and Advisory Council with respect to such process and performance. (I)The practice, health center, or clinic meets the requirements imposed on a covered entity for purposes of applying part C of title XI of the Public Health Service Act (42 U.S.C. 300b–1 et seq.) and all regulatory provisions promulgated there under, including regulations (relating to privacy) adopted pursuant to the authority of the Secretary under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note). (b)

Establishment

(1)

In general

Not later than 2 years after the date of enactment of this Act, the Secretary shall establish a women’s medical home demonstration project (in this section referred to as the project) to— (A)guide the redesign of the health care delivery system for women to provide targeted, accessible, continuous, coordinated, confidential, and comprehensive care to eligible individuals with a particular focus on— (i)coordinating and improving care of women who are deemed at risk for premature birth; (ii)preventing cervical cancer by immunization, periodic cervical cytology and early treatment of precursor lesions; (iii)coordinating and improving care of women with breast or gynecologic cancer; (iv)coordinating and improving care for women experiencing menopause, perimenopause and related issues such as osteoporosis, fracture prevention and mental health concerns; (v)providing and improving care in family planning services; (vi)providing and coordinating care for women postpartum, including those deemed to be at risk for perinatal depression; (vii)providing, coordinating, and improving care of women who are members of a minority population that experiences health disparities; (viii)providing and coordinating care for individuals with chronic conditions; and (ix)providing any other services specified by the Secretary, in consultation with the Advisory Council. (B)provide principal care management payments, performance-based bonus payments, incentive payments for additional operations costs, and any other services, specified by the Secretary in consultation with the Advisory Council, to providers participating in a women’s medical home under the project. (2)

Nature and scope of project

(A)

Duration; scope

The project shall be conducted for a 3-year period and shall include a nationally representative sample of physicians, advance practice nurses, and physician assistants who specialize in women’s health and who serve urban, rural, and underserved areas in a total of no more than 8 States. (B)

Encouraging participation of small physician practices

The project shall be designed to include the participation of physicians in practices with fewer than 4 full-time equivalent physicians, as well as physicians in larger practices, particularly in rural and underserved areas. (3)

Project goals

The project shall be designed in order to determine whether and to what extent women’s medical homes accomplish the following, with special consideration given to the services and outcomes described in clauses (i) through (ix) of paragraph (1)(A): (A)Increase— (i)cost efficiencies of health care delivery; (ii)access to appropriate health care services; (iii)patient satisfaction; (iv)communication among providers, hospitals, and other health care providers; and (v)the quality of health care services provided, as based on measures of quality the Secretary, in consultation with the Advisory Council, has specified. (B)Decrease— (i)inappropriate emergency room utilization; (ii)avoidable hospitalizations; (iii)duplication of health care services provided; and (iv)health disparities. (C)Provide appropriate referrals to multidisciplinary services. (4)

Services performed

A principal provider operating within a women’s medical home shall perform or provide for the performance of services— (A)described in subsection (a)(8)(G); and (B)any additional services specified by Secretary in consultation with the Advisory Council. (5)

Eligible individual and eligible entity participation

(A)

Eligible individuals

The Secretary shall establish a process under which— (i)an eligible individual may elect to participate in a women’s medical home under the project; and (ii)no cost sharing shall be imposed with respect to any service required under paragraph (4) to be provided to the individual under the project. (B)

Assurance of participation of eligible entities that are not participating providers or are in states with managed care

The Secretary shall establish a process to ensure that eligible entities that are not participating providers under the State Medicaid or CHIP program, or, in the case of a State that contracts with a private entity to manage parts of the State Medicaid or CHIP program, do not participate with that entity, are able to participate in the project. (6)

Standard setting process

The Secretary shall, in consultation with the Advisory Council— (A)specify standards for practices, health centers, and clinics to qualify for certification as women’s medical homes, including standards described in subsection (a)(8)(B); (B)specify characteristics of principal women’s health providers consistent with subsection (a)(6); (C)specify services a principal physician, principal advance practice nurse, or principal physician assistant operating within a women’s medical home shall perform or provide for the performance of; (D)develop a women’s medical home reimbursement methodology which shall include at a minimum— (i)recognition of the value of physician and clinical staff work associated with patient care that falls outside the face-to-face visit, such as the time and effort spent on educating family caregivers and arranging appropriate followup services with other health care professionals, such as nurse educators; (ii)services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources; (iii)recognition of expenses that the women’s medical home practices will incur to acquire and utilize health information technology, such as clinical decision support tools, patient registries, or electronic medical records; (iv)reimbursement for separately identifiable e-mail and telephonic consultations, either as separately billable services or as part of a global management fee; (v)recognition of the value of provider work associated with remote monitoring of clinical data using technology; (vi)allowance for separate fee-for-service payments for face-to-face visits; (vii)recognition of case mix differences in the patient population being treated within the practice; (viii)recognition and sharing of savings with respect to reductions in the occurrence of health and pregnancy complications, hospitalization rates, medical errors, adverse drug reactions, and other occurrences, as defined by the Advisory Council; (ix)allowance for additional payments for achieving measurable and continuous quality improvements, including under a process established by the Secretary for paying a performance-based bonus to women's medical homes which meet or achieve substantial improvements in performance (as specified under clinical, patient satisfaction, and efficiency benchmarks established by the Secretary in consultation with the Advisory Council); (x)recognition of the existing payment methodology for federally qualified health centers when determining the most appropriate mechanism for providing bonus payments for women’s medical home services delivered at such centers; and (xi)such other methods as the Secretary, in consultation with the Advisory Council, finds appropriate; (E)develop appropriate risk-adjustment mechanisms to account for varying costs of women’s medical homes based upon characteristics of the eligible individuals participating in the project; (F)select the outcomes and quality measures and level of improvements required to qualify for performance-based bonus payments, with special consideration such payments related to services and outcomes described in clauses (i) through (ix) of paragraph (1)(A); and (G)evaluate the project in accordance with subsection (d). (7)

Planning or implementation grants

The Secretary may award planning or implementation grants to eligible entities desiring or selected to participate in the project. (8)

Ongoing oversight and performance assessment

The Secretary shall establish procedures to ensure that practices, health centers, and clinics participating as women's medical homes under the project, and the physicians, advance practice nurses, and physician assistants providing services at such practices, centers, and clinics, have access to confidential feedback and benchmarking reports as a function of the practice's, health center's, or clinic's monitoring of its clinical process and performance (including process and outcome measures). (9)

Technical assistance

The Secretary shall establish mechanisms to provide technical assistance to practices, health centers, and clinics participating as women's medical homes under the project. (10)

Payments to states

The Secretary shall pay each State participating in the project an amount equal to 100 percent of the amounts expended by the State for services provided to an eligible individual under the project, including administrative expenses. (c)

Advisory council

(1)

Establishment

Not later than 60 days after the date of enactment of this Act, the Secretary shall establish a Women’s Medical Home Advisory Council. (2)

Terms of members

(A)

In general

Each appointed member of the Advisory Council shall hold office for the duration of the project. (B)

Vacancies

The Secretary shall fill any vacancy in the membership of the Advisory Council in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Advisory Council. (3)

Composition

Membership in the Advisory Council shall include— (A)one representative from the Agency for Healthcare Research and Quality; (B)one representative from the Health Resources and Services Administration; (C)one representative from the Office of Women's Health of the Department of Health and Human Services; (D)one representative from the Centers for Medicare & Medicaid Services; (E)representatives from other appropriate Federal agencies; (F)four physicians who specialize in women’s health care, including 3 of which are board-certified in obstetrics and gynecology; (G)one certified nurse midwife; (H)one advanced practice nurse; (I)one physician assistant; (J)one mental health professional; (K)one individual with expertise in coding and reimbursement-related issues; (L)one individual with expertise in quality improvement efforts; and (M)one consumer representative. (4)

Application of faca

The Federal Advisory Committee Act (5 U.S.C. App.) shall apply to the Advisory Council except that, for purposes of section 14 of that Act, the Advisory Council shall terminate 6 years after the date of the Secretary establishes the Council. (5)

Working groups

The Secretary may convene additional working groups to report to the Advisory Committee in order to assist with fulfillment of its duties. (6)

Duties

It shall be the duty of the Advisory Council to assist the Secretary in carrying out the Secretary's duties under this section. (d)

Evaluations and project reports

(1)

Annual interim evaluations and reports

For each year of the project, the Secretary, in consultation with the Advisory Council, shall provide for an interim evaluation of the project and shall submit to Congress reports on the results of such evaluations. (2)

Final evaluation and report

The Secretary, in consultation with the Advisory Council, shall provide for a final evaluation of the project and shall submit to Congress, not later than 1 year after completion of the project, a final report on the project based on the results of such evaluation. The final report required under this paragraph shall include— (A)an assessment of quality improvements and clinical outcomes as a result of the project; (B)an assessment of patient and provider satisfaction; (C)an assessment of which women, based on demographic factors, such as age, race, sexual orientation, disability, ethnicity, and socioeconomic status, benefit the most from participating in a women’s medical home; (D)estimates of cost savings to Medicaid, CHIP, and other Federal programs resulting from the project; and (E)recommendations for such legislation and administrative action as the Secretary determines to be appropriate.